Each year over 600,000 hysterectomies are performed in the United States
The majority of these are performed for problems of excessive bleeding, pain, prolapse, or excessive growth of the uterus. The decision to remove the uterus can be confusing due to the multiple options to consider and opinions available from family, friends, and physicians. In this article, I will outline the options to consider and questions to ask. This article will assume that alternatives to a hysterectomy have already been considered and the decision to proceed with surgery has been made.
How will the procedure be performed?
There are four basic ways to perform a hysterectomy. The method chosen will be determined by your physician based on their experience and skills in handling your condition.
Open hysterectomy is done through a large incision across your abdomen similar to a cesarean section scar. This allows access to remove a large uterus or cyst with ease. This is still the most common method of performing a hysterectomy. This method has the most post-op pain and longest recovery (6-8 weeks). Hospital stay is 2-4 days.
Vaginal hysterectomy is the removal of the uterus through an incision in the vagina and there are no abdominal incisions. This is the oldest method of hysterectomy and is still used for cases involving prolapse or a small to medium size uterus. For most the pain is minimal and recovery time shorter than an open approach (2-4 weeks). Recovery may be longer if additional procedures for vaginal prolapse or bladder leaking are performed.
Laparoscopic hysterectomy is done through several small incisions placed strategically on the abdomen. A camera is used to visualize the pelvis and the surgery is performed using long thin instruments. This has been called “chopstick” surgery. Since its development in the 80’s, the instruments and technology have advanced greatly making this a very safe and effective treatment for most patients needing a hysterectomy. The incisions are small and the post op pain and recovery is similar to a vaginal hysterectomy. Most patients have an overnight stay in the hospital.
da Vinci Robot is the latest tool used to perform a hysterectomy. The technique is similar to a laparoscopic hysterectomy in that small incisions are used to place the instruments into the abdomen. These instruments are attached to the da Vinci robot and the surgeon controls the instruments from a console. This device gives the surgeon a high definition 3-D view of the surgical field and precise control over the instruments. This technique results in the least amount of post op pain and shortest recovery.
Should I remove the cervix?
Removing the cervix is called a total hysterectomy and leaving the cervix is called a subtotal hysterectomy. Total hysterectomy is by far the most common. Removal of the cervix eliminates the possibility of abnormal pap smears and cervical cancer. The argument for a subtotal hysterectomy (not removing the cervix) is that it helps to preserve sexual feeling and prevent prolapse in the future. There is not a lot of evidence supporting these arguments. Leaving the cervix may require its removal at a later time. One advantage of leaving the cervix is that there is less post op pain and return to sexual activity can occur sooner. I do not feel strongly about either method and let the patient decide.
Should I have my ovaries removed?
In the past, the belief was that after the age of 40 the ovaries should be removed at the time of hysterectomy to reduce the risk of ovarian cancer. More recently the recommendations are not to remove the ovaries unless they are abnormal, causing pain, or there is a strong family history of ovarian cancer. Premature removal of the ovaries can result in an increased risk of dying from cardiovascular disease due to the loss of hormones. Current recommendation is that even after menopause, one should consider preserving the ovaries. If the ovaries are removed, you will then need to decide whether or not to take replacement hormone therapy. For additional information please see my article “Should I take Hormones.”
Where should I have my surgery?
Here the choice is limited to a hospital or surgery center. Many surgery centers have overnight stay allowing vaginal and laparoscopic hysterectomies to be observed overnight for pain control. Surgery at a surgery center is usually less expensive compared to most hospital charges. Surgery using the da Vinci robot can only be performed at a hospital.
The decision to have a hysterectomy can be difficult
By far the majority of patients that have a hysterectomy do not regret their decision. An open discussion of your options with your physician will help you make the right choices.
Raj K. Syal, M.D., F.A.C.O.G.