A surgical procedure called a vaginal hysterectomy is the removal of the uterus, including cervix, through an incision made in the deepest recesses of the vagina. This surgery is frequently accompanied by reconstructive surgery (colporrhaphy) to repair bladder muscles and rectal muscles.
MoonDragon's Procedures: Hysterectomy, Abdominal
REASONS FOR PROCEDURE
Uterine cancer or suspected uterine cancer. Cervical Dysplasia (pre-cancerous conditions of the cervix) is another common reason for surgery. Only 10 percent of hysterectomy is performed for cancer. A hysterectomy is also performed to treat uterine cancer or very severe pre-cancers (called dysplasia, carcinoma in situ, or CIN III, or microinvasive carcinoma of the cervix). A hysterectomy for endometrial cancer (uterine lining cancer) has an obvious purpose, that of removal of the cancer from the body. This procedure is the foundation of treatment for cancer of the uterus.
Fibroid tumors of the uterus. The most common reason a hysterectomy is performed is for uterine fibroids (also known as uterine leiomyomata). Uterine fibroids are benign growths of the uterus, the cause of which is unknown. Although the vast majority are benign, meaning they do not cause or turn into cancer, uterine fibroids can cause medical problems. Indications for hysterectomy in cases of uterine fibroids are excessive size (usually greater than the size of an eight month pregnancy), pressure or pain, and/or bleeding severe enough to produce anemia.
Chronic uterine bleeding.
Severe bleeding after childbirth. A hysterectomy may rarely be required in women who have uncontrollable bleeding after childbirth.
Prolapsed (dropped) uterus or pelvic relaxation. Pelvic relaxation is another condition that can require treatment with a hysterectomy. In this condition, a woman experiences a loosening of the support muscles and tissues in the pelvic area. Mild relaxation can cause first degree prolapse, in which the cervix (the uterine opening) is about halfway down into the vagina. In second degree prolapse, the cervix or leading edge of the uterus has moved to the vaginal opening, and in third degree prolapse the cervix and uterus protrude past the vaginal opening. Second and third degree uterine prolapse must be treated with hysterectomy. A loosening, vaginal wall weakness such as a cystocele, rectocele, or urethrocele, can lead to symptoms such as urinary incontinence (unintentional loss of urine), pelvic heaviness, and impaired sexual performance. The urine loss tends to be aggravated by sneezing, coughing, or laughing. Childbearing is probably involved in increasing the risk for pelvic relaxation, though the exact reasons for this remain unclear. Avoidance of vaginal birth and having a caesarean section doesn't eliminate the risk of developing pelvic relaxation.
Endometriosis. Endometrial hyperplasia - Endometrial hyperplasia is the term used to describe excessive growth of the endometrium (the tissue that lines the uterus). It can sometimes lead to endometrial cancer. Although endometrial hyperplasia can often be treated with medication, a hysterectomy is sometimes needed or preferred to medical therapy.
Chronic pelvic infection.
Severe menstrual pain or chronic pelvic pain. Chronic pelvic pain can be due to the effects of endometriosis or scarring (adhesions) in the pelvis and between pelvic organs. However, pelvic pain can also be caused by other sources, including the gastrointestinal and urinary systems. It is important for a woman with pelvic pain to ask about the probability that her pain will improve after hysterectomy.
FALLOPIAN TUBES & OVARIES:
Cancer or suspected cancer of the ovaries.
Pre-cancerous or twisted ovarian cysts.
Tubal or ovarian pregnancy.
Damage to the ovaries from severe endometriosis.
RISK INCREASES WITH
Conditions resulting in excessive estrogen exposure, such as estrogen drugs used in oral contraceptions or hormone replacement therapy, delayed childbirth, chronic anovulation (failure to release eggs from the ovary each month).
Iron deficiency anemia; heart or lung disease; or diabetes mellitus.
Use of drugs such as: cortisone; antihypertensives; diuretics; or beta-adrenergic blockers.
Use of mind-altering drugs such as cocaine and marijuana.
DIAGNOSTIC TESTS PRIOR TO SURGERY
A woman must have a pelvic examination, Pap smear, and a diagnosis prior to proceeding with a hysterectomy. A chest x-ray, EKG and blood testing may be included depending on the age and specific condition of the woman and other medical considerations.
Prior to having a hysterectomy for pelvic pain, women usually undergo more limited (less extensive) exploratory surgery procedures (such as laparoscopy) to rule out other causes of pain. Prior to having a hysterectomy for abnormal uterine bleeding, women require some type of sampling of the lining of the uterus (biopsy of the endometrium) to rule out cancer or pre-cancer of the uterus. This procedure is called endometrial sampling. Also, pelvic ultrasounds and/or pelvic computerized tomography (CT) tests can be done to make a firm diagnosis. In a woman with pelvic pain or bleeding, a trial of medication treatment is often given before a hysterectomy is considered.
ALTERNATIVE THERAPIES TO HYSTERECTOMY
Hysterectomy ends your ability to become pregnant. If you think you might want to become pregnant, ask your health care provider about alternatives to this surgery. In the case of cancer, hysterectomy might be the only option. But other conditions - including fibroids, endometriosis and uterine prolapse - have alternative treatments that you can try first.
A pre-menopausal (still having regular menstrual periods) woman whose uterine fibroids are causing bleeding but no pain is generally first offered medical therapy with hormones. Non-hormonal treatments are also available, such as tranexamic acid and more moderate surgical procedures, such as ablations (removal of the lining of the uterus). If she still has significant bleeding that causes major impairment to her daily life, or the bleeding continues to cause anemia (low red blood cell count due to blood loss), and she has no abnormality on endometrial sampling, she may be considered for a hysterectomy.
A post-menopausal woman (whose menstrual periods have ceased permanently) who has no abnormalities in the samples of her uterus (endometrial sampling) and still has persistent abnormal bleeding after trying hormone therapy, may be considered for a hysterectomy. Several dose adjustments or different types of hormones may be required to decide on the optimal medical treatment for an individual woman.
A hysterectomy for conditions other than cancer is generally not considered until after other tests or medications are unsuccessful. There are also newer procedures, such as uterine artery embolization (UAE) or surgical removal of a portion of the uterus (myomectomy), that are being used to treat excessive uterine bleeding. Endometrial ablation technique, which involves destroying or removing most of the endometrium using an instrument inserted through the vagina and cervix and into the uterus. Newer medications are also alternatives.
Cone biopsy (eg, cold knife cone), cryosurgery, laser surgery, or loop electrocautery (eg, LEEP or LLETZ) are usually used to treat women with high-grade cervical intraepithelial neoplasia or carcinoma in situ of the cervix. These procedures remove the abnormal part of the cervix rather than the entire cervix and uterus.
Pain clinics may be able to treat patients with severe and chronic pelvic pain without surgery.
DESCRIPTION OF PROCEDURE
During this procedure, the uterus is removed through the vagina. In a vaginal hysterectomy, the surgeon reaches your uterus by making a circular incision around the cervix. With a vaginal hysterectomy, you won't have any external scarring. You may also recover more quickly because you are not waiting for a large abdominal incision to heal and the nerve signals from the top of the vagina are not perceived in the same manner as those from the skin. However, vaginal hysterectomy gives the surgeon less room to operate and no real opportunity to view your pelvic organs.
A vaginal hysterectomy is appropriate only for conditions such as uterine prolapse, endometrial hyperplasia, or cervical dysplasia. These are conditions in which the uterus is not too large, and in which the whole abdomen does not require examination using a more extensive surgical procedure. The woman will need to have her legs raised up in a stirrup device throughout the procedure. Women who have not had children may not have a large enough vaginal canal for this type of procedure. If a woman has too large a uterus, cannot have her legs raised in the stirrup device for prolonged periods, or has other reasons why the whole upper abdomen must be further examined, the health care provider will usually recommend an abdominal hysterectomy. In general, laparoscopic vaginal hysterectomy is more expensive and has higher complication rates than abdominal hysterectomy.
MoonDragon's Procedures: Hysterectomy, Abdominal
MoonDragon's Procedures: Hysterectomy, Vaginal With Bilateral Salpingo-Oophorectomy & Colporrhaphy
Antibiotics to prevent post-surgical infection may be prescribed in certain cases.
A general or regional (spinal) anesthesia plus sedation will be administered so the patient feels no pain.
A urinary catheter is placed. Heart rate, blood pressure, blood loss, and respiration are closely monitored throughout the procedure.
The vaginal walls are carefully separated from the bladder and rectal muscles.
The deepest recesses of the vagina are opened. The uterus and cervix are cut free and removed. The rear part of the vagina is closed with sutures.
The bladder muscles and rectal muscles are sewn into their proper position.
After surgery, patients are transferred to the recovery room (also known as post-anesthesia care unit) so that they ca be monitored while waking up. Most patients will be transferred to a hospital room, where they will spend one to two nights.
A small catheter (foley) may be left in the bladder for a few days.
OTHER HYSTERECTOMY PROCEDURES OPTIONS
In the past the most common hysterectomy was done by an incision (cut) through the abdomen (abdominal hysterectomy). Now most surgeries can utilize laparoscopic assisted or vaginal hysterectomies (performed through the vagina rather than through the abdomen) for quicker and easier recovery. The hospital stay generally tends to be longer with an abdominal hysterectomy than with a vaginal hysterectomy, and hospital charges tend to be higher. The procedures seem to take comparable lengths of time (about two hours), unless the uterus is of a very large size, in which case a vaginal hysterectomy may take longer.
There are now a variety of surgical techniques for performing hysterectomies. The ideal surgical procedure for each woman depends on her particular medical condition. Below, the different types of hysterectomy are discussed with general guidelines about which technique is considered for which type of medical situation. However, the final decision must be made from an individualized discussion between the woman and the health care provider who best understands her individual situation.
Remember, as a general rule, before any type of hysterectomy, women should have the following tests in order to select the optimal procedure:
- Complete pelvic exam including manually examining the ovaries and uterus.
- Up-to-date Pap smear.
- Pelvic ultrasound may be appropriate, depending on what the health care provider finds on the above.
- A decision regarding whether or not to remove the ovaries at the time of hysterectomy.
- A complete blood count and an attempt to correct anemia if possible.
TOTAL ABDOMINAL HYSTERECTOMY
This is the most common type of hysterectomy. During a total abdominal hysterectomy, the health care provider removes the uterus, including the cervix. The scar may be horizontal or vertical, depending on the reason the procedure is performed, and the size of the area being treated. Cancer of the ovary(s) and uterus, endometriosis, and large uterine fibroids are treated with total abdominal hysterectomy. Total abdominal hysterectomy may also be done in some unusual cases of very severe pelvic pain, after a very thorough evaluation to identify the cause of the pain, and only after several attempts at non-surgical treatments. Clearly a woman cannot bear children herself after this procedure, so it is not performed on women of childbearing age unless there is a serious condition, such as cancer. Total abdominal hysterectomy allows the whole abdomen and pelvis to be examined, which is an advantage in women with cancer or investigating growths of unclear cause.
The advantage of an abdominal procedure is that your surgeon can see your uterus and other organs and has more room to operate than if the procedure is done vaginally. For health care provider suspects the presence of cancer. On the other hand, abdominal hysterectomy can mean:
- You will be in the hospital longer.
- You will experience greater discomfort than following a vaginal procedure.
- You will have a visible scar on your abdomen.
LAPAROSCOPY-ASSISTED VAGINAL HYSTERECTOMY (LAVH)
Laparoscopy-assisted vaginal hysterectomy (LAVH) is similar to the vaginal hysterectomy procedure described above, but it adds the use of a laparoscope. A laparoscope is a very thin viewing tube with a magnifying glass-like device at the end of it. The surgeon makes a small incision near your navel to insert a thin device (laparoscope) that allows the surgical team to see inside your abdomen. Through other tiny incisions, your surgeon uses special surgical instruments to detach the uterus and then remove it through your vagina.
Certain women would be best served by having laparoscopy used during vaginal hysterectomy because it allows the upper abdomen to be carefully inspected during surgery. Examples of uses of the laparoscope would be for early endometrial cancer (to verify lack of spread of cancer), or if oophorectomy (removal of the ovaries) is planned. Compared to simple vaginal hysterectomy or abdominal hysterectomy, it is a more expensive procedure, is more prone to complications, requires longer to perform, and is associated with longer hospital stays. Just as with simple vaginal hysterectomy without a laparoscope, the uterus must not be excessively large. The health care provider will also review the medical situation to be sure there are no special risks prohibiting use of the procedure, such as prior surgery that could have increased the risk for abnormal scarring (adhesions). If a woman has such a history of prior surgery, or if she has a large pelvic mass, a regular abdominal hysterectomy is probably best.
A supracervical hysterectomy is used to remove the uterus while sparing the cervix, leaving it as a "stump." The cervix is the area that forms the very bottom of the uterus, and sits at the very end (top) of the vaginal canal. The procedure probably does not totally rule out the possibility of developing cancer in this remnant "stump." Women who have had abnormal Pap smears or cervical cancer clearly are not appropriate candidates for this procedure. Other women may be able to have the procedure if there is no reason to have the cervix removed. In some cases the cervix is actually better left in place, such as some cases of severe endometriosis. It is a simpler procedure and requires less time to perform. It may give some added support of the vagina, decreasing the risk for the development of protrusion of the vaginal contents through the vaginal opening (vaginal prolapse).
LAPAROSCOPIC SUPRA CERVICAL HYSTERECTOMY
The laparoscopic supra cervical hysterectomy procedure is performed like the LAVH procedure, although usually cautery is used to cut the cervix off at the cervical stump, and the tissue is all removed through a laparoscopic tool. Recovery is very quick. Cervical preservation is less likely to result in menses (menstruation) as the endocervix is usually cauterized.
The radical hysterectomy procedure involves more extensive surgery than a total abdominal hysterectomy because it also includes removing tissues surrounding the uterus and removal of the upper vagina. Radical hysterectomy is most commonly performed for early cervical cancer. There are more complications with radical hysterectomy compared to abdominal hysterectomy. These include injury to the bowels and urinary system.
OOPHORECTOMY & SALPINGO-OOPHORECTOMY
(Removal of the Ovaries and/or Fallopian tubes)
Oophorectomy is the surgical removal of the ovary(s), while salpingo-oophorectomy is the removal of the ovary and its adjacent Fallopian tube. These two procedures are performed for ovarian cancer, removal of suspicious ovarian tumors, or Fallopian tube cancer (which is very rare). They may also be performed due to complications of infection, or in combination with hysterectomy for cancer. Occasionally, women with inherited types of cancer of the ovary or breast will have an oophorectomy as preventive (prophylactic) surgery in order to reduce the risk of future cancer of the ovary or breast.
Relief from symptoms caused by benign uterine conditions. Symptom relief is associated with improvement of quality of life.
The vagina will be shortened slightly. This should cause no lasting problem. Expect permanent sterility. Allow about 6 weeks for recovery from surgery.
Understand that you won't be back to your usual self for at least four to six weeks. If you have had a vaginal hysterectomy, you might feel better long before this time, but it is important to adhere to activity restrictions. Get plenty of rest. Do not lift anything heavy for a full six weeks after the operation. Your health care provider may recommend other restrictions, but eventually you will return to your normal activities.
If you are pre-menopausal, having your ovaries removed initiates menopause. Discuss with your health care provider ways to handle menopausal symptoms, such as hot flashes and vaginal dryness. If you are younger than age 45 and you had your ovaries removed, you are at increased risk of osteoporosis. Ask your health care provider about an osteoporosis prevention program.
About six weeks after your surgery, you can resume sexual activity. Having a hysterectomy should not affect this aspect of your life. This issue has been carefully studied, and women with a good sex life before hysterectomy maintain it afterward. Some women even experience an increase in sexual pleasure. This may be associated with relief from the chronic pain or heavy bleeding that was caused by a uterine problem.
Complications of a hysterectomy include infection, pain, and bleeding in the surgical area. An abdominal hysterectomy has a higher rate of post-operative infection and pain than does a vaginal hysterectomy.
Excessive bleeding. Hemorrhage occurs in a small number of cases and may require a return to the operating room to identify and stop the bleeding.
Blood clots. Pelvic surgery increases the risk of developing blood clots in the large veins of the leg or lung. The risk is increased for approximately six weeks after surgery. Medications may be given to some women to prevent blood clots. In addition, women taking oral contraceptives or hormone replacement should ideally discontinue them one month prior to surgery since they can further increase the risk of blood clots. Women who are sexually active and pre-menopausal should use alternative methods of birth control (e.g. condoms) to prevent pregnancy before surgery.
Surgical wound infection. Low-grade fever is common after hysterectomy and is not always caused by infection, and usually resolves without treatment. However, a high or persistent fever may signal an infection. Serious infection occurs in less than 10 percent of women, and can usually be treated with intravenous antibiotics. Much less commonly, patients require another surgical procedure.
Inadvertent injury to the bowel, bladder or ureters (the tubes going from the kidneys to the bladder). The urinary bladder, ureters (small tubes leading from the kidneys to the bladder), and large and small intestines are located in the lower abdomen and pelvis and can be injured during hysterectomy. Injury occurs in less than one percent of all women undergoing hysterectomy, and can usually be detected and corrected at the time of surgery. If detected after surgery, another operation may be needed.
Anesthetic complications (depending upon method used).
Urinary tract infection (UTI).
Urinary retention, or the inability to pass urine, can occur after abdominal hysterectomy. It is more common in women who have vaginal hysterectomy. Urine can be drained using a catheter until retention resolves, usually within 24 to 48 hours.
Respiratory infection, particularly pneumonia.
Early menopause - Women who have undergone hysterectomy may experience menopause earlier than the average age of menopause (age 51). This may be due to an interruption in blood flow to the ovaries as a result of removing the uterus.
Muscles supporting bladder and rectum may require a second repair.
GENERAL MEASURES AFTER SURGERY
Hospital stay may be 1 to 3 days (occasionally longer). Fluids and food are generally offered soon after surgery. Intravenous (IV) fluids may be administered during the first day, particularly if there is nausea or vomiting. Pain medicine is given as needed, either intravenously, or by intramuscular (IM) injection, or as a pill. Patients are encouraged to resume their normal daily activities as soon as possible. Regaining mobility is particularly important since it helps to prevent complications, such as blood clots, pneumonia, and gas pains.
To minimize stress on the healing tissues, patients will be asked to avoid lifting greater than 20 pounds (9 kg) for four to six weeks after surgery.
Vaginal intercourse, tampons, and douching are not recommended for the same time period to allow complete healing.
Use sanitary napkins - not tampons to absorb blood or drainage (discharge is normal, but has an unpleasant odor).
To keep lungs clear, cough frequently while using appropriate support. Deep breathing aids are frequently available.
Once home, someone should be available to help care for you the first few days. Walking and stair climbing are encouraged.
Driving should be avoided until full mobility returns and narcotic pain relievers are no longer required.
Use an electric heating pad, a heat lamp or a warm compress to relieve incisional pain or gas pains.
Tub baths and showers are permitted. Use mild unscented soap to wash the perineal area.
After-effects of surgery may include constipation, urinary symptoms, fatigue and weight gain. Constipation is common after surgery and while using narcotic pain medications, and can often be controlled with stool-softening medications such as Colace® (docusate sodium) and stool bulking agents such as psyllium (Metamucil®), methylcellulose (Citrucel®), or calcium polycarbophil (FiberCon®). A woman who does not have a bowel movement within 3 days should contact her health care provider for further advice.
Normal activities can be resumed gradually over a six-week period. Patients may return to work as soon as they have sufficient stamina and mobility.
The psychological aftermath of a hysterectomy will depend on the individual. Some women feel only relief, others experience frequent and unexpected cry episodes (may be due to hormonal changes), and a few suffer from depression and a sense of loss. Seek help and support from family and friends. These feelings may be treated by talking with a therapist, with antidepressant medication, or may resolve with time.
HYSTERECTOMY AND POST-SURGICAL PAP SMEARS
Any woman with a history of abnormal Pap smears is recommended to have Pap smears for the remainder of her life. When the cervix has already been removed, these smears are more accurately called "vaginal cuff" smears, instead of Pap smears. This is because of the low, but real chance that cervical cancer can recur right at the surgical site where the cervix was removed.
In addition to women with a history of abnormal Pap smears, other women who require continued Pap smears are women with supracervical hysterectomy, in which the cervix was left in place. In this case, in contrast to the woman who has had hysterectomy for reasons of cervical cancer, the woman who has had supracervical hysterectomy will be able to follow the same screening guidelines as for other woman who have not had surgery. For example, the health care provider can stop doing Pap smears at age 65 if the woman has been well-screened and has always had normal Pap smears.
Women who do not need to continue having Pap smears are those who have had vaginal hysterectomy or abdominal hysterectomy for benign (not cancer) reasons, such as uterine fibroids. Provided that they have had normal Pap smears prior to the procedure, they need not continue to have Pap smears after their surgery.
After surgery, medicines for pain, gas, nausea or constipation may be prescribed.
Antibiotics if infection develops.
Supplemental hormones may be recommended unless there are reasons why they should not be taken.
To help recovery and aid your well-being, resume daily activities, including work, as soon as you are able. Recovery at home may take 1 to 3 weeks, with full activities resumed in 6 to 8 weeks.
Resume driving 2 weeks after returning home.
Sexual relations may be resumed in 4 to 6 weeks (or when advised). Most women experience no change in sexual function; some report improvement, while others have a worsening sexual function, specifically, loss of libido (sexual desire).
Clear liquid diet until the gastrointestinal tract functions again. Then eat a well-balanced diet for a healthy immune system and to assist in a rapid recovery from your surgery.
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NOTIFY HEALTH CARE PROVIDER IF...
Any of the following occurs:
- Vaginal bleeding that soaks more than 1 pad per hour (bleeding heavier than a menstrual period).
- Frequent urge to urinate or excessive vaginal discharge that persists longer than 1 month. Foul smelling vaginal discharge, or inability to empty the bladder or bowels.
- Increased pain or swelling in the surgical area. Pain not relieved with medication.
- Persistent nausea or vomiting.
- Signs of infection: headache, muscle aches, dizziness, or a general ill feeling and fever greater than 101°F or 38°C.
- Feelings of depression worsen or fail to improve.
- Any unusual or unexpected symptoms occurs. Medications used for pain and treatment may have side effects.
MoonDragon's Procedures: Hysterectomy, Abdominal
MoonDragon's Procedures: Hysterectomy, Vaginal With Bilateral Salpingo-Oophorectomy & Colporrhaphy
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