Hysterectomy – Indications, Procedures and complications | Surgical Removal of the Uterus or womb | Dr N Layyous

Hysterectomy-Surgical Removal of the Uterus or womb

The uterus has two functions:

1. It is the site where pregnancy occurs.
2. The site from where bleeding occurs each month (menses).

Therefore, if the women undergo a process of hysterectomy, she won’t become pregnant and won’t have menses.

Indications for hysterectomy-Removal of the Uterus:

Generally, women who tried all conservative treatments that prevent pregnancy are advised to undergo Hysterectomy. But the followings make the process of Hysterectomy mandatory:

1. Fibroid accounts for 30% of hysterectomy cases.
2. Endometriosis and Adenomyosis accounts for 20% of cases.
3. Uterine prolapsed.
4. Uterine bleeding unresponsive to medical therapy nor balloon diathermy nor mirena accounts for 20% of cases.
5. Uterine, ovarian and cervical cancer accounts for 10% of cases.
6. Chronic pelvic pain.
7. Uncontrollable post-partum hemorrhage.

Type of Hysterectomy-Removal of the Uterus:

Hysterectomy could be done to remove the uterus alone or to remove the uterus, both ovaries and tubes according to the patient’s disease.

There are three types of hysterectomy:

1. Total Hysterectomy which includes removal of the cervix, this is the most common type of hysterectomy.
2. Subtotal Hysterectomy which conserves the cervix mainly used in cases of uterine fibroids or to treat abnormal bleeding patterns.
3. Radical Hysterectomy which includes removal of the cervix, upper part of vagina and parametrical tissue. This type of operation is done in cancer cases only.

Although the number of hysterectomies had declined over the years, 55% of hysterectomies are done for women between 35-49.

Approaches for Hysterectomy:

The best approach of Hysterectomy is determined by:

1. The disease of the patient
2. The experience of the surgeon

The approaches For Removal of the Uterus include:

1. Vaginal Hysterectomy: done through an incision in the vagina. This approach is associated with less pain, no visible scar, shorter stay in the hospital and less recovery time (4 weeks). Because it is more difficult for the surgeon to see the internal organs it is associated with more complications mainly for the urinary tract.
2. This approach is chosen in obese patients, patients who has abdominal adhesions from previous surgery, in cases of uterine prolapse especially if other procedures are planned such as repair of a rectocele or enterocele and in early stage of cervical cancer.
3. Abdominal Hysterectomy: done through an incision in the lower abdominal area, may reach 20 cm in length, it’s the best approach in cancer and huge fibroid cases.
4. Laparoscopic Hysterectomy: A camera will be introduced into three small openings in the abdomen and the Hysterectomy is applied after the decomposition of the uterus to small parts that will be removed through these openings.
5. Laparoscopic assisted vaginal Hysterectomy. Removing the uterus vaginally after releasing using the Laparoscope, the hospital stay is only one day and the recovery time is only two weeks

-Before undergoing hysterectomy the patient should ask her doctor about:

1. Risk of the operation
2. Alternative treatment for the condition
3. Undergoing these procedures to determine the best approach for the condition:
   1. Pap smear (to exclude cervical cancer).
   2. Dilatation and curettage (to exclude uterine cancer and hyperplasia).
   3. Pelvic u/s (to determine the size of fibroid, polyps, ovarian masses).

Risks of uterus removal surgery:

Hysterectomy is one the safest operation in gynecology, although every operation has complications that could occur during surgery or after it, but the advantages of Hysterectomy overcome the disadvantages.

These complications include:

1. Wound infection
2. Internal bleeding
3. Urological and bowel injuries
4. Deep venous thrombosis and pulmonary embolism
5. Anesthesia compilations
6. Paralytic ileus

Preparations of surgery for Removal of the Uterus:

Every patient, undergoing Hysterectomy, should be admitted to the hospital one day before the operation. Shaving the pubic area must be done and antibiotics should be given to decrease the risk of infection.
The operation done under general anesthesia may last for 1 to 2 hours. After the patient is intubated, a Foleys catheter is inserted in the urinary bladder, cleaning and dropping done.

Observation done in the recovery room, for few hours to check the vital signs, and the patient will receive painkillers (The degree of pain varies and its greatest after abdominal hysterectomy) and antibiotics as scheduled.

The patient is advised to mobilize after six hours of the operation after removing the Foleys catheter, in order to decrease the risk of thrombosis.
The admission period varies between 2days in LASH and 4 days in abdominal approach.

There may be few spotting after surgery, which is normal if the amount wasn’t in the form of bleeding as menses (if this happens the patient should consult the doctor immediately).

The patient may return to her daily activities 6 to 8 weeks after the operation and during this time, the patient is advised to do the followings:

1. Avoid doing heavy works
2. Avoid lifting heavy Weights
3. Avoid the sexual intercourse and vaginal douches
4. Avoid constipation
5. Wound care with proper dressing and inform the doctor if redness or swelling develops.
6. Follow the doctor’s instructions regarding her daily activities
7. Counsel the patient about the need for hormonal replacement therapy if the ovaries were removed

Life after hysterectomy

1. Amenorrhea
2. Disappearance of bleeding and abdominal pain that the patient suffered from before surgery.
3. No possibility of pregnancy at all.
4. If the ovaries are removed with the uterus, the patient will suffer from menopausal symptoms like hot flushes, nervousness, vaginal dryness, sleep disturbances, osteoporosis. In these cases, the patient should receive hormonal therapy.
5. Sexual life won’t be affected. However, some females feel excited during intercourse if she felt the uterine contraction, which will disappear after the operation. Others will feel excited during intercourse in absence of pain and bleeding after the operation.
6. In case of subtotal Hysterectomy done, the patient should undergo Pap smear routinely to avoid ID cervical cancer.
7. The patient starts to feel confident in absence of her past problems, but other patients will be depressed because they feel they lost their femininity.
8. Urgency and urge incontinence which may need medical therapy.

Partial hysterectomy

In partial hysterectomy only the body of the uterus is removed keeping the cervix and the ovaries behind, it can be performed abdominally, vaginally or laproscopically.

If you choose this type of hysterectomy you have to do annual Pap smear to screen for cervical cancer.

Advantages

1. Shorter operating time.
2. More sexual enjoyment and healthier inner pelvic architecture.
3. Avoiding vaginal vault prolapse, vaginal shortening and vaginal cuff granulation tissue formation.

Disadvantages

Like any surgical procedure partial hysterectomy has some side effects

1. Pain and wound infection
2. Anesthesia complication
3. Damage to internal organs, bladder, bowel or ureters
4. Emotional issues
5. Hormonal changes: removing the uterus decreases the blood supply to the ovaries, this will decrease circulating estrogen and testosterone resulting in osteopenia, osteoporosis cardiovascular issues and menopausal symptoms such as hot flushes, decrease sexual desire pain during intercourse and urinary incontinence.
6. The risk of developing cervical cancer remains

Dr Najeeb Layyous F.R.C.O.G

Consultant Obstetrician, Gynecologist and Infertility Specialist