Less Invasive Hysterectomy Options
Hysterectomy, the surgical removal of a woman’s uterus, is the most common, non-pregnancy related surgical procedure performed on women in the United States. Each year, about 600,000 hysterectomies are performed. The majority of these procedures are performed through the traditional, abdominal “open” approach. However, in recent years there has been an increase in less invasive surgical techniques that can help reduce pain and scarring, as well as shorten recovery time, compared to the traditional approach. This means that even after alternatives for avoiding a hysterectomy have been explored and a woman decides to have her uterus removed, there are still options and choices to discuss with her physician.
Types of Hysterectomy
There are three basic types of hysterectomy:
- Total hysterectomy. The uterus and cervix are removed. The ovaries and fallopian tubes may or may not be removed at the same time.
- Subtotal or partial hysterectomy. The uterus is removed but the cervix is left in place. The ovaries and fallopian tubes may or may not be removed at the same time. Some gynecologists feel that leaving the cervix intact may reduce the chance of pelvic support problems (such as uterine-vaginal prolapse). Leaving the cervix may also help reduce the chance of developing urinary incontinence later in life. If a woman chooses this option, she should continue to have regular annual pap smears to screen for cervical cancer.
- Radical hysterectomy. The uterus, cervix and some of the pelvic lymph nodes are removed. The ovaries and fallopian tubes may or may not be removed at the same time. This operation is performed to treat some kinds of cancer.
Different Surgical Techniques to Perform Hysterectomy
There are four different approaches to performing hysterectomy. A physician will use one of the following techniques to remove a woman’s uterus:
- Abdominal or “open” hysterectomy. The “traditional” approach involves removal of the uterus and cervix through an abdominal incision about 4 to 6 inches in length. This approach may be recommended if a woman has large fibroids that have not responded to drug therapy or would be difficult to remove vaginally or laparoscopically. It may also be recommended to treat severe endometriosis (uterine lining tissue that has found its way out of the uterus) or pelvic inflammatory disease. This approach is performed under general or regional (spinal or epidural) anesthesia and requires a hospital stay of 3-6 days and a long recovery period (up to six weeks).
- Vaginal hysterectomy. An approach that removes the uterus and cervix through an incision deep in the vagina. This is usually the method chosen to treat uterine-vaginal prolapse, and may be used to help treat early cervical or uterine cancer. Vaginal hysterectomy offers a shorter hospital stay (1-3 days) and less recovery time (4 weeks) compared to “open” hysterectomy. In addition, it offers the lack of visible scarring. However, this approach may not be appropriate for very large fibroids. It can be performed under general or regional anesthesia.
- Laparoscopically-assisted vaginal hysterectomy (LAVH).This technique is similar to the vaginal approach but requires special surgical skills and instruments. A laparoscope (a thin lighted telescope) is inserted through a small incision in the navel. Other thin instruments, used to remove the uterus, can be inserted through tiny incisions. Hospital stay and recovery time is similar to vaginal hysterectomy, and like that approach, the lap-assisted approach is usually not performed if large fibroids are present.
- Laparoscopic Supracervical Hysterectomy (LSH).This is a recently developed surgical technique that uses laparoscopy alone to remove the uterus, but leaves the cervix intact. During the procedure, a laparoscope and small surgical instruments are inserted though tiny incisions in the navel and abdomen. Using these instruments, the surgeon is able to carefully separate the uterus from the cervix and then remove it through one of the incisions. A surgical instrument called a “morcellator” makes it possible to cut up large sections of tissue so that they can be removed through the tiny incisions. However, this approach may not be appropriate if a woman has very large or numerous fibroids. Like LAVH, this approach requires special surgical skills.
LSH is less invasive than traditional “open” hysterectomy. It was developed to reduce pain and trauma to the body, minimize scarring, and shorten recovery time. The procedure can be performed on an outpatient basis under general or regional (spinal or epidural) anesthesia. Most women are home within 24 hours or less. Recovery time is usually about six days. Because the cervix is left in place, a woman should be willing to continue to get regular PAP smears to screen for cervical cancer.