Hysterectomy

Listed below is the step by step procedure of Hysterectomy:

1. What is Hysterectomy?
2. Why is Hysterectomy Required?
3. Pre-operative Preparation
4. Day Before Surgery
5. Procedure Day
6. Methods/Techniques of Hysterectomy
7. Post Procedure
8. Risks and Complications

What is Hysterectomy?

Surgical procedure using which uterus is removed from a female's body is known as hysterectomy. Ovaries, fallopian tubes, vagina and cervix may also be removed along with the uterus. Either the whole uterus is removed or a part of it is retained behind. The extent of surgery depends upon the health condition for which it is being performed.

Hysterectomy can be done by open method or laparoscopically. The procedure lasts for about 1-2 hours. An abdominal or vaginal approach may be used for performing the surgery.

Why is Hysterectomy Required?

Uterus, also known as womb, is a very important organ of the female reproductive system. It can become diseased by a number of anomalies. Surgical removal of uterus is usually the last treatment option. But it is possible that sometimes, other non surgical treatment methods fail to offer any relief. In such cases, surgery to remove the uterus may be the only option available. Some of the indications of hysterectomy are mentioned below:

• Fibroids

  Uterine fibroids are non cancerous growths inside the uterus. They change the internal shape of uterine cavity, cause heavy menstrual bleeding, abdominal pain and cause difficulties in normal conception and carrying of pregnancy. Medicines may help in reducing these growths. But in severe cases or when multiple large fibroids are present, removal of uterus is required.

• Endometriosis

  Cells present along the lining of the uterine cavity are specialized cells not located anywhere else in the body. In endometriosis, these cells migrate out of the uterus and may get deposited at other sites. Here the cells will multiply and undergo normal cycle which a uterine cell undergoes. Symptoms like heavy menstrual bleeding, uterine cramps, may progressively worsen despite medical or surgical intervention. As a last resort, uterus removal may be indicated.

• Prolapsed Uterus

  The uterus is held in place by ligaments and muscles which are firm and tight. Conditions like multiple pregnancies, recurrent abortions, difficult childbirth, put a lot of strain on the uterus and its supporting tissue. This may lead to the uterus being displaced from its normal position. If corrective surgery is not indicated for restoring the normal position, or if it fails, surgical removal of uterus might be opted for.

• Cancer of Uterus

  Uterine cancer can occur individually or due to spread of cancer from some other body tissue. In any case, it could have a fatal outcome. If medical line of treatment and radiation therapy does not curb the cancer, hysterectomy is indicated.

• Adenomyosis

  In this condition, there is thickening of the uterine lining. This leads to excessive menstrual bleeding, cramps in the uterus and abdominal bloating. If symptoms do not respond to other treatment methods, uterus removal surgery can be done.

Hysterectomy surgery has some contraindications. It is not performed in women who are in the childbearing age group. Removal of uterus completely negates the possibility to conceive and carry a pregnancy.

Pre-operative Preparation

Decision to opt for hysterectomy will be taken after a thorough physical examination, viewing detailed medical history and consideration of patient's general health. Proper planning and following some pre-surgical steps is advisable before surgery. They have been discussed below:

• Discussion Between Doctor and Patient

  Hysterectomies are performed by gynecologists. Prior to procedure, the patient and doctor discuss the surgical procedure, its pros and cons, pre-operative and post-operative preparations. The patient can get all her doubts cleared regarding the process.

• Deciding the Type of Hysterectomy

  Hysterectomy can involve removing the uterus partially or completely. Along with uterus, the ovaries, cervix and vagina may also be surgically excised. Depending on the extent of damage involved, the type of surgery which is to be performed is decided.

• Investigations

  Before undergoing hysterectomy, it is mandatory to perform blood tests to determine the patient's blood group, white blood cell count, blood sugar levels, kidney function and liver function. Blood group determination is done to arrange for some blood, matching the patient's blood group. It can be used in case of emergencies for transfusion if there is profuse bleeding during surgery. All the other tests are done to determine normal physiological functions of the body.

After all these steps are taken, the patient is completely prepared for surgery. Hysterectomy is a major surgery and is done in hospitals equipped with modern and advanced technology and surgical and medical facilities.

Day Before Surgery

Patient is advised to get admitted to the hospital a day before surgery. That way, patient is taken at the decided time for surgery. Early admission also helps patient to get acquainted with the hospital environment where she will need to remain for a day or two after surgery.

Patient's blood pressure, pulse rate, breathing rate and body temperature are checked regularly. Laxative and antacids are given to keep the digestive tract clean. Sometimes an enema is given for the lower bowel. Patient is advised not to consume any food since the night before surgery. These precautions are undertaken because hysterectomy is performed under general anesthesia. Therefore, the entire digestive tract is rendered paralyzed during the process. It is better to keep the intestines empty through the duration of surgery.

Procedure Day

On the day of surgery, the patient is asked to dress up in a sterilized gown provided by the hospital. After being taken into the operation theater, the patient is placed in a position such that she lies down flat on her back. The arms are spread out and secured with straps. The skin over the abdomen and pubis is shaved to remove all hair over it. It is cleaned with an antiseptic solution. General anesthesia is administered via an injection in the vein or through nasal route. Anesthetic agents take some time to have their effect. Once the patient is totally under the effect of anesthesia, surgery can start.

Methods/Techniques of Hysterectomy

Surgical removal of uterus can be done using abdominal or vaginal approach. Uterus is removed completely or partially, with or without removing other parts of female reproductive tract. Methods of hysterectomy have been described in detail below:

• Abdominal Hysterectomy

  To perform hysterectomy through abdomen, an incision is given over the lower abdominal skin. The incision is about 5 inches, and it may be given vertically or horizontally. Abdominal muscles, fascia and blood vessels are carefully separated. The ligaments holding the uterus are cut. Care is taken to avoid damage to adjoining healthy organs, nerves and blood vessels.

  

  The uterus is removed. Muscles and other organs are positioned as before and the surgical incision is closed with a suitable, medically designed thread. For enlarged uterus, this route of hysterectomy is more preferred, as the surgical incision is big enough to remove the uterus without much hassles.

• Vaginal Hysterectomy

  For vaginal hysterectomy, no surgical cuts need to be given over the skin. The procedure is minimally invasive as opposed to abdominal hysterectomy, which is an open procedure. Surgical instruments are introduced through the vagina. The vaginal opening might be enlarged surgically. The attachments of uterus are cut, and the uterus is removed via vaginal opening. This method can be done easily as only uterus and cervix are to be excised. Removal of ovaries and fallopian tubes through vagina is not impossible, but it is difficult.

  

  This can be done more easily in abdominal hysterectomy. The vaginal incision which is given before surgery is closed with surgically designed thread. It leads to minimum scar formation which heals very soon.

• Laparoscopic Hysterectomy

  In this minimally invasive procedure, multiple small incisions are given on the abdominal skin. Surgical instruments are inserted through these incisions. A video camera attached to a flexible tube (laparoscope) is inserted via one of the incisions. This helps in visualizing the internal organs and helps the surgeon during the procedure.

  

  Vaginal hysterectomy can also be done using laparoscopic guidance. Laparoscope can be inserted through the vagina, to get real time view of the internal organs. Robotic laparoscopy can also be performed. The surgeon controls the surgical process by operating robotic arms which perform the procedure. The ongoing surgery can be visualized on a screen in 3D view. Greater precision is possible with this type of surgery.

  If only a part of uterus is removed, it is known as subtotal or partial hysterectomy. Cervix remains intact and is not removed. Another type is total hysterectomy, in which the complete uterus along with cervix is surgically removed. Radical hysterectomy involves removal of uterus, both fallopian tubes, cervix and some part of the vagina.

  Removal of ovaries may be done if indicated. They are not usually removed completely. A part of ovaries is usually retained. This is done because ovaries produce estrogen and progesterone which are the two most important hormones of the female reproductive tract. The route of surgery and extent to which uterus is to be excised is decided upon the cause of surgery, patient's age and her general health.

After hysterectomy, it takes about 8 weeks for complete recovery and for resuming normal activities. A lot of post-operative care is advised after this surgery. Taking necessary care is in the patient's best interest and will provide easy and painless recovery.

Post Procedure

After surgery is completed, the patient is transferred to a different room for observation and recovery. The patient will remain unconscious till the anesthetic agent continues to have its effect.

• Post-operative Examination

  After the patient regains consciousness, a complete physical examination is done. Blood pressure, body temperature, breathing rate, heart rate are monitored. The surgical incision is examined. The patient will be hospitalized for 2-3 days, before she is discharged to go home.

• Home Care

  The patient has to continue with post-operative care even after being discharged from the hospital. She should take care to avoid abdominal or pelvic strain. House work, like cleaning, washing clothes or utensils, climbing the stairs is to be strictly avoided for 4-6 weeks after surgery. Care should be taken to prevent any trauma to the abdomen. Exercises are strictly prohibited for a month after surgery. Light physical activity like walking slowly, moving around the house can be started after the gynecologist's permission.

• Caring for the Surgical Incision

  In abdominal hysterectomy, the surgical incision is single and about 5 inches long. It takes a longer time for it to heal than smaller incisions which are made in laparoscopic method. The wound has to be kept dry and clean. Signs like bleeding, pain, pus formation, swelling at the site of incision should be reported immediately to the gynecologist. The wound should be kept covered with cotton and gauze. Stitches will be removed when the wound heals completely. A scar is left behind which takes a long time to fade.

• Physical Activity

  After hysterectomy, long term care is needed to avoid rigorous physical activity. After the uterus is removed, an empty space is created inside the patient's pelvic cavity. A lot of abdominal pressure might lead to hernia formation into that empty space. This has been explained in detail further in this article.

  However, complete absence of activity is also contraindicated. Light physical work helps in keeping blood circulation maintained. This will prevent formation of blood clots within the veins.

If these care instructions are followed well, recovery after surgery becomes easy. Despite the care however, it is likely for some complications to occur after surgery. There could be some complications during surgery as well. They have been described in the following section.

Risks And Complications

During or after hysterectomy, following risks and complications could occur. They can be prevented by taking necessary precautions. If they still occur, they need to be treated separately with medical or surgical intervention. Some of the commonly occurring risks associated with hysterectomy have been described below:

• Bleeding: During the surgery, a blood vessel adjacent to the uterus may be damaged by the surgical instruments. This could lead to bleeding. Blood can obstruct the filed of vision during surgery and needs to be drained. If there is considerable blood loss, it has to be replenished by blood transfusion.
• Organ Damage: Similar to the probable damage to blood vessels explained above, healthy organs adjacent to the uterus could also get damaged accidentally during surgery. If the damage is severe, it could lead to symptoms due to malfunctioning of that particular organ. This might need another corrective surgery.
• Urinary/Stool Incontinence: Accidental injury to the urinary bladder during hysterectomy procedure leads to this condition. There is no control over the passage of urine. Person may get frequent desire to pass urine. Very little urine is passed at a time. A similar thing can happen if the rectum is injured during the surgery. Stool incontinence will occur and could lead to either involuntary passage of stool or even difficulty in passing stool. Surgical intervention is needed to treat these conditions.
• Herniation: The term herniation means protrusion of some organ into a natural or artificially created space within an enclosed cavity. The organ which herniates, is displaced from its normal position. After the uterus is removed, an empty space gets formed within the pelvic cavity. Intestines could herniate into this space. This could lead to symptoms like pain, altered bowel habits, altered digestion. To treat the hernia, another surgery may be needed.
• Infection: Infection could occur at the site where the surgical cut was given. This will manifest as redness, swelling and pain over the cut. Infection could also occur internally, if there was accidental damage to any organs. Antibiotic therapy is often employed in such cases. Pain can be treated using pain killer medicines.
• Hormonal Deficiency: Sometimes, ovaries are partially or completely removed during hysterectomy. In such patients, the levels of estrogen and progesterone drop suddenly. This is because ovaries produce these hormones. They control the functions of the entire female reproductive tract. Hormone deficiency could lead to symptoms like hot flashes, mood swings, depression, digestive and skin disorders. Hormone replacement therapy helps such patients.
• Zero possibility of natural pregnancy: Once uterus has been removed, it becomes impossible for the woman to become pregnant. This is because fetus grows and develops inside the uterus. Therefore, hysterectomy is not done for women in their reproductive age; unless it is the only option.

Every surgery comes with its share of pros and cons. The same applies to hysterectomy. But in some cases, it is the best chance of treatment for patients. It is advisable that the patient gets a detailed idea about what she is about to undergo prior to the procedure. This article helps the reader in doing the same.