Hysterectomy - Ablation of the uterus
Hysterectomy consists in the complete removal of the uterus. It usually includes the removal of the cervix (total hysterectomy), but the latter can sometimes be preserved (sub-total hysterectomy).
Depending of each case, the removal of the fallopian tubes and ovaries can be preferred or necessary, in which case the surgery is known as a hysterectomy with bilateral adnexectomy. (also called non conservative total hysterectomy).
-Abdominal hysterectomy (or under laparoscopy)
This is the oldest surgical approach rarely performed nowadays. This surgery consists in opening the abdomen, usually horizontally (the scar being close to the C-section one), or sometimes vertically, between the umbilicus and pubis.
3 or 4 incisions, of about 5 to10mm each, are made in order to place the trocars which will fill the abdomen with CO2 gas and introduce the surgical instruments. Lately, this technique has be done using only one 10mm umbilical incision (mono-access or mono-trocar surgery) and leads to a single barely visible scar. This technique is more and more carried out because it offers many advantages: reduced postoperative pain and hospitalization stay, complete examination of the peritoneal cavity, possibility to associate other surgical acts (ganglionic cleaning for example). However, in case of peroperative complications or technical difficulties, it might be necessary to switch to laparotomy.
-Vaginal hysterectomy (through the vagina)
The operation is done using the natural female channels and does not require an abdominal incision. It can be done alone or associated with a coelioscopy to facilitate certain surgical acts.
In what case, is it necessary to undergo a hysterectomy ?
Certain pathologies can induce invalidating gynecological symptoms, or even dangerous (genital hemorrhage, pelvic pains..). A hysterectomy can then be indicated but only after the failure of a medical and conservative treatment. In young patients and/or desiring a child, presenting a documented benign pathology, hysterectomy will almost always be avoided or delayed. The most concerned pathologies are:
It is a very common pathology (1/3 rd of the female population in certain ethnic groups). Fibromas are only treated if they are symptomatic (bleedings, pain, infertility..). Some medical treatments can be efficient on the symptomatology but do not remove the fibromas. Conservatory treatments (hysteroscopy, or even fibrosis removal or myomectomy) should always be the preferred approach for young women. Hysterectomy is reserved to peri-menopausal patients with persistent symptoms or voluminous fibromas.
-Adenomyosis (see : endometriosis chapter)
It is equivalent to the endometriosis inside the uterine muscle (myometer), and usually causes genital bleedings not responding to medical treatments.
-Genital prolapsus (see : genital prolapsus chapter)
A hysterectomy can sometimes be indicated in addition to a treatment and eventually include other techniques.
It is defined as a genital hemorrhage right after the delivery. In this situation, hysterectomy is relatively rare but can be necessary in case of severe uncontrollable bleedings. In that case, the hysterectomy is most often sub-total.
It concerns cervix, endometrial and ovarian cancers for which a total hysterectomy is almost always indicated. Other surgical acts are associated: bilateral adnexectomy, lymphadenectomy (ganglion removal)
What happens during the hospitalization ?
A pre-anesthetic consultation must be scheduled at least 48 hours before surgery. It is essential to inform the doctor about your medical history (personal and family) and on all the treatments or medications taken. A drip is set up in the operating room, then the anesthesia begins.
You will be taken into the recovery room under postoperative monitoring for about 2 hours, before being taken back to your room. The urinary catheter is usually removed the following day and the drip will be left for 24 to 48 hours. A drain might have been placed during surgery and will be removed within 48 hours. Preventing phlebitis will be ensured by getting out of bed soon after surgery, an anti-coagulant treatment and support stockings. Moderate vaginal bleeding is normal in the postoperative period. A normal diet is usually resumed within 24 to 48 hours after surgery, depending on the bowel movements. The patient will usually leave the hospital 2 days after surgery for vaginal or coelioscopic hysterectomies, or 5 days after surgery for abdominal hysterectomy. After returning home some precautions must be followed for a month: avoid baths (showers are allowed), no tampons, no sexual or physical activities.
What are the consequences of a hysterectomy ?
-If you are not menopausal before surgery: the major manifestations could be a possible pregnancy or the absence of a menstrual cycle. This does not mean you will necessarily become menopausal. If the ovaries are spared, they will function until your natural menopause. There are usually no hot flashes or other menopause-like symptoms after surgery. If the ovaries are removed, the surgery induces menopause and manifestations like hot flashes can be experienced. In such a case, you can talk to your doctor about the different possible treatments.
-If you are menopausal before surgery: you will not experience any particular changes.
-In all cases: hysterectomy does not alter the possibility or quality of sexual intercourse. There are no reasons why you should experience side effects such as depression or weight gain, sometimes ascribed to hysterectomy.
Risks and complications of the surgery
Hysterectomy is a common and established operation, performed smoothly in the vast majority of cases. Nevertheless, as for any surgery, complications are possible.
-The opening of the abdomen may turn out to be necessary although the surgery was planned to use the natural channels or by coelioscopy. The surgical method can be changed (converted into a laparotomy) depending on the medical observations made during the operation, or in case of postoperative complications.
-Hemorrhage: it is rare, and seldomly requires a blood transfusion. Anemia is often the consequence of the gynecological pathology that led to hysterectomy. In that case, a treatment of supplementary iron can be prescribed before or after surgery.
-Lesions on the organs close to the uterus can occur on an exceptional basis : in case of wounds on the intestines or urinary tract (urethra, bladder), a specific surgical procedure will be undertaken.
-hematoma on the abdominal wall: a local treatment is the most common and a removal by a surgical process is rarely necessary.
-an abscess on the abdominal or vaginal scar will be treated locally or sometimes with a surgical drainage.
-a urinary infection is generally not dangerous and treated with antibiotics.
-phlebitis of the lower limbs and pulmonary embolism : preventing them is systematic and essentially relies on getting out of bed, wearing support stockings and daily anticoagulant injections.
-bowel obstruction is rare and can require medical treatment, or even undergoing another operation.
-as for all surgical acts, this operation can, very exceptionally, present a risk of vital complications or serious after-effects. All these complications are nowadays much less frequent thanks to the development of the coelioscopic technique.