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Different types of hysterectomy

Hysterectomy is the only treatment for menstrual problems that guarantees complete relief of menstrual bleeding. Once it has become clear that a hysterectomy is going to be the best form of treatment for your particular problem, there are further decisions to be made.

A hysterectomy may mean removing all or part of the uterus and does not necessarily mean that your ovaries will be removed at the same time. For each woman, the method selected will depend on the reason why the hysterectomy is being done, her medical and surgical history, the findings of the gynaecologist when he/she carried out a pelvic examination and her own preferences.

Abdominal Hysterectomy

The uterus is removed through an abdominal incision, usually made low down, at or just above the top of the pubic hair line – the so-called ‘bikini line’. If you have previously had an operation with a vertical scar (from just below the belly button to the hairline) this may be re-opened. If the uterus is very large (for example, because you have large fibroids) or if there is a very large ovarian cyst, a vertical scar may be necessary.

A vertical scar heals just as well as a bikini line scar, although it is more uncomfortable initially and is more visible. It is also potentially weaker in the long term because it cuts right through the centre of the muscle sheath that supports the abdominal wall. Both types of abdominal incision involve going through the muscle layer as well as the skin and it takes time for this to heal and recover its strength afterwards.

Various methods are used to close the abdominal incision, including removable clips and staples, dissolving sutures (stitches that dissolve under the skin), and a single or a series of removable sutures. Healing occurs in the same way regardless of which method is used but, if you have encountered any problems with scars in the past and have any anxieties, it is important to let the hospital staff know.

In general, an abdominal hysterectomy involves a hospital stay of three to five days and a recovery period varying between six and twelve weeks, depending on your general health, whether you develop any complications, your family commitments and what sort of job you do.

Total abdominal hysterectomy

This is the most common operation and involves removal of the uterus and the cervix (neck of the womb), leaving a scar at the top of the vagina as well as the one on the abdomen. It does not necessarily include removal of the ovaries (see page xx). The advantage of removing the cervix is that it makes it impossible for abnormal cellular changes to arise which might lead on to the development of cancer. Any such changes are detected when you have a cervical smear.

Having a total hysterectomy means you’ll never need another smear, providing that your cervix was entirely free of abnormal cellular changes when examined by the pathologist after the hysterectomy. If you have had treatment for abnormal cells in the past or who want to avoid having to go for smear checks in future you should have the cervix as well as the uterus removed.

On the other hand, if you have always had regular smears and they have always been negative, your chances of developing cervical cancer are very low and you may be suitable for a subtotal hysterectomy (see below).

Subtotal abdominal hysterectomy

This involves removing the uterus but not the cervix and is a shorter, simpler and safer operation because the removal of the cervix tends to be the most difficult part of the operation. It may be recommended if the gynaecologist is concerned that removal of the cervix may be difficult (for example, if you have had a number of caesarean sections).

The disadvantage is that you may still be at risk of abnormal cellular changes so you must continue to have regular cervical smears. Another potential problem is that leaving the cervix may also leave a fragment of the womb lining and some women experience continuing slight bleeding after subtotal hysterectomy.

One of the main reasons for leaving the cervix behind used to be that this was thought to be important for sexual enjoyment and orgasm. However there is no scientific evidence that the type of hysterectomy makes any difference to a woman’s sex life after the operation.

Vaginal hysterectomy

This is the method used for treatment of a prolapsed uterus. It can be combined with a pelvic floor repair if the walls of the vagina have prolapsed as well. Both the uterus and cervix are removed through an incision at the top of the vagina and so you aren’t left with an abdominal scar. Both the hospital stay and the total recovery time is shorter than with abdominal surgery. You can expect to be in hospital for two to four days and recovery is usually complete six to eight weeks after the operation.

If you’re having your uterus removed because of menstrual problems, you may be offered vaginal hysterectomy, but this method is not suitable for everyone. It is very difficult to perform if there are large fibroids or an ovarian tumour. It is less likely to be offered to women who have had no children, those who have had previous pelvic operations or those who have had only caesarean section births.

The gynaecologist who will be performing the surgery is the best judge of whether the operation can safely be carried out vaginally. When in doubt it is best to opt for an abdominal operation rather than run the risk of complications from a difficult vaginal operation.

Laparoscopically assisted hysterectomy

This uses methods that have become known as ‘keyhole’ surgery. The laparoscope is a viewing instrument which is inserted into the abdomen through a small incision below the umbilicus (belly button). It is connected to a camera and a fibreoptic cable, which allows the uterus and pelvis to be viewed on a screen. Two additional small incisions are made on either side of the abdomen for insertion of the instruments used to carry out the surgery.

Usually the upper part of the uterus is divided from its supporting structures through the laparoscope and then the uterus and cervix are removed through the vagina (laparoscopically assisted vaginal hysterectomy). This makes it possible also to remove the ovaries if this is necessary.

Laparoscopically assisted hysterectomy requires special equipment and training and is not available in all hospitals. It takes longer to perform than the standard methods and there is a slightly greater risk of complications. The advantage is that there is a much smaller scar than for an abdominal hysterectomy and thus recovery should be quicker.

KEY POINTS

• A total hysterectomy involves removal of the uterus and cervix, but does not automatically include removal of the ovaries

   

• A subtotal hysterectomy preserves the cervix, but regular smears are still necessary afterwards

   

• Hysterectomies may be carried out abdominally, through the vagina or with the assistance of laparoscopy

   

• Recovery is quicker after a vaginal hysterectomy, but not all women are suitable for this type of operation

   

• Hysterectomy is the only treatment for menstrual problems that guarantees complete long-term relief of menstrual bleeding