Total hysterectomy refers to the surgical removal of a patient’s uterus. Sometimes, the doctor may need to remove the surrounding parts as well such as the cervix, ovaries, and even the fallopian tubes. There are several conditions that require a total hysterectomy surgery. Here are the main steps of this procedure as well as its most common risks and benefits.

What Is Total Hysterectomy?

A complete or total hysterectomy is a medical procedure during which a female patient’s cervix and uterus are removed. In many cases, the surgeon also removes the ovaries as well as the fallopian tubes. The most common conditions in which a doctor may recommend this procedure are abnormal bleeding, severe cramping, fibroids, or cervical or uterine cancer.

Several options exist and surgeons can make an incision in the abdominal area or even directly in the vagina. The second option is called vaginal hysterectomy.  Nowadays, most patients prefer the use of a robot-assisted laparoscopic system instead of the old fashioned large, painful, abdominal incision.  And almost all hysterectomies can be done robotically, laparoscopically, or vaginally.

If your doctor recommends you have an abdominal incision, you may want to see an experienced robotic surgeon for a second opinion before agreeing to a large abdominal incision. However, sometimes their are a couple of valid reasons for an abdominal hysterectomy:

  • A very large uterus that is close to the umbilicus and obstructs the view of the camera.
  • If due to other unforseen reasons and the surgeon thinks this is the best solution.

Total Hysterectomy – Main Procedure Steps

several surgeons and medical staff
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Picture:  Surgeons finishing a vaginal hysterectomy.

The following description is regarding an abdominal hysterectomy.  The surgeon will make an incision in the lower midline of the abdomen. The incision is usually made vertically in the patient’s skin, using a no. 10 scalpel. The doctors do the dissection with a Bovie cautery, through the subcutaneous tissue.

Then, the surgeon finds the location of the midline, which is between the rectus muscles. Once the fascia is incised, the surgeon pulls upwards and outward with a metal retractor and raises skin flaps to allow better exposure of the rectus muscles. In some cases, when the patient is larger, the surgeon cuts the rectus muscles to get a better overview of the organs.

Forceps and clamps are used to grasp the tissues. It is necessary to place moist sponges in the abdomen push the bowel away from the lower pelvis.  Only if it is possible, the doctor lifts out the uterus to get better visualization of the cervical uterine junction.

With the abdominal approach, a common way to develop the avascular plane of the broad ligament’s posterior leaf to locate and protect the ureter is with blunt finger dissection. Further on, the surgeon applies an medium duty clamp, also called a Haney clamp, on the round ligament to retract and control it. The specialist removes this clamp only after he/she divides and seals or sutures the round ligament.  Next another clamp is placed on the other side of the uterine fundus and opposite round ligament

The next step for the gynecologist is to detect the location of the bladder by palpating the cervix, using two fingers. He/she will then dissect the bladder off the patient’s uterus. Through the entire process, the doctor must be careful not to tear the bladder or the broad ligament’s blood vessels.

This dissection phase is not completed until the gynecologist is able to compress the vaginal wall between his/her fingers to be sure the dissection is past the cervix.

After the entire procedure is conducted, the doctor makes sure to close all the dissections, using absorbable dissolving sutures.

Who Needs a Total Hysterectomy?

a hysterectomy surgery scheme
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Your doctors might suggest you go through a total hysterectomy in the following cases:

  • When you suffer from chronic pelvic pain.
  • When you have heavy bleeding during your periods.
  • When there are signs of ovaries, uterus, or cervix cancer.
  • In the case of a pelvic inflammatory disease or severe adhesions
  • When you have benign tumors in your uterus, called fibroids.
  • After a uterine prolapse, which happens when your uterus falls into or outside of the vagina
  • Sometimes in cases of  endometriosis. This is a condition in which your uterus’ inner lining grows outside its normal location and causes pain and cramping
  • If you were diagnosed with adenomyosis, which is a disorder in which your uterus’ inner lining develops into the uterus’ muscle.

Health Risks Involved in a Total Hysterectomy

Although this operation is considered safe and performed frequently, there are cases in which complications or side effects might appear. Among the common ones are:

  • Heavy bleeding.
  • Blood clot in lungs or legs.
  • Infections.
  • Bowel or bladder injuries.

Other Possible Complications

  • Pelvic muscle weakness. If you want to strengthen your pelvic muscles after this medical intervention, you should regularly perform Kegel exercises. Many patients will need pelvic physical therapy to teach them how to strengthen their pelvic floor.
  • Temporary difficulty urinating due to swelling during surgery.
  • Infection of the vaginal cuff and sutures at the top of the vagina where the cervix was removed.
  • Vaginal spotting from where the sutures are dissolving
  • In some cases, scar tissue will form in the pelvic area.
  • A very small number of patients may deal with early menopause.

Recovery – What to Expect

Usually, after a total abdominal hysterectomy, the patient needs to remain hospitalized for a several days. However, the recovery time for a robotic or vaginal or laparoscopic hysterectomy is much less.   Many patients can go home the same day or next day from the hospital.

Even though you may be home from the hospital, the complete recovery can take up to six weeks. You should avoid heavy lifting for at least two weeks. On the other hand, you should walk every day. Except for an abdominal hysterectomy, you can drive 24 hours after surgery.  You can walk up and down stairs, and shower immediately.  Again, except for abdominal hysterectomy, you can return to office work as early as 1, 2 or 3 weeks.  However, most people are still given 6 weeks off of work by their jobs.

Alternatives to Total Hysterectomy

the main types of hysterectomy surgery
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According to research conducted by the National Women’s Health Network, this type of medical procedure is the second most popular surgical intervention that gynecologists perform on women across the United States. Most people and specialists say that it is a safe and low-risk intervention.

Still, this might not be the proper option for all women out there. For example, women who still want to have children should consider other alternatives. They should choose a total hysterectomy only as a last resort. Fortunately, there are other ways to treat some diseases that affect one’s reproductive system.

For instance, endometriosis can sometimes be effectively cured with hormone therapy. Other types of surgery can treat fibroids. These other options will spare the uterus. However, in more severe fibroid cases, a total hysterectomy is the only choice one has. It is usually the only option in cases of cervical or uterine cancer. Either way, you should always discuss it with your doctor.

Putting It All Together

A total hysterectomy is usually safe, but not completely without risks. Therefore, you should talk to your gynecologist and ask him/her for everything related to this medical intervention. If you are a patient or a doctor with knowledge or experience in this particular field, feel free to share with us your valuable insights.

Image sources: 1, 2, 3, 4

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