Hysterectomy (Vaginal, Laparoscopic, Abdominal)
This information sheet provides general information. It does not provide advice to the individual. It is important that you talk to your Doctor who understands your level of fitness and medical condition.
The uterus (also known as the womb) is a pear shaped organ that sits between the bladder and the rectum (back passage).From puberty, every 26 to 30days the uterus begins a menstrual cycle, during which time the uterus prepares itself to receive and nourish a fertilised egg (ovum). If the egg is not fertilised, then the thickened lining of the uterus sheds as a period (menstrual bleeding). If the egg is fertilised, then the cycle changes. Periods stop and the uterus grows to provide nourishment and support for the growing baby until birth.
The uterus, tubes and ovaries
The most common conditions of the uterus, for having a hysterectomy are:
• Uterine disease.
• Diseases of tubes and ovaries.
• As part of the treatment for a prolapse.
• Bleeding not controlled by conservative.
There are three ways to remove the uterus:
Removal of the uterus through the vagina. The vagina is stitched from below and there is no cut in the abdomen. Sometimes, a laparoscope (telescope type of instrument) is also used. The surgeon will discuss this with you.
Removal of the uterus through a cut in the lower abdomen. The cut is about 15 – 30 cm’s depending on your size and weight and is usually below the bikini line from side to side. It may be necessary to cut down the abdomen from the belly button down to the pubic area rather than across. The surgeon will discuss with you the best surgery for your condition. You may need removal of one or both of the ovaries, but this depends on the reason for your hysterectomy, your age and their condition in relation to disease.
Laparoscopic Assisted Hysterectomy
About 4 small “keyhole” cuts are made in abdomen to divide the attachments of uterus, ovaries and tubes in pelvis. The uterus is usually removed via vaginal route.
Benefits of having the surgery
The decision to have a hysterectomy depends on the type of problems you are having and how bad they are. It also depends on whether you need major surgery to make your life better or, if you have a life threatening illness, to prolong your life. You need to discuss this with your surgeon. This depends on the reason for the surgery:
For prolonged bleeding, you may develop anaemia, which may need blood transfusions, and continued problems with heavy and irregular periods. If you have a prolapse, the uterus can drop down into the vagina and even outside the vagina where it can develop ulcers and cause considerable pain and discomfort.
If you have a suspected tumour, then possible spread of cancer may result.
General risks of a procedure
There are risks with any operation, and these risks can happen with a hysterectomy. They include:
(a) Small areas of the lungs may collapse, increasing the risk of chest infection. This may need antibiotics and physiotherapy.
(b) Clots in the legs with pain and swelling. Rarely part of this clot may break off and go to the lungs which can be fatal.
(c) A heart attack because of strain on the heart or a stroke.
(d) Death is possible but very rare due to the procedure.
Other treatment options will depend very much on what the cause of the problem is.
For prolonged and heavy bleeding
• Birth control pills or other oral medicines.
• A Mirena, a slow-release hormone system inserted into the womb, lasting 5 years.
• Endometrial ablation (removal of the lining of the uterus). This controls bleeding in 70 – 80% of cases but also causes sterility.
• Myomectomy (surgical removal of fibroids) if womb is desired to be retained.
For chronic pain
This may require treatment with:
• anti- inflammatory drugs
• birth control pills
• physical therapy
• psychological counselling
Specific risks of vaginal hysterectomy
(a) Failure after vaginal repair ie. vaginal repair may not be successful, in the short or long term and may need later corrective surgery. This is recurrence of the prolapse.
(b) Occurrence of pain during sexual intercourse or altered sexual function after vaginal repair.
The risk.. What happens? What can be done about it? Excessive bleeding - Severe bleeding from large blood vessels about the uterus or vault of vagina may occur. This is not common. Emergency surgery to repair the damaged blood vessels after the operation. A blood transfusion may be required to replace blood loss. A vaginal pack may be used to control the bleeding.
Infection- Infection in the operation site or pelvis or urinary tract may occur. This is not uncommon.
Treatment may be wound dressings and antibiotics.
Bladder or Bowel injury
Nearby organs such as the ureter(s) (tube leading from kidney to bladder), bladder or bowel may be injured. The rate of risk is about 1 in 140 women. Further surgery will be needed to repair the injuries. For bladder injuries, a catheter (plastic tube) may be put into the bladder to drain the urine away until the bladder is healed.
For ureter injury, a plastic tube (stent) is placed in the ureter for 6 weeks and then removed by cystoscopy or sometimes a ureteric reimplantation via laparotomy will be necessary.
If the bowel is injured, part of the bowel may be removed, with a possibility of a temporary or permanent colostomy (opening onto the abdomen so that waste can pass out).
A leak between the bladder and vagina
Rarely a connection (fistula) may develop between the bladder and the vagina. This causes leakage of urine via the vagina, which you will have no control over. This will require further corrective surgery.
Bleeding into the wound
There may be bleeding into the wound from surrounding blood vessels. A drain into the wound for a few days and treatment with antibiotics.
The bowels may not work after the operation. This may be temporary or in the longer term, a bowel obstruction can develop. Treatment may be a drip to give fluids into the vein and no food or fluids by mouth. If it doesn’t get better, bowel surgery may be necessary which may include a colostomy. This can be temporary or permanent.
Poor wound healing
The layers of the wound may not heal well and the wound may burst open. A hernia (rupture) may form in the long term. This may require long term wound care with dressings and antibiotics. A hernia may need repair by further surgery.
May not heal normally. The scar can be thickened, red and may be painful. This can be disfiguring. This is permanent.
After the operation, the nursing staff will closely watch you until you have recovered from the anaesthetic. You will then go back to the ward where you will recover until you are well enough to go home, usually about 2 days after vaginal surgery and 4 - 5 days after abdominal surgery. If you have any side effects from the anaesthetic, such as headache, nausea, vomiting, you should tell the nurse looking after you, who will be able to give you some medication to help.
You can expect to have pain in the operation site. There are a number of ways in managing your pain. You may have:
• a drip with painkillers into the spine, which deadens the area below your waist.
• a drip with painkillers that you can give yourself when you feel pain.
• be given injections.
It is important that you tell the nursing staff if you are having pain. Your pain should wear off within 7 - 10 days. If it does not, you must tell your Doctor.
You will have a drip in your arm when you come back from surgery. This will be removed when you are able to take food and fluids by mouth and you are no longer feeling sick. It is not unusual to feel sick for a day or two after surgery. Tell the nurse if this happens to you so that you can have drugs to stop it. To begin with, you can have small sips of water, then slowly take more until you are eating.