A hysterectomy is a surgery to remove the uterus. If you and your gynecologist have decided that a hysterectomy is the best choice, then the next most important decision you need to make is how the surgery should be performed.
There are three different approaches. At Grace OB/GYN, we highly recommend the vaginal approach. We feel strongly that you should understand why we make that recommendation and be fully informed about the benefits and risks of each method as you consider this important decision.
Abdominal Hysterectomy (TAH)
Laparoscopic Assisted Vaginal Hysterectomy (LAVH)
Vaginal Hysterectomy (TVH)
Abdominal Hysterectomy (TAH)
The conditions that usually necessitate an abdominal hysterectomy are cancer, overwhelming infection, extremely large fibroid tumors, and advanced endometriosis. An abdominal hysterectomy requires both a vaginal incision and a four to six inch incision in the lower abdomen. The uterus is removed, and in most cases the cervix is removed as well. The fallopian tubes and ovaries can be removed if patient and doctor agree to this prior to surgery. The hospital stay is generally 2-3 nights, and the recovery time is 6-8 weeks. Due to the large incision, unfortunately there is often considerable postoperative pain. The recuperative process will be a long one, and the scar will be permanent.
There are risks to any surgery, but the risks of the abdominal hysterectomy are greater than the risks of the vaginal hysterectomy or the laparoscopic hysterectomy. General anesthesia, which is required for the abdominal hysterectomy and the risks of infection, bleeding, blood clotting, or possible damage to other organs are also greater. Women who are overweight, who smoke or have other medical problems will be at greater risk during any kind of surgery.
Approximately 800 hysterectomies are performed in the Asheville area annually. Of these, about 75% are done using abdominal wall incisions. Only 25% are done trans-vaginally. In contrast, Grace OB/GYN's vaginal hysterectomy rate approaches 75%. In other words, we do 75% of our hysterectomies vaginally; compared to only 25% vaginally in the rest of the community as a whole. Up to 75% of patients who need hysterectomies are good candidates for a vaginal hysterectomy, but they may be being denied the many benefits of the vaginal approach. Chances are, if you need a hysterectomy, the vaginal approach is a possibility for you.
Laparoscopic Assisted Vaginal Hysterectomy (LAVH)
The laparoscopic hysterectomy is very similar to the vaginal hysterectomy — the difference being that a laparoscope is used to assist in the removal of the uterus. Laparoscopy was pioneered by gynecologists in the early 1960s, and has been widely used in a range of procedures; including tubal ligation, the removal of ovaries and fibroid tumors, and the treatment of tubal pregnancies.
The technique of laparoscopic hysterectomy was developed in 1989, when several laparoscopic hysterectomies were performed with very successful results. With this procedure, a laparoscope (a tiny telescope) is inserted through a small incision in the navel. Thus, the surgeon can view a magnified image of the patient's internal organs on a video monitor. This procedure enables the surgeon to perform the hysterectomy, as well as to diagnose and treat related conditions at the same time. Often, one or two additional small (1/4") incisions are made elsewhere in the lower abdomen, in order to allow the use of other tiny surgical instruments. These tiny incisions are closed with sutures or surgical tape. Within a few months, the incisions are barely visible.
BENEFITS OF A LAPAROSCOPIC HYSTERECTOMY OVER AN ABDOMINAL HYSTERECTOMY:
- Increased safety
- No visible scars
- Much less pain
- Faster recovery
- Lower cost
In a laparoscopic hysterectomy the vascular pedicles are secured and the uterus freed from the ligamentous attachments .The fallopian tubes and ovaries can be removed in this way as well if clinically indicated. The uterus can then be removed through a vaginal incision, much like a vaginal hysterectomy. The patient is under general anesthesia throughout the procedure. Many patients who would otherwise have an abdominal hysterectomy may benefit from choosing a laparoscopic approach.
Vaginal Hysterectomy (TVH)
If you need a hysterectomy, there is a better way. It's called "Vaginal Hysterectomy." This type of surgery frees you from the large incision that is normally required for a hysterectomy. The uterus is removed at its internal source instead — the upper end of the vagina. Small retractors and special headlights are used in the surgery. The ovaries can also be removed during this surgery if clinically indicated. The vagina is not harmed or stretched in anyway. If the uterus is enlarged by tumors, these can be removed in small sections through the vagina using a technique called morcellation.
Benefits of a Vaginal Hysterectomy:
- Increased safety
- No visible scars
- Much less pain
- Faster recovery
- Lower cost
Surgical skill, experience, and complication rates vary among gynecologists. Since the vaginal approach requires the most skill and experience, your existing gynecologist may not be comfortable in offering this minimally invasive technique to you. Some gynecologists are still telling patients that the vaginal hysterectomy cannot be done if the patient has never had a baby, has had a previous cesarean section, has large tumors of the uterus (fibroids), or needs to have the ovaries removed as well. Our physicians do not consider those conditions to be necessary barriers to the vaginal approach. We believe that the vaginal hysterectomy is the safest and most pleasant approach for the majority of patients.