Synonym: Hysterectomy (from the Greek “hyster” = uterus and “ectomy” = excision)
Definition
In hysterectomy, the removal of the uterus is a procedure that removes the woman’s uterus based on various clinical situations. A common reason for hysterectomy is benign growths of the uterus, so-called myomas. However, malignant diseases such as cervical cancer or endometrial carcinoma, also a cancer of the uterus, can also be reasons for a hysterectomy. There are three different removal options available to the doctor (abdominal, vaginal, laparoscopic). This procedure is one of the most common in gynecology.
Indications
The indications for hysterectomy are divided into absolute indications, i.e. cases in which hysterectomy must be performed in any case, and relative indications, in which removal of the uterus is recommended but not absolutely necessary. The absolute indications include Relative indications are: Ultimately, however, a woman must always decide for herself whether she would rather live with certain pain or risks than have the uterus removed, thereby giving up the possibility of pregnancy. The gynaecologist can only ever take on an advisory role.
- Ovarian and uterine cancer,
- Severe inflammation of the internal genitals (if these cannot be controlled by conventional measures) and
- Threatening bleeding from the uterus, such as can occur during childbirth (also only if it cannot be controlled otherwise).
- Muscle tumors (myomas) or other benign tumors in the uterus,
- A prolapsed uterus (prolapsed prolapse of the uterus) or uterus prolapse after birth
- Adhesions in the lower abdomen area,
- An endometriosis,
- Bleeding disorders (frequent, heavy or painful periods) or
- A highly enlarged uterus
- A pelvic floor lowering
Implementation
There are now three procedures available to a gynecologist for removing a uterus. Which of these is best suited to a particular patient must be decided individually for each case. This decision depends mainly on the disease, the patient’s age or physical condition, the difficulties or complications that can be expected during surgery (for example, due to concomitant diseases, inflammation or previous surgery), the size and mobility of the uterus, and most importantly, the patient’s wishes.
The three procedures differ according to their access route to the uterus: there is abdominal, vaginal and laparoscopic hysterectomy. In all three options, it is important that the bladder is completely emptied before the operation using a bladder catheter. This catheter is removed after the removal of the uterus, sometimes it must remain in place for a few days.
The oldest method is abdominal hysterectomy (laparohysterectomy), in which the entire uterus is removed through an incision in the lower abdomen. Not so long ago, this was the only alternative. Decisive advantages of this access route are that the surgeon has a good overview, that the operation can be extended if necessary (for example to the ovaries) and that adhesions can be easily removed.
Therefore, this method is always chosen for malignant diseases. Even if the uterus is significantly enlarged, this method is still suitable. However, the disadvantage of abdominal hysterectomy is the large skin incision, which is associated with a large scar, a higher risk of infection, a long hospital stay and a longer recovery period.
In vaginal hysterectomy (colphysterectomy), the uterus can be removed through the vagina using special instruments. This method is advantageous because the procedure can be performed without scarring. Moreover, compared to abdominal hysterectomy, the recovery time is shorter and the pain caused is usually reduced.However, this procedure can only be performed if the uterus is not too large.
The newest method is the laparoscopic hysterectomy. This is a minimally invasive procedure. The abdominal wall is not really opened, but special instruments for laparoscopy are inserted into the abdomen through tiny skin incisions.
On the one hand, a laparoscope is necessary, which contains a small camera, a magnification system and a light source. On the other hand, the instruments are of course needed to perform the dissection of the uterus. Once this is done, the uterus can be removed through the vagina (laparoscopically assisted hysterectomy).
Even more modern is the laparoscopically assisted supracervical hysterectomy, in which the cervix remains in the body. The body of the uterus (corpus) is cut into small pieces and then removed through the incisions in the abdominal wall. In addition, a distinction can also be made between a complete (total) hysterectomy, in which the entire uterus including the cervix is removed, and a partial (subtotal) hysterectomy, in which the cervix remains in the body.
In radical hysterectomy (which is performed in case of cancer), not only the uterus is removed, but also part of the supporting apparatus, the upper part of the vagina, the pelvic lymph nodes and, if necessary, the ovaries. After the removal of the uterus, one should rest for some time. During the first four weeks, sporting activities should be avoided – walks etc.
are fine, if you feel well, to keep your circulation going. Depending on the surgical method, sports can be started again 2-3 months after the uterus removal. The uterus can be removed using various surgical techniques.
The procedure used is adapted to the underlying disease, so not every procedure can be used for every disease. The duration of the operation can therefore also vary. As mentioned above, a distinction is made between vaginal hysterectomy, in which the uterus is removed through the vagina, abdominal hysterectomy, in which the removal is performed through an abdominal incision, and laparoscopic hysterectomy, in which treatment instruments are inserted through small incisions.
The latter is also often referred to as a keyhole technique. The duration of the operation can last between 1 and 3 hours, depending on the procedure used and the underlying disease. LASH is a laparoscopic supracervical hysterectomy.
This procedure represents a modified form of uterus removal. The LASH is performed exclusively for benign diseases of the uterus and is not suitable for the treatment of cancer or precancerous lesions. Typical diseases for which the procedure is used are myomas and endometriosis of the muscle layer of the uterus (adenomyosis uteri).
In LASH, the uterus is removed by means of tiny surgical accesses, which are only a few millimeters in size. Therefore, only very small surgical wounds occur. This procedure is called minimally invasive surgery.
A part of the cervix is left in place. In the following some advantages as well as disadvantages of LASH will be discussed. Advantages of LASH: The advantages and disadvantages of LASH are currently still the subject of various studies.
However, some advantages for the patients already seem to be apparent, so that LASH is definitely justified as a modern procedure. Due to the small surgical accesses, only small wounds occur, which can heal very well. The recovery of the patient is therefore faster.
Due to the preservation of the pelvic floor, sequelae such as incontinence or a deterioration of sexuality seem to be rare. To what extent these are less frequent than with other procedures, however, has not yet been conclusively clarified. The risk of concomitant diseases (morbidity) is lower than with other procedures.
Intraoperative complications are also less frequent. The inpatient stay is shorter and the recovery phase is faster. However, LASH cannot be performed on an outpatient basis.
This is often mistakenly assumed, but is not the case. Disadvantages: The LASH also has some disadvantages, which will be briefly discussed here. Since part of the cervix is left in place, the patient still has to undergo cancer screening after the removal of the uterus.Slight postoperative menstrual bleeding is also still possible. This is the case in about 10 to 17% of patients who have undergone LASH.
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