Hysterectomy (HE; removal of the uterus) is the removal of the uterus (womb). Women with symptoms, completed family planning, and lack of response to conservative therapy may benefit from hysterectomy.
Indications (areas of application)
- Benign (benign) diseases:
- Benign tumors of the uterus such as fibroids (benign muscular growths)/uterus myomatosus – fibroids that grow significantly, affect adjacent organs, and cause heavy bleeding that cannot be stopped in any other way
- Hysterectomy for symptomatic uterus myomatosus, completed family planning, failure of treatment alternatives, and/or patient’s wishes
- Dysfunctional uterine (“uterine-related”) bleeding disorders after exclusion of focal pathologies as the cause of bleeding, in the endometrium and myometrium (endometrium and uterine musculature), i.e., prior exclusion of premalignant and malignant changes as well; in case of failure of hormone therapy and completed family planning, endometrial ablation (gold mesh method; synonym: endometrial ablation) represents a treatment option
- Hysterectomy in case of failure of endometrial ablation.
- Endometriosis (painful chronic proliferation of endometrium outside the uterus) /adenomyosis uteri (= endometrial islets/mucosal islets within the myometrium/muscle of the uterus (endometriosis uteri interna)); confirm diagnosis by sonography; if extragenital endometriosis is suspected, laparoscopy should also be performed
- Hysterectomy in cases of pronounced pain symptoms, ineffectiveness of other treatment strategies, and completed family planning, hysterectomy is considered indicated as part of surgical therapy
- Cytological suspicion of squamous precancerous lesions; after successfully treated CIN 2/3, these women should be closely followed up cytologically and colposcopically or by HPV test.
- Hysterectomy for deep endocervical residual CIN 2 / 3 after conization (surgery on the cervix in which a cone of tissue (cone) is excised from the cervix and then examined microscopically).
- Prophylactic hysterectomy, if the patient does not want to or can not comply with such follow-up checks.
- Cytological suspicion of glandular precancerous lesions (incidence of adenocarcinoma in situ (AIS) is 1.25/100,000 women per year, significantly lower than that of CIN 3, 41.4/100,000); conization with endocervical curettage (“scraping”) of the high cervical canal (cervical canal) is indicated to confirm the diagnosis and exclude invasive adenocarcinoma. In the case of a histologic diagnosis of adenocarcinoma in situ (AIS) of the cervix uteri, hysterectomy should not be primarily performed but conization with endocervical curettage of the high cervical canal should be performed to exclude invasive adenocarcinoma.
- Hysterectomy for deep endocervical residual glandular neoplasia after conization.
- Atypical endometrial hyperplasia in aspiration histology or curettage material.
- Hysterectomy for endometrial hyperplasia with atypia when family planning is complete.
- Descensus (uteri) – Descending / lowering of the uterus (uterus) According to expert consensus following the guideline Descensus genitalis of women, the uterus can be left in the surgical treatment of descensus genitalis. In this case, the presence of a malignancy should be excluded.For hysterectomy for incontinence problems should be a separate indication.
- Uncontrollable infections of the internal genitals – may be an indication for hysterectomy.
- Nonpuerpural emergency hysterectomy (trauma, coagulopathy, bleeding, infection).
- Benign tumors of the uterus such as fibroids (benign muscular growths)/uterus myomatosus – fibroids that grow significantly, affect adjacent organs, and cause heavy bleeding that cannot be stopped in any other way
- Malignant (malignant) disease:
- Malignant tumors of the uterus such as cervical carcinoma (carcinoma in situ) – LASH surgery is contraindicated in this case.
- Malignant diseases of the cervix (collum carcinoma) or the body of the uterus (corpus carcinoma) – but must be approached individually, that is, depending on the stage of the disease.
- Malignant primary tumors outside the female genital organs (eg hysterectomy wg.Debulking/reduction of tumor tissue in colorectal carcinoma and urothelial carcinoma).
Different forms of hysterectomy can be distinguished:
- Abdominal hysterectomy – removal of the uterus through the abdominal wall.
- By laparotomy (abdominal incision)
- Per laparoscopy (laparoscopy)
- Vaginal hysterectomy (VH) – removal of the uterus from the vagina.
- Laparoscopic-assisted vaginal hysterectomy (LAVH) – removal of the uterus from the vagina, combined with laparoscopy to better release possible adhesions.
- Laparoscopic supracervical hysterectomy (LASH) – this is a removal of the uterus through the abdominal wall; however, the cervix (neck of the uterus) is not removed in the process
Approximately 55% of all vaginal hysterectomies (HE) are performed because of benign (benign) diseases of the female genital organs; in 23% of all HE or in 12% of all HE because of benign diseases, a bilateral ovarectomy (bilateral removal of the ovaries) was performed. In about 4% of all HE, a subtotal hysterectomy was performed (in this procedure, only the uterine body is removed. The cervix remains). LAVH and vaginal hysterectomy (VH) are associated with significantly lower postoperative pain scores.
Before surgery
- Before surgery, the patient should not take acetylsalicylic acid (ASA), sleeping pills, or alcohol for about fourteen days. Acetylsalicylic acid (platelet aggregation inhibitor) and also other analgesics delay blood clotting.
- If hysterectomy is planned because of fibroids, preoperative preparation with GNRH analogues or ulipristal may reduce the size of the fibroids and uterus, making vaginal hysterectomy easier in terms of size and favorably affecting preoperative iron deficiency and anemia (anemia).
Note: There is a second opinion claim for hysterectomies.
The surgical procedures
In abdominal hysterectomy, the removal of the uterus is performed either through an abdominal incision (laparotomy) or a laparoscopy. In laparoscopy, surgical instruments are inserted into the abdominal cavity through small incisions. With the help of these instruments, the uterus is separated. In order to remove it, it must first be crushed with a so-called morcellator Abdominal hysterectomy by laparoscopy requires a lot of experience on the part of the surgeon. In vaginal hysterectomy, the uterus is removed from the vagina. For this purpose, the connective tissue-like holding apparatus and the supplying vessels of the uterus are cut and the uterus is removed through the vagina. In laparoscopically assisted vaginal hysterectomy, the uterus is removed through the vagina as in vaginal hysterectomy, but before that the uterus is separated from the connective tissue-like holding apparatus and the supplying blood vessels by laparoscopy. This form of uterus removal is mainly performed in case of adhesions in the abdominal cavity (adhesions) after several abdominal surgeries. Supracervical hysterectomy is a special form of abdominal hysterectomy in which only the body of the uterus is removed, leaving the cervix. It can be performed through an abdominal incision, for example, in the case of a very large uterus, or laparoscopically. This surgical procedure is performed very rarely.Advantages of this form of hysterectomy are shorter operation times, lower complication rates (no bladder dissection, lower risk of injuring the ureter), better wound healing because smaller wound areas are created, and faster recovery. One of the most important – but so far not scientifically proven – arguments is that the preserved integrity of the pelvic floor prevents problems for descent and incontinence complaints. The disadvantage of this procedure is the risk of cervical stump carcinoma (cervical cancer). Hysterectomy is a standard surgery today. The surgery is performed under general anesthesia.
Possible complications
- Wound healing disorders and wound infections
- Bleeding
- Nerve or vascular damage
- Suture insufficiency (dissolution of the suture) in the area of the aborted uterus
- Injury to the ureters and / or urinary bladder, urethra.
- Injury to the intestine or other internal organs.
- Keloid (excessive scarring).
- Premature menopause (menopause)
The above complications may occur with varying frequency in all forms of hysterectomy. Further notes
- Meanwhile, total laparoscopic hysterectomy for endometrial cancer (uterine cancer) shows equally good long-term results as removal via an abdominal approach.
