Patients considering a hysterectomy are often faced with a confusing list of choices about how exactly the procedure is done. In other cases they are not offered any choices and their doctor will simply tell them the way that it will be done. Sometimes there is only one way that is possible but many times there are options, and patients should be aware of those and should be encouraged to ask questions.
First of all the language can be confusing. Medically speaking, a “total hysterectomy” means we are taking out the whole uterus. It does not mean that we are taking out the ovaries. Taking out the ovaries has a different name all together. A “subtotal hysterectomy” or “supracervical hysterectomy” means we are taking out the uterus but leaving the cervix (which is the mouth of the uterus leading into the vagina).
Hysterectomies can also be approached in several ways.
Traditionally an abdominal incision was made and the uterus was removed through either a horizontal bikini-line incision or through a vertical incision below the belly button. These days that procedure is most often done if the uterus is quite large or if there are other issues such as adhesions or scar tissue that would make this the safest approach. Hysterectomies can also be done with laparoscopy, which means a camera looking through the belly-button can guide the surgeon to remove the uterus through small incisions. A laparoscopic hysterectomy may remove either the whole uterus which is a “total laparoscopic hysterectomy” or a “supracervical laparoscopic hysterectomy”.
The decision of whether or not to remove the cervix is controversial and many surgeons disagree about whether this should be routinely done. Of course if the cervix is abnormal we always remove it. But if the cervix is normal and the risk of cervical cancer is almost zero because the patient is negative for the HPV virus (which causes cervical cancer), it is very reasonable to leave it in place. Generally a supracervical hysterectomy is a slightly quicker operation, and because there are no stitches in the vagina it can reduce complications and infection risk. Some doctors also believe that keeping the cervix retains some of the supportive ligaments that may reduce the risk of prolapsed of the vagina or bladder in the future.
Some laparoscopic hysterectomies are performed with the assistant of a robot. So called “robotic hysterectomies” sound fancy, but they are simply a laparoscopic hysterectomy using technology which allows the surgeon to be sitting remote to the patient (in the same room) and guiding the instruments from a console. There is no evidence suggesting that robotic assistance is necessary or beneficial for the average case, but some surgeons prefer it. Certainly it is much more expensive and time consuming than other alternatives and may involve larger incisions than a routine laparoscopic hysterectomy. There are certainly cases in which it is used as marketing, since it sounds fancy or “better”. Although some of our doctors are trained to use the robot we very rarely do it since we find it is not helpful except possibly in very difficult cases.
The best way in our opinion to do a hysterectomy is through the vagina with no incisions at all. Many surgeons do not perform vaginal hysterectomies as they were not trained to do so, and the trend is to use laparoscopy. At Complete Women’s Care Center we are proud to be one of the only groups that routinely perform vaginal hysterectomies, as we are lucky to have some highly trained surgeons in our group with many years of experience in this procedure.
A wise saying that I like to repeat was told to me by an old surgeon once, and I always remember it. He said “if you were having a tonsillectomy would you ask the surgeon do it through your mouth, which is the hole God gave you? Or would you ask him to poke a bunch of holes in your neck and insert complicated cameras to get it out?” Of course we would choose the former approach in that case, and similarly in many cases the uterus can be safely removed “through the hole God gave us” with no incisions and a very minimal recovery. We did three vaginal hysterectomies this week, and every time I do one I am reminded about what a great procedure it is. Patients have minimal pain and go home in less than 24 hours and often return to work in a week. Our patients tell us that the pain is similar to after having a vaginal delivery; they feel sore and achy but it passes very soon and they are back up on their feet, walking, eating, and going to the bathroom the very next day.
There is certainly a trend in this country which is worrisome, that is to use the most complicated and expensive equipment and machinery to do procedures that could be done much more easily without them. There is no question that laparoscopic hysterectomies have a place, for example in a patient who has had cesarean sections and would not be a good candidate for the uterus to come out vaginally. But in our opinion doing hysterectomies laparoscopically that could be done vaginally is a waste of time, money, and resources, and also causes the patient unnecessary pain and incisions that are painful and visible. A recent study showed pictures of the incisions for different types of hysterectomies to a group of women, and had them rank which one they would rather have. It’s not surprising that the incisions for a vaginal hysterectomy (which are none) scored the highest. The interesting part is that the incisions for a laparoscopic hysterectomy, which include a visible incision in the mid abdomen on the right and left side, scored lower than a traditional abdominal hysterectomy with a large bikini cut incision. (Of course the bikini cut incision can be hidden in a bikini whereas the laparoscopic incisions although small are definitely visible).
We hope that all about patients ask questions and are educated about the different choices if they are facing a hysterectomy and particularly asked about whether vaginal hysterectomy would be appropriate for them, as this is clearly the best way to perform this surgery in many cases.
Did you learn something from this post? If so let us know! What topics would you like to see discussed in future posts? Please send feedback regarding this post to firstname.lastname@example.org.
7900 Fannin Street #3000,
Houston, TX 77054
5757 Woodway Suite 101
Houston, TX 77057
2950 Cullen Pkwy Suite 201
Pearland, Texas 77584
Site Design: LOUD! Creative