Laparoscopic Hysterectomy

Total Laparoscopic Hysterectomy (TLH) or

Laparoscopically Assisted Vaginal Hysterectomy (LAVH)

What is a Hysterectomy?

Hysterectomy involves removal of the uterus and usually the cervix. The ovaries are conserved unless it is specified before surgery that they are to be removed. There is no ‘gap' left behind once the uterus has been removed as its place is taken up by both small and large bowel. A normal sized uterus is equivalent to the size of a pear, but in some instances the uterus may be enlarged up to the size of a person's head; usually due to the presence of fibroids which are non-cancerous tumours of the muscle of the uterus.

Why is hysterectomy performed?

The uterus may be removed to treat cancer, but cancer would be one of the least common reasons that hysterectomy is performed. The majority of hysterectomies are performed to treat the symptoms of debilitating vaginal bleeding or pain. Heavy, painful or heavy and painful periods may produce distress even if the uterus is not enlarged or apparently diseased in any way.

How does laparoscopic hysterectomy differ from conventional surgery?

The surgery is carried out through small incisions 5-10mm in length and is classified under the category of minimally invasive or minimal access surgery.

Through one of the incisions, a telescope is placed attached to a camera so that the internal organs occupying the abdomen and pelvis can be viewed on a television screen. The other small incisions allow instruments to be passed into the abdomen and pelvis. The instruments consist of forceps and scissors etc.

Gas is gently pumped into the abdomen and pelvis to cause it to tent and create a cavity in which the surgeon can operate by viewing through the camera, as mentioned above. Tubes with valves in them pass through the small incision sites and allow the instruments to be placed in and out of the abdomen and pelvis without gas escaping. These tubes are called ‘ports'.

Conventional surgery generally involves a large incision across the lower abdomen, or sometimes a vertical incision up and down the middle of the abdomen below the navel. Such incisions take a long time to heal and they are usually very painful in the course of doing so. A conventional vaginal hysterectomy is performed entirely through the vagina, but does not allow the surgeon to see detail within the pelvis and thus diseases, such as endometriosis or ovarian cysts, may be missed entirely and cannot be treated adequately concurrently.

Advantages of Laparoscopic Hysterectomy

As a general rule the smaller the incision the less post-operative pain. This is certainly true for the laparoscopic procedure when compared to a standard conventional abdominal hysterectomy. Less pain and smaller incisions make for quicker recovery, which can be up to four weeks faster than conventional surgery. Smaller wounds also allow a better cosmetic result. Scar visibility depends to a degree upon the skin type of the individual patient, but in some patients the small laparoscopic port site scars are almost impossible to see once complete healing has taken place.

Because the internal tissues are handled to a lesser degree in laparoscopic surgery there tends to be less internal scarring and therefore a lesser chance of adhesions forming within the abdomen and pelvis during the recovery stages. This is important as adhesions within the abdomen and pelvis can be a cause of persistent pain.

Finally, the technique of laparoscopic hysterectomy is considered worldwide by surgeons to be safer, with less risk of post-operative haemorrhage or infection than conventional surgery. It also allows a much better view than open surgery affords which confers huge advantages when treating such conditions as endometriosis.

Recovery Timeline

• Day 0
  Admission occurs a few hours before surgery. The surgery takes approximately 90 minutes although it tends to vary between 60 - 120 minutes. A full general anaesthetic is used.
• Day 1
  Many patients are able to go home on day-1 and you are certainly able to eat breakfast the following morning and usually the IV line ‘drip' is removed. A bladder catheter is often left in place overnight and this is also removed on the first post-operative morning. Following the first 24 hour stay most patients elect to go home, but some need to stay another day. Usually Paracetamol and Voltaren are all that is required to control pain. During the first night, between day-0 and day-1, injections of Pethidine may be required.
• Day 5
  On the fifth post-operative day it is reasonable to drive a car, providing it is for short distances only, around town. No attempt should be made to vacuum, hang out laundry or push a supermarket trolley for the first two weeks post-operatively.
• Day 14
  If you have a desk job and feel adequately recovered it is reasonable to return to work. Jobs that have physical components such as nursing, cleaning, or long episodes of standing, such as teaching or retail work, require four weeks post-operatively before returning to work. Intercourse can usually resume from day-14 onwards, unless specifically advised otherwise by your gynaecologist.

Sometimes additional surgery is utilised to correct prolapse, treat incontinence or endometriosis and is combined with the hysterectomy procedure. Specific details of surgery and recovery will be discussed by your gynaecologist.

Hormones Following Hysterectomy

Providing the ovaries are retained at hysterectomy then the monthly hormonal cycle is preserved in those women who are pre-menopausal. Curiously, however, the symptoms of premenstrual syndrome can be improved significantly in up to 60% of women although the mechanism for this is not entirely understood.

Generally it is felt that the ‘menopause' will take place at the preordained time irrespective of surgery with the average age being around 51 years. It is sometimes said, however, that the menopause can occur a little earlier in a small number of women, but it is difficult to produce research to confirm this. Providing the ovaries have been conserved, there is no ‘deficiency' following a hysterectomy and hence one does not put on weight or sprout extra hairs.

Emotional Impact

Providing you have considered all the options of treatment open to you and you feel that as a woman you have been ‘in charge' of the decision making process with regard to choosing a hysterectomy as your preferred treatment option, then it is unlikely that you will suffer regret or emotional disturbance following surgery. For some women however, it is appropriate that they undergo counselling before surgery. If you feel that you may have difficulty coping with the loss of your uterus and yet still wish to proceed then if counselling has not been mentioned to you, you should ask specifically to be referred for this.

Although it has already been stated above that cancer represents one of the least common reasons to perform a hysterectomy, its presence nonetheless seems to take the decision out of your hands so this factor, coupled with the fear of the term ‘cancer' may make pre-operative counselling a wise choice. This is of course a personal decision.

Sexual Impact

The vaginal length is unchanged by a hysterectomy. The amount of vaginal lubrication is also the same. If the ovaries are removed, however, then unless hormone replacement therapy is given, added lubrication is often required as it is the oestrogen produced by the ovaries that is responsible for producing normal lubrication of the vagina. The top of the vagina is closed off and it should be completely comfortable during intercourse. Some women believe that rocking of the cervix during intercourse by the male's penis is responsible for adding to their sexual enjoyment. This is difficult to prove however and probably only amounts to a small amount of the percentage enjoyment experienced by at most 10% of women. There are many more women, of course, who feel that intercourse is more enjoyable as the cause of pelvic pain and bleeding has been removed and with that there is a corresponding growth in confidence and the ability to enjoy one's sexuality.

Summary

Hysterectomy should be approached in a positive way and seen as a process of regaining the quality of life that has been compromised by heavy bleeding and/or pain.

The technique of laparoscopic hysterectomy offers a more speedy recovery towards improved quality of life with a level of safety equal to, or better than, conventional surgery. All surgery, however, carries with it the risk of complications occurring most of which are minor and short-lived and simply irritating. Rarely, more major complications may occur that delay recovery. Specific complication risks are always discussed as part of the operative consent process.

Relevant Links

Endometriosis Treatment Centre
Gynaecological Laparoscopic Surgery
Menopause and Midlife
Pelvic Floor Repair Proceedures