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What is it?
Hysterectomy is the surgical removal of the uterus (or the womb). It may be done with or without the removal of ovaries (if both ovaries are removed, it is called hysterectomy with bilateral salpingo oophorectomy). It can also be total or subtotal hysterectomy. A total hysterectomy is one where the cervix is left behind. The type of hysterectomy done will depend on the reason for which the operation is being done and the profile of the patient.
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Why is it done?
It is done for several conditions like:
- Heavy menstrual bleeding is the commonest reason for hysterectomy. Usually
hysterectomy is done when the bleeding is very distressing to the patient and
other treatments have failed. In some cases, the patient can become severely
anaemic due to this bleeding.
- Uterine fibroids – which are non-cancerous tumours of muscle cells in the
wall of the uterus.
- Prolapse of uterus – where the uterus slides down into the vagina due to
weakness of its supports.
- Endometriosis – a condition where patches of the lining of the uterus
(endometrium) break away and settled down into the abdomen. These patches can
still spread to the monthly changes in the hormone level and hence can bleed and
form sticky barriers between them and other organs, called adhesions.
- Pelvic Inflammatory Disease – characterised by chronic pain in the lower abdomen and vaginal discharge.
- Endometrial Cancer/Cervical Cancer when the hysterectomy is more extensive and surrounding structures like lymph nodes and tissue around the uterus is also removed.
- Heavy menstrual bleeding is the commonest reason for hysterectomy. Usually
hysterectomy is done when the bleeding is very distressing to the patient and
other treatments have failed. In some cases, the patient can become severely
anaemic due to this bleeding.
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How is the hysterectomy done?
There are three different approaches for removal of the uterus – abdominal, vaginal and laparoscopic. The choice of method will depend on the indicaton for hysterectomy, size of the uterus, profile of patient and expertise of the doctor in the particular route.
- Abdominal hysterectomy – uterus is removed by incision made in the abdomen like a caesarean operation.
- Vaginal hysterectomy is done through the vagina. The cut is made inside the body on top of the vagina, so no scar is visible and the uterus is taken out through the vagina.
- Laparoscopic hysterectomy – also known as keyhole surgery, it uses a laparoscope, which is inserted through a very small hole in the navel. Two or three small cuts are made in the abdomen to act as channels to introduce other instruments required for the surgery. Once the supports of the uterus are freed surgically, it is removed through the vagina or the abdomen. This surgery needs more expertise and technical skill.
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How to prepare for the operation?
The patient is usually required to come in a day before the surgery to complete some tests. Pre anesthetic work up is done sometime before surgery and on the day of admission for fitness for surgery. The doctor’s instructions must be followed before the operation. The patient is generally advised not to eat or drink anything, not even water, tea or coffee, 8 hours before the operation. The patient may be given a medicine an hour or two before the operation to relax her.
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What type of anaesthesia is used?
The operation may be done under general anaesthesia or regional anaesthesia (spinal or epidural), which blocks the pain. With epidural anaesthesia post-surgery pain relief can also be given. The operation can take anything between 1-3 hours, depending on the type of hysterectomy.
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What happens after the procedure?
The patient is kept in the hospital from 1-3 days for vaginal or laparoscopic surgery and a little longer; 2-5 days for abdominal surgery depending on post-operative condition. A thin tube is put into the bladder to drain it so that she does not have to get up. She is encouraged to sit up and move around on the first day after the surgery. A liquid diet is maintained for the first couple of days, which is gradually shifted to a soft, and finally a normal diet. Some breathing exercises may be prescribed to the patient if she was put under general anaesthesia. Leg exercises are also prescribed to prevent a clot from forming in the legs.
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What are the risks involved?
Hysterectomy involves risks like any other surgery. The risks can be minor or major and can occur at any stage of the procedure. During surgery, risks include that of anaesthesia, bleeding and injury to the neighbouring organs like ureter, bladder or bowel.
Post operative risks may include nausea, vomiting, infection, trouble in breathing and other complications which include:
- Paralysis of bowel (ileus)
- Untimely breakage of stitches
- Blood clots in lungs, heart, legs and the brain
- Allergy to the medications
- Internal bleeding.
- Paralysis of bowel (ileus)
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What lies in place of the uterus in its absence?
The uterus is not very big and as all abdominal organs lie very closely, the bowel tends to move and occupy the space.
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What happens when the patient comes home?
It is important to have help at home. The patient may need to rest and avoid heavy work for the first few weeks. Gentle exercise everyday is important. Resumption of normal activity depends on the type of operation and the post operative period. There may be some vaginal discharge for 3-4 weeks. It may be red or brown and is due to healing of the wound and dissolving of the stitches. If the bleeding is fresh, heavy or smelly, the doctor's opinion must be sought. Recovery time is usually 4 weeks for vaginal hysterectomy and 6 weeks for abdominal hysterectomy. She should not lift weights like a bucket of water or a heavy pressure cooker for at least 3 months.
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When can the patient start her routine tasks?
Job can be resumed depending on the type of job and the hours of work. One can return to work about 6 weeks after the operation after consultation with the doctor. Driving can be resumed 4 weeks after the surgery.
Sexual intercourse can be started 6 weeks after the post operative check up. There is no need for any contraceptive as the uterus has been removed and the patient cannot have a baby. -
What about hormonal treatment?
HRT or hormone replacement therapy must be discussed with the doctor. If the ovaries have been removed, HRT may be begun soon after surgery, since removal of the ovaries brings about sudden menopause and hence menopausal symptoms like hot flushes, poor sleep, mood swings, frequency of urine and dryness of vagina may be experienced.
