While there is controversy in some quarters regarding the advisability or need for a hysterectomy, this mostly comes from those who are not having problems. For women who are bleeding frequently and excessively, or who are having pain from fibroid tumors or endometriosis, or who are having any number of other conditions that interfere with their lives in a major way, hysterectomy is not a choice, but a necessity.
Many women fight the idea of having a hysterectomy far longer than they might, and it is common to hear women say after their surgery, "I don't know why I waited so long". Depending on the problem that leads you to hysterectomy, there are any number of treatments and tests that may be done before choosing this operation. It is important to make sure that there has been adequate workup and evaluation to be sure that this is the proper surgery for you.
Once the decision for hysterectomy has been made, the next question is what to do with the ovaries. Do you leave them in place, or do you take them out? There are several considerations in this regard. If the ovaries are part of the problem, such as in some endometriosis cases, then they probably should be removed. If the ovaries are not really part of the problem, then we revert to an analysis of benefits and risks. This analysis is largely age based. Under age 40 it is clearly advisable to keep the ovaries if possible. Over 45, there are fewer years of function left in the ovaries when weighed against the future risk of a pain from an ovary, or a problematic ovarian cyst, or ovarian cancer issues. The chance that a woman might need to have surgery because of an ovary that has been left behind is about 0.9%. This is a relatively low risk, but for a woman who may only have one or two years of function left in the ovaries it may make sense to take them out.
The next question that arises is which kind of hysterectomy to have. There are four types of hysterectomy which are listed below:
1. Abdominal Hysterectomy - this has been the old standby for many years, and still has a place when the uterus is very large, or there are extensive pelvic adhesions. Abdominal Hysterectomy has the advantage of better ability to see the pelvic structures and more room to remove the uterus, but has a significantly greater recovery than other methods. Usually recovery is 2 days in the hospital and 4-6 weeks to be back to work and feel relatively normal.
2. Vaginal Hysterectomy - For many years this was my preferred method whenever possible. It is technically more difficult and requires a surgeon who is comfortable operating this way. Some surgeons will only do a vaginal case if the uterus is practically falling out, and is normal size. Others can do this procedure in most cases and can remove a uterus up to 12 - 14 gestational size in this manner. Vaginal Hysterectomy has an easier recovery, usually 2 nights in the hospital, and 2 -4 weeks to be back to work.
3. Laparoscopic Hysterectomy - This procedure means different things to different people. Some people mean they will look in with the laparoscope to see if it is feasible to do the case vaginally. They may free the ovaries with the laparoscope, but will then primarily do the case vaginally. Other doctors will do the complete hysterectomy with the laparoscope which can be a rather long and tedious operation because of the awkwardness of working with a conventional laparoscope. There are a few surgeons in the country who have become very adept at doing a full hysterectomy with the laparoscope, but there are not many. There are still others, and this is probably the largest group, who will perform a supracervical hysterectomy via the laparoscope. This means that the top portion of the uterus is removed, but the cervix is left behind. This is sometimes done because the patient prefers it, or because the doctor thinks it is better in that case, but it is often done simply because the doctor finds it easier to do this operation than the more difficult procedure to remove the cervix with the laparoscope.
4. daVinci Robotic Hysterectomy - This is another form of laparoscopic hysterectomy, and has become my current preferred method for hysterectomy for most cases. The daVinci Robotic Hysterectomy uses the daVinci Robot, a very high tech piece of equipment that is different from conventional laparoscopy in two important ways. First, the laparoscope has two visual channels which allows for true 3-D stereoscopic vision. This grants the ability to magnify the image and see tiny blood vessels even better than they can be seen with open surgery. It also allows very precise laparoscopic work. The second major difference is that the working instruments are not simply straight rods as they are with regular laparoscopy, but the instruments have a built in "endowrist" action which allows the surgeon to manipulate tissue and suture much, much more effectively. This makes doing a full hysterectomy with removal of the cervix much easier, though a supracervical hysterectomy can still be done if the patient or doctor prefer. It also makes suturing the top of the vagina closed much easier, this is a task that is difficult at best with regular laparoscopy. The daVinci Robotic Hysterectomy usually requires 1 night in the hospital (though I have had a few patients go home the same day), and usually 1 - 3 weeks to be back to work. Commonly women are back in their offices at 2 weeks.
As I have alluded to above, many of these choices are driven by the physician involved. Most women are already "attached" to a gynecologist whom they have seen in the past and often whom they feel attached to. If the hysterectomy choice is made it is common for women to stay with the doctor they know, in which case the method of hysterectomy should certainly be the method that doctor is most comfortable with and gets the best results with. However, not all doctors are equally trained in all areas. Depending on where a doctor trained, and what their experiences have been since, they may or may not be very comfortable with vaginal hysterectomies. They often have had no training in, or have no access to a daVinci Robot, since these are not available in every hospital. The best example is a patient I saw recently who has been having problems for years with bleeding and had fibroid tumors. Her doctors over the last 10 years had been very reluctant to consider hysterectomy and had told her that her uterus was too big to remove vaginally and would have to be done abdominally. She had been miserable most of the 10 years with bleeding and pain issues. When I examined her I was somewhat shocked that to me, this uterus was not that big. Yes, she had a few small fibroid tumors, but I would have easily done this as a vaginal hysterectomy, and a few years ago that would have been my choice. Today, we have chosen daVinci Robotic Hysterectomy because she wants to get on with her life. She wants to get back to work, and she has a vacation planned in the near future.
The message in this article is that in today's world, women have choices about their bodies, and those choices include when and whether surgery is warranted, and include choosing a doctor who is well versed in surgical techniques and can offer the best long-term result with the least down time.
Dr. Daryl Greebon is a board certified OBGYN with Women's Specialists of Plano. He is a member of the Baylor Regional Medical Center at Plano medical staff. Daryl Greebon, M.D., gynecologist, graduated from the University of Texas Southwestern Medical School. He went on to serve his internship and residency at the University of Pittsburgh Medical Center. http://www.obgynplano.com.
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