Hysterectomy – Minimally Invasive Approaches
Gynecologists at Gynecology Specialists are experienced in minimally invasive approaches to hysterectomy as well as other procedures that provide relief from symptoms that in the past would have required hysterectomy.
There are two traditional types of hysterectomy: abdominal and vaginal. With vaginal hysterectomy, the surgeon makes an incision at the top of the vagina, dissects the structures connected to the uterus and then removes the uterus. The entire operation is carried out through the vagina.
“Vaginal hysterectomy tends to be many physicians’ first choice because there is no incision needed on the outside of the body, and there’s a quick recovery time,” said Laura Wang, M.D., FACOG, a Gynecology Specialists gynecologist.
However, some conditions preclude vaginal hysterectomy: a significantly enlarged uterus (often the result of fibroids), previous operations, a history of severe endometriosis or adhesive disease, or simply the need for better exposure to the uterus.
Abdominal hysterectomy was, until relatively recently, the only other method available if vaginal hysterectomy was not feasible. An incision is made in the lower abdomen and the uterus is dissected and removed through that incision. This is often the most appropriate choice in women with very large fibroids, pelvic adhesive disease or severe infection. It is also often the procedure used in cases of malignancy.
More recently, advances in technology have led to the adoption of minimally invasive laparoscopic techniques for hysterectomy. Laparoscopic hysterectomy requires only small incisions in the lower abdomen for the insertion of ports that allow placement of a laparoscope and other surgical instruments. The laparoscope is then used to see inside, while the surgeons and assistants watch on video monitors. The ports are used to place instruments such as scissors or graspers into the field to do the operation. Several different laparoscopic techniques have been developed, but each of them allows the surgeon to carefully inspect the pelvis and abdomen. This enables the surgeon to identify and dissect adhesions or to remove benign tumors that might have prevented vaginal hysterectomy. Benefits to the patient include less bleeding and scarring, reduced pain, much shorter hospital stay and decreased recovery time as compared with abdominal hysterectomy.
Three Laparoscopic Approaches
Laparoscopic assisted vaginal hysterectomy
In this operation, the surgeon inserts ports through small incisions in the umbilicus and lower abdomen. A laparoscope is used to inspect the pelvis and upper abdomen. During the procedure, the surgeon uses instruments placed through the other ports to dissect most of the attachments of the uterus. The surgeon then operates through the vagina to complete the procedure by making an incision in the top of the vagina and completing the dissection like a vaginal hysterectomy. The uterus, with or without the ovaries, is then removed through the vagina. The vaginal opening is then also closed through the vagina.
Total laparoscopic hysterectomy (TLH)
This procedure involves the use of the laparoscope to dissect the entire uterus, including the cervix. The top of the vagina is then incised, also laparoscopically, and the uterus and cervix is removed through the vagina. The vaginal opening inside the abdomen is then sewn together using the laparoscopic approach.
Laparoscopic supracervical hysterectomy (LSH)
In this less-invasive approach the surgeon dissects the attachments to the uterus laparoscopically, but stops at the top of the cervix. The uterus is them separated from the cervix, leaving the cervix and its fibrous support structures intact. The uterus is cut into small strips, which are pulled out through ports. The vagina is never entered, reducing the chance of infection. This approach may be associated with a decrease in future vaginal prolapse. There may also be advantages in terms of decreased blood loss and a shorter recovery time.
Alternatives to Hysterectomy
While hysterectomy is often the right choice for solving problems related to the uterus, it is by no means the only choice. As technology advances, women have more choices, especially to control symptoms related to heavy menstrual bleeding. Uterine fibroids, common noncancerous tumors of the uterine musculature, are a common cause of abnormal bleeding in women and there are now several options for treatment that stop short of hysterectomy. Other causes of abnormal uterine bleeding can also be addressed using new technology.
- Myomectomy. With this operation, the surgeon cuts away uterine fibroids without removing the uterus, so that a woman can maintain her ability to bear children. This may be done using laparoscopic techniques or through an abdominal incision. Removal of the fibroids tends to weaken and scar the uterine wall, so future deliveries may have to be performed by cesarean section. Myomectomy may not be recommended for women who do not desire future fertility or who are menopausal.
- Uterine artery embolization. This minimally invasive hysterectomy alternative preserves the uterus but is not advised for women who want to become pregnant. Sometimes called uterine fibroid embolization, the operation is performed by interventional radiologists, usually on an outpatient basis. Under X-ray guidance a catheter is placed through an artery in the groin. The radiologist then specifically blocks the arteries carrying blood to the uterus as well as the fibroids. The procedure typically relieves heavy menstrual blood loss as well as pelvic pressure and pain caused by large fibroids.
- Endometrial ablation. This operation can reduce or stop abnormal uterine bleeding by destroying the endometrium (tissue lining the inside of the uterus). The surgeon works through the vagina (no abdominal incisions) to place a device inside the uterus which uses heat or electrical energy to cauterize the endometrium. This procedure cannot be performed when large fibroids are present and is generally used to treat abnormal uterine bleeding due to other causes. It is not recommended for women who want to bear children. This procedure can be performed in the office or in the outpatient surgery setting.
- Hysteroscopic Sterilization. For women who desire permanent sterilization but do not want to undergo an abdominal operation, Gynecology Specialists offers the Essure® Micro-Insert System. The first FDA-approved hysteroscopic approach to tubal sterilization, Essure® requires no incision or general anesthesia and can be performed in approximately 30 minutes in an outpatient setting.
- Laparoscopic Bilateral Tubal Ligation.