Hysterectomy

Hysterectomy is the surgical removal of the uterus, and it may be total (removal of the body, fundus, and cervix of the uterus) or partial (removal of the uterine body while leaving the cervix intact; also called supracervical, Pic. 1). It is the most commonly performed gynecological surgical procedure, and in the majority of cases, it is performed for benign conditions. 

This procedure in particular could be:

• Subtotal hysterectomy (supracervical): removal of the uterus, leaving the cervix in situ (intact).
• Total hysterectomy: complete removal of the uterus and cervix.
• Radical hysterectomy: complete removal of the uterus, cervix, upper vagina, and parametrium (connective tissue adjacent to the uterus). Indicated for cancer. Lymph nodes, ovaries, and fallopian tubes are also usually removed in this situation.

Hysterectomy can be performed in different ways:

• Abdominal hysterectomy
  Abdominal hysterectomy is done via laparotomy, a surgical incision in the abdominal wall. A transverse (Pfannenstiel) incision is made through the abdominal wall, usually above the pubic bone, as close to the upper hair line of the individual's lower pelvis as possible, similar to the incision made for a caesarean section. This technique allows physicians the greatest access to the reproductive structures and is normally done for removal of the entire reproductive complex. The recovery time for an open hysterectomy is 4–6 weeks and sometimes longer due to the need to cut through the abdominal wall. Abdominal hysterectomy, the most common method, is used in cases such as after caesarean delivery, when the indication is cancer, when complications are expected, or surgical exploration is required.

• Vaginal hysterectomy
  Vaginal hysterectomy (VH) is performed entirely through the vaginal canal and has clear advantages over abdominal surgery such as fewer complications, shorter hospital stays and shorter healing time. Although prolapsed uterus (uterus descended from its localization and protruding through the vagina) constitutes the most common reason for VH, its use should not be limited to the surgery of pelvic floor reconstruction. VH has benefits also in the treatment of myomas (uterine fibroids) and abnormal uterine bleeding, which are usually the indications to hysterectomy.
  
  
• Laparoscopic hysterectomy
  The laparoscopic approach is usually used in total hysterectomy, and is performed through several incisions in the abdominal wall (Pic. 2). The entire uterus is disconnected from its attachments using long thin instruments through the "ports". Then all tissue to be removed is passed through the small abdominal incisions. Total laparoscopic hysterectomy (TLH) is associated with less blood loss, shorter hospital stay, and low rate of infection and ileus in comparison to laparotomy. Patients can avoid painful abdominal incision and return more quickly to their activities.
  Supracervical hysterectomy can also be performed using the laparoscopic approach. Symptomatic uterine myomatosis (multiple uterine fibroids) or adenomyosis causing bleeding disorders or dysmenorrhea (painful menstruation) is the main indications for LASH (laparoscopic supracervical hysterectomy).
  
  
• Laparoscopic-assisted vaginal hysterectomy
  In comparison with abdominal hysterectomy, the laparoscopic-assisted vaginal hysterectomy (LAVH) is less invasive and the post-operative recovery is much faster. It also allows better exploration and slightly more complicated surgeries than the vaginal procedure. LAVH begins with laparoscopy and is completed such that the final removal of the uterus (with or without removing the ovaries) is via the vaginal canal. Thus, LAVH is also a total hysterectomy; the cervix must be removed with the uterus.

Hysterectomy may be made due to several reasons. It includes from heavy or irregular menstruation periods, through severe chronic pains as the result of adenomyosis (inner lining of the uterus grows into uterus muscle, Pic. 3) or endometriosis (inner lining of the uterus grows outside and cause pain and bleeding), uterine prolapse (when uterus drops through the cervix and protrudes from the vagina) until uterine fibroids (non-cancerous growths within the muscular walls of the uterus, outside the uterus and within the uterine cavity) and several types of cancer (cervical, uterine, ovarian, fallopian tube cancer).

Removal of the uterus renders the patient unable to bear children (as does removal of ovaries and fallopian tubes) and has surgical risks as well as long-term effects, so the surgery is normally recommended when other treatment options are not available or have failed. It is expected that the frequency of hysterectomies for non-malignant indications will fall as there are good alternatives in many cases.

Symptoms

Symptoms may be connected to associated diseases, mostly in case, when hysterectomy is later executed. For hysterectomy, the most common reason is uterine fibroids, benign growths of the uterus. Uterine fibroids may cause excessive size of uterus, pressure or pain, bleeding or even severe anemia. Pelvic relaxation is another condition which may lead until hysterectomy. Mild relaxation may cause first degree prolapse when the cervix is on the halfway down to vagina. A woman experiences a loosening of the support muscles and tissues in the pelvic floor area.

Associated diseases

• uterine prolapse
• endometriosis
• uterine, cervical, ovarian cancer or the cancer of fallopian tubes
• adenomyosis 
• uterine fibroids

Complications

The complications of hysterectomy can be divided into intraoperative and postoperative:

The main intraoperative complications are ureteral laceration, rectal injury, main arteries or vein injury, and eventual bladder laceration (if not opened intentionally).

The main postoperative complications could be hemorrhage, wound infection, urine retention, ureter stricture (narrowing of the ureter), and lymphedema (accumulation of lymph in a certain part of the body, due to damage to lymph vessels).

In addition, the nerve-sparing radical hysterectomy was introduced with the intent to spare autonomic nerves and in particular bladder function but not compromising surgical radicality.
In general, open surgery compared to laparoscopic approach seems to be more prone to have operative complications and stump recurrence. Furthermore, the laparoscopic approach seems to have significant reduction of blood loss and hospital stay.

Risk factors

• heavy bleeding
• irregular menstruation periods
• hormonal imbalance (estrogen level dominance)
• chronic pain 
• infections 
• injury of surrounding organs 
• vaginal prolapse (part of the vagina coming out of body)
• uterine cancer
• uterine leiomyomas (fibroids - smooth muscle tumors arising from the muscular part of the uterus)
• abnormal heavy bleeding (or other complication) during caesarian section delivery

Prevention

Possible methods of prevention of a hysterectomy include prevention of conditions that may be ultimately treated by a hysterectomy. Some of these conditions, such as uterine fibroids or adenomyosis, have no known and efficient prevention methods. In the case of uterine cancer, avoiding estrogen excess, e.g. by keeping fit and avoiding obesity or overconsumption of exogenous estrogens, is a possible way of prevention, as certain types of uterine cancer are estrogen-dependent. For cervical cancer, avoiding infection with high-risk types of the HPV (human papillomavirus, a virus causing wart-like growths on the skin and mucosal surfaces) is an effective way of prevention.

Uterus is the main part of female reproductive system and represents the place in the body, where the embryo and fetus develop after the conception. Without the uterus, the eggs from ovaries cannot be fertilized naturally and woman cannot conceive the baby and be pregnant.

Infertility is an inevitable result of hysterectomy, with surrogacy and adoption being the only options left for having children. Therefore, hysterectomy is usually performed only in life-threatening conditions, in women who have already completed their reproduction, or in conditions where the uterus is already incapable of a successful pregnancy.