La hysterectomy consiste en la surgical removal of the uterus. Nowadays the tubal removal when the uterus, since these lose their usefulness and it is known that the ovarian cancer It originates from them, so by removing them, it is being prevented. However, the ovaries must be preserved in young women (under 60 years of age).
What types of hysterectomy are there?
They are basically three:
- Subtotal hysterectomy(also called supracervical): only the upper part (body) of the uterus. He cervix it is left in place. In our opinion, it is a surgery incomplete that is justified only when we are treating a genital prolapse for laparoscopy using the sacropexy technique, since in this way we avoid placing the mesh directly in contact with the open vagina.
- Total hysterectomy- The entire uterus and cervix are removed. We consider this to be the technique of choice when performing this operation.
- Radical hysterectomy: the uterusIn its entirety, the tissue that is found on both sides of the cervix, the upper part of the vagina and the pelvic nodes. This type of hysterectomy is performed in cases of cervical cancer.
What are the boarding routes?
There are three different ways to carry out a hysterectomy: vaginally, abdominally or laparoscopically. The doctor must help decide what type of approach is the most appropriate in each case.
The specific procedure will depend on the medical history and the indication for surgery. However, it can be assured that the best approach is the vaginal one and that when this is not applicable, the laparoscopic route should be chosen.
Today, more than 95% of hysterectomies can and should be performed by one of these two routes, both considered minimally invasive.
- Abdominal hysterectomy- The surgeon makes a 12 to 15 cm surgical incision in the lower abdomen. This incision can be vertical (from the navel to the pubis) or transverse, just above the birth of the pubic hair. This type of hysterectomyIt is the one that is associated with the longest recovery time and the highest rate of complications.
- Vaginal hysterectomy: the surgeon makes a cut in the upper part of the vagina, through which he performs the intervention and removes the uterus. The fundus wound is closed with stitches. This type is the one that is associated with fewer complications and shorter recovery time. However, it has the disadvantage that the abdominal cavity cannot be explored.
- Laparoscopic hysterectomy: A laparoscopeit is a narrow tube of 0,5 cm. or 1 cm. in diameter, equipped with a lens at one end and connected, via fiber optics, to a television camera and a light source at the other. The surgeon It generally makes 4 small incisions (5 to 10 mm in length) in the abdomen through which it introduces, through trocars, the laparoscope and other surgical instruments that allow the entire surgery with perfect vision of the operative field. In some cases, a surgical robot. Some doctors think that it provides greater surgical precision, but all the studies carried out show that there is no difference in terms of results when a laparoscopy standard or robotic surgery.
We believe that today the so-called Laparoscopic-assisted vaginal hysterectomy. This technique combines the previous two and, in our opinion, only manages to lose the advantages that the two techniques provide separately.
However, the recent modifications to the laparoscopy that achieve a much lower aggressiveness in the operation. Among these options ultra minimally invasive, we highlight the so-called single port laparoscopy or the even more recent modification of the technique that allows the placement of 3-millimeter instruments without the use of trocars, which allows a perfect aesthetic result.
Indications for hysterectomy
There are many reasons why a woman may need a hysterectomy. The procedure may be recommended if the patient has:
- Endometrial cancer.
- Cervical canceror a precancerous entity of the cervix called cervical dysplasia.
- Ovarian cancer.
- Complications during childbirthsuch as uncontrollable bleeding.
- Severe endometriosisthat does not respond to medical treatment.
- Drop of the uterus into the vagina (uterine prolapse).
Alternatives to hysterectomy
La hysterectomy is a surgery complex that is not without complications. Depending on the cause that indicates it, there may be alternatives to this procedure. The gynecologist can inform the patient about other less invasive techniques that could replace hysterectomy depending on each case.
These less invasive procedures include:
- Uterine artery embolization.
- High Intensity Focused Ultrasound (HIFU).
- Endometrial ablation.
In some cases, alternative medical treatment may be attempted, such as placement of a hormone-releasing IUD (mirena).
Risks of hysterectomy
La hysterectomy may present the complications common to any other surgery:
- Allergic reactions to medications.
- Breathing problems related to anesthesia or surgery.
- Appearance of blood clots within the veins that can rarely affect the lungs.
The more specific risks of hysterectomy are:
- Injury to the bladder, ureters, or intestine.
- Rarely pain during intercourse after surgery.
When using a minimally invasive technique (vaginal or laparoscopic), full recovery takes 2 to 4 weeks for most patients. However, when the abdominal route is used, the recovery time is longer and usually takes between 4 to 8 weeks. The patient may experience some degree of tiredness or lack of appetite during this period.
Showering is recommended as soon as the patient recovers from anesthesia after the surgery and can get up. This is possible in most cases within the first 12-24 hours after surgery. It is advisable to eat a variety of foods, with smaller portions than normal and to have healthy snacks between meals.
It is advisable to increase your intake of fruits and vegetables, and drink two liters of water a day to avoid constipation. It is advisable to restart moderate physical activity (walking) right after the surgery. Walking around the house or using the stairs is possible from the first postoperative days.
It is also recommended to restart daily activities as soon as the patient feels able to do so. There is no problem in lifting moderate weights (4-5 kg maximum), but you should not lift anything heavy or make excessive efforts during the first 3 weeks. The rule should be that if it hurts or bothers when a certain activity is taking place, that activity should be stopped.
Nor should sit-ups or other sports be done until the doctor has examined the patient. In some cases, patients can return to work two weeks after the operation, but by that time the patient may easily feel tired. In some cases, it is also possible to drive, with medical permission, 4-5 days after the operation.
Due to the suture that closes the vaginal fundus wound, nothing should be put inside the vagina for the first 4-6 weeks (it should always be done with medical permission). This includes bathing, douching, the use of tampons, and, of course, sexual intercourse. These should not be started before that time and always after the surgeon have confirmed that they can be restarted.
In this sense, if the sexual life was satisfactory before the surgery, it should remain the same after the operation. If, on the contrary, the symptoms that the patient presented and that motivated the surgery interfered with the sexual intercourse, quality of sexual life often improves after surgery.
As for the care of the wounds, it is best to keep them in the air, taking care that they are well clean and dry until the doctor removes the sutures that close them.
When to call the doctor
It is convenient to contact the surgeon In the following cases:
- Body temperature is equal to or greater than 38 ° C.
- The surgical wound is bleeding, red and hot to the touch, or has a thick, milky yellow or green discharge.
- The pain persists despite taking the indicated analgesic regimen.
- There is shortness of breath.
- The patient cannot drink or eat.
- Nausea or vomiting occurs.
- The patient cannot pass gas or have a bowel movement.
- There is difficulty or pain when urinating.
- There is leucorrhea (vaginal discharge) with a bad or very heavy odor.
- There is vaginal bleeding as heavy or greater than that of a period
- There is swelling or redness in one of the legs.
The first postoperative review with the surgeon is normally done 7 to 10 days after the surgery. During the procedure, the doctor will carry out a gynecological examination to determine that both the vaginal suture and the abdominal incisions have healed well and the stitches can be removed. The next revision, normally the definitive one, as long as it is not due to a malignant process, is one month after the surgery.
Dr Francisco Carmona
Women's Medical Director