Hysterectomy

There are four (4) approaches used to perform a Hysterectomy.
Please note that a Full Hysterectomy refers to removal of the whole uterus, which includes the cervix. It does not refer to removal of the ovaries, although this may also be performed as an additional procedure.
The method of hysterectomy which your surgeon selects is usually dictated by

• the reason for surgery
• size of uterus
• ease of access and
• the experience of the surgeon with particular techniques

In brief, the methods compare as follows:

	Total Laparoscopic Hysterectomy (TLH)	Laparoscopically Assisted Vaginal Hysterectomy (LAVH)	Vaginal Hysterectomy (VH)	Total Abdominal Hysterectomy (TAH)
Operating Time	1-2 hours	1-2 hours	30-60 mins	1 hour
Pain Relief Needed	Least			Most
Hospital Stay	2 days	2-3 days	2-3 days	4-5 days
Time to mobilisation	Shortest			Longest
Full Recovery	6 weeks	6 weeks	6 weeks	6 weeks
Complications	*	*	*	*Lowest Rate

Regardless of the method by which a hysterectomy is performed, each operation requires division of the same structures and the rebuilding of support for the vaginal vault (top of the vagina).  
For this reason, full recovery is always six weeks and women often feel tired for around three months after surgery.  
The method of surgery will determine how rapidly you will return to normal activities including walking, cooking, driving and general mobilisation around the home.

Complications

Any operation may have complications and certain complications are specific to or more common with particular procedures.  For instance, a collection of blood (haematoma) at the top of the vagina is more common after a Vaginal Hysterectomy (VH) and wound infections are more common with large incisions found in Abdominal Hysterectomy (TAH).
A full list of recognised complications of Hysterectomy is too extensive to place here, but some of the better known are: 

• Bleeding requiring transfusion (notify your doctor if you are taking aspirin, anti-inflammatory agents such as Ibuprofen or any herbal remedy starting with the letter 'G')
• Wound infection
• Deep vein thrombosis
• Bladder injury
• Vascular injury
• Ureteric injury (connects kidney to bladder)
• Vault haematoma
• Urinary tract infection

Weird Things That Can Happen

Adhesions:  These can occur after any surgery but are generally less common with Laparoscopic procedures. With any hysterectomy, small and large bowel may become adherent to the top of the vagina in the weeks following the operation. This is more likely to happen if there is bleeding (vault haematoma) or infection. Adhesions cannot be completely prevented and some patients appear to be more prone to developing these than others.   
Further surgery can be required to divide the adhesions.



Bleeding after Hysterectomy may occur:

• Early, due to evacuation of a haematoma at the top of the vagina. This will usually happen within 10-14 days of surgery
• Late, due to vascular healing tissue called granulation tissue at the vault. This is relatively common and may not present until sex is resumed at which time some bleeding and sensitivity will be noticed. Silver nitrate is used to chemically cauterize this tissue.  If there is a large amout of this tissue, it may need to be removed in theatre.

Pre-operative Care: It is important to make sure you are not constipated prior to surgery, as the drugs used for pain relief can make this much worse. Coloxyl, agarol, metamucil and plenty of fluids in the week prior to surgery can make a big difference to your recovery.
Postoperative Care:  Naturally, the care which you receive following your surgery will depend to a certain extent on the type of procedure which you have.  
Abdominal incisions will be covered with dressings which are removed after 24-48 hours.  Sometimes sutures pass through small vessels in the skin and these can ooze overnight causing dressings to look very bloodstained.
If you have a vaginal hysterectomy then there may be a pack in the vagina to minimise blood loss. This is usually removed the next morning but can cause some discomfort overnight. Regardless of your procedure, vaginal loss is monitored following a hysterectomy.
Depending on how you feel, you will be mobilised the day after surgery in order to minimise your risk of deep vein thrombosis and to assist your general recovery.  All patients will have a catheter in the bladder which will be removed, in most cases, the next morning.  Drips are also taken out the next day but may be left if they are also providing access for antibiotics or pain relief.
Some patients will have a drain coming through the abdominal wall and this is usually removed after 24 hours.
Constipation should be avoided. Use something to keep the bowels flowing smoothly (eg Metamucil).

Total Laparoscopic Hysterectomy (TLH)

All of the surgery in this advanced laparoscopic procedure is performed through 4 small incisions in the abdomen.  There are 2 x 1cm incisions in the midline  (-)  and 2 x 5mm incisions (+)on either side of the lower abdomen.
All of the suturing is performed through these incisions and so this approach is able to replace the large incision needed for a Total Abdominal Hysterectomy. This approach is similar to the evolution from open gall bladder surgery to the, now common, laparoscopic gall bladder operation.  It is particularly good for women who have not had a vaginal delivery and otherwise would require the traditional abdominal approach through a transverse incision.
It is a relatively new procedure and has evolved from the Laparoscopically Assisted Vaginal Hysterectomy. New equipment and techniques have now made this a reliable and relatively quick operation.
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