Hysterectomy and the Different Routes

Hysterectomy is a common procedure done by Gynaecologists in the Caribbean, the commonest indication being heavy menstrual bleeding due to uterine fibroids.

When counselling a patient for hysterectomy one should have an indication for example symptomatic uterine fibroids or cancer, one must also enquire if the patient has completed her family as this determines if hysterectomy is suitable for the patient. In addition one needs to know the cervical (pap) smear history of the last up to date smear. If the hysterectomy is done for a benign cause then an endometrial biopsy should be done prior to rule out any endometrial pathology especially if there is heavy menstrual bleeding to diagnose endometrial hyperplasia or endometrial cancer prior to surgery.

When describing the procedure it is essentially removing of the uterus, tubes and cervix and removal of ovaries should be discussed especially in pre-menopausal women.

The route can consist of the traditional abdominal route, vaginal or more recently the laparoscopic route.
Both the vaginal and the laparoscopic route are associated with a quicker return to normal activity, less blood loss and better cosmesis.

The laparoscopic route can be divided into a laparoscopic assisted vaginal hysterectomy where the ovarian ligament is ligated laparoscopically (the blood supply to the ovary)and the remainder of the procedure is done via the vaginal route or total laparoscopic hysterectomy where the entire procedure is done laparoscopically.

The vaginal route is indicated if the uterus is less than 12 weeks size and if there is adequate descent of the uterus in the vagina and no previous surgery where the probability of adhesions/scar tissue is minimal.

The abdominal route is the more traditional route where the hysterectomy is done through a ‘bikini’ incision or a midline incision this is associated with a longer recovery and pain when compared to the laparoscopic and vaginal route.

Common risks post operatively include wound infection, UTI, occasionally one may need a blood transfusion due to blood loss, rare risks include injury to the ureter and bowel injury although rare these risks are significant.

It is important that the patient is properly and thoroughly counselled on the indication and the risks of the surgery to make an informed decision.

Once this is done the patient is consented and any pre-operative investigations done these include a full blood count and the patient may be asked to get donors in case a blood transfusion is needed.

In conclusion hysterectomy is a commonly performed procedure and minimal access surgery (laparoscopy)is associated with better pain and recovery outcomes when compared to traditional routes.

When counselling a patient for hysterectomy one must explain the procedure itself and the associated risks and the route so the patient can make an informed incision.

Dr John Barker Bsc MBBS MRCOG, Dip (Risk Management).

Obstetrician/Gynaecologist at Arnos Vale Medical Center, Consultant Obstetrician/Gynaecologist UK
He has completed the Advanced Training Skills Module in Benign Gynaecology in the UK and has an interest in advanced laparoscopic and hysteroscopic
(instagram@gynaestvincent, facebook@gynaestvincent)