What is a Hysterectomy?
Hysterectomies are a common surgical procedure performed on women, approximately 600,000/year. The procedure involves the removal of the uterus and usually the cervix. The tubes and ovaries can also be removed.
There are several approaches to hysterectomy and it's important to select the best approach for your situation. The four approaches are:
- Vaginal: This approach requires no incisions on the abdomen. Access to the uterus is through a natural opening, the vagina. All stitches are internal and dissolve in about 6 weeks. The American Board of Obstetrics and Gynecology recommends all hysterectomies be done this way unless there is a reason another approach is necessary. It is the safest and most cost-effective choice. It is not a good choice for a very large uterus, severe scarring in the pelvic cavity, or cancer. It is the least invasive and has the quickest recovery time.
- Abdominal: This approach requires a large incision in the lower abdomen. It allows the easiest access to the uterus. Most Gynecologists do not perform this type of hysterectomy often due to technological advances that have developed over the past several years. This approach requires the longest recovery time.
- Laparoscopic: This approach requires 3 or 4 small incisions in the abdomen. A camera and instruments are placed through the incisions and the surgery is done with these instruments. Once the uterus is detached from the pelvis, it is removed through the vagina. There is a slightly increased risk of internal organ damage from initially placing the instruments as well as post-op hernias through one of the small incisions. The recovery time is similar to a vaginal hysterectomy.
- Robotic: This approach also requires 4 small incisions in the abdomen. It also requires a robotic machine to perform the surgery. The uterus can be removed through the vagina or through the incision in the belly button. It is the most expensive option and requires significant training by the surgeon. It is a good choice for a very large uterus, severe scarring as you may have due to endometriosis or an infection, or gynecologic cancer. Recovery is similar to vaginal hysterectomy depending on how extensive the procedure is.
Choosing the right approach is a decision made by you and your surgeon. The decision is based on why you are having the surgery. Prolapse is best approached vaginally, cancer is best robotically. It is also based on your surgeon's skill set. Vaginal surgery is not taught in residencies much anymore so many surgeons are not comfortable with this approach. Laparoscopic and robotic approaches are being taught more but they are more expensive and carry more risks. There are surgeons that have specialized training in these approaches and this is who you want to perform these surgeries. Insurance pays the same for all the approaches and does not participate in the choice of which approach is best for each patient. The most important part of making this decision is to talk with your surgeon. If you are uncomfortable with the recommendation, seek a second opinion. There isn't always a medically right choice. The right choice is what feels best to you.