How Hysterectomies Happen
The rate of hysterectomies in this country has led to innovative procedures
By Ruth Kaufman
Hysterectomies are happening quite often. Their frequency and the desire for so many of these women to recover quickly has caused a wave of innovative procedures to emerge.
DuPage Medical Group’s Donald Adeli, MD, obstetrician and gynecologist, says the need for a woman to have a hysterectomy usually presents itself in one of two ways. The first is the emergency hysterectomy, when the disease process threatens a patient’s life, requiring the procedure to be done immediately, usually due to an acute life-threatening hemorrhage or severe infection. The other hysterectomy is what physicians refer to as elective, although the procedure may still be necessary.
“A hysterectomy to treat a cancer diagnosis would be considered elective,” Adeli says, since he and the patient could decide when to schedule the procedure.
Common reasons for a hysterectomy include uterine fibroids, endometriosis, pelvic support problems, abnormal bleeding, cancer or chronic pelvic pain. Hysterectomies can be performed abdominally, vaginally or laparoscopically, which Adeli says is usually an adjunct to the vaginal approach. An abdominal hysterectomy causes the most postoperative pain and takes the longest to heal, while the vaginal approach causes less pain, and, generally, patients can go home and return to work sooner.
“From a surgical perspective, the abdominal approach enables better visualization of other organs,” he says. “The vaginal approach requires more surgical skill and may not be feasible for difficult hysterectomies or in women who haven’t delivered a child vaginally.”
Adeli says that difficult surgeries may include large fibroids, patients who have undergone a previous abdominal surgery or have scar tissue from previous infections or endometriosis. “It’s often difficult to remove ovaries and tubes vaginally,” he says. He points to recent studies, which recommend removing the tubes when leaving the ovaries, which seems to reduce the risk of ovarian cancer.
Laparoscopic hysterectomies are newer and can alleviate some difficulties with a vaginal approach. A tiny camera that can be about a half-inch in size is inserted into the belly button, and two small quarter-inch holes are made on either side. The abdomen is then readily inspected, allowing for potential complications to be avoided. The upper parts of the uterus, including the tubes and ovaries, are readily removed and delivered through the vagina.
Studies have shown less postoperative pain with the laparoscopic approach compared to the vaginal approach. “This may be due to the fact that surgery is usually performed with electricity as opposed to crushing the tissue with clamps and tying [it] with sutures,” Adeli explains. “Sometimes by looking, it becomes obvious that it might be safer to complete the procedure abdominally instead. A patient should be told that though the surgery will be attempted vaginally or laparoscopically, it may [still] need to be completed through an abdominal procedure.”
Robotic surgery is a new kind of laparoscopic surgery. The holes are placed by the surgeon, but the tools are controlled by a robot, which is in turn controlled by the surgeon at a console. This gives the surgeon the ability to see in 3D with actual depth perception.
“The surgeon is also able to maneuver the instruments more like using one’s hands, versus the straight laparoscopic approach, in which the instrument only opens and closes,” Adeli says. This allows the surgeon to perform surgeries laparoscopically that previously could
only be attempted abdominally.
“Overall, I prefer the robotic approach since it causes less pain. It’s unusual for me to convert a case to the abdominal approach. For very large uteri or other hysterectomies where I anticipate complications, I may choose the abdominal approach and prepare the patient accordingly during the consultation process,” says Adeli. “Generally, physicians do what they can to complete the surgery safely, and above all, what’s in the best interest of the patient.”
For women contemplating a hysterectomy, Ashley Gast, who had a hysterectomy at 21 due to severe stage 4 endometriosis, advises, “Research, research, research! It’s a huge decision at any age. Don’t be afraid to present questions, [documented] research
and any other important findings to your physician.”
Various surgical options were presented to Gast, but she was advised that a traditional abdominal incision would be the best and safest option for her, due to the severity of her endometriosis.
“I was pleased with the way the incision was done and have no regrets being cut open,” she says. “I was confident that I’d be pain free posthysterectomy, and feel that my positive mind-set helped the recovery process.”
She adds, “Listen to your body. One of the best tools we have is the ability to listen, see and feel the clues around us. Some days, you’ll achieve a postoperative milestone, while other days, there’ll be minor setbacks. Listening to your body will give you optimal healing ability.”
Originally published in the Summer/Fall 2014 print edition
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