Laparoscopic Hysterectomy

What is a laparoscopic hysterectomy?

A laparoscopic hysterectomy is removal of the uterus through four small (0.5 to 1.5cm) abdominal incisions. This may or may not be done using the robot surgical system based on your doctor’s preference.  Hysterectomy may be done to treat conditions that affect the uterus, such as uterine fibroids, abnormal uterine bleeding, endometriosis, pelvic pain, pelvic support problems (such as uterine prolapse), and cancer of the reproductive organs. For benign (non-cancerous conditions), medical therapies should usually be attempted prior to proceeding with hysterectomy.

Laparoscopic hysterectomy is one type of minimally invasive hysterectomy that is associated with lower blood less, less risk of infection, less postoperative pain, and quicker recovery when compared to an abdominal hysterectomy performed through a large abdominal incision.

How will I be evaluated prior to surgery?

Depending on the reason for hysterectomy, your physician may recommend additional tests such as ultrasound, MRI, endometrial biopsy, pap smear, and/or blood tests.  Depending on your underlying symptoms and medical history, some of these tests are used to look for precancerous or cancerous conditions of the reproductive organs.

Although many of these tests are often accurate, there is no single test that is 100% accurate and these tests may miss an underlying cancer.  In the general population, fewer than 3 out of 1000 women who undergo hysterectomy for uterine fibroids will have an underlying cancer.  Furthermore, there are no reliable methods to tell the difference between benign (non-cancerous) fibroids from cancerous fibroids before they are removed. 

Should I keep or remove the cervix?

There is no long-term medical benefit to keeping or removing the cervix and this decision is a personal one.  There does not seem to be a difference in prolapse (bulging of the vaginal walls), incontinence (leaking of urine) or sexual function if the cervix is or is not removed.

Depending on the reason for hysterectomy, some women have the option of keeping versus removing the cervix.  Keeping the cervix would not be considered appropriate in women who have a history of severely abnormal pap smears, cancer or precancerous changes in the uterus.  Please discuss with your surgeon if keeping the cervix is a reasonable option for you.

Women who choose to remove the cervix (supracervical hysterectomy) may be discharged home on the same day of surgery and may have a slightly shorter postoperative recovery time (4 weeks compared to 6 weeks for a total hysterectomy).  However, there does not appear to be a long-term benefit in recovery.

If you choose to keep your cervix, you will need to continue to have cervical cancer screening with periodic pap smears.  There is also a 5-8% risk of continuing to have vaginal bleeding.  Often this bleeding is very light, such as spotting or a very light period, but can be heavy. The bleeding can be cyclic, like a monthly period, or can be erratic or irregular.  You may need additional evaluation or treatment for cervical problems, and rarely may need an additional surgery to remove the cervix. If you choose to keep your cervix and are found to have a pre-cancerous or cancerous condition at the time of your hysterectomy, you may need additional surgery to remove your cervix and/or additional treatment for your condition.  This may also make the cancer more difficult to treat and may worsen the chances for survival.

If you choose to remove your cervix, stitches will need to be placed at the top of the vagina to close it.  There is a risk that these stitches may open up, which is called a vaginal cuff dehiscence.  This is a rare postoperative complication that may require an emergency surgery to close it again.  This risk is approximately 1-3% with a laparoscopic approach. Because of this risk, we recommend pelvic rest (nothing in the vagina) for 8 weeks after surgery, which may reduce the risk of this complication.

What is the risk of an undetected cancer in my uterus or cervix?

Despite testing available today, not all cancers can be diagnosed before surgery.  For example, a serious cancer called uterine sarcoma (which appears similar to non-cancerous fibroids) cannot be ruled out in every case prior to surgery; definite diagnosis can only be done by looking at the tissue under a microscope after the procedure is completed.  Approximately 3 in 1000 women who undergo surgery for uterine fibroids may have a type of cancer called uterine sarcoma.  This risk increases with increasing age.  If sarcoma or other unexpected cancers are found, a woman may need a second surgery to re-explore the abdomen by a gynecologic oncologist.  This surgery may include removal of the cervix if a supracervical hysterectomy is performed.

Should I keep or remove the ovaries and fallopian tubes?

For most women, we recommend that patients keep their ovaries as long as the ovaries appear normal.  The removal of the ovaries prior to menopause has been shown to increase the risks of heart disease and osteoporosis (weakening of the bones).  If the ovaries are left in place, there is a low risk of developing cysts (either benign or cancerous) the future that may require further surgery, and you will need to continue to have annual pelvic exams to assess for ovarian masses.

Once a hysterectomy is performed, the fallopian tubes are no longer necessary.  After hysterectomy, a remaining fallopian tube can form a cyst, called a hydrosalpinx, which can cause pain.  We think that some ovarian cancers may actually come from the fallopian tubes.  Since there is very little risk to removing the fallopian tubes, we recommend removing both fallopian tubes (bilateral salpingectomy) at the time of hysterectomy.

What can I expect?

If you choose to have a supracervical hysterectomy, you will be discharged home the same day as your surgery.  If you have a total hysterectomy, most patients are able to safely go home on the same day of surgery.  Please discuss this with your physician.

You will need to return to clinic in 6 weeks to see your doctor for a postoperative visit.

Most patients can return to work and most of their usual activities in 4-6 weeks.

A detailed review of your postoperative instructions will be reviewed at your preoperative appointment, and again prior to your discharge from the hospital.  Vaginal intercourse should be avoided for 8 weeks if your cervix is removed.

What are the risks of the surgery?

Although there can be problems that result from surgery, we work very hard to make sure it is as safe as possible. However, problems can occur, even when things go as planned, and you should be aware of these risks.

Possible risks during surgery include:

1. Bleeding: If there is excessive bleeding, you will be given a blood transfusion unless you have personal or religious reasons for not wanting blood. This should be discussed with your doctor prior to the surgery. 

2. Damage to other organs, such as the bowel, bladder, ureters (the tubes that drain the kidneys into the bladder), blood vessels and nerves. Damage occurs in less than 1% of surgeries. Some injuries may not be recognized at the time of surgery and may require re-hospitalization and/or a second surgery.

3. Conversion to an open surgery requiring an up-and-down or Bikini incision: If a bigger open incision is needed during your surgery, you may need to stay in the hospital for one or two nights.

4. Death: All surgeries have a risk of death. Some surgeries have a higher risk than others.

Possible risks that can occur days to weeks after surgery include:

1. Urinary retention: Inability to feel the urge to urinate and/or empty your bladder. This is usually temporary and usually resolves in 12-72 hours after the surgery. Prior to discharge, the nursing team will check and make sure that you can adequately empty your bladder. If you are unable to adequately empty your bladder after surgery, you will need to use a catheter to drain your bladder until your symptoms resolve. If this occurs, our nurses will teach you how to do this safely before going home. 

2. A blood clot in the legs (deep venous thrombosis, DVT) or lungs (pulmonary embolus, PE): Swelling or pain in your legs, shortness of breath, or chest pain are possible signs of blood clots. This is considered an emergency. Call you doctor immediately if you experience swelling or pain in your legs. Call 911 or go to the nearest emergency room if you develop chest pain or shortness of breath. 

3. Bowel obstruction: A block in the bowel that results in not being able to pass stool or gas. May cause stomach pain, bloating or vomiting. This may require hospitalization or another surgery. 

4. Infection: This includes infection of the bladder, kidneys, skin or the site of surgery. This may cause fever, redness, swelling or pain. This may require treatment with antibiotics, admission to the hospital, and possible drainage of infected tissue or fluid. 

5. Hernia: Weakness in the muscle at the incision that allows a piece of intestine or the tissue around them to pass through. This can cause a lump under the skin and sometimes, an organ or tissue gets stuck in the hernia, which can cause problems. 

6. If you choose to keep your cervix, you may continue to have cyclic bleeding. You will also need to continue to have pap smears 

7. If you choose to remove your cervix, there is a 1-3% risk that the vaginal stitches may open up, which is called a vaginal cuff dehiscence. This is a rare postoperative complication that may require an emergency surgery to close it again 

8. Persistent pain that does not get better after surgery. Or, onset of new pelvic or abdominal pain that was not present before surgery. 

9. Failure to relieve symptoms or recurrence of the symptoms for which you are having hysterectomy. 

10. Development or recurrence of scar tissue

11. Occasionally, your surgeon may need to cut your uterus into smaller pieces during the hysterectomy (This is called “morcellation“). This is sometimes done to help see critical structures during the surgery, if your uterus/fibroids are too large to remove through the vaginal opening, or if you choose to keep your cervix. Morcellation is only an option for women if the risk of cancer in the uterus is thought to be low.  Most uterine tissue (including fibroid tumors) are benign (non-cancerous). However, there is no medical test that can accurately detect all cancers before surgery and cancer within fibroid tumors or the uterine wall are extremely difficult to diagnose before surgery. We estimate the risk of an undetected cancer in a women undergoing hysterectomy is less than 1 in 500.  If the uterus contains an undetected cancer, morcellation of the uterus may spread cancer cells within the abdomen.  This may make the cancer more difficult to treat and may worsen the chances for survival, although the prognosis for this type of cancer is poor even when the uterus is removed in one piece. Sometimes, the only way to perform a hysterectomy without morcellation is to make a large incision on the abdomen.  Larger incisions on the abdomen can be associated with increased postoperative pain, longer recovery, more blood loss, higher risk of infection, and higher risk of wound healing problems.  Please discuss whether morcellation will be considered for your surgery.