In other blogs, I have reviewed medical and surgical options for managing and treating abnormal uterine bleeding. One of the most common reasons for a visit in my office is to determine whether a patient is a good candidate for a minimally invasive surgical approach, such as laparoscopic hysterectomy. The benefits of laparoscopy are many and include a faster recovery, less blood loss, greater visibility for the surgeon during surgery and less need for pain medication. Depending on the experience of your gynecologic surgeon, most gynecologic conditions can now be treated with laparoscopic surgery rather than with the traditional open/abdominal surgery.
When it comes to performing laparoscopic hysterectomy, the experience of your surgeon is crucial. It is very important to review your expectation of surgery with your gynecologist and find out if you’re a good candidate for a laparoscopic hysterectomy. I address the most frequently asked questions about laparoscopic hysterectomy below based on my experience of more than 10 years performing laparoscopic hysterectomies and reviewing the current literature on the topic.
What is the difference between a supracervical and total hysterectomy?
There are two different ways to perform a laparoscopic hysterectomy: one in which the cervix remains in place and one in which it is removed. When the cervix remains in place, it is called a laparoscopic supracervical hysterectomy (or LSH, which you may have heard mentioned on television). When the cervix is removed, it is called a total laparoscopic hysterectomy (TLH). Many patients have told me that they thought "total" meant removal of the ovaries. While this can be done at the same time, it is a separate discussion between you and your doctor. In the absence of cancer or an increased risk of cancer, the hormones produced by the ovaries have protective benefits for women younger than 50. You should fully understand the risks associated and consent to their removal separately.
Who is a good candidate for a LSH?
If you have a history of normal pap smears, you may be a good candidate for keeping your cervix. In addition, there should be no evidence of bleeding from the cervix (typically during sex), no evidence of the cervix relaxing into the vagina (prolapse) and no evidence or suspicion of pain in the cervix with intercourse or exams. If you have severe cramping with or without bleeding and your gynecologist thinks you may have a condition called adenomyosis (endometriosis of the uterus) or endometriosis, you should discuss the pros and cons of keeping your cervix with your doctor. In my opinion, it is typically beneficial to remove your cervix if you have this condition.
What are the possible side effects of keeping my cervix?
Women who opt for an LSH may experience cyclic spotting that comes from the cervix. This means that you will have some spotting at the time of your typical menstrual cycle. This is caused by a small amount of endometrial tissue that stays with the endocervical canal of the cervix. While care is taken during surgery to decrease this risk using various surgical techniques, the literature indicates that it will occur in 4% to 10% of cases. In my experience, it occurs in less than 2% of women undergoing an LSH.
Is there any difference to a woman’s sexuality if the cervix is removed?
There is no evidence that removing your cervix will change or improve sexuality. There is an old study that is often quoted by proponents of LSH that states that satisfaction is better with the cervix in place. Several more recent (and better) studies all agree that women who had a hysterectomy, whether the cervix is kept or removed, experience an increase in sexual satisfaction or at least a return to baseline sexual satisfaction. This is likely related to the fact that there is no longer the hassle or inconvenience of abnormal uterine bleeding, pelvic pain or the need for contraception. In addition, there is no evidence that orgasms will change if the cervix is removed. Nonetheless, this should always be reviewed with your gynecologist if you have any concerns.
What are the advantages of removing the cervix?
If you opt for a TLH, the entire uterus is removed, including the cervix (the ovaries are left in place). The advantages include no further need for pap smears (if you have had normal pap smears in the past) and no monthly/cyclic spotting. In addition, as discussed above, if your provider suspects that there may be a problem related to the cervix, then it is best to remove it to avoid the possibility of another surgery to do so later. If you have your cervix removed, you will have sutures placed at the top of the vagina, so a return to sex is often about six to eight weeks after surgery. You may also experience some spotting during your recovery phase that comes from the top of the vagina as it is healing. If you experience heavy bleeding during recovery, you should always alert your physician.
Will there be any changes to the pelvic floor?
The pelvic floor is the network of muscles that support the vagina, bladder, rectum and uterus. A relaxation of the pelvic floor can lead to prolapse of these structures, which means they begin to protrude into the vagina. If there is no evidence of relaxation of the pelvic floor prior to a hysterectomy, then typically there is a small chance of future prolapse. Pelvic relaxation and prolapse may be due to a number of risk factors, but whether or not the cervix is removed during the hysterectomy typically has no bearing on prolapse. If your provider suspects that your cervix is relaxing prior to your hysterectomy, then it would be best to remove it as part of the surgery.
When can I expect to go home and get back to my routine activities?
In my practice, about 85% of patients are able to go home the same day of surgery. In the 15% that require an overnight stay, nearly all go home the next day. I typically suggest that my patients plan to take two to three weeks off work. Most are able to go back to some work after two weeks, but I caution all patients that it should be light duty and limited hours until after week three. Almost all of my patients report that even though they are able to return to work in two weeks, they are often still very tired and have to take midday break(s) or nap(s). Of course, if your job entails heavy lifting or being very active all day, you may need more time off. Most patients are also typically getting back to some form of light exercise after two to three weeks.
In order to prepare for a successful recovery, it is important to make sure you are in as good of health as possible. If you have any medical conditions, make sure to talk with your surgeon and your primary care doctor to see if you will need any additional tests prior to surgery.
Is LSH or TLH more difficult to perform?
Performing a TLH is typically more complex than LSH, but there are many factors the influence the complexity of your surgery that your surgeon must consider. For example, the size of your uterus, any previous surgeries and any other conditions you may have, such as endometriosis or ovarian cysts. For total laparoscopic hysterectomies (where the cervix is removed), the uterus is removed through a vaginal incision, which means that your surgeon must suture the vagina closed laparoscopically. This requires a different skill set than when the surgery is completed through a large abdominal incision or vaginally, and you should feel completely comfortable with your surgeon’s experience.
For a LSH, the uterus is removed through a laparoscopic incision with the use of a special device (called a morcellator) that removes the uterus in small strips in order to avoid a larger abdominal incision. This also requires a specific skill set, experience and careful attention to surrounding structures in the pelvis. Most hospitals require surgeons to be credentialed (demonstrate competence) in both morcellator use and laparoscopic suture tying.
I encourage all my patients to ask questions about my experience with any procedure they are considering, as well as what they can expect in terms of outcomes. If you are not comfortable asking your surgeon these questions or are not comfortable with his or her answers, it is always best to get a second opinion.
What should I do if my surgeon recommends an abdominal hysterectomy?
There are situations where the uterus is so large or the pelvic anatomy too difficult for a laparoscopic or vaginal approach hysterectomy. In general, your surgeon will recommend what they feel most comfortable and safe performing based on their skills and experience. Having performed more than 700 minimally invasive hysterectomies since 2003, I feel that most can be done safely using laparoscopy. Websites, such as the American Association of Gynecologic Laparoscopists (AAGL), can help you find a provider in your area that has experience with minimally invasive hysterectomy.
At Women's Healthcare Associates, our OB/GYN physicians are also surgeons experienced in many surgical techniques and approaches. If you're experiencing abnormal menstrual bleeding or have been told you might need a hysterectomy, contact one of our offices to make an appointment >
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Dr. Liberato Mukul is a board-certified OB/GYN physician and fellowship-trained minimally invasive surgeon. He sees patients at Northwest Gynecology Center, Peterkort. His clinical focus includes menstrual irregularities, fibroid treatment options, endometriosis, ovarian cysts, pelvic pain, polycystic ovary syndrome and infertility. In his spare time, Dr. Mukul enjoys spending time with his family, hiking, soccer and travel. He is fluent in Spanish.