Laparoscopic hysterectomy

Laparoscopic hysterectomy

Before you read this page, please refer to the information page on laparoscopy to answer your general questions that are common to all laparoscopic procedures. Questions such as “what to expect after surgery?”, “what happens on the day?” and many other questions.

In this page, we will deal with what is unique to laparoscopic removal of the uterus or ‘laparoscopic hysterectomy’ and explain how the procedure is usually done.

Is a hysterectomy necessary?

If you have been offered a laparoscopic hysterectomy as part of your treatment, this should mean that non-surgical alternatives are either not suitable or have failed to adequately solve your problem. Mr. Khazali will have gone through all the alternatives of hysterectomy with you.

What are the conditions for which a hysterectomy is performed?

Laparoscopic hysterectomy is most commonly used in the treatment of:

  • menorrhagia (heavy bleeding) and/or dysmenorrhoea (painful periods
  • fibroids (non-cancerous growths) that grow in the wall of the Uterus
  • endometriosis and other causes of pelvic pain

What are the advantages of Laparoscopic hysterectomy?

Hysterectomy, or removal of the uterus, is increasingly performed through laparoscopic route as this has been shown to have significant advantages over the conventional “open” surgery. Unfortunately, in the UK, on average only 21% of hysterectomies for benign conditions are done laparoscopically, however, this rate is improving as gynaecologists learn the technique.

Mr. Khazali performs more than 96% of hysterectomies through the laparoscopic route.

Compared to conventional “open” hysterectomy, Laparoscopic hysterectomy is less invasive. This is why it is also called “Minimally Invasive surgery”. Patient who have undergone a Laparoscopic hysterectomy have:

Quicker recovery and shorter hospital stay
Less pain
Smaller incisions on the skin and therefore better cosmetic results.

Laparoscopic route also results in less scar formation (adhesions) inside the abdomen.

Types of laparoscopic hysterectomy

There are various types of Laparoscopic Hysterectomy. Mr. Khazali will explain to you which type he is proposing to perform and why that type is the most suitable for you. These types are:

Total Laparoscopic Hysterectomy (TLH)
The procedure is done completely through keyhole surgery. The uterus (womb) and the cervix (neck of the womb) are removed through the vagina and the top of the vagina where the uterus was attached is closed using stitches.

Laparoscopic-Assisted Vaginal Hysterectomy (LAVH)
This is similar to total laparoscopic hysterectomy but some elements of the procedure will be done through the vagina.

Subtotal Laparoscopic Hysterectomy (STLH)
The procedure is done completely through keyhole surgery. The uterus is separated from the cervix. The uterus is removed through the small cuts in your abdomen but the cervix will be preserved.

This means you will still need your cervical smears and there is a small chance that you will have monthly spotting.

Will Ovaries and Fallopian Tubes be removed?

Fallopian tubes are usually removed during hysterectomy. Recently, it has been shown that a significant proportion of ovarian cancers originate from the fallopian tubes (these are the tubes that take the egg from the ovary to the uterus, if you have a hysterectomy, these organs are no longer needed). For this reason, Mr. Khazali usually recommends that the Fallopian tubes are removed at the time of hysterectomy, even when ovaries are being preserved. Removal of fallopian tubes should not have any detrimental effects on you but may reduce your risk of developing ovarian cancer in later life by significantly.

Whether or not your ovaries are removed, depends on your age, the reason you are having a hysterectomy, whether or not your ovaries are healthy and most importantly, your personal preference. This will have been discussed with Mr. Khazali before the operation.

If you are still having your periods, removing your ovaries mean that you will go through menopause immediately after the operation. You may need to consider starting hormone replacement therapy (HRT) at least until the age of 50 to prevent your bones from becoming weak and fragile (osteoporosis).

Occasionally, the decision about removal of the ovaries will need to be made at the time of the operation. Make sure you let Mr. Khazali know what your preference is.

How is the procedure performed?

The procedure is done under general anaesthetic. This means you will be put to sleep. A small cut (incision) is made through the umbilicus (belly button) to pass the laparoscope. Further incisions (usually 2 or 3) are made above the bikini line and on the sides to pass the instruments. These cuts are usually between 5 and 10 millimetres long.

The uterus will then be carefully separated from its attachments and blood supplies, using various methods.

How is the uterus removed?

If the cervix is also removed (total hysterectomy), the uterus is usually removed through the vagina. If the cervix is retained (subtotal or supracervical hysterectomy), then an instrument called “morcellator” is used to cut the uterus into small pieces and remove the pieces through the small incisions on the abdomen.

Occasionally, a small bikini line cut is made to retrieve the uterus.

What is a Morcellator?

If you are due to have a subtotal laparoscopic hysterectomy, an instrument called “morcellator” will be used to cut the uterus to pieces and remove the pieces through the small holes on your abdomen. Of every 500 women who have this procedure, one will have an undiagnosed cancer and using a morcellator means that the cancer will spread into the abdominal cavity. Recently, there has been significant media attention to this risk, particularly in the US and the use of morcellators have been discouraged (in some places banned). In Europe, the advice is that there is a place for the use of morcellation and that the risk is small, however, this should be a joint informed decision by the patient and her clinician, having considered the risks throughly. Mr. Khazali will be happy to talk to you in detail about this as well as all other risks of surgery. For most women, the advantages of a minimally invasive route, outweighs the small potential risk.

Read a recent statement by the British Society for Gynaecological Endoscopy (BSGE) 

Morcellation may be used at total laparoscopic hysterectomy only when the uterus is unusually large.

How long will the procedure take?

Between 1 and 2 hours. It can take significantly longer if the procedure is complex. After the procedure, you will be taken to the recovery area to be closely monitored for a while. When you are fully awake, you will be taken back to your room.

What happens to the uterus after removal?

It is always sent to a pathology lab to be examined under the microscope to confirm there is nothing abnormal in the endometrium (lining of the womb) or the uterus wall (myometrium).

You can watch a video Mr Khazali has done for the Royal College of Obstetricians and Gynaecologists (RCOG) here, in which he explains how to recover well from a laparoscopic hysterectomy, or you can also visit the Royal College website for more information.