Which hysterectomy is better

Even today, many gynecologists who are graduating from residency programs do not feel comfortable performing advanced laparoscopic procedures upon graduation. This has led to the development of special fellowship programs in advanced laparoscopic surgery, where gynecologists spend additional one or two years performing a large number of advanced procedures perhaps at a center that specializes in minimally invasive surgery. Another problem is lack of patient awareness. Unfortunately, many patients are not aware that there are other options available to treat their condition and so they do not question their gynecologist when they suggest that the best plan of action is an abdominal hysterectomy.

An abdominal hysterectomy is of course warranted in certain cases and patients usually do not have enough knowledge to know when there is a clear indication for an abdominal hysterectomy and when there is not. Also, they may know that their mother or grandmother had an abdominal hysterectomy and consider this to be the normal way of performing the procedure. Yet anther problem is reimbursement. Gynecologists get paid about the same amount of money to perform a hysterectomy regardless of the technique used.

Since the abdominal approach is the easiest for most gynecologists and requires the least amount of training, there is not much impetus for gynecologists to learn to perform other procedures that initially will take them much longer to do and therefore slow down their practice.

Increased patient awareness will prompt patients to seek alternative surgical options for their problem. This will put pressure on gynecologists to seek additional training or refer their patients to high volume minimally invasive surgeons. A three level tier system should be in place.

First, gynecologists should perform simple vaginal hysterectomies or laparoscopic hysterectomies as long as they have sufficient experience and training to do so.

Second, when the average gynecologist feels uncomfortable performing a minimally invasive hysterectomy and would like to seek additional training, he or she should enlist the help of a high volume minimally invasive gynecologic surgeon who will help with the case, sharing his expertise and thereby potentially enabling the gynecologist to feel more comfortable with these cases in the future.

More challenging cases should be referred to a high volume minimally invasive surgeon, since it has been relatively well established that high volume surgeons have fewer complications and better patient outcomes than low volume surgeons, especially in complicated surgical cases.

Finally, national physician organizations should lobby policy makers and lawmakers to make them aware of this disparity so that reimbursement is increased for minimally invasive procedures that result in decreased pain and shorter time away from work and daily activities.

There are several alternatives that can be tried before performing a hysterectomy. Simply placing a hormonal IUD can significantly reduce menstrual bleeding and allow some women to avoid major surgery.

Uterine fibroid embolization or laparoscopic myomectomy can be minimally invasive options to a hysterectomy in women with uterine fibroids. A hysterectomy is a permanent solution for uterine fibroids, abnormal uterine bleeding and adenomyosis. It is also often helpful for women with endometriosis, although this is not always the case. Hysterectomies have traditionally been performed in many women with pelvic organ prolapse, but physicians have recently come to understand that the uterus is really just an "innocent bystander" and has nothing to do with the prolapse itself, since this is due to torn ligaments and weak connective tissue.

Hysterectomies are also commonly performed for cancer of the uterus and cervix. When these cases are very advanced however, it is better to leave the uterus in place, since these women will need radiotherapy and the uterus helps to shield other pelvic organs, such as the urinary bladder and the rectum.

The minimally invasive approaches to hysterectomy are vaginal hysterectomy and laparoscopic hysterectomy. Before discussing these techniques we will briefly describe the abdominal hysterectomy technique. In abdominal hysterectomy, the physician will make an approximately 15 cm incision on the belly. Most often these incisions are made above the hairline bikini cut , but sometimes the cut is running up and down, starting at the pubic hairline and sometimes going above the belly button vertical incision.

When dealing with a very large mass, the physician may elect to perform a vertical incision since this allows for better visibility and it gives more room to remove the mass through. The problem with the vertical incision is that it is less cosmetically appealing to most women and it is more painful.

Following the skin incision, there are several layers of the abdominal wall that the surgeons needs to cut through. These are fat, fascia strong tissue that holds the abdominal organs in place , muscles and peritoneum thin lining of the inside of the abdominal cavity. Sometimes it is necessary to cut the muscles to get more room, but most often they are split in the middle and pushed to the sides. Once inside the abdomen, the bowel is usually pushed away using large sponges and a retractor is put into the incision to keep it maximally open so that the doctor can see better what he or she is doing.

Retractors come in many shapes and sizes, but usually have a locking system in place, so that once they have been set in a certain way they stay put. The uterus is identified and the physician clamps the attachments and blood vessels of the uterus, cuts the attachments and places sutures to prevent any bleeding.

The uterus needs to be freed from its attachment to the ovaries, ligaments, urinary bladder and vagina. This can be difficult at times, especially if there are adhesions scar tissue from previous surgeries, in the case of endometriosis or a very large uterus. Once the uterus is completely freed it is removed through the abdominal incision. The top of the vagina is sutured with suture that will go away on its own over a period of weeks. Once the surgeon is happy that there is no bleeding, all instruments and sponges are removed from the abdomen and the abdominal incision is closed in a few layers.

Most abdominal hysterectomies are so called total abdominal hysterectomies TAH. This is in contrast with a supracervical hysterectomy SCH. In a total abdominal hysterectomy, the cervix is removed whereas in a supracervical hysterectomy the cervix is left in place.

Robotic-Assisted surgery provides the surgeon with a superior surgical tool for dissection and removal of lymph nodes during cancer operations, as compared to traditional open or minimally invasive approaches. At the Johns Hopkins Hospital, our surgeons also perform a pelvic lymphadenectomy with staging during a hysterectomy for suspected or confirmed gynecological cancers.

By performing this at the same time as the hysterectomy, our physicians receive real time critical information that may affect the surgery and treatment. Robotic-Assisted Radical Total Laparoscopic Hysterectomy usually takes hours under general anesthesia. You will be hospitalized for at least one night so your physicians can monitor your healing progress.

Most patients return to normal daily activities within one week. Your physician will give you detailed instructions so your recovery is unremarkable. Our surgeons are committed to providing the best treatment option for every individual patient.

While radical hysterectomy or abdominal hysterectomy performed using robotic-assisted surgery is considered safe and effective, these procedures may not be appropriate for every patient. Always ask your doctor about all treatment options, as well as their risks and benefits. Request your next appointment through My Chart! Whether you're crossing the country or the globe, we make it easy to access world-class care at Johns Hopkins. Learn more about pregnancy and childbirth in the Johns Hopkins Health Library.

Take a tour of our birthing centers. Visit one of our convenient patient care locations. Other times, it runs up and down on the abdomen. Drawbacks to this traditional technique include increased pain after surgery, greater risk of complications and longer recovery time.

In this procedure, the uterus is removed through a small incision inside the vagina, with no abdominal incisions. This minimally invasive technique generally causes fewer complications, less pain, and faster recovery than open procedures. This technique may not be possible with a larger uterus or when the surgeon wishes to evaluate other structures in the abdomen.

In this minimally invasive procedure, several thin instruments and a tiny video camera attached to a telescope are inserted through multiple small incisions in the abdomen. The surgeon can remove the uterus through a vaginal incision, a larger abdominal incision or by breaking it up into small pieces through a small abdominal incision.

This technique leads to fewer complications, less pain and faster recovery compared to an open procedure. Robotic hysterectomy is a type of laparoscopic surgery that uses a robot. This allows surgeons to perform more complex procedures and finer dissections. This technique also results in fewer complications, less pain and faster recovery compared to an open procedure.

Recovery is essentially the same as traditional laparoscopic surgery. Hysterectomies are generally safe, but problems can occur as is the case in any necessary surgery.

Risks include infection, bleeding, damage to nearby organs bladder, intestines , reactions to anesthesia and blood clot formation.