Beads of cold sweat dripped from her forehead. Her face was as white as a sheet. Her extremities were cold and clammy. Her pulse was rapid and blood pressure was low. She was bleeding profusely from the vagina. L, a 43 year- old housewife was rushed to the hospital by her husband in a state of ” shock”. She had been having “menstrual bleeding” on and off for a month and had passed out clots for the past 5 days. She felt very weak and collapsed at home. After resuscitation with intravenous fluid and blood transfusion, L’s condition improved. Ultrasound examination of her uterus showed a huge fibroid about 10 cm in diameter. “Doc, I should have it removed 4 years ago when it was only 5 cm," she sighed. “ I was so scared of having an operation that I avoided seeing the doctor after that and only took some Chinese herbal tonics every month after my menses.” When her condition stabilized, I discussed various options of treatment with her and her spouse. She finally decided to have her womb removed with conservation of the ovaries. This was performed successfully by key-hole surgery. She was discharged well on the third day after operation.
Removal of the womb or hysterectomy is a common gynaecological operation. It is done for the following conditions:
• Cancer of the uterus, cervix, or ovaries
• Uterine fibroids: These are non-cancerous growths in the muscle wall of the womb causing pain, bleeding, or pressure symptoms
• Uterine prolapse: The womb protrudes out of the vagina causing severe discomfort
• Endometriosis: Backflow of menstrual blood into the pelvic cavity causing severe menstrual cramps and/or pain during sexual intimacy
• Chronic pelvic infection: Usually from sexually transmitted diseases- with severe menstrual pain and pain during sexual intimacy
• Adenomyosis: This occurs when the lining of the womb grows into its muscular wall and causes severe menstrual pain and heavy bleeding
TYPES OF HYSTERECTOMY
There are 3 types of hysterectomy:
1. Total hysterectomy: The whole womb is removed together with the neck of the womb (cervix)
2. Subtotal hysterectomy or partial hysterectomy: Only the upper part of the womb is removed, leaving the cervix behind
3. Radical hysterectomy: The whole womb, tissue on the sides of the womb, the neck of the womb (cervix) and the top part of the vagina are removed. This operation is done when cervical cancer is present.
APPROACHES OF HYSTERECTOMY
Hysterectomy can be done through the abdomen or vagina depending on the surgeon’s experience, previous history of abdominal surgery, the reason for the hysterectomy, and the overall health of the patient.
1. Abdominal approach:
This can be done through open surgery or key-hole surgery.
Open surgery is the traditional approach. An incision of 10 to 20 cm is made either vertically or horizontally across the abdomen. The pelvic cavity is entered and the uterus removed. The hospital stay is about 3-4 days if there are no complications.
Key-hole surgery is done using a laparoscope ( a telescope with a lighted camera) and delicate surgical tools. These are inserted through several small cuts, measuring 0.5 cm to 1 cm in diameter, in the abdomen. The surgeon performs the operation from outside the body, viewing through a video screen or a sophisticated robotic system.
Key-hole surgery offers a number of benefits compared to the traditional open surgery. Recovery is faster with shorter hospital stays. Scars are smaller and post-operative pain is much less. There are less chances of wound infection and adhesions from the intestines and other abdominal organs
The surgeon makes a cut in the vagina and removes the uterus through the incision which is then closed, leaving no visible scar.
RISKS OF HYSTERECTOMY
Most women who undergo hysterectomy have no serious complications. However, as with any surgery, complications may arise in a small minority of women. These include:
• Excessive bleeding
• Wound infection
• Adverse reaction to anaesthesia
• Damage to the urinary tract, bladder, rectum or other pelvic structures during surgery, which may require further surgical repair
• Urinary incontinence
• Vaginal prolapse (part of the vagina "prolapsing" out )
• Chronic pain in the abdomen
• Pulmonary embolism from blood clots in the veins of the pelvis
If the ovaries are removed together with the womb, the patient will experience menopausal symptoms straight away. She may require hormone replacement therapy or alternative treatment to manage her menopause. If the ovaries are conserved, studies have suggested that the patient may enter menopause earlier. Full recovery usually takes several weeks. Activities such as lifting heavy objects should be avoided.