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By Paul MacKoul, MD – Laparoscopic GYN Surgeon and Co-Founder of CIGC.

Types of Hysterectomy Procedures ​

Though a hysterectomy is a GYN surgical procedure which simply refers to the removal of the uterus, including the cervix, there are variations available. A total hysterectomy removes the uterus, cervix, tubes, and ovaries. A partial hysterectomy removes only the uterus. Patients undergoing a partial hysterectomy retain their ovaries, so therefore they do not go into menopause — as the ovaries are what make hormones, not the uterus. A supracervical hysterectomy means removal of the uterus ABOVE the cervix, thereby leaving the cervix in place. It should be noted that any type of hysterectomy should also involve removing the fallopian tubes. This has been associated with a 30% decreased risk of developing cancer of the ovaries/tubes, so should always be performed.

Anatomy of Pelvis
Anatomy of the Pelvis
Supracervical Hysterectomy
Partial Hysterectomy
Complete Hysterectomy

Retroperitoneal Dissection: DualPortGYN and ARH Techniques

DualPortGYN and ARH procedures use retroperitoneal (RP) dissection. Retro (behind) peritoneal (the lining) dissection allows the surgeon to visualize the anatomy behind the lining. Standard, robotic, and open hysterectomy procedures do not, in general, use RP dissection.

The retroperitoneal space is an area that is normally covered by a lining called the peritoneum. This lining covers important structures such as:

  • The Uterine artery
  • Ureter
  • Lower portion of the bladder
  • Large vessels of the pelvic and nerves

Retroperitoneal dissection is the safest way to access all vital structures in the pelvis, and avoids bleeding and injury to surrounding structures such as the ureter and bladder. This approach is NOT commonly used by OBGYN’s and specialists performing GYN surgery, since it is difficult to master, and requires special training. When used properly however, this technique provides excellent results, is safe, and avoids major complications to the ureter, bladder, and bowel. Each structure in the space is discussed below.

Once the retroperitoneal space has been opened, the vital structures of that space have essentially been mapped out, or identified. The following diagram shows the difference between not opening the retroperitoneal space on the left, and opening the space with vital structures clearly marked.

body mapping

The Uterine Artery. By using this approach, the uterine artery can be ligated, or blocked, at its takeoff point from the large vessel in the side of the pelvis, the internal iliac artery. This has many advantages, the most important being that blockage of the uterine arteries at this level allows for excellent blood control to the uterus and avoids many problems associated with excess bleeding if the vessels are ligated at the side of the uterus where many other vessels such as veins are located. In the picture below, the exact location of ligation of the uterine artery in the retroperitoneal space is shown in green on the right, whereas with standard laparoscopic approaches, the uterine artery is ligated at the side of the uterus, on the left, where many other vessels are located, often leading to bleeding at this point.

The Ureter. Note in the diagram how close the ureter is to the uterine artery, whether the artery is blocked at the side of the uterus or in the retroperitoneal space. Ureterolysis, or removal of adhesions involving the ureter, allows for safe and effective isolation of the artery to avoid ureteral injury. This is especially important for removal of a very large fibroid uterus, or patients with endometriosis or prior surgery. Opening the retroperitoneal space allows the surgeon to fully access and visualize the ureter, something that is NOT possible with standard laparoscopic procedures.

The Bladder and Rectum. Although not shown on this diagram, the bladder lies on top of the uterus, and can be scarred to the uterus at the time of Cesarean Section. The rectum lies below the uterus, and can be scarred from endometriosis or prior surgery. Opening the retroperitoneal space allows the bladder to be isolated away from the uterus using a technique called “lateral bladder dissection” which safely and effectively dissects the bladder off the uterus to avoid injury. This is very helpful in many patients with prior Cesarean Section, or those with prior surgery involving the bladder, and for those patients with extensive endometriosis. Opening the retroperitoneal space also allows the rectum to be isolated from the side, further decreasing risk of injury to the rectum during a complicated surgery.

Large Vessels and Nerves. Dissection of the retroperitoneal space identifies the large vessels to the side of the body, and avoids direct injury as well as to nerves.

Surgical Techniques

DualPortGYN Hysterectomy
The DualPortGYN® hysterectomy is a minimally invasive procedure which uses two 5 mm incisions to perform the surgery, along with the retroperitoneal dissection technique. Retroperitoneal dissection effectively maps the anatomy of the pelvis, so that all vital structures are identified completely to avoid injury. This allows the DualPortGYN hysterectomy to be performed safely and effectively. Referring to the diagram and video in the above section, the bladder, ureters, large vessels, bowel, and nerves are clearly identified with retroperitoneal dissection. Mapping allows the surgery to be performed with only two small incisions faster, safer, and with less blood loss and complications compared to other forms of hysterectomy, such as standard laparoscopy and all forms of robotic surgery.
  • Two 5mm (1/4 inch) incisions only, located at the belly button and just above the pubic bone
    • Incision location is between the abdominal muscles, thereby avoiding the bleeding and pain seen with conventional and robotic procedures in which the trocars — or ports — are placed through the muscles
    • Incision size and location avoid herniation of bowel through the incision site
  • Excellent cosmetic result with almost invisible scars after surgery
  • Can be used for patients with prior cesarean section and other prior pelvic surgical procedures
  • An excellent alternative for patients who are not candidates for vaginal hysterectomy
  • Full access to the pelvis to evaluate and treat endometriosis, scar tissue for pelvic pain, and ovarian cyst removal
  • Minimal pain, very fast recovery with discharge from the hospital or surgical center the same day, and back to work usually at seven to 10 days
  • Electronic morcellation is never used, thereby eliminating any potential spread of cancer through fibroid removal
  • DualPortGYN hysterectomy replaces open, laparoscopic, or robotic procedures that have larger incisions, more pain, higher complication rates, and longer recovery times
  • DualPortGYN is far less expensive, decreasing costs to the patient and the healthcare system
    • Compared to conventional or robotic procedures, DualPortGYN results in savings of $5,000 over robotics, and $3,000 over standard laparoscopy1
  • Can be used to remove fibroids and the uterus up to 5,000 g
    • The average uterus weighs between 70 and 100 g so almost all patients are candidates for this approach
  • Ninety-five percent of women are candidates for this minimally invasive approach
    • Robotic, standard laparoscopic, and open surgery are not required and should not be performed if the surgeon is skilled in this approach to laparoscopy. DualPortGYN is faster, safer, and has lower complication rates than these procedures, and is, therefore, the procedure of choice.

Five ports in place used for a robotic hysterectomy

Four ports in place used for a robotic hysterectomy

Advanced Retroperitoneal Hysterectomy (ARH)
The advanced retroperitoneal hysterectomy (ARH) is a form of the DualPortGYN technique performed on those patients that have a very large uterus, have a large pelvic mass, extreme endometriosis, and/or have very extensive scar tissue that requires more than two ports to complete the surgery. In these patients, the use of one to two additional 5 mm (1/4 inch) ports is needed to ensure the procedure is completed laparoscopically. The technique of retroperitoneal dissection is used extensively in these operations, and in greater than 95 percent of patients prevents the need for an open incision surgery. Many patients who would otherwise have had an open or robotic surgery using larger incisions can have an advanced retroperitoneal hysterectomy, thereby preventing the severe pain, longer recovery time, and higher complication rates.

DualPortGYN Technique - Before and After

Uterus removed

  • Retroperitoneal hysterectomy prevents open or robotic procedures that have larger incisions, more pain, higher complications, and longer recovery times
    • Using this technique, most patients are candidates for this minimally invasive approach
  • Three to four 5 mm incisions can remove even the largest fibroids or uterus
  • The uterus is removed vaginally in most cases
    • For massive fibroid cases, a 3 to 4 cm incision (1.5 inches) is used to remove the fibroid through an incision in the bikini line
Fibroids and Infertility
  • Discharge the same day, with a recovery time of seven to 10 days, with minimal pain
  • Can be used for patients with prior cesarean section and other prior pelvic surgical procedures and very heavy patients including the morbidly obese
  • An excellent alternative for patients who are not candidates for vaginal hysterectomy
  • Full access to the pelvis to evaluate and treat endometriosis, scar tissue for pelvic pain, and ovarian cyst removal
  • Minimal to no scarring
  • Total incision length can be increased with this procedure, but will still remain far smaller than robotic and open procedures.

Other Procedures

Laparoscopic Hysterectomy (Standard)
This standard procedure uses between three and five incisions, ranging in size from 5 to 15 mm. This conventional approach to laparoscopic hysterectomy is used by laparoscopic specialists and OBGYN surgeons. Standard conventional laparoscopy is preferred to robotics or open procedures. The incisions are smaller and the recovery can be faster. Standard conventional laparoscopy does not use retroperitoneal dissection techniques, and can be limited in the extent of surgery performed. It is important to understand that not all surgeons performing this technique have the same skills or experience.The results with conventional laparoscopy depend on the training and focus of the surgeon doing the procedure.
  • Three to four incisions, 5 mm to 1.5 cm in length, located in the pelvis
  • Fast recovery with discharge home usually the next day, back to work in two weeks
  • Can be used for patients with prior cesarean section and other prior pelvic surgical procedures, as well as for very heavy patients
  • An excellent alternative for patients who are not candidates for vaginal hysterectomy
  • Full access to the pelvis to evaluate and treat endometriosis, scar tissue for pelvic pain, and ovarian cyst removal
  • Good cosmesis
  • Non-retroperitoneal approach with increased risk of bleeding, injury to surrounding organs compared to DualPortGYN or retroperitoneal hysterectomy
  • Limited success with extreme endometriosis, massive fibroids, large pelvic masses, with possible conversion to an open procedure
  • Larger size and number of incisions, as compared to vaginal hysterectomy and DualPortGYN procedures
  • Higher complication rates seen in patients undergoing these procedures with the average OBGYN surgeon
    • Patients should not undergo these procedures with OBGYNs that have not had sufficient training or expertise in this approach
  • Total incision length, abdominal wall: 1.5 to 3.5 cm

Robotic Hysterectomy

Robotic techniques have recently been applied to benign GYN surgery with some controversy. In general, robotic procedures enable an OBGYN not well trained or comfortable with DualPortGYN, retroperitoneal, or conventional laparoscopy to complete a hysterectomy through a minimally invasive approach.In fact, all minimally invasive procedures are not the same. According to the American Association of Gynecologic Laparoscopists (AAGL), robotic-assisted laparoscopic surgery should not replace conventional laparoscopic or vaginal procedures for women who could otherwise undergo conventional laparoscopic or vaginal surgery for benign gynecological diseases.Robotic hysterectomies use up to five incisions located throughout the pelvic and abdominal cavity, often placed through the abdominal wall musculature. This means the incisions are often located above the belly button to the right and left sides of the abdomen. The size of the incisions is larger, and range between 8 mm and 1.5 cm, totaling up to 50 mm in length. Single site robotic approaches use one larger incision at the umbilicus (belly button) for surgery. This incision can be much larger than even standard laparoscopy, and the procedure itself has significant limitations for the removal of more complex cases or larger uteri. There is also a higher herniation rate with single site procedures, in which the bowel can herniate through the abdominal wall. As a comparison, DualPortGYN procedures use only two incisions at 5 mm each to perform the exact same procedure. The total incision length for DualPortGYN is 10 mm, 1/5 the size of the standard robotic approach, and 1/3 or less the size of single site
Single Site robotic hysterectomy. With this procedure, the incision is 3 to 3.5 cm localized to the umbilicus. Single site robotics are signficantly limited in the size and complexity of hysterectomy performed.
  • Comparative studies of robotic procedures to conventional laparoscopy have shown no clinical advantage (AMA, AAGL, ACOG)
    • This means that patients who underwent a robotic procedure did not do better than patients undergoing a conventional laparoscopy, despite the higher technology and higher cost of robotics2
  • Significantly higher cost, as compared to conventional laparoscopy
    • Robotics cost $5,000 more than the DualPortGYN approach, increasing costs to the patient and the healthcare system
  • Increased size and number of incisions, as compared to other laparoscopic procedures with possible increasing pain and longer recovery
  • Placement of incisions throughout the abdomen and pelvis, with larger incisions increasing the risk of herniation
  • Increased complication rates and breakdown of the vaginal “cuff” for hysterectomy
  • Standard use of “bipolar cautery” for coagulation of vessels, which increases the risk for thermal injury versus other methods

Open Abdominal Hysterectomy

Open abdominal hysterectomy is still the most common method used for hysterectomy in the US. This operation uses a large incision, either horizontal or vertical, to open the abdomen and remove the uterus. The reason most patients undergo an open abdominal hysterectomy is the limited laparoscopic training of their OBGYN. Beware of explanations of how “your uterus is too large to remove laparoscopically,” “you are too heavy,” or “you have had a cesarean section.” There are much better approaches to a hysterectomy for almost all patients and any size uterus, resulting in much faster recovery, less pain, and fewer complications than open procedures. Open surgery, with an eight-week recovery time, is almost completely eliminated using DualPortGYN procedures. There are rare cases in which open surgery is necessary — discuss the options to open surgery with your surgeon so that you are ensured of the best possible approach to hysterectomy.

open incision
Open Hysterectomy Incision, Standard Transverse
open incision
Open Hysterectomy Incision, Transverse, with breakdown. Large open incisions and complications such as wound breakdown can be avoided using DualPortGYN or LAAM techniques.

Vaginal Hysterectomy

Vaginal hysterectomy is the removal of the uterus, with or without the tubes and ovaries, completely through the vaginal opening. This procedure does not use any incisions in the abdominal wall.

Studies by The Center for Innovative GYN Care® (CIGC®) have shown that DualPortGYN hysterectomies offer a significant advantage over vaginal hysterectomies. These include a greater capacity to remove very large uteri, the ability to diagnose and treat other conditions at the same time which cannot be seen with vaginal hysterectomy (endometriosis for example), and overall a better recovery time, lower costs, and lower complications than the vaginal approach. In addition, DualPortGYN can perform hysterectomy in almost any patient, regardless of their prior surgical history, and is a better option for those patients who have never delivered vaginally.

Hysterectomy Recovery

What to Expect After a Hysterectomy
After undergoing a hysterectomy, possible side effects to expect include:
  • Pain
    • General pain: Pain should resolve over time and will get better every day
      • If pain persists or becomes worse, a visit to the ER is recommended
    • Pain around the incision sites: Minimal to moderate pain around the incision sites is common, and is expected to resolve over several days
    • Pelvic and rectal pain: Pressure and pain with urination or with bowel movements can occur due to irritation to the rectum and bladder from the surgery, and will resolve with time
    • Chest and shoulder pain: During the procedure, the surgeon will use carbon dioxide gas to insufflate the abdomen and be able to see. This can irritate the phrenic nerve, leading to mild to severe pain which can occur during deep breaths. This nerve tracks pain impulses from the lining of the chest cavity. If the pain is extreme or does not resolve within two to three days, a visit to the local ER is indicated to rule out other causes of chest pain, such as heart or lung issues.
  • Bruises
    • Bruises sometimes develop at the incision sites, and will resolve on their own. Sometimes trocars used during surgery (for the incision sites) cut tiny vessels just beneath the skin, causing limited bleeding.
  • Bleeding
    • Vaginal spotting can occur during the first week after surgery, and should resolve shortly after. If you have increased or heavy bleeding, a foul odor, or if you experience urinary or rectal bleeding, call your physician.
  • Nausea
    • Anesthesia causes nausea immediately after surgery, and can later be caused by narcotic pain medication or antibiotics. If you experience severe nausea, please call your doctor.
  • Swelling
    • Abdominal swelling: Mild to moderate abdominal distension (swelling) is common after surgery due to irritation of the intestines. This will resolve over time.
  • Constipation
    • Constipation can cause severe pain that can get worse with increased amounts of medication. If you experience constipation, drink lots of fluid and eat a high fiber diet. You may also use a mild laxative, such as Milk of Magnesia, or a stool softener, such as Colace. No prescription is required for either.
  • Diarrhea
    • Diarrhea is sometimes caused by antibiotics and will resolve once the antibiotics are stopped. A probiotic such as lactobacillus can help with this process. Rarely, severe diarrhea can develop. Call your doctor if you have severe diarrhea, bloody diarrhea, or if your diarrhea is accompanied by fever or worsening pain.
  • Urinary retention
    • Urinary retention is the inability to pass urine through the bladder. A very small number of patients will develop this problem due to the anesthetic used for the surgery. Most patients will have their bladder catheter removed immediately after the surgery. If you are sent home and are not able to pass urine, please go to a local ER. A catheter will be placed to allow the bladder to rest after the surgery and will be removed no less than five days after the surgery. It is important to have this catheter placed to avoid injury to the bladder.

Hysterectomy Recovery Time

The information below provide insights into proper recovery time after undergoing a hysterectomy for various aspects of your daily life.

  • Getting back to work
    • Most patients are back to work in seven to 10 days after a DualPortGYN hysterectomy. After ARH procedures for removal of very large uteri, recovery can be up to two weeks, but often is similar to the DualPortGYN procedure.
  • Sex
  • Driving after surgery
    • You may drive only after you have stopped taking narcotics, and if you feel strong enough to be able to stop the vehicle in case of an emergency. If you are not confident, have someone drive you.

Hysterectomy Recovery Tips

The tips below provide information that ensures proper recovery after undergoing a hysterectomy.

  • If indicated, you will be given a written prescription for pain medication the day of surgery
    • Narcotics should be used sparingly since they will cause constipation. It is safe to use a heating pad on the lower abdomen to help relieve pain. Coughing can be uncomfortable initially, placing a pillow on the abdomen for support can help.
  • When starting an exercise routine after surgery, use caution and start out slowly, gradually increasing time, distance, and speed
  • During your recovery, avoid lifting, swimming, and heavy exercise

Changes After Hysterectomy

Hormone Effects
  • If having a hysterectomy before natural menopause, if only the uterus, cervix, or fallopian tubes are removed, periods will cease, but hormone production should not be affected
    • This type of partial hysterectomy will not result in menopausal symptoms
  • Only a hysterectomy with a bilateral oophorectomy (ovaries are removed on both sides) procedure will induce menopause
    • For this type of complete hysterectomy, estrogen replacement therapy can often be used with excellent results, and without an increased risk of breast cancer. Estrogen-only therapy is safe to use per the Women’s Health Initiative study, and will help prevent menopausal symptoms such as hot flashes, night sweats, mood swings, anxiety, depression, vaginal dryness, painful intercourse, as well as prevent osteoporosis. When considering estrogen therapy after your hysterectomy procedure, talk with your physician. Be sure your physician understands the results of the Women’s Health Initiative and what this means to you after hysterectomy.

Hysterectomy Risks and Complications

Additional risks and complications after a hysterectomy include:

  • Blood clots
  • Infection
  • Excessive bleeding
  • Anesthesia reaction
  • Damage to bladder, rectum, bowel, urinary tract, vessels, or nerves
  • Early-onset of menopause
  • Death (rare)

The CIGC Difference

CIGC surgeons are fellowship-trained, minimally invasive surgeons who are dedicated to the development of techniques and procedures that optimize surgical care and recovery for women.If your standard OBGYN is qualified to perform gynecological surgery, you may be considering having him or her perform your hysterectomy procedure. Here is something to consider: an OBGYN performs an average of 10 to 15 hysterectomies per year, while CIGC surgeons perform an average of 400. By focusing solely on minimally invasive GYN surgery, our patients benefit from our experience and skill. We are specialists.As blood loss is one of the most concerning aspects of GYN surgery, Uterine Artery Ligation/Occlusion (UAL or UAO) is a technique used by CIGC surgeons to control the loss of blood during the procedure, and to prevent complications both during and after the surgery. This is an important skill that is essential to performing CIGC procedures, and requires special training. Many women with complex GYN conditions often have uncontrolled bleeding during the surgery. Without using these techniques, non-CIGC surgeons often have to convert to open surgery, which increases risks, recovery time, and pain. More concerning is the potential for injury to other structures near the areas of bleeding, such as the ureter and bladder, which can lead to complications and additional surgery.
Prior to your surgery:
  • All patients need to complete preoperative testing within 14 days of the surgical date
    • Fax all preoperative testing results to your surgeon’s office at least five days prior to surgery, unless instructed otherwise. A nurse will contact you one to two days before your scheduled day of surgery to review your medical history and preoperative instructions
  • You cannot have anything to eat after midnight the night before the procedure
  • Do not take any aspirin products or blood thinners one week prior to your surgery
  • Bathe or shower with Hibiclens soap (found at the drugstore) the day of or the night before the surgery
  • Wear loose fitting clothing, and no jewelry or make-up or creams/lotions on your skin
  • Please bring your insurance card and picture ID and any form of copay
  • The surgery scheduling team will send to your local pharmacy the appropriate prescriptions for after surgery
  • All patients must have an adult escort to take them home due to anesthesia; you may not go home in a taxi unaccompanied
  • If you have any preoperative or postoperative questions, please contact your surgeon’s office

Hysterectomy FAQs

Does a hysterectomy include cervical removal?

Yes, in general, a hysterectomy refers to removal of only the uterus and the cervix. There is no benefit to keeping the cervix, and if retained, patients will still need annual well woman exams to check for cervical cancer.

Is there a benefit to keeping the cervix and removing just the top of the uterus?

No. Unfortunately, there is much incorrect information about the cervix on the internet, or from OBGYNs that believe keeping the cervix is better than removing it. Patients should seek out the expertise of an experienced laparoscopic surgeon to remove the cervix during the surgery. There are no advantages to leaving the cervix in place when a skilled laparoscopic surgeon is performing the procedure.

The disadvantages of not removing the cervix include:
  • In up to 11 percent of patients, vaginal bleeding can occur from the retained cervix after the procedure on a monthly basis
  • Pap smears need to be performed due to potential for precancerous or cancerous conditions of the cervix
  • Surgical removal of the cervix at a later date may be necessary due to bleeding, precancerous or cancerous conditions, or pain
Does the removal of the cervix decrease lubrication during intercourse or cause pain with intercourse?

No. Removing or keeping the cervix has no effect on lubrication during intercourse. Several studies  looked at patients who underwent supracervical hysterectomy (retaining the cervix) or partial hysterectomy (removal of the uterus and cervix), and compared the results3,4. They found no difference in lubrication.

Does the removal of the cervix lead to the prolapse or “drop-down” of the bladder, vagina, or rectum?

No. Comparison trials have shown that removing the cervix does NOT increase the rate of prolapse of the bladder, rectum, or vagina5.

Ready for a Consultation

If you’re considering a hysterectomy for fibroids, our specialists are ready to provide an evaluation of your symptoms and condition(s) and recommend an appropriate solution.


1 Danilyants N, MacKoul P, Baxi R, et al. Value-based assessment of hysterectomy approaches. J Obstet Gynaecol Res. 2019 Feb;45(2):389-98

2 Rosero EB, Kho KA, Joshi GP, et al. Comparison of robotic and laparoscopic hysterectomy for benign gynecologic disease. Obstet Gynecol. 2013 Oct;122(4):778-86

3 Mokate T, Wright C, Mander T. Hysterectomy and sexual function. J Br Menopause Soc. 2006 Dec;12(4):153-7

4 Rhodes JC, Kjerulff KH, Landenberg PW, et al. Hysterectomy and sexual functioning. JAMA. 1999 Nov 24;282(20):193-41

5 Blandon RE, Bharucha AE, Melton LJ 3rd, et al. Incidence of pelvic floor repair after hysterectomy: a population-based cohort study. Am J Obstet Gynecol. 2007 Dec;197(6):664.e1-7.