HYSTERECTOMY
By Paul MacKoul, MD – Laparoscopic GYN Surgeon and Co-Founder of CIGC.
Last updated: July 7, 2021
Hysterectomy Types and Techniques
Having a hysterectomy involves several important decisions for the patient and doctor, most notably concerning the type of hysterectomy — meaning which organs are involved — and the surgical technique, or approach, used to perform it.
A surgeon considers several factors when recommending both the type of hysterectomy and the method used to access the organs. These factors include any underlying diseases, health conditions, the size of the uterus and the patient’s age and preferences.
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Hysterectomy Types
CIGC’s fellowship-trained experts have performed thousands of hysterectomies and can help determine what type of procedure is right for you.
Partial Hysterectomy without removal of the ovaries
Partial hysterectomy means that only the uterus, tubes, and cervix are removed. The ovaries are not removed, so menopause will not occur. Any hysterectomy type performed should always remove the fallopian tubes, since this will significantly decrease the risk of tubal cancer.1
Supracervical Hysterectomy
In a supracervical hysterectomy, the cervix is kept intact. The uterus is removed above (“supra”) the cervix. The fallopian tubes are removed and the ovaries can either be removed or retained.
Complete Hysterectomy with Removal of the Ovaries
Complete hysterectomy means that the uterus, fallopian tubes, and cervix are removed along with the ovaries. It is important to understand that the ovaries make the important female hormone estrogen, not the uterus. Since the ovaries are removed, estrogen will no longer be made, and menopause will result. For patients in menopause, estrogen therapy is a very safe and effective option to control menopausal symptoms and can be started immediately after the procedure.
Hysterectomy Techniques
Hysterectomy procedures can be performed through three different approaches: laparoscopic (minimally invasive), vaginal (through the vagina), or open (through a large incision).
Laparoscopic hysterectomy is performed through a standard approach, robotics, or DualportGYN. CIGC surgeons exclusively perform DualportGYN procedures, and do not perform robotic or open surgery for hysterectomy. DualPortGYN® is an advanced surgical approach that allows the patient to go home the same day. It requires less time under anesthesia and just two small incisions. Patients experience less pain, smaller incisions, fewer complications and a shorter recovery time compared to robotic or standard laparoscopic methods.
DualPortGYN Compared to Other Hysterectomy Methods
Results published in Gynecological Surgery
Comparative results for Open Hysterectomy estimated from literature review of comparable studies.
DualPortGYN Hysterectomy: The CIGC Choice for Laparoscopic Hysterectomy
The DualPortGYN hysterectomy is also known as laparoscopic retroperitoneal hysterectomy (LRH). It is a minimally invasive procedure that uses just two 1/4-inch incisions — one through the belly button and the other at the bikini line. The two key elements to this technique are called retroperitoneal dissection (RPD) and uterine artery ligation (UAL).
Retroperitoneal dissection involves entering the peritoneum, which is a filmy “blanket” covering the reproductive organs. This route lets the surgeon map the anatomy of the pelvis so that nearby vital structures — including the bladder, ureters, bowel and nerves — are clearly identified to reduce the risk of injury. Retroperitoneal dissection is a technically difficult procedure and should be performed by specially trained, high-volume surgical experts.
GYN Oncologists or GYN Oncology trained surgeons master Retroperitoneal Dissection as part of their training. CIGC surgeons are GYN Oncology trained and have been trained exclusively in the RPD approach and use it for all hysterectomy procedures performed. OBGYN’s and Laparoscopic Fellowship trained surgeons in general are not GYN Oncology trained, have minimal exposure to the RPD approach, and do not use it routinely for surgery.
Uterine artery ligation, or clamping the uterine artery, is one of the most important aspects of DualportGYN hysterectomy. By ligating the uterine artery in the retroperitoneal space, blood loss is far better controlled than ligation of the artery at the side of the uterus as with robotic and standard laparoscopic hysterectomy. This dramatically decreases complications and operative times and allows for removal of very large fibroid uteri.
- Safety of the DualportGYN approach leads to fast operative times and very low complication rates. The RPD approach controls bleeding, identifies structures, and avoids injury to the bladder and large vessels.
- Uterine artery ligation for control of bleeding
- Ureter (tube that drains urine from the kidney to the bladder) identification
- Lateral bladder dissection to isolate and avoid injury to the bladder
- Superior Recovery
- Patients go home the same day.
- Patients are usually back to their normal routine in about seven days.
- Cosmetic results are excellent. Two small scars are barely visible just a few months after surgery. Keeping the incisions as small as possible leads to less pain and a quick recovery.
- Overall, 95% of women are candidates for this minimally invasive approach, including:
- Heavy or Obese Patients
- DualPortGYN can be used for heavier patients with a high body-mass index (BMI)
- Very large or “massive” fibroid uteri patients are candidates.
- A third ¼ inch incision is sometimes used in these instances.
- Previous Surgery or Cesarean Section
- Patients with multiple prior surgical procedures/Cesarean section are good candidates for this procedure.
- Patients with multiple prior surgical procedures/Cesarean section are good candidates for this procedure.
- Heavy or Obese Patients
- Those patients with endometriosis can have endometriosis excision and scar tissue treated with this approach.
- The Technique of Choice
- Because DualPortGYN is faster, safer and has lower complication rates2 than other hysterectomy methods, it should be the technique of choice for surgeons skilled in this approach to laparoscopy.
- Because DualPortGYN is faster, safer and has lower complication rates2 than other hysterectomy methods, it should be the technique of choice for surgeons skilled in this approach to laparoscopy.
- DualportGYN compared to robotic or standard approaches
- Faster operative times
- Smaller overall size and number of incisions
- Lower complication rates
- Less pain
- Faster recovery
- Performed in the ambulatory surgical center outpatient setting to decrease infection, Covid and increase patient satisfaction
- Conversion to open surgery is less than 1%
- Lower cost to the patient and healthcare system
Because it requires a high degree of advanced training and is difficult to master, CIGC specialists are among the few hysterectomy specialists nationally and internationally routinely using the DualPortGYN surgical approach.
Other Surgical Approaches
CIGC surgeons do not use Robotic, Standard Laparoscopic, Vaginal, or Open surgery to perform hysterectomy. Please refer to published studies by CIGC comparing hysterectomy approaches for further information and verification in this website.
For completeness, a short summary of these procedures is included.
Robotic Hysterectomy
In a robotic-assisted laparoscopic surgery, the surgeon sits at a console several feet away from the patient and electronically manipulates a multi-armed surgical instrument unit placed over the surgical area, while a camera provides 3D, magnified viewing. An assistant is at the patient’s side.
- As with other methods, when compared to open procedures robotic hysterectomy results in a lower rate of complications, less blood loss, a shorter hospital stay and less post-operative pain. Recovery is also several weeks shorter.
- Compared to the standard laparoscopic method, robotic hysterectomy has a lower rate of mid-procedure conversion to open surgery.
- Robotic equipment enables an OBGYN trained in open hysterectomy, not laparoscopy, to perform a minimally invasive procedure. As a result, when compared to the DualportGYN approach:
- Complications are higher
- Operative times are increased
- Incision size and number is increased with up to 5 incisions or more required
- Increased pain and recovery times
- Hospitalization often required
- Cost profile is much higher
- Despite the robotic method’s more complex technology and much higher cost, studies have not found any “meaningful differences” in outcomes that would make it a better choice for patients than laparoscopic hysterectomy. Compared to the standard laparoscopic method, robotic hysterectomy has a lower rate of mid-procedure conversion to open surgery.3
- DualPortGYN uses two small incisions and allows for recovery in about a week to 10 days. The robotic approach requires up to seven incisions placed throughout the abdomen and pelvis and can result in a more painful recovery that takes up to eight weeks.
- DualPortGYN is suitable for uteri of all sizes, while robotic-assisted hysterectomy has significant limitations for more complex cases.
- DualPortGYN patients go home the same day and robotic procedures require a one- to two-day hospital stay.
Laparoscopic Hysterectomy
Standard minimally invasive hysterectomy uses between three and four ¼-inch to ½-inch incisions. This method is used by laparoscopic specialists and many OBGYN surgeons alike. As with all surgical methods for hysterectomy, standard laparoscopy depends on the training and skill of the surgeon doing the procedure. Most OBGYNs do not have the same skills or perform as many laparoscopic hysterectomies as GYN surgical specialists.
- Compared to open hysterectomy, the laparoscopic method uses smaller incisions, has lower complication rates and results in fewer abdominal wall and incision site infections.
- Patients are discharged either the same or next day, which can be faster than with robotic and open surgeries.
- Patients are usually back to their normal routine in about two to three weeks — a shorter recovery compared to robotic, vaginal and open hysterectomies.
- Skilled surgeons have full access to the pelvis to evaluate and treat any associated endometriosis, ovarian cysts or scar tissue causing pelvic pain.
- Incisions are often made through the abdominal muscles, which results in a slower and more painful recovery compared to DualPortGYN procedures.
- Because standard laparoscopy does not have DualPortGYN’s ability to map nearby organs, nor its uterine artery blood-control technique, complications — including injury to nearby organs — are higher with this approach.
- Compared to other methods, there is a greater chance that the surgeon will need to convert to an open hysterectomy during the procedure.
DualPortGYN’s retroperitoneal dissection and uterine artery ligation techniques result in:
- Significantly fewer complications, such as potential injury to surrounding organs, bleeding and the need for the surgeon to convert to an open procedure.
- Less time under anesthesia.
- Just two small incisions compared to three or four.
- Recovery that is roughly two weeks shorter.
Vaginal Hysterectomy
Vaginal hysterectomy (also called total vaginal hysterectomy) is the removal of the uterus, with or without the ovaries, completely through the vaginal opening. This procedure does not require any incisions in the abdomen. This approach is limited to normal size or smaller uteri, often in patients who have had a vaginal delivery to allow for greater access for the surgery.
- Patients have no external scarring.
- Compared to open hysterectomy, hospital stay is shorter, and patients recover in half the time.
- Vaginal hysterectomy is well suited for women with a small uterus.
A vaginal approach offers the surgeon a more limited anatomical view compared to DualPortGYN’s retroperitoneal dissection and standard laparoscopy4. A vaginal approach may not be feasible for patients with:
- A very large uterus
- Severe endometriosis
- Pelvic adhesions
- Prior pelvic surgeries
- Pelvic inflammatory disease
- No vaginal deliveries
- The vaginal approach is frequently used by low-volume surgeons2 (those who perform 10 or fewer GYN surgeries a year). CIGC’s high-volume specialists have performed more than 25,000 GYN surgeries, including thousands of DualPortGYN hysterectomies, which have been proven to have lower complication rates and better outcomes than vaginal hysterectomies (and all other methods).2
- Patients may take up to a month to recover from vaginal hysterectomy, while recovery from DualPortGYN takes roughly a week to 10 days.
- DualPortGYN is suitable for most patients, while there are a number of factors that may preclude a patient from having a vaginal hysterectomy.
- If endometriosis, scar tissue or other conditions are present, a surgeon using DualPortGYN can treat it during the hysterectomy. A vaginal approach may require the surgeon to convert5 to an open approach or perform additional surgery later.
- One survey of more than 300 hysterectomy patients found a higher rate of satisfaction among those who had a laparoscopic retroperitoneal hysterectomy (DualPortGYN) than those who had a vaginal hysterectomy.2
Open Hysterectomy
Open hysterectomy, also called abdominal hysterectomy, is still the most common method used for hysterectomy in the United States. This procedure uses a large incision, either horizontal or vertical, to open the abdomen and remove the uterus.
The reason most patients undergo an open hysterectomy is the limited laparoscopic training of their OBGYN. There are rare cases in which open surgery is necessary — discuss the alternatives to open surgery with your surgeon so that you are ensured of the best possible approach to your procedure.
- This technique is well suited for accessing reproductive organs that are cancerous or suspected of being cancerous.
- Surgery can be performed faster than with standard laparoscopic and robotic hysterectomy, so patients are under anesthesia for less time.
- The surgeon can easily see the uterus and other reproductive organs.
- The technique requires the longest incision — roughly 6 inches — of any hysterectomy method, and the incision takes longer to heal.
- Surgical involvement of the abdominal muscles results in a more painful recovery, which can take roughly eight weeks—several weeks longer than with any other method.
- When combined, complication rates during and after surgery are far greater than with any other method.
- Patients who experience significant blood loss during surgery may require a blood transfusion.
- DualPortGYN allows for recovery in about a week; open hysterectomy recovery can take up to eight weeks.
- Many doctors recommend open hysterectomy for patients with a large uterus, high body mass index (BMI) or prior cesarean section. In contrast, DualPortGYN is well suited for almost every patient.
- The DualPortGYN technique requires no hospital stay, while an open procedure can require up to a three-day hospitalization.
- With DualPortGYN, patients are off anesthesia in half the time compared to open hysterectomy.
- DualPortGYN’s combined intraoperative and post-operative complication rates are the lowest of any hysterectomy method, while open hysterectomy often results in complications in roughly 25% of cases.
- DualPortGYN’s two ¼-inch scars are nearly invisible after a few months, unlike the 6-inch incision required for an open hysterectomy.
- DualPortGYN is performed by fellowship-trained, high-volume GYN surgeons who perform hundreds of surgeries a year, while many open hysterectomies are performed by low-volume OBGYNs.
Consult an Expert for More Information
CIGC’s hysterectomy specialists can help you learn more about the significant advantages of the DualportGYN approach to hysterectomy. Contact our team to schedule an evaluation.
References
1ACOG Committee Opinion No. 774 Summary: Opportunistic salpingectomy as a strategy for epithelial ovarian cancer prevention. Obstet Gynecol. 2019;133(4):842-843. doi:10.1097/AOG.0000000000003165
2Danilyants, N, MacKoul, P, van der Does, L et al. A value-based evaluation of minimally invasive hysterectomy approaches. Gynecol Surg. 2019:16(5)
3Committee Opinion No 701: Choosing the route of hysterectomy for benign disease. Obstet Gynecol. 2017:129(6):e155-e159. doi: 10.1097/AOG.0000000000002112
4Lee S, Oh S, Cho Y et al. Comparison of vaginal hysterectomy and laparoscopic hysterectomy: a systematic review and meta-analysis. BMC Womens Health. 2019;19(1):83.
