Procedure Laparoscopic Hysterectomy
The Center for Innovative GYN Care is a known pioneer in the field of GYN surgery, and we are minimally invasive hysterectomy specialists. We have developed powerful and widely adopted laparoscopic hysterectomy procedures using our exclusive DualPortGYN technique. Patients get the benefits of hysterectomy with fast recovery and less pain. Our reputation has been earned, so you know you are in the care of professionals you can trust.
TYPES OF HYSTERECTOMY
- From the Latin supra (above) cervical (cervix), hyster (uterus) ectomy (remove);
- Removal of the portion of the uterus ABOVE the cervix;
- There is no benefit to preservation of the cervix. For more information regarding this issue, please read What about the cervix?
- From the Latin, hyster (uterus) ectomy (remove);
- Removal of the uterus ONLY with preservation of the ovaries;
- Also known as a “partial” hysterectomy;
- Partial hysterectomy = hysterectomy.
Hysterectomy and bilateralsalpingo-oophorectomy
- From the Latin hyster (uterus) ectomy (remove), bilateral (two) salpingo (tubes) oophor (ovaries) ectomy (remove);
- Removal of the uterus, tubes, and ovaries;
- Also known as a “complete” or “total” hysterectomy;
- Complete or total hysterectomy = hysterectomy and bilateral salpingo-oophorectomy.
WHAT IS THE FUNCTION OF THE UTERUS?
The uterus is necessary to allow for the growth of a pregnancy. It is, in essence, the chamber in which the pregnancy grows. The uterus does NOT make eggs and does NOT make hormones.
WHAT IS THE FUNCTION OF THE OVARIES?
The ovaries produce eggs and release the hormones estrogen and progesterone. During the first half of a woman’s monthly menstrual cycle, estrogen prepares the lining of the uterus for pregnancy. Midway through the cycle, the egg is released from the ovary. The ovary then starts to produce progesterone, which matures the lining of the uterus for implantation.
If intercourse occurs, and the sperm meets the egg to form the embryo, the embryo travels down the tube and implants into the matured uterine lining. If this occurs, the pregnancy develops and a menstrual cycle will NOT occur.
If intercourse does NOT occur, the sperm does not meet the egg, an embryo does not develop, there is no implantation of the embryo into the lining, and menstruation occurs (a period).
As you can see from these events, the ovary is responsible for all hormone production. At menopause, the ovaries stop producing eggs and stop producing hormones. The symptoms of loss of hormones, or menopause, include hot flashes, night sweats, mood sweats, anxiety, depression, vaginal dryness, and development of osteoporosis, all of which are due to lack of estrogen.
PARTIAL VERSUS COMPLETE OR TOTAL HYSTERECTOMY
A hysterectomy is a GYN surgery procedure, which simply refers to the removal of the uterus, including the cervix. The terms “partial hysterectomy” and “total hysterectomy” are commonly used by non-medical people but are not technically accurate.
- Partial hysterectomy usually refers to removal of only the uterus. The ovaries are detached from the uterus and kept in place. Menopause does NOT occur even though a menstrual cycle does not happen. Removal of the uterus will stop menstruation, but the ovaries continue to function as usual.
- Complete or total hysterectomy refers to the removal of the uterus, tubes, and ovaries. The removal of the ovaries WILL lead to menopause in patients who are still having periods.
- Removal of the ovaries in menopausal patients will not lead to menopause. These patients have already gone through menopause, and have experienced menopausal symptoms that occur when estrogen is no longer produced, such as hot flashes, night sweats, mood swings, etc. In these menopausal patients, removal of the ovaries will have no effect since they are no longer making estrogen.
A common misconception by patients of all ages and educational backgrounds is that the uterus makes hormones. This is simply not true. Despite what you may have read, what you have heard from friends, or what you may have gathered from you research online, the uterus is not responsible for hormone production at any point in your life. It does not make any hormone or compounds that are necessary for your well-being. Simply stated, the uterus is a muscle, and muscles do not make hormones.
TECHNIQUES FOR HYSTERECTOMY
There are different ways hysterectomy can be performed, from least invasive to most invasive. It is always better for the patient to have a minimally invasive hysterectomy, as recovery is faster than open. Each method has its own limitations. Look carefully at the advantages and disadvantages of each technique, the total incision length, and the recovery time.
WHAT ABOUT THE CERVIX?
The cervix is the lower portion of the uterus. It is part of the uterus and is not a separate organ from the uterus.
WHAT IS THE FUNCTION OF THE CERVIX?
The cervix functions to allow for delivery of the baby during childbirth. As the uterus contracts, the cervix “dilates”, or opens up, to allow the baby to pass from the uterus to the vagina. The cervix has no other known function, and is not essential for lubrication of the vagina.
DOES A HYSTERECTOMY MEAN REMOVAL OF THE CERVIX?
Yes. A hysterectomy refers to removal of ONLY the uterus and the cervix. The ovaries and the tubes are not removed during this procedure. The ovaries continue to make estrogen and function normally, so menopause or “the change” will not occur. A partial hysterectomy refers to removal of the uterus and cervix. A complete hysterectomy refers to removal of the uterus, cervix, tubes and ovaries.
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 OB/GYNs that believe keeping the cervix is better than removing it. In general, the OB/GYN may promote keeping the cervix – also known as a “supracervical hysterectomy” – because it is easier to perform and avoids complication rates. This is especially true for OB/GYNs that do not perform much laparoscopic surgery. It is not acceptable for the OB/GYN to leave the cervix in due to his or her lack of experience or discomfort with the procedure. 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. There are some disadvantages, however. The real story about the cervix is outlined below, and is supported by references at the end of this article.
DOES 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, according to several comparative studies that have evaluated these issues. (These studies looked at patients who underwent supracervical hysterectomy (retaining the cervix) or partial hysterectomy (removal of the uterus and cervix), and compared the results.)
DOES REMOVAL OF THE CERVIX LEAD TO 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 vagina.
WILL REMOVAL OF THE CERVIX LEAD TO LESS SEXUAL SATISFACTION THAN IF I KEEP THE CERVIX?
No. There were no differences in these trials in sexual satisfaction, pain with intercourse, or sexual function. (56,66)
MY OB/GYN TOLD ME THAT KEEPING THE CERVIX IN PLACE MAKES THE SURGERY SAFER THAN REMOVING IT. IS THAT TRUE?
No. The comparative studies clearly showed no increase or decrease in complications of the surgery, recovery, or readmission to the hospital, whether or not the cervix was removed. There are no medical or sexual advantages to keeping the cervix in place. There can be some disadvantages, as listed below.
- Vaginal bleeding can occur from the retained cervix after the procedure on a monthly basis in up to 11 percent of patients.
- Pap smears need to be performed due to potential for pre-cancerous or cancerous conditions of the cervix.
- Surgical removal of the cervix may be necessary due to bleeding, pre-cancerous or cancerous conditions, or pain.
In summary, removal of the cervix has no disadvantages when compared to retaining the cervix in patients if the surgery is performed by an experienced, well-trained laparoscopic surgeon. There are disadvantages, however, to keeping the cervix in place. Supracervical hysterectomy, therefore, is NOT a better approach to removal of the cervix, and can lead to bleeding, continued evaluation of the cervix for pre-cancerous conditions, and in some cases the need for an additional surgical procedure to remove the cervix.
- Cochran Database Systemic Review 2006
- British Medical Journal 2003
- New England Journal of Medicine 2002
- Obstetrics and Gynecology Journal 2003
- European Journal of Obstetrics and Gynecology 2010
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. It is the least invasive of all the hysterectomy procedures.
- No abdominal wall incisions = very fast recovery;
- Excellent for prolapse procedures to correct “drop down” of the uterus, vagina, bladder, and rectum;
- Cost-effective and the procedure of choice for select patients needing hysterectomies.
- Not the best option for patients who have not had children vaginally. This is because a vaginal delivery results in increased “room” in the vagina, which is needed to perform a vaginal hysterectomy.
- Moderate to large uteri due to fibroids or other causes can be difficult to remove vaginally. A laparoscopic approach may be a better option.
- Patients with larger ovarian masses may be difficult to treat with the vaginal approach.
- Higher risk of bleeding with larger uteri due to bleeding from the uterine artery and ovarian arteries.
- Higher risk of complications to the bladder, bowel, ureter with prior cesarean section and pelvic surgery. Prior C/S and surgery causes scar tissue, which may make the surgery more difficult to accomplish.
- Inability to see and treat other pelvic problems, such as endometriosis, scar tissue, ovarian masses, cancers, etc. A laparoscopic approach allows full visualization of all pelvic organs and treatment as needed.
- Inability to assess for bleeding or other complications after surgery. The laparoscopic approach allows for full evaluation of the pelvis after the procedure to identify bleeding or other potential complications of the surgery.
Total Incision size, Abdominal wall: 0 cm
DualPortGYN Minimally Invasive Hysterectomy
DualPortGYN minimally invasive hysterectomy procedures use two 5 mm incisions to perform the procedure, along with a technique called “Retroperitoneal Dissection”, which allows the surgery to be performed safely and effectively.
The retroperitoneal space is an area that is normally covered by a lining called the peritoneum. This lining covers important structures such as:
- Ureter (the tube that drains urine from the kidney to the bladder)
- Large vessels of the pelvis
- Lower portion of the bladder
By going behind (retro) the lining (peritoneal), the surgeon completely visualizes all of the anatomy of the pelvis, and avoids complications such as excessive bleeding, bladder injury, injury to the ureter and bladder. OB/GYN surgeons do NOT perform RP dissection, and very few specialized laparoscopic surgeons are well-trained in this powerful technique. Once the uterus is detached laparoscopically, the uterus and fibroids are removed through the vaginal opening through specialized techniques. This avoids the need to extend the incision in order to remove the uterus. Keeping the incisions as small as possible leads to less pain, fewer complications, and a much faster recovery. It also avoids the use of morcellators, which are specialized machines used to cut the uterus into small pieces in order to remove it laparoscopically. Morcellators are expensive and time-consuming, meaning longer time under anesthesia. DualPortGYN procedures offer patients a laparoscopic surgery using the smallest possible incisions, along with the safety of RP dissection to create amazing results for patients requiring hysterectomy. DualPortGYN procedures are very different than conventional laparoscopy, and offer far more advantages than robotic procedures.
INCISION COMPARISON CHART
- Excellent cosmetic result with almost invisible scars after surgery.
- Two 5 mm incisions only, located at the belly button and just above the pubic bone.
- Incision location is between the abdominal muscles, thereby avoiding bleeding and pain seen with conventional and robotic procedures.
- Incision size and location avoids herniation of bowel through the incision site.
- 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 prevents “open” or “robotic” procedures that have larger incisions, more pain, higher complications, and longer recovery times.
- DualPortGYN is far less expensive, decreasing costs to the patient and the healthcare system. Very low cost compared to conventional or robotic procedures.
- Using this technique, 85 percent of women are candidates for this minimally invasive approach. Robotic and open surgery is not required and SHOULD NOT BE PERFORMED if the surgeon is skilled in this approach to laparoscopy. For those patients that are not candidates for DualPortGYN, a Retroperitoneal Hysterectomy can be accomplished.
- Can be used to remove fibroids and the uterus up to 2,500 g. The average uterus weighs between 70 and 100 g so almost all patients are candidates for this approach.
- Higher cost than the vaginal approach; and
- Limited for patients with extreme adhesive disease.
Total Incision Length, Abdominal Wall: 1 cm (.5 to ¾ inch)
This approach uses three to four 5 mm incisions to remove the uterus.
This procedure is limited to those patients that have a very large uterus, have a large pelvic mass, extreme endometriosis, and have very extensive scar tissue that requires more than two ports to complete the surgery. In these patients, the use of additional ports is needed to ensure the procedure is completed laparoscopically. The technique of retroperitoneal dissection is used extensively in these operations, and in 99.5 percent of patients prevents the use of an open incision. Many patients that would otherwise have had an “open” surgery using a large incision can be converted to a retroperitoneal hysterectomy, thereby preventing the severe pain, six to eight week recovery, and higher complication rates with open procedures. Special techniques are used to remove very large fibroid uteri, with the largest detached using this technique at over 20 pounds.
- Retroperitoneal hysterectomy prevents “open” or “robotic” procedures that have larger incisions, more pain, higher complications, longer recovery times and increased costs. Using this technique, almost every patient (>99 percent) are candidates for this minimally invasive approach. Robotic and open surgery are not required and SHOULD NOT BE PERFORMED if the surgeon is skilled in this approach to laparoscopy.
- Four 5 mm incisions to detach even the largest fibroid uterus.
- Removal of the uterus vaginally in most cases. In massive fibroid cases, a 3 cm incision (1.5 inches) is used to remove the fibroid through an incision in the bikini line.
- Discharge from the hospital the same day, recovery 10 to 14 days back to work. Minimal pain with fast recovery.
- Can be used for patients with prior cesarean section and other prior pelvic surgical procedures, very heavy patients including 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.
- Very good cosmesis.
Total Incision Length, Abdominal Wall: 1.5 to 2 cm in most cases.
Additional 3 cm incision may be needed in the bikini line to remove massive fibroid uteri.
Other non-CIGC procedures for comparison
STANDARD CONVENTIONAL LAPAROSCOPIC HYSTERECTOMY
This procedure uses between three and five incisions, ranging in size from 5 mm to 15 mm. This is the standard approach used by laparoscopic specialists and OB/GYN surgeons.
Retroperitoneal dissection is usually never used, and in most cases for larger fibroid uteri, a “morcellator” is used to cut up the fibroids in smaller pieces or strips for removal from the pelvis through an incision made in the abdominal wall. Standard Conventional Laparoscopy is preferred to robotics or open procedures. The incisions are smaller, the recovery can be faster, and there is a significant cost savings. 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, therefore, depend on the training and focus of the surgeon doing the procedure. Surgeons specializing in laparoscopic surgery are able to apply conventional laparoscopy to difficult cases with success, whereas the OB/GYN performing only one to two hysterectomies a month (the average) may be limited to patients with smaller uteri and no risk factors such as prior surgery, endometriosis, etc.
- A very good alternative to “open” or “robotic” procedures, decreasing the increased incision size, pain, and recovery associated with these procedures. In skilled hands, this approach produces very good results for the majority of patients.
- Three to four incisions, 5 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 (see above).
- 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” OB/GYN surgeon. Patients should not undergo these procedures with OB/GYNs that have not had sufficient training or expertise in this approach.
Total Incision Length, Abdominal Wall: 1.5 to 3.5 cm.
Robotic techniques have recently been applied to benign GYN surgery with some controversy. In general, robotic procedures “enable” an OB/GYN 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. Robotic procedures use up to five incisions located throughout the pelvic AND the 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 are larger, and range between 8 mm and 1.5 cm totaling up to 50 mm in length. 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 10mm, one fifth the size of the robotic approach.
INCISION COMPARISON CHART
Robotic hysterectomy has NOT been advocated by major medical societies. In fact, the opposite is true. The American Medical Association clearly stated that there is no medical advantage to robotic hysterectomies, but there is dramatically higher cost. The same has been stated by the American Association of Gynecologic Laparoscopic Surgeons, and the American Congress of OB/GYN (see references below). In addition, complications with this approach have been higher, with many class action lawsuits arising from complications reported in GYN and urological procedures. The FDA also recently submitted a warning to a company regarding the use of a robot for surgery. In summary, there are better options that use smaller incisions, better recovery, and much lower cost that robotic procedures. Please read All About Robotics. As a patient, realize that not all OB/GYN surgeons are the same. Please read the section Why CIGS on Your Surgeon to familiarize yourself with the training and experience of different surgeons performing laparoscopic hysterectomies.
- As an “enabler”, the robot helps OB/GYNs perform minimally invasive surgery. The robot helps the OB/GYN convert open procedures to robotic procedures.
- Excellent visualization.
- Excellent ability to perform laparoscopic suturing and dissection.
- 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 robotics.
- Significantly higher cost, as compared to conventional laparoscopy.
- 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.
- 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.
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 this approach is the limited laparoscopic training of their OB/GYN. Beware of explanations of how “your uterus is too large to remove laparoscopically”, “you are too heavy”, or 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 abdominal hysterectomy is not advocated for any patient that can undergo a laparoscopic procedure. Patients need to do their research to find experts in minimally invasive GYN surgery in their area. Most laparoscopic experts can perform hysterectomies safely and effectively without the use of invasive open techniques. Patients need to consider a second opinion to these experts to optimize their surgical care and avoid unnecessary complications and long recovery. Remember YOU are undergoing the open surgery, not your OB/GYN. Ask the right questions and be your own best advocate! Find the best possible surgical care to avoid the increased pain, recovery, and complications of an unnecessary open surgical procedure. Please refer to Why CIGC to read more on how to select a surgeon.
- Removal of any size fibroid uterus.
- Open incision with severe pain, six to eight week recovery;
- Higher rates of complications;
- There are better alternatives available.
WHY CIGC FOR MY HYSTERECTOMY?
We are minimally invasive hysterectomy surgeons who are dedicated to the development of techniques and procedures that optimize surgical care and recovery of women.
If your standard OB/GYN is qualified to perform gynecological surgery, you may be considering having him or her perform your hysterectomy procedure. Here is something to consider: an OB/GYN performs an average of 27 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.
All CIGC surgeons have the following qualifications:
- Fellowship-trained in Minimally Invasive Surgery or Gynecologic Oncology;
- 100 percent focused on GYN surgery;
- Does not perform Obstetrics – no distractions from the main focus;
- High volume of patients, making for a high level of experience; and
- No open or robotic procedures.
We lead our field. CIGC is a known pioneer in the field of minimally invasive gynecological surgery, as we have developed powerful and widely adopted procedures such as DualPortGYN and LAAM fibroid removal options. Our reputation has been earned, so you know you are in the care of professionals you can trust.
We explore the options.
There are many different ways to approach a hysterectomy. We can explain in detail the difference between a partial and total hysterectomy and what each will entail so that you can make the best possible decision for your situation.
Your recovery in mind.
When choosing a treatment option, we will always opt for the most minimally invasive procedure possible to achieve the results you want. We prioritize your speedy recovery; we will tell you what you can expect so you can choose what makes you the most comfortable.
As a patient, it is your decision where to get treated. As experts in the field, we urge you to visit our experts and find peace of mind in the form of nuanced expertise and years of experience. If you want to know more about the practices and techniques we employ to perform hysterectomies, don’t hesitate to give us a call at (888) 787-4379.
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