Hysterectomy

Comparison of Hysterectomy Procedures

There are several different hysterectomy procedures, each with advantages and disadvantages. Depending on your reason for considering a hysterectomy, you may have a choice between two or more procedures. For complicated or cancer-related conditions that require maximum access and careful examination, your doctor will likely recommend only an abdominal hysterectomy.

Vaginal hysterectomy

This type of hysterectomy is performed through a small incision in the vagina, rather than through an abdominal incision. The ovaries and other organs may also be removed. Vaginal hysterectomy tends to cause less pain, and takes less healing time than abdominal hysterectomy. A vaginal hysterectomy can be done:

• To remove small uterine fibroids.
• When the uterus is of normal size or slightly enlarged. However, some experienced surgeons are able to safely remove a very enlarged uterus without higher risk of complications.⁷
• When endometriosis growths (implants) are not present.

Vaginal hysterectomy requires more specialized surgical skill than an abdominal hysterectomy. It can pose a higher risk of injury to other organs. Vaginal hysterectomy is not used when there is a question about possible cancer in the uterus, cervix, or ovaries.

Abdominal hysterectomy

This type of hysterectomy is done through a larger abdominal incision, giving the surgeon the best possible access to the pelvic organs. The cervix may be removed with the uterus (total hysterectomy) or left in place (subtotal hysterectomy). The ovaries and other organs may also be removed. An abdominal hysterectomy is typically done when:

• The uterus is very large.
• Uterine fibroids are larger than 20 cm (8 in.) across or located around blood vessels.
• Cancer of the uterus, ovaries, or cervix is possible.
• An ovarian growth (mass) is suspected but can't be diagnosed on ultrasound.
• There is significant scarring or severe endometriosis in the pelvic area.

If a hysterectomy is chosen to treat endometriosis, an abdominal hysterectomy is usually required; for example, when endometriosis growths (implants) or scar tissue (adhesions) must be removed to restore the function of other organs.

Laparoscopically assisted vaginal hysterectomy (LAVH)

Laparoscopic hysterectomy is done with a viewing instrument (laparoscope) and surgical instruments inserted through a vaginal incision and one or more small abdominal incisions. The ovaries and other organs may also be removed. The uterus is detached from scar tissue, then removed through the vagina. It is done:

• When uterine fibroids are small to moderate in size.
• When the uterus is slightly larger than normal.
• To remove endometriosis and scar tissue (adhesions) confined to the uterus, fallopian tubes, and ovaries.
• To assess or remove ovaries at the same time as a vaginal hysterectomy.

LAVH is a newer surgery and requires the surgeon to have specialized training.

Laparoscopic supracervical hysterectomy (LSH)

Laparoscopic supracervical hysterectomy is done by inserting a laparoscope and surgical instruments through several small abdominal incisions. The uterus is removed in small pieces through a surgical instrument; the cervix is left intact (this is also known as subtotal or partial hysterectomy). This type of procedure usually causes minimal blood loss and pain. The hospital stay is shorter than for total abdominal surgery. Most women can return to normal activity a week or two afterward. LSH can be done:

• To remove uterine fibroids of any size.
• To remove a uterus of any size.

LSH is a newer surgery and requires special training. It usually takes longer to perform than abdominal or vaginal hysterectomy. LSH is not available in some geographic areas.

Total laparoscopic hysterectomy (TLH)

The total laparoscopic hysterectomy is done by inserting a laparoscope and surgical instruments through several small incisions in the abdomen. The uterus and the cervix are removed in small pieces through one of the incisions. TLH can be done:

• To remove uterine fibroids that are small to moderate in size.
• When there is not a lot of scar tissue in the pelvic area.
• When there is not a worry about cancer in the ovaries.

TLH is a newer surgery and requires the surgeon to have special training. It usually takes longer to do than abdominal or vaginal hysterectomy. But recovery and hospital stay are shorter than for total abdominal hysterectomy. TLH is not available in many parts of the country.

Advantages and disadvantages of hysterectomy procedures

Hysterectomy procedure	Advantages	Disadvantages
Vaginal hysterectomy	Enables removal of a normal to slightly larger-than-normal uterus and small uterine fibroids (some experienced surgeons are able to safely remove a very enlarged uterus)7 When compared with LAVH or abdominal hysterectomy, requires a shorter hospital stay8 Tends to cause less pain during recovery than after an abdominal surgery Doesn't leave scars on the abdomen	When compared with abdominal hysterectomy, a routine vaginal hysterectomy: Doesn't allow free access to the pelvic organs—the doctor may not be able to remove a very large uterus; large fibroids; areas of endometriosis, adenomyosis, or scar tissue (adhesions). Isn't used for cancer-related surgery. May need to be switched to an abdominal surgery if the doctor is unable to remove a very large uterus or areas of endometriosis, adenomyosis, or scar tissue (adhesions).
Abdominal hysterectomy	Provides the surgeon good visibility and easy access to the pelvic organs Enables removal of a very large uterus or large areas of endometriosis, adenomyosis, or scar tissue (adhesions) Cervix can be removed or left in place Requires less time under anesthesia and in surgery than a laparoscopic hysterectomy9	When compared with other types of hysterectomy, a routine abdominal hysterectomy: Requires longer hospital stay and recovery time.8 Tends to lead to more pain during recovery. Leaves a visible scar on the abdomen. A bikini-line incision may be possible.
Laparoscopically assisted vaginal hysterectomy (LAVH)	Allows your doctor to examine your pelvic organs and remove cysts, scar tissue (adhesions), fibroids, and areas of infection When compared with abdominal hysterectomy, requires a shorter hospital stay and causes less pain during recovery Smaller scars on the abdomen than with an abdominal hysterectomy	When compared with other types of hysterectomy, a routine LAVH: May need to be switched to an abdominal surgery if the doctor is unable to remove a very large uterus or areas of endometriosis, adenomyosis, or scar tissue (adhesions). May have an increased risk of injury if the surgeon is inexperienced.8
Laparoscopic supracervical hysterectomy (LSH)	When compared with abdominal hysterectomy, requires a shorter hospital stay, with a faster and less painful recovery Leaves smaller scars on the abdomen than with an abdominal hysterectomy	When compared with other types of hysterectomy, a routine LSH: May need to be switched to an abdominal surgery if the doctor is unable to remove a very large uterus or areas of endometriosis, adenomyosis, or scar tissue (adhesions). May have an increased risk of injury if the surgeon is inexperienced.8
Total laparoscopic hysterectomy (TLH)	Does not use an incision in the wall of the vagina When compared with abdominal hysterectomy, requires a shorter hospital stay, with a faster and less painful recovery Leaves smaller scars on the abdomen than with an abdominal hysterectomy	When compared with other types of hysterectomy, a routine TLH: May need to be switched to an abdominal surgery if the doctor is unable to remove a very large uterus or areas of endometriosis, adenomyosis, or scar tissue (adhesions).

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Author:	Kathe Gallagher, MSW Carrie Henley	Last Updated: November 7, 2006
Medical Review:	Adam Husney, MD - Family Medicine Joy Melnikow, MD, MPH - Family Medicine Liisa Honey, MD, FRCSC - Obstetrics and Gynecology Kirtly Jones, MD - Obstetrics and Gynecology
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