Hysterectomy - Technique

Technique

Hysterectomy can be performed in different ways. The oldest known technique is abdominal incision. Subsequently the vaginal (performing the hysterectomy through the vaginal canal) and later laparoscopic vaginal (with additional instruments inserted through a; small hole, frequently close to the navel) techniques were developed.

Most hysterectomies in the United States are done via laparotomy (abdominal incision, not to be confused with laparoscopy). A transverse (Pfannenstiel) incision is made through the abdominal wall, usually above the pubic bone, as close to the upper hair line of the individual's lower pelvis as possible, similar to the incision made for a caesarean section. This technique allows doctors the greatest access to the reproductive structures and is normally done for removal of the entire reproductive complex. The recovery time for an open hysterectomy is 4–6 weeks and sometimes longer due to the need to cut through the abdominal wall. Historically, the biggest problem with this technique were infections, but infection rates are well-controlled and not a major concern in modern medical practice. An open hysterectomy provides the most effective way to explore the abdominal cavity and perform complicated surgeries. Before the refinement of the vaginal and laparoscopic vaginal techniques it was also the only possibility to achieve subtotal hysterectomy, meanwhile vaginal route is the preferable technique in most circumstances.

Vaginal hysterectomy is performed entirely through the vaginal canal and has clear advantages over abdominal surgery such as fewer complications, shorter hospital stays and shorter healing time. Abdominal hysterectomy, the most common method, is used in cases such as after caesarean delivery, when the indication is cancer, when complications are expected or surgical exploration is required.

With the development of the laparoscopic techniques in the 1970-1980s, the "laparoscopic-assisted vaginal hysterectomy" (LAVH) has gained great popularity among gynecologists because compared with the abdominal procedure it is less invasive and the post-operative recovery is much faster. It also allows better exploration and slightly more complicated surgeries than the vaginal procedure. LAVH begins with laparoscopy and is completed such that the final removal of the uterus (with or without removing the ovaries) is via the vaginal canal. Thus, LAVH is also a total hysterectomy, the cervix must be removed with the uterus. Total laparoscopic hysterectomy (TLH) is more advanced than a LAVH and does not require a double-setup, laparoscopic and vaginal.

The "laparoscopic-assisted supracervical hysterectomy" (LASH) was later developed to remove the uterus without removing the cervix using a morcellator which cuts the uterus into small pieces that can be removed from the abdominal cavity via the laparoscopic ports.

Total laparoscopic hysterectomy (TLH) is performed solely through the laparoscopes in the abdomen, starting at the top of the uterus. The entire uterus is disconnected from its attachments using long thin instruments through the "ports". Then all tissue to be removed is passed through the small abdominal incisions

Supracervical (subtotal) laparoscopic hysterectomy (LSH) is performed similar to the total laparoscopic surgery but the uterus is amputated between the cervix and fundus.

"Robotic hysterectomy" is a variant of laparoscopic surgery using special remotely controlled instruments that allow the surgeon finer control as well as three-dimensional magnified vision.

• uterus before hysterectomy

• laparoscopical hysterectomy

• transvaginal extraction of the uterus in total laparoscopical hysterectomy

• cervical stump (white) after removal of the uterine corpus at laparoscopic supracervical hysterectomy

• end of an laparoscopical hysterectomy