Service provided by: Donald I. Galen, M.D., Surgical Director
Reproductive Science Centerª of the San Francisco Bay Area
Removal of the uterus (hysterectomy) is the most common gynecologic operation in the United States, with over 700,000 cases done yearly. The vast majority (75%) of hysterectomies are traditionally performed using an abdominal incision. This results in a 3-5 day post-operative hospital stay and a 6-8 week recovery time. It also produces a large and permanent abdominal scar. The abdominal approach for hysterectomy, however, has usually been favored over the vaginal approach because the former allows for easy removal of tubes and/or ovaries along with the uterus (removal of both ovaries at the time of hysterectomy is recommended for most patients over age 44). It is also difficult to perform a vaginal hysterectomy if the woman has significant uterine enlargement from fibroids, pelvic adhesions (scar tissue), or if she has a narrow vaginal canal.
The vaginal approach for hysterectomy is advantageous as it results in a shorter hospital stay, faster recovery, and no or minimal abdominal scar. Traditionally however, most patients have not been good candidates for a vaginal hysterectomy because of associated uterine fibroids, pelvic adhesions, endometriosis, or the need to remove ovaries at the time of surgery (it is difficult to remove ovaries vaginally).
In 1989, the first laparoscopic hysterectomies were reported with very successful results. The advantage of this new technique is the avoidance of a large abdominal incision, patient discharge from the hospital the next morning, and a much more rapid and less painful recovery. There are also significant cost savings with this technique. In 1997, we began performing Supracervical Laparoscopic Hysterectomies which leaves the woman's cervix and supporting ligaments intact. This provides better pelvic support and an even faster and less painful recovery.
With laparoscopic hysterectomy, the tubes and ovaries and much of the uterus is first disconnected through the laparoscope, and then removed through a vaginal incision or through one of the abdominal access ports using a morcellator. Approximately 95% of patients in our practice are candidates for a laparoscopic approach. However, there are certain patients (with large uterine tumors, pelvic malignancy, extensive pelvic adhesions) for which an abdominal approach is still preferred.
The complications of hysterectomy (by any route) include risk of bleeding, infection, anesthetic problems, or injury to bowel or bladder. Generally, the laparoscopic approach results in less blood loss, less bowel irritation and thus less post-operative gas pains. The potential for subsequent post-operative adhesions is also lessened. Lastly, since patients can ambulate sooner, complications such as thromboembolism (blood clots) and pulmonary problems are reduced and finally, hospital costs are significantly reduced for either the patient and/or her insurance company.
We have been strong advocates for women either avoiding hysterectomy altogether by use of endometrial ablation or myomectomy, or if hysterectomy is required, using the least invasive, least painful form of hysterectomy which would be a laparoscopic supracervical, or laparoscopic total hysterectomy. Because these advanced laparoscopic procedures require extensive additional physician training and experience, they are offered by only a minority of gynecologists at this time.
Copyright 2000-2005 Donald I. Galen, M.D.
Physician partner in the Reproductive
Science Centerª of the San Francisco Bay Area
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