"The Pain-Less" Hysterectomy
Approximately 600,000 hysterectomies are performed every year in the United States alone, but only 10% or so for cancer of the uterus, or ovaries and rarely the fallopian tubes. The uterine indications usually are related to problems of bleeding, pain, pelvic tenderness, or a failure of pelvic support that causes uterine prolapse. Much less commonly, ovarian tumors will suggest the need for hysterectomy.
Most hysterectomies are performed through a large abdominal incision, with recuperation time of about 6 weeks. Vaginal hysterectomy is the second most common approach, whereby the uterus is removed through the vagina. By avoiding the abdominal incision, pain and disfigurement is less, and recuperation faster, which is about 4 weeks.
Laparoscopic hysterectomy utilizes small 1 / 2 inch incisions, and most often is used to allow treatment of other diseases in the pelvis (such as adhesions or endometriosis). The uterus itself is removed from the pelvis through the vagina. This approach is associated with even less pain and post-operative recuperation because the incisions are tiny, and tissue injury is less. Most gynecologists are not familiar and skilled in this technique however.
Recently, an old operation for removal of the uterus has been updated with modern technology, and the result is remarkable. The operation is called a "Laparoscopic Supracervical Hysterectomy". The procedure is performed through tiny incisions as previously described, but the cervix is not removed. The body of the uterus (with or without the ovaries and tubes) is removed through one of these small half-inch incisions utilizing a new high-tech instrument called a power morcellator.
By allowing the cervix to remain intact, the special anatomical relationship of the cervix to the bladder and upper vagina is not impaired. This results in a lesser tendency for bladder injury and dysfunction, and it has been observed that later problems with prolapse may be lessened significantly. Allowing the cervix to remain avoids any shortening of the vagina that may occur with conventional hysterectomy, as this problem may cause post-operative pain with intercourse.
The cervix is a highly erogenous area for many women, and the supracervical technique will not affect this structure. Whether or not sexual performance is better if the cervix is not disturbed is indeed controversial as there is no scientific way to truly evaluate this question. We have seen however much faster resumption of sexual activity (2 weeks) if the supracervical technique is utilized. (ie. there is no vaginal incision to heal, which normally takes 6 weeks).
Coincident abnormalities of the ovaries, endometriosis, pelvic adhesions, and bladder problems may all be treated at the time of the hysterectomy. Large uterine fibroids are not a contra-indication to the procedure as the morcellator takes the tissue out in small pieces, irrespective of the original size of the uterus. Obviously, the smaller the uterus to start with, the shorter the operation. A patient with a normal size uterus requires less than one hour operating time.
Critics of supracervical hysterectomy would suggest that leaving the cervix will predispose the patient to the development of cervical cancer. Fortunately, cervical cancer is almost 100% preventable, as long as the patient has regular screening with annual PAP smears. Its development is usually very slow, over many years, and precancerous changes allow simple intervention for treatment before the cancer actually develops.
The laparoscopic supracervical hysterectomy is almost pain-free. We have been impressed by the number of patients who require very little or NO postoperative pain medication whatsoever!!! The bladder catheter is removed in the operating room and patients are able to be up to void whenever necessary. Most describe a sensation of mild "discomfort" or mild cramps. The patients are usually eating a full course dinner the evening of surgery, and some have been discharged from the hospital at that time. Most prefer to stay overnight, with the vast majority going home the following morning. Resumption of normal activities is also remarkably fast ( a few days) as they can drive their car soon after going home. This surgeon has not seen any other hysterectomy technique that provides such fast recuperation, with such minimal post-operative discomfort.
As with any medical procedure recovery times, pain, and discomfort will vary for each individual. Furthermore, you should always seek the advice of your own physician when making treatment decisions, and to discuss recovery expectations.
Some further Reading regarding Laparoscopic supracervical hysterectomy:
Laparoscopic supracervical hysterectomy. Baillieres Clin Obstet Gynaecol 1997 Mar;11(1):167-79 (ISSN: 0950-3552) Lyons TL Department of Obstetrics and Gynecology, Emory University Medical School, Atlanta, GA, USA.
Comparison of classic intrafascial supracervical hysterectomy with total laparoscopic and laparoscopic-assisted vaginal hysterectomy. J Am Assoc Gynecol Laparosc 1998 Aug;5(3):253-60 (ISSN: 1074-3804) Kim DH; Bae DH; Hur M; Kim SH Department of Obstetrics and Gynecology, Chung-Ang University, Pil-Dong Hospital, 82-1, 2Ga, Pil-Dong, Chung-Gu, Seoul, Korea
Laparoscopic hysterectomy. Supracervical vs. assisted vaginal. J Reprod Med 1994 Aug;39(8):625-30 (ISSN: 0024-7758) Schwartz RO Department of Obstetrics and Gynecology, Medical College of Georgia, Atlanta