Historically, hysterectomies have been performed either by making an incision in the abdomen (either a "bikini" incision or a vertical incision between the belly button and the pubic bone) or, if the uterus is not too large, an incision in the top of the vagina-a vaginal hysterectomy. When an incision is made in the abdomen, not only the skin but many other layers need to be cut and to heal. This produces a significant amount of post-operative pain and recovery time. It is actually the healing of the skin and other layers beneath it that accounts for most of the pain women experience after a hysterectomy, not the actual removal of the uterus. A vaginal hysterectomy reduces the pain of recovery, but can only be performed on women who have a relatively small uterus and have no other diseases or prior surgery that may have caused adhesions. Also, the cervix must be removed in a vaginal hysterectomy.

A laparoscopic assisted vaginal hysterectomy is a relatively new procedure that allows some women with adhesions to be candidates for a vaginal hysterectomy but does not solve the problem of a too-large uterus and still requires that the cervix be removed.

A laparoscopic supracervical hysterectomy is performed through 3 small incisions-one in the base of the belly button and 2 smaller incisions near the hip bones. The uterus is cut away from its blood supply and from the cervix and then cut into strips and pulled in strips through a tube. This procedure can be done in women with mild to moderate adhesions and can be done in the case of a large uterus. Tubes and ovaries can be removed this way also. A laparoscopic total hysterectomy can also be performed in women who need to have their cervix removed.

A Laparoscopic Total Hysterectomy is similar to a Laparoscopic Supracervical Hysterectomy, but it involves removing the uterus and cervix. If the uterus is not greatly enlarged, the uterus (and possibly the tubes and ovaries) are removed vaginally, and the top of the vagina is sewn closed with sutures placed through the laparoscope. The apex, or top, of the vagina, is then supported by incorporating the uterosacral ligaments into the vaginal apex.

Why leave the cervix? Why remove the cervix? The answers to these questions are very controversial. Historically, the cervix has always been removed along with the uterus when a hysterectomy was performed. In the late 1990's, it became popular to leave the cervix after a few studies indicated that sexual function after supracervical hysterectomies was better than after a total hysterectomy. There was also the thought that the cervix served a supportive function in the base of the pelvis.

Studies comparing laparoscopic supracervical hysterectomy (leaving the cervix in place) and laparoscopic total hysterectomy (removing the cervix along with the uterus) have been recently published. It appears that there is really no difference in sexual function between the two procedures. Women generally report that sexual function is better after any type of hysterectomy, probably related to the fact that these women are no longer bleeding, cramping, and hurting.

In this practice, a woman has a choice. She can elect to leave the cervix or she can elect to have it removed. If a woman has had abnormal pap smears or has cervical prolapse as a result of childbirth, we will advise her to have her cervix removed. If a woman absolutely does not want to bleed any longer, we should remove the cervix because despite our best efforts, some women who retain the cervix still have periods.

If a woman has no problems with pelvic relaxation and has a history of normal pap smears, she can opt to leave the cervix. The potential negative consequences of leaving the cervix include the possibility of monthly periods, the chance that the cervix may eventually prolapse (fall) as she ages, or the potential for an abnormal pap smear or even cervical or uterine cancer.

If a supracervical hysterectomy is performed and problems develop with the cervix later, a laparoscopic trachelectomy (removal of the cervix) can be performed. This, however, is not an optimal situation and we would rather anticipate problems and make the correct procedure choice the first time.

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Fibroids occur in 40% of women at some point in their lives. Fibroids run in families, so if your mother and sister had fibroids, you have a good chance of developing them, too. They are almost always benign, but can cause very heavy menstrual bleeding, bleeding between periods, or simply pain and pressure due to the space they take up. A woman can have just one fibroid or many. Sometimes just one fibroid can grow quite large. The most common reason for having a hysterectomy is fibroids. If the fibroid uterus is large, a vaginal hysterectomy can be difficult. A laparoscopic hysterectomy is generally possible in these cases unless the uterus is enormous. Even if the uterus is very large, drugs such as Lupron can be used for a few months before the procedure to shrink the uterus and make a laparoscopic hysterectomy possible.

You might ask: -Why not just use Lupron to shrink my fibroid and not do surgery? Lupron will only temporarily shrink a fibroid uterus. As soon as the Lupron is stopped, the uterus will go back to its previous size. Lupron is not a drug that can be used over a long period of time due to its side effects. It creates a temporary state of menopause which causes hot flushes, night sweats, mood swings and bone loss. For a short period of time, Lupron is tolerable and safe, but not for more than a few months.

Women with fibroids are the largest group of women who undergo laparoscopic hysterectomies. Since fibroids rarely occur in the cervix, a woman with fibroids may choose between a laparoscopic supracervical hysterectomy and a laparoscopic total hysterectomy. Either way, most fibroid uteri can be removed laparoscopically, and the recovery is much shorter than a hysterectomy that involves a large incision.

Adenomyosis is a disease in which the glands that normally line the muscle of the uterus, and bleed off monthly, grow backwards into the muscle. Adenomyosis is a benign condition but can cause cramping and bleeding that can become quite severe and debilitating. A uterus affected by adenomyosis can be only slightly enlarged or can get to be very large. Again, laparoscopic hysterectomy is a good solution for this problem.

Endometrial polyps are growths of uterine lining tissue that do not shed off with the monthly period and can cause abnormal bleeding. They can be removed during a D&C, but tend to grow back. A laparoscopic hysterectomy removes the uterus so that this cannot happen again.

Hyperplasia is overgrowth of the uterine lining. Hyperplasia can cause heavy bleeding and bleeding between periods. If hyperplasia is left untreated, it can develop into cancer. Simple hyperplasia is an early benign form of the disease. As the disease progresses, hyperplasia can develop into complex hyperplasia, complex hyperplasia with atypia, and finally cancer of the uterus. A woman with simple hyperplasia is a candidate for a laparoscopic hysterectomy. It is generally recommended that a laparoscopic total hysterectomy be performed in this case, since this procedure avoids morcellization. Morcellization is the process of cutting the uterus into strips, which is necessary to remove the uterus in a supracervical hysterectomy. If any cancer cells do exist inside the uterus, these would be spread throughout the abdominal cavity during the morcellization process. This is obviously undesirable. If the hyperplasia is complex or involves atypia, a laparoscopic total hysterectomy can be performed. The reason for not doing a supracervical hysterectomy on a woman with complex or atypical hyperplasia is that we would not want to spread disease throughout the pelvis by cutting the uterus into strips. A laparoscopic total hysterectomy avoids this step; the uterus is removed in one piece along with the cervix.

Pelvic adhesions can make a vaginal hysterectomy difficult or impossible. Adhesions can result from prior surgery, endometriosis, or infection. If the adhesions are not severe, a laparoscopic supracervical hysterectomy is possible. If the cervix needs to be removed, a laparoscopic total hysterectomy or a laparoscopic assisted vaginal hysterectomy can be done.

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Whenever a patient has surgery, she must accept that there is a risk of injury from the instruments inserted into the abdomen. Injuries that have been reported in association with this procedure include puncture injuries of the bowel and bladder, burn injuries of the bowel and bladder, injuries to the ureters (the tube that runs from the kidney to the bladder), and blood vessel injuries. Generally speaking, as long as these injuries are recognized right away, they can be fixed at the time of surgery, but may require another specialist to operate and may require a larger incision. However, if an injury is not recognized, the consequences can be more severe, and may result in permanent injury and even death. We are very careful to warn our post-operative patients to contact us if there is fever, severe pain, severe bleeding or any other symptoms that seem unusual. As long as these symptoms are evaluated, negative consequences should be avoided.

"I was so afraid of having a hysterectomy that I suffered with bleeding and pain for 5 years, hoping that it would just get better. Finally, I was missing so much work that I had to have surgery. I had a laparoscopic supracervical hysterectomy and felt perfect within a few days. I went back to work in 10 days and felt better than I'd felt in years. I told Dr. Wilson at my 2 week post-operative visit that I wished she had forced me to do it 5 years earlier!"