Hysterectomy is a surgical removal of the uterus. This may also involve the removal of the cervix, ovaries, fallopian tubes and other surrounding structures.
Usually performed by a gynecologist, a total hysterectomy (removing the body, fundus, and cervix, often called "complete") or partial (removal of the uterine body while leaving the cervix intact, also called "supracervical"). This is the most commonly performed gynecological surgery procedure. In 2003, more than 600,000 hysterectomies were performed in the United States alone, where more than 90% were performed for benign conditions. Such figures are the highest in the industrialized world has caused great controversy that hysterectomy is mostly done for unwarranted and unnecessary reasons.
The removal of the uterus makes the patient unable to bear children (such as ovaries and fallopian tubes) and has surgical risks and long-term effects, so surgery is usually recommended when other treatment options are not available or fail. It is expected that the frequency of hysterectomy for non-malignant indications will fall as there are good alternatives in many cases.
Oophorectomy (removal of the ovaries) is often performed in conjunction with hysterectomy to reduce the risk of ovarian cancer. However, recent research has shown that prophylactic oophorectomy without urgent medical indications lowers a woman's long-term survival rate substantially and has other serious side effects. This effect is not limited to pre-menopausal women; even postmenopausal women have been shown to decrease post-oophorectomy longevity survivability.
Video Hysterectomy
Medical use
Hysterectomy is a major surgical procedure that has risks and benefits, and affects the female hormonal balance and overall health for the rest of her life. Therefore, hysterectomy is usually recommended as a last resort to improve the condition of certain uterine/reproductive systems that are difficult to solve. Such conditions include, but are not limited to:
- Severe and difficult endometriosis (growth of the uterine lining outside the uterine cavity) and/or adenomyosis (form of endometriosis, where the uterine lining has grown into and occasionally through the uterine wall muscle), after pharmaceutical or other surgical options already empty.
- Chronic pelvic pain, after other surgical or surgical options have been exhausted.
- Postpartum to remove one of the cases of severe preevia placenta (placenta above or inside the birth canal) or placenta percreta (placenta growing inside and penetrating the uterine wall to attach itself to other organs), as well as the last attempt in the case excessive obstetric bleeding.
- Some forms of vaginal prolapse.
Women may also express a desire to undergo elective hysterectomy for reasons other than resolution of conditions or disease of the reproductive system. Some conditions in which a person may request to undergo a hysterectomy (or request one for her if the woman is unable to make a request) for non-illness reasons may include prophylaxis against certain cancers of the reproductive system, especially if there is a strong family history of reproductive system cancer (especially breast cancer in conjunction with BRCA1 or BRCA2 mutations), or as part of the recovery from the cancer. Some with severe developmental disabilities have a hysterectomy although this treatment is most controversial. In the United States, special cases of sterilization due to developmental defects have been found by state-level High Court to violate the constitutional rights and common law of patients.
Gynecological malignancy
Many types of reproductive system cancers are treated with surgery. These include uterine, cervical, ovarian, or endometrial tumors, and uterine fibroids that do not respond to more conservative treatment options.
Risk and adverse effects
In 1995, short-term mortality (within 40 days of surgery) was reported at 0.38 cases per 1000 when performed for benign causes. The risk for surgical complications is the presence of fibroids, younger age (pelvis of blood vessels with higher bleeding risk and larger uterus), dysfunctional uterine bleeding and parity.
The mortality rate is several times higher when performed in patients who are pregnant, suffering from cancer or other complications.
Long-term effects on all cases of death are relatively small. Women under 45 have significantly increased long-term mortality that is believed to be caused by hormonal side-effects of hysterectomy and prophylactic oophorectomy.
Approximately 35% of women after hysterectomy underwent other related surgery within 2 years.
Ureter injury is not uncommon and occurs in 0.2 per 1,000 cases of vaginal hysterectomy and 1.3 per 1,000 cases of abdominal hysterectomy. Injury usually occurs in the distal ureter close to the infundibulopelvic ligament or as the ureter that crosses beneath the uterine artery, often from blind clamping and ligature placement to control bleeding.
Recovery
The hospital stay is 3 to 5 days or more for stomach procedures and between 1 and 2 days (but possibly longer) for vaginal or laparoscopically assisted vaginal procedures.
Unwelcome oophorectomy and premature ovarian failure
Removal of one or both ovaries is done in a large number of hysterectomies that are intended to be thermally saving.
The median age of onset of menopause after hysterectomy with ovarian conservation was 3.7 years earlier than average. This has been suggested because of the disruption of blood supply to the ovaries after hysterectomy or due to loss of endocrine feedback from the uterus. The remaining function of the ovary is significantly affected in about 40% of women, some of whom even require hormone replacement treatments. Curiously, the same and only slightly weaker effect has been observed for endometrial ablation which is often considered an alternative to hysterectomy.
A large number of women develop benign ovarian cysts after hysterectomy.
Effects on sexual life and pelvic pain
After a hysterectomy for benign indications most women reported an increase in sexual life and pelvic pain. A small percentage of women report a worsening of sexual life and other problems. This picture differs significantly for hysterectomy performed for malignant reasons; the procedure is often more radical with large side effects. The proportion of patients undergoing hysterectomy for chronic pelvic pain continues to suffer pelvic pain after hysterectomy and develop dyspareunia (painful sexual intercourse).
Early menopause and its effects
Estrogen levels drop sharply when the ovaries are removed, eliminating the protective effects of estrogen on the cardiovascular and skeletal systems. This condition is often referred to as "surgical menopause", although it is substantially different from the natural menopausal state; the first is a sudden hormonal shock on the body that causes rapid menopausal symptoms such as hot flashes, while the latter is a gradual decrease in hormone levels over a period of years with intact uterus and ovaries capable of producing hormones even after the cessation of the menstrual period.
One study showed that the risk of subsequent cardiovascular disease was substantially increased for women undergoing hysterectomy at age 50 or younger. No association was found for women undergoing this procedure after the age of 50 years. The risk is higher when the ovaries are removed but still visible even when the ovaries are preserved.
Several other studies have found that osteoporosis (decreased bone density) and increased risk of fractures are associated with hysterectomy. This has been linked to the effects of estrogen modulation on calcium metabolism and decreased serum estrogen levels after menopause can lead to excessive calcium losses that lead to bone waste.
Hysterectomy is also associated with higher rates of heart disease and weakened bone. Those who have had a hysterectomy with both ovaries removed usually have less testosterone levels than those remaining intact. Reduced levels of testosterone in women are predictive of height loss, which may occur as a result of reduced bone density, while elevated testosterone levels in women are associated with greater sexual desire.
Oophorectomy before age 45 is associated with a fivefold death of neurological and mental disorders.
Urinary incontinence and vaginal prolapse
Urinary incontinence and vaginal prolapse are well known side effects that develop at high frequency very long after surgery. Typically, these complications develop 10-20 years after surgery. For this reason, the exact figure is unknown, and the risk factors are poorly understood. It is also not known whether the choice of surgical technique has any effect. It has been assessed that the risk of urinary incontinence is about twice that within 20 years after hysterectomy. One long-term study found a 2.4-fold increased risk for surgery to improve urinary stress incontinence after hysterectomy.
The risk of vaginal prolapse depends on factors such as number of vaginal delivery, delivery difficulties, and type of labor. The overall incidence is about twice that after hysterectomy.
The formation of adhesions and bowel obstruction
The formation of postoperative adhesion is a particular risk after hysterectomy due to the degree of dissection involved as well as the fact that hysterectomy lesions are in the most dependent part of the gravity of the pelvis where the intestinal loop can easily fall. In one review, the incidence of small bowel obstruction due to bowel adhesion was found to be 15.6% in a total non-laparoscopic hysterectomy hysterectomy vs 0.0% in laparoscopic hystericoscopy.
Wound infection
Wound infections occur in about 3% of cases of abdominal hysterectomy. The risk is increased by obesity, diabetes, immunodeficiency disorders, systemic corticosteroid use, smoking, wound hematoma, and pre-existing infections such as chorioamnionitis and pelvic inflammatory disease. Such wound infections are mainly in the form of an incisional abscess or a wound cellulitis. Usually, both provide erythema, but only an incisional abscess that provides purulent drainage. The recommended treatment for incisional abscesses after hysterectomy is with incision and drainage, and then covered with a thin layer of gauze followed by a sterile dressing. The sauce should be replaced and the wound is irrigated with normal salt water at least twice daily. In addition, it is recommended to provide antibiotics that are active against staphylococci and streptococci, preferably vancomycin when there is a risk of MRSA. The wound can be left closed with secondary intentions. Alternatively, if the infection is cleansed and healthy granulation tissue is visible at the wound base, the incision tips can be determined again, such as by using butterfly stitches, staples or stitches. Sexual intercourse is possible after a hysterectomy. Reconstructive surgery remains an option for women who have experienced benign and malignant conditions.
Other rare issues
Hysterectomy may lead to an increased risk of rare cell carcinoma. Increased risk is especially pronounced for young women; the risk is lower after a vaginal hysterectomy. Hormonal effects or ureteral injury are considered as possible explanations. In some cases, renal cell carcinoma may be a manifestation of hereditary leiomyomatosis and undiagnosed renal cell kidney syndrome.
The removal of the uterus without removing the ovaries may result in a situation that on rare occasions may result in an ectopic pregnancy due to undetected fertilization that has not yet descended into the uterus prior to surgery. Two cases have been identified and profiled in an issue about the Blackwell Journal of Obstetrics and Gynecology ; more than 20 other cases have been discussed in additional medical literature. There is the possibility of another case of ectopic pregnancy after a hysterectomy that occurred in 2016, although no additional information was submitted. On very rare occasions, sexual intercourse after a hysterectomy may result in removal of transvaginal stomach contents from the small intestine. The vaginal cuff is the uppermost area of ​​the vagina that has been stitched up close. Rare complications, can damage and allow the expulsion of the small intestine into the vagina.
Maps Hysterectomy
Alternative
Depending on an indication there is an alternative to hysterectomy:
Heavy bleeding
Levonorgestrel intrauterine devices are highly effective in controlling dysfunctional uterine bleeding (DUB) or menorrhagia and should be considered before surgery.
Menorrhagia (heavy or abnormal menstrual bleeding) can also be treated with a less invasive endometrial ablation that is an outpatient procedure in which the lining of the uterus is destroyed by heat, mechanics or by radio frequency ablation. Endometrial ablation greatly reduces or completely eliminates monthly bleeding in ninety percent of patients with DUB. This is not effective for patients with very thick uterine lining or uterine fibroids.
Uterine fibroids
The Levonorgestrel intrauterine tool is very effective in limiting menstrual blood flow and improving other symptoms. Side effects are usually very moderate because levonorgestrel (progestin) is released in low concentration locally. There is now substantial evidence that Levongestrel-IUD provides symptomatic relief for women with fibroids.
Uterine fibroids can be removed and the uterus is reconstructed in a procedure called "myomectomy." Myomectomy may be performed through an open incision, laparoscopy or through the vagina (hysteroscopy).
Embolization of the uterine artery (UAE) is a minimally invasive procedure for the treatment of uterine fibroids. Under local anesthesia the catheter is inserted into the femoral artery in the groin and forward under radiographic control into the uterine artery. A microsphere mass or a polyvinyl alcohol material (an embolus) is injected into the uterine artery to block blood flow through the vessels. Restriction of blood supply usually results in significant reduction of fibroids and an increased tendency of severe bleeding. A review of Cochrane 2012 compares hysterectomy and the UAE found no major advantages for both procedures. While the UAE is associated with shorter hospital stay and faster return to normal daily activities, it is also associated with higher risk for minor complications later in life. There is no difference between UAE and hysterectomy with respect to major complications.
Uterine fibroids can be removed by a non-invasive procedure called Magnetic Resonance Guided Focused Ultrasound (MRgFUS).
Prolapse
Prolapse can also be corrected surgically without removal of the uterus.
Type
Hysterectomy, in the literal sense of the word, means only the removal of the uterus. Yet other organs such as the ovaries, fallopian tubes and cervix are very often removed as part of surgery.
- Radical hysterectomy : complete removal of the uterus, cervix, upper vagina, and parametrium. Indicated for cancer. Lymph nodes, ovaries and fallopian tubes are also usually discarded in these situations, such as in Wertheim's
- Total hysterectomy : complete removal of the uterus and cervix, with or without oophorectomy.
- Subtotal hysterectomy : removal of the uterus, leaving the cervix in situ.
Subtotal (supracervical) hysterectomy was initially proposed in the hope of improving sexual function after hysterectomy, it has been postulated that removing the cervix causes excessive neurological and anatomical disturbances, leading to vaginal shortening, vaginal dome prolapse, and vaginal cuff granulation. This theoretical advantage is not confirmed in practice, but another advantage of total hysterectomy appears. The main disadvantage is that the risk of cervical cancer is not eliminated and women can continue cyclical bleeding (albeit substantially less than before surgery). These problems are discussed in systematic review of total versus supracervical hysterectomy for benign gynecological conditions, which report the following findings:
- There is no difference in levels of incontinence, constipation, sexual function measurement or pre-operative symptom relief.
- The duration of surgery and the amount of blood lost during surgery was significantly reduced during supracervical hysterectomy compared with total hysterectomy, but there was no difference in postoperative transfusion rates.
- The dengue morbidity of dengue is less likely and cyclic vaginal bleeding that lasts a year after surgery is more likely after supracervical hysterectomy.
- There is no difference in the degree of other complications, recovery from surgery, or regeneration rate.
In the short term, randomized trials have shown that cervical preservation or release does not affect subsequent pelvic organ prolapse rates.
Supracervical hysterectomy does not eliminate the possibility of having cervical cancer because the cervix itself remains intact and may be contraindicated in women with an increased risk of this cancer; Regular Pap smears to check for cervical dysplasia or cancer are still needed.
Technique
Hysterectomy can be done in various ways. The oldest known technique is the abdominal incision. Furthermore, the vagina (hysterectomy through the vaginal canal) and then laparoscopic vagina (with additional instruments inserted through small holes, often close to the navel) technique developed.
Abdominal hysterectomy
Most hysterectomies in the United States are done through laparotomy (abdominal incision, not to be confused with laparoscopy). The transverse incision (Pfannenstiel) is made through the abdominal wall, usually above the pubic bone, as it is close to the hairline over the individual lower pelvis, similar to an incision made for a caesarean section. This technique allows physicians the greatest access to reproductive structures and is usually done to remove the entire reproductive complex. The recovery time for open hysterectomy is 4-6 weeks and sometimes longer because of the need to cut the abdominal wall. Historically, the biggest problem with this technique was infection, but the infection rate was well controlled and not a major concern in modern medical practice. Open hysterectomy provides the most effective way to explore the abdominal cavity and perform complex surgery. Before the refinement of vaginal and laparoscopic techniques, it is also the only possibility to achieve subtotal hysterectomy; Meanwhile, the vaginal route is a preferred technique in many situations.
Vaginal hysterectomy
The vaginal hysterectomy is performed entirely through the vaginal canal and has clear advantages over abdominal surgery such as fewer complications, shorter hospitalization times and shorter healing times. Abdominal hysterectomy, the most common method, is used in such cases after caesarean delivery, when indications are cancer, when complications are expected, or surgical exploration is necessary.
Hunger-hungry vaginal hysterectomy
With the development of laparoscopic techniques in the 1970s and 1980s, "laparoscopically assisted vaginal hysterectomy" (LAVH) has gained immense popularity among obstetricians as compared to less invasive stomach procedures and much faster postoperative recovery. It also allows for better exploration and operation that is slightly more complicated than vaginal procedures. LAVH begins with laparoscopy and is completed so that the final uterine removal (with or without ovaries) is through the vaginal canal. Thus, LAVH is also a total hysterectomy; the cervix should be removed with the uterus. If the cervix is ​​removed along with the uterus, the top of the vagina is sewn together and is called the vagina.
Supracervical laparoscopic assisted hysterectomy
The "laparoscopic-assisted supracervical hysterectomy" (LASH) was then developed to remove the uterus without lifting the cervix using a morcellator that cuts the uterus into small pieces that can be removed from the abdominal cavity via a laparoscopic port.
Total laparoscopic hysterectomy
Total laparoscopic hysterectomy (TLH) was developed in the early 90s by Prabhat K. Ahluwalia in Upstate New York. TLH is performed only through laparoscopy in the abdomen, beginning at the top of the uterus, usually with a uterine manipulator. The entire uterus is disconnected from its attachment using a long thin instrument through the "port". Then all the tissue that must be removed through a small abdominal incision.
Other techniques
Supracervical (subtotal) laparoscopic hysterectomy (LSH) is performed similarly to total laparoscopic surgery but the uterus is amputated between the cervix and fundus.
Double-port laparoscopy is a form of laparoscopic surgery using two 5 mm midline incisions: the uterus is released through two ports and removed through the vagina.
"Robotic hysterectomy" is a variant of laparoscopic surgery using a remote controlled special instrument that allows a smoother controller and enhanced three-dimensional vision.
Comparison of techniques
Patients 'characteristics such as the need for hysterectomy, uterine size, uterine descent, presence of diseased tissue around the uterus, previous pelvic surgery, obesity, pregnancy history, the possibility of endometriosis, or the need for oophorectomy will affect surgical surgeons' approach to hysterectomy.
Vaginal hysterectomy is recommended above other variants where possible for women with benign disease. Vaginal hysterectomy proves better than LAVH and some types of laparoscopic surgery cause short-term and long-term complications, a more favorable effect on sexual experience with shorter recovery times and less cost.
Laparoscopic surgery offers certain advantages when vaginal surgery is not possible but also has significantly longer loss of time required for surgery.
In one 2004 study conducted in the UK comparing abdominal (laparotomic) and laparoscopic techniques, laparoscopic surgery was found to result in longer surgery time and higher rates of major complications while offering faster healing. In another study conducted in 2014, laparoscopy was found to be a "safe alternative to laparotomy" in patients who received total hysterectomy for endometrial cancer. The investigators concluded the procedure "offers significantly improved perioperative outcomes with lower reoperation rates and fewer postoperative complications when standard maintenance shifts from open surgery to laparoscopy at a university hospital".
Vaginal hysterectomy is the only viable option available without total anesthesia or in ambulatory settings (although doing so without anesthesia is recommended only in exceptional cases).
Abdominal techniques are very often applied in difficult circumstances or when complications are expected. Given these circumstances, the level of complications and the time required for surgery is very favorable compared to other techniques, but the time required for healing is much longer.
Hysterectomy with stomach laparotomy correlates with a higher incidence of intestinal adhesion than any other technique.
The time required to complete operations in the eVAL trial is reported as follows:
- average stomach 55.2 minutes, range 19-155
- vagina 46.6 minutes on average, range 14-168
- laparoscopy (all variants) averaged 82.5 minutes, range 10-325 (combined data from both arms)
Morcellation has been widely used mainly in laparoscopic techniques and occasionally for vaginal techniques, but now appears to be associated with the risk of spreading benign or malignant tumors. In April 2014, the FDA issued a memo warning medical practitioners of the moral risks of power.
Robotic assist surgery is currently used in some countries for hysterectomy. Additional research is needed to determine the benefits and risks involved, compared with conventional laparoscopic surgery.
A 2014 Cochrane review found that robotic-assist surgery may have similar complication rates when compared with conventional laparoscopic surgery. In addition, there is evidence to suggest that although surgery makes it longer, robot-assisted surgery may result in shorter hospital stays. Further research is needed to determine whether robotic assisted hysterectomy is beneficial for cancer patients.
The previously reported marginal gains from robotic aid surgery can not be confirmed; only differences in hospitalization and cost remain statistically significant. In addition, concerns over the number of misleading marketing claims have been raised.
Incident
Canada
In Canada, the number of hysterectomies between 2008 and 2009 was almost 47,000. The national rate for the same time line is 338 per 100,000 population, down from 484 per 100,000 in 1997. The reasons for hysterectomy differ depending on whether the woman lives in an urban or rural location. Urban women choose hysterectomy because uterine fibroids and rural women have a hysterectomy mostly for menstrual disorders.
United States
According to the National Center for Health Statistics, of 617,000 hysterectomies performed in 2004, 73% also involved surgical removal of the ovaries. In the United States, 1 in 3 women can be expected to undergo hysterectomy at 60 years of age. There are currently an estimated 22 million women in the United States who have undergone this procedure.
According to the same source, hysterectomy is the second most common surgery among women in the United States (the first of which is part of cesaerean). In the 1980s and 1990s, these statistics were a source of concern among some groups of consumer rights and confusion among the medical community, and led information-choice advocacy groups such as the Hersektomi Resources Education and Services (HERS) Foundation, established by Nora W. Coffey in 1982.
United Kingdom
In the UK, 1 in 5 women are prone to hysterectomy at age 60, and the ovaries are released about 20% of hysterectomy.
German
The number of hysterectomies in Germany has been constant over the years. In 2006, 149,456 hysterectomies were performed. In addition, Of these, 126,743 (84.8%) successfully benefited patients without incident. Women between the ages of 40 and 49 years are responsible for 50 percent of hysterectomy, and those aged between 50 and 59 accounted for 20 percent. In 2007, the number of hysterectomies decreased to 138,164. In recent years, laparoscopic or laparoscopically assisted hysterectomy techniques have been lifted into the foreground.
Denmark
In Denmark, the number of hysterectomies from the 1980s to the 1990s decreased 38 percent. In 1988, there were 173 such operations per 100,000 women, and by 1998 this number had been reduced to 107. The proportion of abdominal supracervical hysterectomies in the same time period increased from 7.5 to 41 percent. A total of 67,096 women undergo hysterectomy during these years.
See also
- List of operations by type
References
External links
- Hysterectomy in Curlie (based on DMOZ)
- MedlinePlus Encyclopedia Hysterectomy
- Oncolex.org displays live video recording showing radical hysterectomy
- Hudson FTM Resource Guide , "GTF FTM Rejuvenation Operation
Source of the article : Wikipedia
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