Overview of Abdominal Hysterectomy
The first abdominal hysterectomy, a surgery that removes the uterus through the abdomen, was performed in 1843. However, earlier attempts to remove the uterus go back to ancient times as vaginal hysterectomies were performed to treat a uterus that had fallen or inverted. In 1989, surgeons started using laparoscopic assistance to make hysterectomies less invasive, and the technique was further refined in 2005 with the approval of robot-assisted surgeries. Nowadays, surgeons can choose between abdominal, vaginal, laparoscopic, robot-assisted, or a combination of vaginal and laparoscopic techniques for this surgery. The decision depends on the reason for the surgery, patient’s overall health, the surgeon’s experience, available resources, and the patient’s personal choice.
With the rise in minimally invasive techniques, fewer abdominal hysterectomies are being performed. These non-invasive methods offer advantages like less post-surgery pain, quicker recovery times, a better short-term quality of life, shorter hospital stays, and lower costs. Additionally, the prevalence of hysterectomies in general has lessened because there are now alternatives for treating uterine bleeding and uterine leiomyomas (benign tumors in the uterus), like the scraping of the uterine lining (endometrial ablation) and cutting off the blood flow to the uterus (uterine artery embolization). Despite these alternatives, a hysterectomy still remains the best treatment option for many patients.
A large uterus used to be a common reason for opting for an abdominal hysterectomy, since it was believed that a bigger uterus could lead to more bleeding, potential harm to nearby organs, and a longer surgery time. But, there’s no specific guideline for the weight or size of the uterus that mandates an abdominal hysterectomy, and recent studies have indicated that minimally invasive techniques can also efficiently remove larger uteruses. However, abdominal hysterectomy is still frequently performed for conditions like uterine fibroids (noncancerous growths in the uterus), abnormal uterine bleeding, prolapsed uterus (uterus slipping down into or protruding out of the vagina), and endometriosis (a disorder in which the tissue that normally lines the uterus grows outside the uterus).
Anatomy and Physiology of Abdominal Hysterectomy
The vulva, formally known as the external genitalia, is the collection of external structures that belong to the reproductive and urinary systems of females. They sit outside the vagina.
The vagina is a canal that creates a link between the cervix (the lowermost part of the uterus) and the vulva.
The cervix is the lowest part of the uterus and it has a canal that connects the uterus to the vagina. This canal is bordered by the internal and external cervical os.
The main part of the uterus, known as the uterus corpus, is positioned deep in a woman’s pelvic area. It sits behind the urinary bladder and in front of the rectum.
The Broad ligaments are like a sheet that covers the uterus, fallopian tubes, and ovaries. It stretches out to the side walls of the pelvis.
The Round ligaments are attached to the corners of the uterus and they extend through the inguinal canal to join with the labia majora and mons pubis. These ligaments contain the artery of Sampson.
The Cardinal ligaments form the lower border of the broad ligament. They attach to the side of the cervix. These ligaments contain the uterine artery and veins.
The Infundibulopelvic ligaments are a fold in the pelvic area that stretches from the ovary to the sidewalls of the pelvis. They contain the ovarian artery and vein, ovarian nerve plexus, and lymphatic vessels.
The Uterosacral ligaments are bands of fibrous tissue. They extend from the cervix and the vaginal tube towards the sacrum, maintaining their upward and backward direction.
Why do People Need Abdominal Hysterectomy
An abdominal hysterectomy is a surgical procedure to remove the uterus through an incision in the lower belly. A doctor may recommend an abdominal hysterectomy for several reasons, including:
- Unusual or heavy bleeding from the uterus
- Cancerous or precancerous conditions
- Leiomyoma, a type of non-cancerous growth in the uterus
- Endometriosis, a condition where tissue similar to the lining of the uterus starts growing elsewhere in the body
- Problems with the positioning or support of pelvic organs (pelvic organ prolapse)
- Chronic pain in the pelvic region
- Long-lasting pelvic infection
When possible, doctors usually prefer to perform a hysterectomy through the vagina as it’s less invasive. However, an abdominal hysterectomy is often chosen in certain situations. These might include cases where the uterus is very large, or the patient has had previous abdominal surgeries. It might also be necessary if there’s disease outside of the uterus, severe scarring (adhesions) or severe endometriosis. It can also be the preferred method if the patient has cancer of the female reproductive organs.
In the past, if the uterus was roughly the size of a 12-week pregnancy or larger, an abdominal hysterectomy might have been recommended. But as surgical techniques have improved, less invasive methods are often chosen when it is safe and practical to do so. These methods tend to lead to better outcomes for patients.
When a Person Should Avoid Abdominal Hysterectomy
There are some situations where a hysterectomy, which is a surgical operation to remove the uterus, might not be safe or beneficial for a patient. For example, a traditional abdominal hysterectomy (a simpler form of the surgery) could only cure a very early stage of cervical cancer that hasn’t spread yet. If the cancer is still only in the cervix but has spread further, then a more thorough surgery to ensure all affected areas are removed might be considered.
But, if the cancer in the uterine cervix, the lower part of the uterus attaching to the vagina, has advanced beyond early stages (specifically past Stage IB), the hysterectomy won’t be performed before the patient undergoes combined chemotherapy and radiation treatment due to the risk and potential lack of benefit.
Equipment used for Abdominal Hysterectomy
Your doctor will need the following tools to safely and effectively perform your procedure:
A long, angled #3 knife handle and blade is used to make precise cuts in the body.
The curved and straight Zepplin forceps, Kelly forceps, and Tonsil forceps are types of surgical tweezers used to hold and manipulate tissues inside the body.
Long Allis clamps are used to securely hold tissues during surgery.
Curved and straight Mayo uterine scissors, and Jorgenson scissors are specific types of surgical scissors used for cutting tissue. The shape and size of these scissors help the doctor to cut accurately.
A sponge forceps is a tool that’s designed to hold a sponge, which is used to absorb blood and other liquids during the operation.
Self-retaining retractor, Deaver retractors, Richardson retractors, and malleable retractors are instruments that help the doctor to hold the body open, so they can see and work inside.
Short and long needle holders are used to hold the needle when the doctor is sewing the body back together.
Sutures are the medical ‘threads’ used to close wounds or surgical incisions.
An electrosurgical device uses electrical current to cut or coagulate tissues in the body.
A suction apparatus is used to remove blood or other liquids, to keep the area clean and visible during surgery.
Who is needed to perform Abdominal Hysterectomy?
For your medical procedure, there will be a team of healthcare professionals working to ensure the operation goes smoothly. These include:
A Gynecologist, who is a doctor specialized in women’s reproductive health. This professional will be conducting your procedure. They have a lot of knowledge and training to make sure the operation is performed safely and effectively.
An Anesthesiologist, who is a doctor responsible for providing anesthesia, a type of medicine that puts patients to sleep or numbs a area of the body, during medical procedures. They will make sure you are not in any pain during the procedure.
A Scrub Nurse, who assists the doctors during surgery. They are a registered nurse specially trained to work in the operating room. Their job is to handle the sterile equipment, instruments and supplies needed during your surgery and to ensure that everything runs smoothly.
A Circulating Nurse, who does not scrub during surgery but takes care of the overall management of the operating room such as arranging needed supplies and equipment, communicating with other healthcare team members and ensuring a safe and clean environment.
And finally, a Surgical Assistant or Assistants, who help with tasks during the surgery. They might help by holding tools, suturing, stopping bleeding, and making sure the operation goes as planned.
Preparing for Abdominal Hysterectomy
The following steps are taken when preparing for a hysterectomy:
* Before the surgery begins, it is recommended that women who could potentially be pregnant take a pregnancy test. Doctors will also check the patient’s hemoglobin or hematocrit levels, which can provide information about the patient’s overall health and any potential complications they might face. They might also require additional blood tests depending on the patient’s existing health conditions.
* If the patient has pubic/vulvar hair that could interfere with the surgery, they might use either scissors or an electric clipper device to remove it. However, shaving is not advised because it can increase the risk of getting an infection or inflammation of the skin after the operation.
* To prevent deep vein thrombosis (DVT), which is a type of blood clot, doctors will place a device on the patient’s legs that keeps blood flowing. This is important because staying still for too long, such as during surgery, can increase the risk of developing DVT.
* The patient is properly positioned for the surgery. They are usually lying flat on their back, but sometimes they may be placed in a specific position with their legs in stirrups.
* The doctors give the patient a dose of antibiotics through an IV about 15 to 60 minutes before they start the surgery. This helps to prevent infection at the site of the surgery. If the surgery takes longer than 3 hours, or there’s a lot of blood loss, they will give a second dose.
* Before starting the operation, everyone in the operating team takes a moment to pause. During this time, they check the patient’s identifying information, the planned operation, the necessary equipment, and the surgical team.
* While the patient is still under anesthesia, doctors will do a pelvic exam to check the shape, size, and mobility of the uterus to decide the best surgical approach.
* To prepare the skin for surgery:
– For the area around the pelvis, doctors will apply a scrub that inhibits bacteria inside the vagina and on the skin.
– For the abdominal area, doctors will first clean the navel with Q-tips. Then, they will apply a scrub that kills bacteria in a circular motion, starting at the navel and extending to the upper and lower parts of the abdomen.
* A sterile surgical drape is used to cover the patient and make sure the surgical area remains free of germs throughout the operation.
* To keep the bladder empty during surgery and to help with recovery after surgery, doctors will insert a Foley catheter. This is a thin, flexible tube that carries urine from the bladder to a bag outside the body. In certain situations, other preparations might be necessary, including getting blood ready to use in case it’s needed during surgery or using a urinary stent if there is a high risk for ureteral injury, which means damage to the tubes carrying urine from the kidneys to the bladder.
How is Abdominal Hysterectomy performed
The method used to perform a hysterectomy, which is a surgery to remove the uterus, varies from patient to patient. Several factors play into the decision, such as the size, mobility, and position of the uterus, as well as any additional medical issues. The patient’s past surgeries also matter, as they may have caused sticky bands of tissue called adhesions that can complicate the surgery. Other considerations include the size and shape of the vagina, the risk of complications from other health conditions the patient might have, any other medical issues that exist alongside the need for the hysterectomy, the patient’s personal preference, and the surgeon’s level of experience.
One of the ways to perform the surgery is through the abdomen. This is done by cutting into the lower stomach area, with the particular type of cut depending on a few different factors such as if it is believed that the patient has cancer or if the upper abdomen also needs to be reached. Once inside, the surgeon examines the area and cuts through any adhesions, freeing the organs in the pelvis and making it easier to see and operate in the surgical area.
The uterus is lifted out of the pelvis by clamping the links connecting it to the ovaries. The links to the far side of the uterus are also cut to make more room. After this, the bladder is carefully separated from the cervix. The surgeon then reveals the arteries in the area.
If the ovaries are being removed too, the blood vessels to them are clamped and cut. Otherwise, the vessels near to the uterus are cut. If the rectum is sticking to the uterus, it will be separated carefully. The surgeon then works systematically to cut through the tissues and ligaments holding the uterus in place, until they reach the top of the vagina. The vagina is then cut below the cervix which detaches the uterus. Stitches are then used to close the top of the vagina.
The surgeon then cleans the area and ensures there’s no bleeding before stitching the cut in the abdomen closed. Sometimes, the surgeon may opt to perform a subtotal hysterectomy, where only the upper part of the uterus is removed, leaving the cervix in place. However, research shows there’s no difference in terms of sexual satisfaction, bowel or urinary problems whether the cervix is kept or removed. Women who keep their cervix do need to continue pap smear screenings to check for cervical cancer, though.
The decision to remove the ovaries and fallopian tubes should be made on a case-by-case basis, after a conversation between the patient and her doctor about the pros and cons. In some cases, it may be beneficial to remove the fallopian tubes, as this can prevent a particular type of cancer. Whether or not to remove the ovaries depends on several factors, including the patient’s age and their medical history.
Possible Complications of Abdominal Hysterectomy
Hysterectomy, or the surgical removal of the uterus, can sometimes have complications. These could include infections, blood clotting issues, injury to urinary and digestive organs, bleeding, nerve damage, and weakening of the vaginal area. There are also potential complications specifically after an abdominal hysterectomy, where the uterus is removed through a cut in the lower abdomen. These could include issues related to pelvic organs, urine leakage, and bowel obstruction. Like all surgeries, there’s also a risk of adverse reactions to anesthesia used during the procedure. Overall, it has been found that abdominal hysterectomy has a higher risk of complications in the first 30 days after the procedure, compared to less invasive methods such as laparoscopy.
Infections are the most common problem after removal of the uterus. These could happen in the stitches on the vagina, in a pocket of blood in the pelvic area, in the wound from surgery, or in the urinary tract. Some factors that increase the chances of infection are longer surgery time, not taking antibiotics before surgery, other health issues, a weak immune system, obesity, and poor nutrition. Signs of infection can appear later during the hospital stay or soon after being discharged from the hospital
In addition to infections, a serious potential risk includes the formation of blood clots, particularly in the veins of the legs (deep vein thrombosis or DVT) which can travel to the lungs (pulmonary embolism or PE). This is more likely to happen in bigger surgeries and in patients with cancers. However, not every patient may need medications to prevent formation of blood clots, and the benefits and risks need to be considered carefully by the doctors.
There could also be accidental injury to the urinary or digestive organs during the surgery. For example, injuries could occur to the bladder or ureters (tubes that carry urine from the kidneys to the bladder). Such injuries are rare but can lead to significant discomfort and complications for the patient. Also, unintended injuries can happen to the digestive organs during an abdominal hysterectomy.
Bleeding could be another issue, and it is often seen more with abdominal hysterectomy than other types of hysterectomy procedures. More blood loss during surgery can lead to severe post-surgical issues and may lengthen the hospital stay. Besides, nerve injuries could also occur during the surgery and are more often seen with pelvic surgeries.
Lastly, a complication called vaginal cuff dehiscence, where the top of the vagina separates may occur days or years after surgery. This can happen along the entire length or a portion of the surgical incision and can lead to serious complications like internal organs slipping out into the vagina.
What Else Should I Know About Abdominal Hysterectomy?
Research shows that a hysterectomy, or the removal of the uterus, can significantly enhance many aspects of a woman’s life when it’s medically necessary. However, one method of doing this surgery, called an abdominal hysterectomy, while popular, generally means longer recovery times and stays in the hospital. It also carries a greater risk for problems during and after the surgery.
There usually isn’t a specific guideline as to which method should be used for a hysterectomy. The final choice should be decided by a mutually agreed conversation between the doctor and the patient. The doctor has to consider their technical capabilities, and the patient needs to understand the procedure and agree to it.
Surgeons nowadays often tend to use a method known as endoscopic surgery, which is less invasive than traditional abdominal surgery. But it’s still crucial for new surgeons to learn how to do a conventional abdominal hysterectomy. This method is still needed in gynecologic oncology, which is the field dealing with cancers of the female reproductive organs, and in many cases of benign (non-cancerous) gynecologic disease, where open surgery remains necessary.
The American College of Obstetricians and Gynecologists, an authority in matters related to women’s health, made a statement in 2017 suggesting that a vaginal hysterectomy should be the first choice of technique. This is when the uterus is removed through the vagina rather than through an abdominal incision. If that’s not possible, then a laparoscopic hysterectomy, which uses very small cuts in the abdomen, should be considered. If both of those options can’t be done, then an abdominal hysterectomy would be the next step.
Keep in mind that an abdominal hysterectomy is a significant surgery and can affect a woman’s physical and emotional health. It’s crucial for the doctor to help patients deal with the emotional changes that may come with a hysterectomy. It’s beneficial for doctors to ask the patient how they feel about the surgery to relieve anxiety and offer emotional support during their appointments before the operation.