Hysterectomy is a surgical procedure that involves removing the uterus.
Four types of hysterectomies can be performed depending on the problem to be treated and the age of the patient:
– Subtotal hysterectomy, which removes the body from the uterus, but leaves the cervix in place.
– Total hysterectomy in which the body and the cervix are removed.
– Total hysterectomy with salpingo-oophorectomy (called non-conservative) during which the body of the uterus, the cervix, as well as the ovaries and fallopian tubes are removed.
– Radical hysterectomy, which is performed in the case of invasive gynecological cancers, associates total hysterectomy with the tubes and ovaries plus the removal of the upper 1/3 of the vagina and the pelvic lymph nodes.
Several surgical techniques are possible and chosen, again, depending on the pathology to be treated, the morphology and the patient’s history. It is thus possible to perform hysterectomies vaginally, abdominally or by laparoscopy.
The pathologies requiring a hysterectomy are:
Uterine fibroids (myomas) . Uterine fibroids are benign masses that develop in the lining of the uterus. One or more fibroids can occur simultaneously. Their occurrence is a frequent event that affects nearly one in two women after 35-40 years. Most of the time, they are not responsible for any symptoms and therefore require no treatment. In some cases, their large size or their number can be the cause of menorrhagia (too heavy periods), pelvic pain, feeling of heaviness in the lower abdomen or urinary or digestive discomfort that justify treatment.
Menometrorrhagia(too heavy periods or bleeding between periods). These may be due to the hormonal change in perimenopause or the presence of fibroids. They can be responsible for anemia and considerably affect the quality of life. Medical or hysteroscopic treatments may be offered in some cases, but if this fails, a hysterectomy will be necessary.
Endometriosis . Endometriosis corresponds to the migration of the endometrium (mucous membrane lining the uterus) outside the uterine cavity: it is grafted onto the peritoneum, the ovaries most often, but also the intestine, the bladder and the rectum. .. This can cause severe pain, especially during menstruation or during sex. In some cases, in patients who have obtained the desired pregnancies and for whom the various medical treatments are no longer effective, hysterectomy may be considered in order to improve their quality of life.
Uterine prolapse . With age and pregnancy, the uterus may descend into the vagina, due to the relaxation of the pelvic muscles and ligaments. This organ descent most often causes discomfort and heaviness, as well as problems with urine leakage.
Pelvic pain . There are many etiologies to pelvic pain and hysterectomy can, in some cases, provide healing for patients. However, it is important to identify the problem correctly before taking action. Endometriosis, fibroids, adhesions and infections are the main causes of this pain.
Cancers or precancerous conditions of the uterus or ovaries . Depending on their degree of severity, uterine (body and cervix) and ovarian cancers most often require a hysterectomy.
Abdominal hysterectomy (via the upper route) is performed through an opening in the abdomen (most often transverse scar, or median subumbilical).
It has the advantage of allowing easy access to the uterus and facilitates its extraction in the case of a large uterus (in some patients, fibroids can weigh several pounds!). However, compared to other routes of entry, it requires a longer hospital stay, leaves a scar and delays the resumption of daily activities and work more.
Most often, the patient is hospitalized the day before the operation and remains fasting from there. The same morning, an infusion will be placed in the room or in the operating room.
Once general anesthesia is performed (general anesthesia or spinal anesthesia), disinfection of the skin of the abdomen and inside the vagina is performed, then surgical drapes are put in place. A urinary catheter is placed at the start of the operation. The first operative stage consists of a generally horizontal 15 to 20 cm incision just above the pubis, called the Pfannenstiel incision. More rarely, this incision can be vertical between the pubis and the umbilicus, if the uterus is very large.
The attachments of the uterus are gradually released (blood vessels, ligaments) and coagulated or sutured. The uterus is cleaved from the organs it sits against: the bladder in front and the rectum behind and detached from the vagina (or cervix if left in place).
The vagina is then sutured and the intestine naturally occupies the place of the uterus.
The surgical specimen is always sent to the laboratory for histological analysis.
The intervention lasts between 45 minutes and 2 hours.
3. Operative suites
The urinary catheter is left in place for 24 hours, the removal is not painful.
A drain is sometimes put in place during the procedure, most often removed after two to three days.
To avoid postoperative pain, analgesics are administered through the veins first (for 1 to 2 days) then orally. A preventive treatment of phlebitis by anticoagulants (subcutaneous injection) and wearing of compression stockings, is started from the day of the operation.
It is generally possible to get up the day after the operation. Food will be resumed quickly depending on the resumption of intestinal transit.
Light vaginal bleeding is normal for the first few days.
The removal of the wires or staples will take place within 5 to 7 days following the operation.
Hospitalization of 3 to 6 days is necessary.
On discharge, oral analgesics and anticoagulant injections will be prescribed for 3 weeks to a month. This treatment requires monitoring of blood platelets by taking blood twice a week for the duration of the treatment.
A work stoppage of about 1 month is necessary. You have to be vigilant to rest well and not to carry heavy loads for the first month. Baths, intercourse and the wearing of vaginal tampons are prohibited during the first month.
It is necessary to contact the surgeon in the following weeks in case of heavy vaginal bleeding, fever, severe abdominal or vaginal pain, pain when urinating, redness or discharge from the scar, pain in the calf or difficulty in breathing.
A postoperative appointment with the surgeon is necessary in the following month (usually 3 to 4 weeks later) to check for scars, pain and to receive the results of histological analyzes.
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Although hysterectomy is a very common operation, it presents a minimal but real rate of complications, like any surgical procedure.
The main complications encountered are:
During the intervention:
• Reactions to anesthesia;
• Heavy bleeding during the procedure, sometimes requiring a blood transfusion or more often treatment with intravenous iron infusion;
• Injuries to organs around the uterus: bladder, ureter, colon, small intestine. These lesions have little impact if they are discovered and repaired during the procedure.
In the days or weeks that follow:
• Phlebitis and pulmonary embolism (presence of clots in the veins). This is the reason why a preventive anticoagulant treatment will be systematically instituted from the day of the operation;
• An infection of the surgical site in the following days requiring treatment with antibiotics;
• Bowel obstruction which may require medical treatment or even a new intervention;
• A urinary tract infection, usually not serious and treated with antibiotics;
• Heavy postoperative vaginal bleeding;
• A disunion, infection or hematoma of the skin scar in the days or weeks that follow.
In the long term, other complications such as bladder or rectal prolapse (descent of the bladder or rectum) or urinary incontinence may occur.
5. What changes after a hysterectomy
Women who were not menopausal will no longer have their period and can no longer be pregnant after the procedure, even if the ovaries have been left in place. If the ovaries are removed, symptoms of menopause may appear: hot flashes, weight gain, night sweats, irritability, vaginal dryness, decreased libido. It is then possible, in the absence of contraindications, to start hormone replacement therapy for menopause, to be reviewed with the gynecologist. Most often, this treatment is started upon discharge to avoid climacteric effects.
The hysterectomy seems to have little impact on sexuality, except for the decrease in libido that can cause the removal of the ovaries (but which will be corrected by treatment). Some women will even see their sexuality take off again, because they are relieved of the discomfort they felt before the hysterectomy and which made sex painful and in some cases impossible (pain, daily bleeding). It should also be emphasized that the removal of the cervix does not affect the orgasm.
Finally, it should be emphasized that the uterus is a highly symbolic organ and its removal requires mourning for motherhood, which can be difficult even after 40 years. Some women may feel that they have lost part of their femininity. Questioning about their image of themselves as a woman and their sexual attraction can be part of the postoperative process. The help of a psychologist may then be necessary.
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