Laparoscopic Hysterectomy


A laparoscopic hysterectomy is the removal of the uterus (womb) using minimally invasive, or ‘key-hole’, surgery through small abdominal incisions. It is an alternative to abdominal hysterectomy, where a larger transverse or vertical incision is made in the abdomen, but is not intended to replace vaginal hysterectomy if this is possible. It is intended to be an extended day case procedure meaning you will go home first thing the next day.

This procedure requires advanced laparoscopic training and the National Institutue for Health and Clinical Excellence (NICE) state 'Advanced laparoscopic skills are required for these procedures, and clinicians should undergo special training and mentorship'.

There are three different types of hysterectomy that can be performed laparoscopically:

  • Total Hysterectomy – removal of the womb and cervix
  • Total Hysterectomy and removal of the ovaries and fallopian tubes
  • Sub-Total Hysterectomy – removal of the ‘body’ of the womb leaving the cervix


How is the operation performed?
A small telescope is passed through a small incision in the abdomen (usually the belly button).  The abdomen is gently inflated with carbon dioxide to separate the tissues and allow space within the pelvis to operate.

Two or three further small incisions are made to allow instruments to be passed in to the abdomen to perform the operation.  These incisions are closed with dissolvable stitches and covered with a small waterproof plaster.

Advantages of Laparoscopic Hysterectomy over Abdominal Hysterectomy
By using keyhole surgery there is less post operative pain, less blood loss, fewer wound infections, less scarring, shorter hospital stay and quicker return to full normal activity


Complications
Injury to surrounding structures / organs
There is a small risk of accidental injury to the bowel, blood vessels, the bladder or the ureters (the tubes from the kidney to the bladder). The incidence of injury to the ureters is greater in laparoscopic hysterectomy than abdominal hysterectomy (1.1% v’s 0.2%). If such complications occur, a larger incision (laparotomy) may be required to do the necessary repair.

All surgeons should be able to provide you with detailed information of their complication rates. Mr Carpenter's complication rate for laparoscopic hysterectomy is shown in the table below.

Complication

NICE Heavy menstrual bleeding guideline (Clinical Guideline 44 Jan 07)

NICE Lap. techniques for hysterectomy  (Interven. Proc. Guid. 239  Nov 07)

Mr Carpenter’s rate to Oct 2014

 

Abdo Hyst

Vag Hyst

Lap Hyst

 

 

Vascular Injury

   0.77%

   0.94%

  1.81%

                        1.76%

       0

Intestinal injury

   0.67%

     0 %

  0.20%

                         0.30%

       0

Ureteric injury

 

 

 

                       1.1-1.3%

     0.4%

Bladder injury

   0.86%

   1.60%

  2.33%

                       0.4-1.3%

     0.9%

Bleeding requiring Transfusion

   3.33%

   3.87%

   4.23

                       0.3-0.97%

     0.4%

Need to covert to laparotomy (not  sub total)

      _

   2.88%

  4.17%

                       2.79-7%

     1.8%

Vesicovaginal fistula

 

 

 

                       0.20%

       0

Combined vessel, bowel, ureter, bladder injury rate

 

   2.3%

 

  2.54%

 

  4.34%

 

                    3.56-4.66%

 

     1.3%

 

General Surgical Risks
As with all surgery there is a risk of infection, bleeding, deep vein thrombosis, pulmonary embolism (blood clot on the lung). Keyhole surgery, however, allows  early discharge  and more rapid return to normal activity with the aim to minimise these risks.

Alternative surgery
Abdominal hysterectomy is an alternative to laparoscopic hysterectomy.  This procedure requires a larger incision on your abdomen, longer hospital stay and a longer time to resume normal activities.  

Specific post-operative care

  • From theatre you will be taken to the recovery room where staff will monitor your pulse, blood pressure, pain, sickness and wound sites.
  • You will have an intravenous drip in your arm and a catheter in the bladder.
  • If you experience some nausea (sickness) this can be controlled with medications.
  • Around half an hour later you will return to the ward.
  • On the ward you will receive regular pain killers and any anti-sickness medication you require
  • You will be able to drink and eat as you feel able and to gradually increase what you are able to tolerate.
  • Initially you may experience some shoulder tip discomfort, which is due to trapped gas from the operation.  This will settle as the gas is absorbed.  Gentle mobilisation may also help once you are able.
  • You may have some vaginal bleeding, so a sanitary pad will be provided.
  • At around 2200 on the evening of your operation (prior to you going to sleep) the drip will be taken down and the catheter removed.
  • You will need to inform the nursing staff each time you pass urine so this can be measured.
  • The following morning you should be ready for home so will need to ensure someone is able to collect you and be with you at home.


Specific discharge information

Pain Killers - you will need to take regular pain killers at home to it is best to ensure you have a good supply of paracetamol and ibruprofen (if you can take these) at home.

Activity - You may feel tired and lethargic after your operation and this may continue for a few weeks.  This is quite normal and you should take short periods of rest during the day.  Despite this it is important to resume a normal lifestyle as soon as possible.  We usually recommend that for the first week after your operation that you take things gently.  
During the second week following your operation it is reasonable to consider light duties and during the third week you should be resuming normal activities.  This may vary depending on the individual but most women are back to full normal activity by four weeks.

Lifting / Exercise – avoid heavy lifting and aerobic workouts or strenuous exercise for 2-4 weeks.  You may start again gently when you feel comfortable.

Hygiene – you may shower but do not soak in a bath until a week post operatively.  Ensure that your incisions are clean and dry after showering or bathing. You may remove the dressings / plasters over your incisions two days after the operation

Stitches - the stitches used are dissolvable however, the part of the stitch on the outside may take longer than that on the inside to dissolve. Over time the outside part will fall away however if the stitch is irritating more than a week after surgery it can usually be removed by gently pulling on the end or cutting it carefully with scissors. If you have any significant problems with your stitches or if the area becomes sore, red or discharges please contact Mr Carpenter’s Secretary or your GP.

Vaginal loss - Some vaginal bleeding / discharge is normal after surgery which should decrease over time. You may well notice an increase in loss 10-14 days after the operation, as the stitches at the top of the vagina dissolve, this is quite normal. You may also notice these stitches on your pad. If your loss becomes heavy or offensive please contact Mr Carpenter’s Secretary.

Urine – if you experience any discomfort i.e. burning or stinging when passing urine please contact Mr Carpenters Secretary or your GP

Diet - Try to eat a healthy well balanced diet, including plenty of fibre and drink sufficient water to avoid constipation.  

Driving – you must not drive for 2 – 4 days after your anaesthetic, and you should not drive until you feel comfortable and are able to undertake an emergency stop.  

Sexual activity – refrain from penetrative sex for 6 weeks to allow the internal wounds to heal.  If you have had a sub-total hysterectomy and your cervix is still present you may resume normal sexual activity when you feel comfortable.

Work – you usually require 4 weeks off work.  Please ask for a sickness certificate before you leave hospital.

Cervical smear tests – will no longer be necessary if you have had a total hysterectomy.  If you have had a sub-total hysterectomy it will still be necessary to continue with regular smear tests as advised by your G.P. surgery

Follow Up
You will be seen by Mr Carpenter in 4-8 weeks time

Additional information about the do's and don't after laparoscopic hysterectomy as well as what to expect day to day can be found on the Royal College of Obstetricians & Gynaecologists website.