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Hysterectomy

Comparison of Hysterectomy Procedures

There are several different hysterectomy procedures, each with advantages and disadvantages. Depending on your reason for considering a hysterectomy, you may have a choice between two or more procedures. For complicated or cancer-related conditions that require maximum access and careful examination, your doctor will likely recommend an abdominal hysterectomy.

Vaginal hysterectomy

This type of hysterectomy is done through a small incision in the Reference vagina Opens New Window, rather than through an abdominal incision. The Reference ovaries Opens New Window and other organs may also be removed. Vaginal hysterectomy tends to cause less pain, and takes less healing time than abdominal hysterectomy. A vaginal hysterectomy can be done:

To remove small Reference uterine fibroids Opens New Window.
When the uterus is of normal size or slightly enlarged.
When Reference endometriosis Opens New Window growths (implants) are not present.
When there is no significant scarring in the pelvis from previous surgeries.

Vaginal hysterectomy requires more specialized surgical skill than an abdominal hysterectomy. It can pose a higher risk of injury to other organs. Vaginal hysterectomy is not used when there is a question about possible cancer in the uterus, cervix, or ovaries.

Abdominal hysterectomy

This type of hysterectomy is done through a larger abdominal incision, giving the surgeon the best possible access to the pelvic organs. The cervix may be removed with the uterus (total hysterectomy) or left in place (subtotal hysterectomy). The Reference ovaries Opens New Window and other organs may also be removed. An abdominal hysterectomy is typically done when:

The uterus is very large.
Uterine fibroids are larger than 8 in. (20 cm) across or located around blood vessels.
Cancer of the uterus, ovaries, or cervix is possible.
An ovarian growth (mass) is suspected but can't be diagnosed on ultrasound.
There is significant scarring or severe endometriosis in the pelvic area.

If a hysterectomy is chosen to treat endometriosis, an abdominal hysterectomy is usually required. One example is when endometriosis growths (implants) or scar tissue (adhesions) must be removed to restore the function of other organs.

Laparoscopically assisted vaginal hysterectomy (LAVH)

Laparoscopic hysterectomy is done with a viewing instrument (Reference laparoscope Opens New Window) and surgical instruments inserted through a vaginal incision and one or more small abdominal incisions. The ovaries and other organs may also be removed. The uterus is removed through the vagina. It is done:

When uterine fibroids are small to moderate in size.
When the uterus is slightly larger than normal.
To remove endometriosis and scar tissue (Reference adhesions Opens New Window) confined to the uterus, Reference fallopian tubes Opens New Window, and Reference ovaries Opens New Window.
To assess or remove ovaries at the same time as a vaginal hysterectomy.

LAVH requires the surgeon to have specialized training.

Laparoscopic supracervical hysterectomy (LSH)

Laparoscopic supracervical hysterectomy is done by inserting a laparoscope and surgical instruments through several small abdominal incisions. The uterus is removed in small pieces through one of the incisions and the cervix is left intact. This is also known as subtotal or partial hysterectomy. This type of procedure usually causes minimal blood loss and pain. The hospital stay is shorter than for total abdominal surgery. Most women can return to normal activity a week or two afterward. LSH can be done:

To remove uterine fibroids of any size.
To remove a uterus of any size.

LSH usually takes longer to do than abdominal or vaginal hysterectomy. LSH is not available in some areas.

Total laparoscopic hysterectomy (TLH)

The total laparoscopic hysterectomy is done by inserting a laparoscope and surgical instruments through several small incisions in the abdomen. The uterus and the cervix are removed in small pieces through one of the incisions. TLH can be done:

To remove uterine fibroids that are small to moderate in size.
When there is not a lot of scar tissue in the pelvic area.
When there is not a worry about cancer in the ovaries.

TLH requires the surgeon to have special training. It usually takes longer to do than abdominal or vaginal hysterectomy. But recovery and hospital stay are shorter than for total abdominal hysterectomy. TLH is not available in many parts of the country.

**Advantages and disadvantages of hysterectomy procedures**
Procedure	Advantages	Disadvantages
Vaginal hysterectomy	Enables removal of a normal to slightly larger-than-normal uterus and small Reference uterine fibroids Opens New Window When compared with abdominal hysterectomy, requires a shorter hospital stay^{Reference 2} Usually has a faster recovery than an abdominal hysterectomy^{Reference 2} Tends to cause less pain during recovery than after an abdominal surgery Doesn't leave scars on the abdomen	When compared with abdominal hysterectomy, a routine vaginal hysterectomy: Doesn't allow free access to the pelvic organs. The doctor may not be able to remove a very large uterus; large fibroids; areas of Reference endometriosis Opens New Window, Reference adenomyosis Opens New Window, or scar tissue (Reference adhesions Opens New Window). Isn't used for cancer-related surgery. May need to be switched to an abdominal surgery if the doctor is unable to remove a very large uterus or areas of endometriosis, adenomyosis, or scar tissue (adhesions).
Abdominal hysterectomy	Provides the surgeon good visibility and easy access to the pelvic organs Enables removal of a very large uterus or large areas of Reference endometriosis Opens New Window, Reference adenomyosis Opens New Window, or scar tissue (Reference adhesions Opens New Window) Cervix can be removed or left in place Requires less time under Reference anesthesia Opens New Window and in surgery than a laparoscopic hysterectomy^{Reference 3}	When compared with other types of hysterectomy, a routine abdominal hysterectomy: Requires longer hospital stay and recovery time.^{Reference 2} Tends to lead to more pain during recovery. Leaves a visible scar on the abdomen. A bikini-line incision may be possible.
Laparoscopically assisted vaginal hysterectomy (LAVH)	Allows your doctor to examine your Reference pelvic organs Opens New Window Reference Opens New Window and remove cysts, scar tissue (Reference adhesions Opens New Window), Reference fibroids Opens New Window, and areas of infection When compared with abdominal hysterectomy, requires a shorter hospital stay and causes less pain during recovery^{Reference 2} Smaller scars on the abdomen than with an abdominal hysterectomy	When compared with other types of hysterectomy, a routine LAVH: May need to be switched to an abdominal surgery if the doctor is unable to remove a very large uterus or areas of Reference endometriosis Opens New Window, Reference adenomyosis Opens New Window, or scar tissue (Reference adhesions Opens New Window). Takes more time to perform.^{Reference 2} May have an increased risk of injury if the surgeon is inexperienced.
Laparoscopic supracervical hysterectomy (LSH)	When compared with abdominal hysterectomy, requires a shorter hospital stay, with a faster and less painful recovery Leaves smaller scars on the abdomen than with an abdominal hysterectomy	When compared with other types of hysterectomy, a routine LSH: May need to be switched to an abdominal surgery if the doctor is unable to remove a very large uterus or areas of Reference endometriosis Opens New Window, Reference adenomyosis Opens New Window, or scar tissue (Reference adhesions Opens New Window). Is likely to cost more. May have an increased risk of injury if the surgeon is inexperienced.
Total laparoscopic hysterectomy (TLH)	Does not use an incision in the wall of the vagina When compared with abdominal hysterectomy, requires a shorter hospital stay, with a faster and less painful recovery Leaves smaller scars on the abdomen than with an abdominal hysterectomy	When compared with other types of hysterectomy, a routine TLH: May need to be switched to an abdominal surgery if the doctor is unable to remove a very large uterus or areas of Reference endometriosis Opens New Window, Reference adenomyosis Opens New Window, or scar tissue (Reference adhesions Opens New Window). Is likely to cost more.

By:	Reference Healthwise Staff	Last Revised: Reference January 9, 2012
Medical Review:	Reference Sarah Marshall, MD - Family Medicine Reference Kirtly Jones, MD - Obstetrics and Gynecology

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