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Laparoscopic Outpatient Hysterectomy

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What is laparoscopic hysterectomy?

Laparoscopic hysterectomy is a procedure to remove the uterus through a few tiny incisions in the abdomen below the navel. This is also known as "keyhole surgery". Sometimes the ovaries and fallopian tubes are removed at the same time, a procedure called "salpingo-oophorectomy". Removing the ovaries induces menopause. If the ovaries are left in, menopause occurs at the usual age that it otherwise would. For most women, that is 50 to 52.

What is removed during a hysterectomy?

In a total hysterectomy, the surgeon will remove the uterus and the cervix (bottom part of the uterus which is protrudes into the vagina). In a sub-total hysterectomy, also known as a "supracervical hysterectomy", the surgeon removes only the uterus.

At Women's Health Connection, the surgeon will discuss with you the advantages and disadvantages of removing your cervix or leaving it in, and of removing your ovaries or leaving them in.

Why are hysterectomies done?

A hysterectomy may be carried out to treat many different conditions. These may include:

  • Heavy or irregular periods
  • Fibroids
  • Suspected or proven precancer or cancer
  • Painful periods/endometriosis/adenomyosis
  • Prolapse

You will be given adivce on alternatives to surgery such as natural hormones, drug treatments, or more minor procedures, therapy or surgery. The choice of treatment depends on the nature and extent of your condition as well as personal factors.

If you have a hysterectomy

  • You won't have any more periods
  • You can't become pregnant - so there's no need for contraception

A hysterectomy does NOT mean

  • Premature ageing
  • Becoming less of a woman or losing your sex drive
  • A space left inside your body. This does not happen as the bowel naturally moves to fill the space
  • It also does NOT necessarily mean you will need hormones. You will only become menopausal if the ovaries are removed. Otherwise, your hormone production will continue as usual.

What types of hysterectomies do you do at Women's Health Connection?

We do abdominal, vaginal and laparoscopic supracervical hysterectomies (LaSH). The vast majority of hysterectomies we do are laparoscopic supracervical hysterectomies, because we believe it has major advantages. (This is "not your mother's hysterectomy"!)

 What is it?Hospital stayRecovery timePain and scarringInfection
Abdominal Hysterectomy Uterus, cervix and sometimes other organs are removed via a 4 to 8-inch horizontal incision below the belly button 3-6 days 4-6 weeks Possibility of substantial pain and scarring 4-5%

(2-3% with intra-operative antibiotics)

Vaginal Hysterectomy Uterus, cervix and sometimes other organs are removed via a smaller incision inside the vagina 1-3 days 4 weeks No visible scarring; can be mildly painful during recovery 4-5%

(2-3% with intra-operative antibiotics)

Laparoscopic Supracervical Hysterectomy (LaSH) A specific type of laparoscopic hysterectomy in which the cervix is left in place 1 day or less 6 days Minimal recovery, pain and scarring; retaining the cervix may help pelvic floor support and preserve sexual function <1%

How will a hysterectomy help me?

The benefits of hysterectomy depend on the type and severity of problems that you are having. Your hysterectomy may be part of a continuing treatment or it may mean the end of a health problem.

Your surgeon at Women's Health Connection willl discuss with you the chances of a hysterectomy leading to a cure or improvement in your condition. You should weigh this against the severity of your condition and other available treatments, and also against the risk of not having the operation.

  • Overall, more than 90% of women who have a hysterectomy are highly satisfied or satisfied with the operation, and 97% of women who've had a laparoscopic supracervical hysterectomy are highly satisfied or satisfied
  • Problems like very heavy periods and any related pain will be nearly always be cured by hysterectomy

What are the benefits of laparoscopic hysterectomy?

Less pain and quicker recovery than vaginal or abdominal hysterectomy (see table above), also less scarring on the inside and the outside of the abdomen

What are the advantages of leaving the cervix in ("supracervical" or "subtotal") hysterectomy?

With a supracervical hysterectomy, the cervix is not removed. There are several potential benefits to this:

  • The operation is easier and quicker
  • The risk of damage to your bladder or ureters (tubes from your kidney to your bladder) is lower
  • The risk of you suffering a prolapse of the vagina in the future is reduced
  • You will lose less blood during the operation (our surgeons at Women's Health Connection typically have less than 1 tablespoon of blood loss during the procedure. Compare this to the usual blood loss nationally during a vaginal or abdominal hysterectomy, which is between 1/2 to 1 cup of blood loss)
  • You will spend less time in hospital (Most patients of Women's Health Connection spend only a few hours in hospital. About 5% stay overnight. Compare this to vaginal or abdominal hysterectomy which requires a 1-3 day hospital stay, usually for pain control.)
  • You are less likely to develop a fever or infection after your operation.

However, there are some possible disadvantages of supracervical hysterectomy:

  • You may still experience spotting every month at the time of your periods - this occurs in about 6% of women.
  • The cervix continues to be a potential site for cancer in the future...this risk is reduced dramatically by regular PAP smears, which you will still need.

What are the risks of hysterectomy?

There are risks associated with all operations. Although hysterectomy is a relatively safe operation and serious side effects are not very common, it is still a major operation. You need to be aware of the risks when deciding on the right treatment for you. Your surgeon at Women's Health Connection will help you weight the risks and benefits and what the alternatives may be for you.

  • Damage to the bladder or bowel

    During the operation, the surgeon may accidentally damage organs that are nearby. Damage to the bladder or one of the tubes which drain the kidneys (the ureters) occurs in about 1 in 150 women. Very rarely there can be damage to the bowel - one in 2500 women.

    The risk of damage to the surrounding organs is higher in women who have had previous operations involving the bowel or women with endometriosis. If such damage occurs, you may need an additional operation which was not planned. This happens in about 1 in 500 women.

  • Excessive bleeding

    National statistics suggest that excessive bleeding to the point of requiring transfusion during or after the procedure occurs is well under 1%.

    However, just to be safe, we do still advise a "type and screen" 2 days before your procedure. This needs to be done at Sacred Heart Hospital - it cannot be done offsite. This allows the hospital to have blood ready in the very unlikely event that you would need it. We also check a complete blood count at that time. If you do not wish to have a blood transfusion under any circumstances, please discuss this with the surgeon before your operation.

  • Blood clots (deep vein thrombosis) in legs or lungs

    Blood clots can form in a leg vein. With regular abdominal hysterectomy, this risk is less 1/250 women. With laparoscopic surgery, it is far less than that. A blood clot can move to the lungs causnig a very serious condition called pulmonary embolism. As a safety measure, we place pneumatic compression stockings on patients prior to every surgery to prevent this complication.

  • Infection

    One big advantage of laparoscopic hysterectomy is that the risk of infection is very low. Rarely, infection may occur inside the abdomen or pelvis (1 in 500 women, compared to 1 in 30 with a standard abdominal or vaginal hysterectomy). Infection may also affect the bladder, lungs or small incisions in your abdomen. Most are very easily treated with a course of antibiotics, but occasionally they can be more severe. Women's Health Connection surgeons use antibiotics through your IV as we are starting the procedure to minimize this complication.

  • Laparotomy

    Any laparoscopic surgery always carries a risk of needing to abandon the “keyhole” laparoscopic incisions, and proceed to making a larger abdominal incision. This is usually done under emergency circumstances only. At Women's Health Connection, our conversion rate is less than 1%.

  • Hematoma

    Very occasionally, some bleeding may begin to occur several hours, or even days after the procedure, in the pelvis or in the abdominal wall. Usually this is self-limiting, and forms a collection of clotted blood (hematoma) that your body slower reabsorbs it over several days. It can slightly delay your recovery. Rarely, they are more severe and can become infected and need to be drained.

  • Menopausal Symptoms

    These are associated with removing the ovaries, and usually don't happen if you choose to leave your ovaries in. If your ovaries are removed, hormone replacement or balancing may be necessary to help with your symptoms.

What are the alternatives to hysterectomy?

Alternative treatments are available for most of the conditions for which we do hysterectomies. These range from doing nothing (expectant management), to hormone balancing, to medications to minor procedures. The pros and cons of each of these treatments for the various conditions for which you might want or need a hysterectomy, are discussed at length on our website, www.whconnection.com, and will be further discussed at your visit with one of our providers.

What should I do to prepare for the surgery?

  • Plan ahead - when you come out of the hospital, you are going to need extra help at home for the first 2 weeks. Make sure your family knows this too. Weight restriction will be less than 10 pounds. This means no laundry, vacuuming or grocery shopping for two weeks after a laparoscopic surgery. For vaginal or abdominal surgery, this restriction extends for 6 to 8 weeks. Visit www.hystersisters.com for other planning thoughts and ideas.
  • Smoking - If you smoke, try to stop completely. This will make your anesthetic safer, reduce the risk of complications after the operation, and speed up the time it takes to recover. Perhaps this is a good opportunity to give up completely. If you are not able to stop completely, even doing so for a few days will e helpful. You will not be able to smoke while at the hospital.
  • Weight - If you are considering surgery in a period of time more than 3 months away, do try to be as close to your body weight as you can manage. Being overweight increases the risk of surgery, including anesthetic risk, infection risk and risks of injury during surgery.
  • Medicines - Do not take aspirin or ibuprofen or other “NSAID” medications for 2 weeks prior to your surgery. Tylenol with or without hydrocodone, codeine, etc, are OK. Darvocet and Tramadol are acceptable options for pain control. Some medicines need to be stopped or altered prior to the operation. Most can be taken with a sip of water at 5 AM on the morning of the surgery. Check with your Women's Health Care provider or primary care provider on how to manage your medicines. Usually the oral contraceptive pill should be stopped, if possible 2-4 weeks prior to surgery. If you are anemic, iron supplements are often recommended.
  • Vitamins and Supplements - Many supplements and some vitamins increase bleeding tendency, and in general, they should all be stopped at least 2 weeks prior to surgery.
  • Shaving - Please do NOT shave near the surgical area in the few days prior to surgery - it actually INCREASES your risk of infection. We usually look after excess hair in the area of the incision by clipping it after you are under anesthetic.
  • Pre-Op Visit - A few days prior to your visit, we will have you return to the office to be sure that you have a good understanding of the procedure and of what to expect at the hospital and at your recovery. We will review the indications for the surgery and be sure that nothing has changed. We will fill out consents and other paperwork. We will do an exam to be sure nothing has changed about your general health and address it if it has. We will answer any additional questions that you have thought of. We will arrange bloodwork or other tests. A pregnancy test is done if you are under age 52, even if you've had your tubes tied or your husband has a vasectomy (because there is a small failure rate). We usually check your urine for infection.
  • Chest x-ray and EKG - These may be recommended if you are over age 60, or over age 50 with cardiovascular risk factors in the few days prior to surgery.
  • Nothing by Mouth - Beginning at midnight on the evening prior to your procedure, you should have nothing by mouth, not even water or gum, except possibly for recommended medications at 5AM with a very small sip of water. Food and liquid in your stomach puts you at a higher risk of aspiration, a serious complication of anesthesia. The risk of aspiration is only 1/30,000, but is much higher if your stomach is not empty.

What happens during the operation?

Arrival at the hospital

Almost all of our laparoscopic hysterectomies are done in the Doctor's Building at Sacred Heart Hospital, an outpatient surgical center on the 5th floor of that building. For directions to Sacred Heart, please click here. Once at the Doctor's Building, proceed up the elevators to the 5th floor, and check in at the reception desk. There will be considerable paperwork to fill out. You will be introduced to the pre-op nurse, the circulating nurse (ie the nurse who looks after you during surgery), the anesthesiologist and anesthetist, and you'll have a chance to ask you WHC surgeon more questions as well. You will have the opportunity to ask questions about your anesthetic and your procedure. Your circulating nurse will ask your understanding of the procedure you are having done. You will change into a gown and your IV will be started. Occasionally, additional tests may be ordered just prior to surgery, such as bloodtests, urine tests, or EKGs.

The Anesthetic

You will meet the anesthetist before your operation and have the opportunity to ask any questions about the anesthetic. The anaesthetist will also tell you about pain relief after your operation. You will usually be given a general anesthetic to put you to sleep.

You will arrive in the OR on a stretcher, and will move to the OR table. Blankets will be placed to help keep you warm, and you will be given oxygen to breathe via mask. The anesthetist will place general anesthetic agents through your IV and via gases that you breathe. An antibiotic will be placed through your IV to help prevent infections. Your next moment “aware” will be when you are waking up.

In the meantime the OR staff will position you for surgery, clean the area, prep it with a sterilizing solution, and place sterile drapes.

The Operation

At the beginning of the procedure, a small tube is placed in the bladder (a catheter) to keep it empty throughout the procedure. The uterus and cervix are numbed with a regional anesthetic called a paracervical block. This reduces the amount of general anesthetic you need and helps with your recovery. A small incision is made in the belly button (smaller than the width of your little fingernail, usually 5mm), and carbon dioxide gas is placed in your abdomen to raise the abdominal wall off the bowel, giving a window for the surgeon to see to your pelvis. A camera is placed through a port in the small belly button incision. Two to four (usually 3) additional very small incisions are placed in the lower part of your abdomen. The uterus is carefully removed with laparoscopic instruments through these tiny incisions. The pelvis is then irrigated with warm sterile water, and a gel applied over the cervix to help prevent scarring. The carbon dioxide gas is released from your abdomen to the extent possible (a little always stays behind and your body absorbs it) and the instruments are removed from your abdomen. The incisions are carefully closed, and the catheter is removed.

The OR staff will remove your drapes, clean your skin, bandage the incisions, and wrap you in warm blankets. The breathing tube is removed as you wake up and you are moved to a stretcher and taken to the Recovery Room.

What happens after the operation and when do I go home?

You will be in "Phase One" of the recovery room for about an hour, where you will have 1 on 1 nursing care as the anesthetic wears off and your vital signs are carefully monitored.

Then you move to "Phase Two" where you will rest and your family may join you. Once you have met the discharge criteria, you will be allowed to go home. The discharge criteria are that any pain or discomfort is well controlled, you are able to eat, drink, walk around and empty your bladder easily, and your vital signs are stable. Should and neck discomfort are common - this is referred pain from the little bit of carbon dioxide that is left in your abdomen. It irritates the diaphragm which refers its discomfort to the shoulders and neck, usually on the right side. It should be easily controlled with small doses of pain medication by mouth.

Most people leave the hospital a few hours after this procedure. A few stay the night (about 5%).

What can I expect in the first few days at home?

You should be getting better every day. You will be given a prescription for pain medications and we encourage you to take them as needed. Being relatively pain-free speeds up your recovery. Ibuprofen should generally be used around the clock every 6 hours for the first few days, and stronger medications will be prescribed as well to use if you need them. Most people experience relatively little pain after this procedure, but when they do, they describe a gassy discomfort, kind of a bloating sensation, and some shoulder tip discomfort. This usually lasts a few days.

Get lots of rest and plenty of water. When you are up, go for short walks. Don't overdo it and do listen to your body. Rest as you need to. You should be able to eat a regular diet without problems. Stairs should be fine - you may need to take them slowly. Don't lift anything heavier than 10 pounds for the first few weeks - that means no laundry, groceries or vacuuming. Enlist the help of family and friends as needed.

A light pink to at times bright red vaginal discharge is normal and usually persists about 3 weeks. It may persist as long as 8 weeks. It is normal to feel some pulling when you empty your bladder, particularly near the end of your stream, but you shouldn't feel pain or burning with urination.

It is important to keep your stool soft. This generally means taking the stool softeners (Colace) regularly while on the stronger pain medications, which can be constipating. If you start to become constipated, here are some over the counter options:

  • Senokot
  • Dulcolax suppositories
  • Glycerin suppositiories
  • Miralax
  • Metamucil
  • Peppermint tea
  • Fresh and dried fruits (prunes, blueberries, plums especially helpful)
  • Lots of water

If you experience any of the following, you should let Women's Health Connection know right away:

  • Vaginal bleeding that saturates a pad in an hour
  • Pain that is not easily controlled with your pain prescription
  • Foul smelling vaginal discharge
  • Chest pain or shortness of breath
  • Pain, swelling or redness of your lower leg
  • Fever or chills
  • Bleeding or pus from an incision
  • Burning with urination, urinary urgency or frequency

You should be getting better and feeling better every day. Please let us know if you are not. There are no "silly questions". Please feel free to call us. The website www.hystersisters.com can a good resource as well (do bear in mind that anyone can post anything to this site, so it is not necessarily all medically sound, but much of it is).

When can I return to work?

It really depends on what you do and how you're feeling. Jobs that require mostly sitting can be resumed more quickly than jobs that involve a lot of physical labor, but almost everyone is back to work within 3 weeks of a laparoscopic hysterectomy unless there have been complications.

What about sex? When can we resume sexual activity and will it be different?

Penetrating sexual activity such as intercourse should be delayed until after you see your surgeon for follow-up, usually at 3-4 weeks after your procedure, and they confirm that everything is healing well, but other forms of sexual activity may begin whenever you are feeling ready.

You may experience a change in sexual response after hysterectomy. Many women say their sex life improves because they no longer have discomfort or the concerns about pregnancy. If you are used to feeling uterine contractions during orgasm, you will no longer feel these.

If your ovaries have been removed, low libido and vaginal dryness can be issues. Both tend to respond, at least to some degree, to hormone balancing and/or replacement. Lubricating gels, and vaginal estrogen creams and suppositories can make a big difference.

When can I exercise?

Usually walking can resume right away, and short walks, even during the first few days of recovery, are encouraged. More vigorous exercise and lifting should wait until after your post-op appointment at 3 weeks.

When can I drive?

It is usually recommended that you not drive for 2 weeks after a laparoscopic hysterectomy. This period of time may be a little longer if you have complications or if you require longer courses of pain medications. Do check with your collision insurance company, because they sometimes do not provide coverage if your are in a collision while driving within 6 weeks of a surgery.

What about ongoing care?

The American College of Obstetricians and Gynecologists recommends an annual preventative visit for all women. At this visit, a pelvic exam is usually done, and if you still have your cervix, regular PAPs will continue to be an important part of many of these exams. If you were referred to our clinic by a different physician, we recommend that you follow-up with them as you normally would. If you see Women's Health Connection providers for care, we recommend that you follow-up with us at the usual time that your annual is due. Your surgeon can provide guidance on this at your post-op follow-up visit.

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vert-spacerWomen's Health Connection, PS
Northpointe Professional Center
9425 N Nevada, Suite 300
Spokane, WA 99218

Womens Health Connection in Spokane, Washington provides women of all ages comprehensive gynecological services ranging from well woman exams to aesthetic gynecological surgery to minimally invasive surgery. Led by Dr. Debra Ravasia, women from the surrounding communities of Spokane and neighboring Idaho can find relief from bladder problems, such as urinary leaking, pelvic disorders, pelvic prolapsed, heavy bleeding, infertility. Other services include minimally invasive surgery for hysterectomy, hysteroscopy, endometrial ablation and many more.