Choosing how to approach a hysterectomy

Most surgical procedures, including a hysterectomy, have more than one approach. Until the advent of laparoscopy, two approaches were common: the abdominal incision (laparotomy) or a vaginal removal. All three methods have their advocates. Because no one right choice exists for everyone or every situation, you and your doctor should discuss the route for your surgery.

Making an incision: The abdominal method

In most cases where the surgery involves removing ovaries, the abdominal incision allows easier and less risky access for oophorectomy. Even when a cul-de-sac and other scarring aren't likely or present, adhesions are likely around the ovary in cases of endometriosis. In this situation, a vaginal removal of ovaries is more difficult and dangerous.

A frozen pelvis from severe adhesions makes the abdominal approach a necessity. The laparotomy has all the same advantages we discuss in "Noting the treatment advantages of laparotomy to laparoscopy" earlier in this chapter, and it's often the method of choice for radical surgery. A supracervical hysterectomy via laparotomy is easier via laparotomy, and all gynecologists are trained in this approach. The mini-laparotomy (smaller incision) is another option but offers slightly less access.

Going through the canal: The vaginal method

As the name implies, the surgeon performs a vaginal hysterectomy through the vagina. Obviously, access is much more limited than with a laparotomy, and hands and instruments greatly reduce visibility during the procedure. Because the surgeon can't really get his hands in to feel for structures, he has to rely on that limited sight. With many pelvic surgeries, limited access isn't a si major problem for the experienced surgeon, but when dealing with endometriosis, the limitations can become a real disadvantage. As a result, vaginal hysterectomies are less common for endometriosis because they offer little access to probable adhesions and distorted anatomy.

Nonetheless, vaginal hysterectomy has advantages. It's an ideal method for removal of the fairly normal-sized uterus for benign conditions like fibroids, adenomyosis (growths in the uterine wall), refractory dysfunctional bleeding, abnormal Pap smears, and prolapse (collapse of the uterus into the vagina through the cervix). And because this surgery involves no large abdominal incisions, recovery is usually quicker than with a laparotomy. Unfortunately, many younger surgeons aren't getting enough exposure to this procedure in training programs, and it's an underused procedure in gynecology today.

Using new technology: The laparoscopic method

With the development of laparoscopy for hysterectomy, surgery is minimally invasive and provides better tolerance and recovery for the patient. However, for patients with endometriosis and severe adhesions — where structures are stuck together — a laparoscopic approach may not be safe. If the patient has a possible frozen pelvis, severe adhesions, or a much-distorted anatomy, the surgeon may initially use laparoscopy to assess the viability of that approach. But, if he determines that the route isn't appropriate, he can then convert the approach to a laparotomy.

The scope offers two ways to perform a hysterectomy. Each method has its proponents, but your surgeon makes the final decision.

1 Laparoscopic assisted vaginal hysterectomy (LAVH): This method was the original laparoscopy. A wise surgeon decided that he could accomplish vaginal hysterectomies more easily and safely if he used the laparoscope. The most difficult part of the vaginal hysterectomy was getting the upper attachments and blood vessels under control. These structures (the round ligaments and ovarian arteries) are fairly easy to tie off, coagulate, and cut via the laparoscope. After this upper work is complete, the rest of the procedure can proceed vaginally.

This method also allows surgeons to check for adhesions or anatomical abnormalities and deal with the problems via the scope, under direct visualization. Likewise, a surgeon can evaluate ovaries and tubes and then detach them much more effectively through the scope. So, with only a few tiny incisions on the abdominal wall, LAVH makes vaginal hysterectomies a better possibility.

1 Laparoscopic hysterectomy (LH): This option uses laparoscopy exclusively. As the name implies, the surgeon detaches and removes the uterus (and tubes and ovaries if necessary) from the pelvis via the laparoscope. You may wonder how he gets that large uterus (at least the size of a small pear) out through that tiny incision. Good question! In the LAVH, the surgeon takes the uterus out through the vagina. If a baby can fit, then a uterus is a piece of cake! With LH, as soon as the surgeon has secured the blood vessels and cut the support structures, he can extricate the uterus, tubes, and ovaries through the laparoscopic incision.

Your surgeon has two ways to remove the organs:

• He can enlarge one of the incisions to afford removal of the organs. This may seem somewhat self-defeating because the advantage of an LH is the small incisions. Why not just take the uterus out through the vagina? Two reasons: The uterus may be too big (not usual with endometriosis), or the surgeon performed a supracervical hysterectomy, which offers no opening to the vagina because the cervix is left in place.

• He can morcelate (shred) the uterus, tubes, and ovaries into pieces less than a centimeter with an instrument (powered or manual) and then remove the tissue through the normal-size incisions. Because these instruments can cause inadvertent damage, the surgeon must be careful to avoid injury to other organs, such as the intestines or major blood vessels. The other potential problem is that the organs are in pieces, which can make microscopic diagnosis more difficult and can leave other diseases undiagnosed (such as cancer, in the worst-case scenario).

Whichever route your surgeon takes, the two of you must be on the same page. Discuss these options, and be sure that you're comfortable with your doctor's suggestion.

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51 Tips for Dealing with Endometriosis

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