Having a laparoscopic hysterectomy: What is involved?

A laparoscopic hysterectomy is a surgical procedure performed under general anaesthetic to remove the womb (uterus) using a minimally invasive surgical technique.

Here, Mr Michael Magro, renowned consultant gynaecologist based in London, provides an expert insight into a laparoscopic hysterectomy, including how it compares to a traditional open hysterectomy.

What are the key advantages of performing a laparoscopic hysterectomy?

There are a large number of advantages. However, when we talk about a laparoscopic hysterectomy, what we are really comparing it to is the traditional method of an open hysterectomy (a cut in the abdomen).

Hence, the main benefit of a laparoscopic hysterectomy is that it provides a quicker recovery compared to an open hysterectomy. This is because there is usually less pain, less bleeding, less risk of infection, and an overall reduction in complications with a laparoscopic hysterectomy. As a result, most patients go home within 24 hours of the surgery, and some clinics are now even performing the operation as a day-case procedure. Most patients are fully recovered in two to three weeks. In comparison, an open hysterectomy requires two to four days at the hospital and full recovery usually takes anywhere between four to eight weeks.

The other main reason for performing a laparoscopic hysterectomy is that with this approach the specialist is able to see inside of the abdomen very clearly, enabling the treatment of other pathologies. Patients who have had previous surgeries, patients who have scar tissue or adhesions, or patients who have endometriosis – with a laparoscopic hysterectomy, all of this can be seen and therefore treated at the same time.

What are the different types of laparoscopic hysterectomy techniques available?

The technique for a laparoscopic hysterectomy is relatively standard. However, there are two main types of hysterectomies, including:

• Subtotal hysterectomy: The womb is removed, but not the cervix.
• Total hysterectomy: The whole womb and the cervix are removed.

If a total hysterectomy is performed, the specimen is usually removed through the vagina. The vagina is stitched up afterwards.

If a subtotal hysterectomy is performed, the womb needs to be removed through the small ports that have been created. This involves a morcellation, which is a procedure used to break down womb tissue into smaller pieces. The benefit of a subtotal hysterectomy is that it actually allows the specialist to perform more complex surgery. This means that patients who have very large fibroids and whose womb cannot be removed through the vagina due to the large size of the womb can now still have minimally invasive surgery.

The other type of laparoscopic hysterectomy involves the removal, or not, of the fallopian tubes and the ovaries. This is called a salpingo-oophorectomy, and it is a procedure that each patient needs to discuss with their specialist.

Can you explain the potential complications or risks associated with a laparoscopic hysterectomy?

I always try and break down the risks into those that are relatively common (and usually quite minor) and those that are more serious (and usually very rare).

In terms of minor and relatively common complications, these include:

• Having small scars.
• Feeling a bit of pain after the operation.
• Sometimes, feeling pain in the tip where the tummy has been inflated with gas. However, this usually goes away after 24 hours.
• The wounds getting infected. However, antibiotics are provided and the skin is cleaned, so this risk is small.
• Developing a haematoma, which is a bit of bleeding underneath the skin. However, this usually resolves by itself.

In terms of major but usually very rare complications (about 1 in 1,000), these include:

• Needing a blood transfusion.
• Damaging structures inside the tummy, such as the bladder, the bowels, the ureters, or a blood vessel.
• Developing blood clots in the legs and the lungs after the operation. However, this risk is lower if a laparoscopic hysterectomy is performed because patients regain their mobility more quickly.

In which cases would you recommend a laparoscopic hysterectomy over other treatment options?

I never recommend only one type of procedure to my patients. I believe it is always important to try and understand why any operation is performed in order to therefore individualise the care that we provide. For this reason, I always spend a lot of time explaining the advantages and the disadvantages of any procedure, as well as all the different types of treatment options that are available, as my patient reviews online reveal.

When it comes to a hysterectomy, the procedure is performed for a variety of reasons, including:

• heavy menstrual bleeding
• pelvic pain
• pre-cancerous changes
• prolapse
• uterine fibroids

The best treatment for all of these conditions could, in fact, be a laparoscopic hysterectomy. However, it could also be a number of other different treatment options. Some patients, for example, prefer to never have surgery and thus I provide them will all the different non-surgical options available. Other patients, in contrast, prefer to undergo surgery straight away to sort out all their symptoms there and then. This is why I believe it is very important to have an individualised approach.

Despite this, choosing a laparoscopic hysterectomy over an open hysterectomy reduces the chances of complications in terms of hospital stay and post-operative pain. For patients who have a high BMI, the risks of wound infection and blood clots are also reduced if a laparoscopic hysterectomy is performed.

What are the considerations for pre-operative preparation and patient selection in performing a successful laparoscopic hysterectomy?

When discussing a laparoscopic hysterectomy with patients, I think it is really important that they make an informed decision, and the only way to do this is to discuss what the surgery entails, what the recovery is like, and also what the patient expectations are like. I can easily perform a laparoscopic hysterectomy, but if my patient has different expectations about what the operation will involve and how they will feel afterwards they might not be pleased with the results.

It is very important to go through all the details. This is because, for example, some patients may have certain concerns about anaesthetic risks and may therefore want to see an anaesthetist before the operation. Some patients who have a high BMI may want to discuss different treatment options, which are perhaps safer for them, before choosing to undergo surgery.

In addition, it is also important to discuss things like anaemia to make sure that the patient’s haemoglobin levels are optimised, as well as any allergies. Even small things, such as if patients have had previous hip surgery, can be very important when it comes to positioning the patient in the correct place during surgery to prevent hip pain after the operation.

Perhaps the biggest consideration, however, is whether or not patients have had previous surgery because this will impact the chances of complications and how the surgery may be performed. For example, patients who have previously had multiple caesareans are more likely to suffer from a bladder injury and therefore, this is something that needs to be discussed.

Lastly, patients who have had major operations by cuts in the abdomen or previous myomectomies may, for example, have more bowel adhesions and scarring. These patients may need further imaging pre-operatively to try and decide the best place to have the operation. A second specialist, which may be a gastroenterologist or a urologist, may actually need to be present if there are lots of expected adhesions. Thus, it is very important to have all of these considerations before the start of the operation.

Mr Michael Magro is a leading consultant gynaecologist with over a decade of experience.

If you require a laparoscopic hysterectomy, don’t hesitate to book an appointment with Mr Michael Magro via his Top Doctors profile today to consult your options with an expert.