A hysterectomy is the surgical removal of the uterus, the home of the developing fetus. It serves as an incubator and then transport for the baby. It primarily made of smooth muscle and lined with a vascular rich layer called the endometrium which provides nourishment to the developing embryo. The uterus is attached to the pelvis by fascia and ligaments which contain blood vessels, nerves and connective tissue. The major ligaments include the uteroovarian, the round, uterine vessel, cardinal, and the uterosacral. The cervix, which is the exit, through which the baby passes for delivery, is directly and densely attached to the top of the urogenital vault.
Detailed surgical dissection and incisions are required to remove the uterus safely. These listed ligaments need to be transected and the bladder needs to be dissected off the anterior surface of the uterus. This is done in a fashion to minimize bleeding and injury to other major structures. The most common errors involve not properly tying a blood vessel and injury to the ureter whose course runs close to the uterus and ovaries at several locations. The surgeon should be well versed in both performing the procedure but in identifying and managing the complications.
A hysterectomy can be performed through 3 routes and this is dependent on a number of factors. The traditional route is via laparotomy where a long incision is made on the abdomen. This is called a Total Abdominal Hysterectomy (TAH). This incision can be either transverse or vertical and the decision to use one type or the other is dependent on a number of factors. Another traditional route that requires a special skill set is the natural cavity route through the birth canal. This is called a TVH. In the past 3 decades laparoscopy as evolved, allowing for more involved ways. The uterus can be removed totally through the laparoscope (TLH) or laparoscopy can assist a urogenital route. This is referred to as a LAVH. Recently there has been the introduction of robotic surgery. The hysterectomy is performed using a modified laparoscopic route, the only difference being the location of the surgeon. In the robotic assisted route the surgeon is not directly hands on but located away from the surgical table in a control center working hand devices much like a video game.
Each route has its pros and cons and the decision tends to be left to the surgeon. Some Gynecologist can perform the procedure through the traditional laparotomy route while others maybe able to perform the procedure through the other route. It is less common to find a surgeon who is highly skilled in performing the surgery through all 3 routes. Factors that contribute to the decision include size of the uterus, previous surgeries, internal scarring, the degree of pelvic support and the need to perform concomitant surgeries. The risk of complications appears to be lowest with the route through the birth canal while the slowest recovery is associated with the laparotomy approach. Other factors include the skill of the surgeon and the length of the procedure.
The decision to have surgery is not an easy one but this is only the first step. Stay plugged in, do the appropriate research and ask the right questions so you can chose the right surgeon and best procedure that will allow a speedy recovery with minimal complications.
I hope this article has provided you with information that will help you make wise choices, so you may:
Live healthy, live well and live long!
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