Decision to have a Hysterectomy
A hysterectomy is the removal of the uterus but the uterus has 2 components: the uterine fundus and the cervix. Should the whole uterus be removed? This depends on a number of factors. Why are you having the hysterectomy? If it is because of fibroids or abnormal bleeding, then the cervix doesn’t have to be removed but if it is because of recurrent dysplasia then the cervix must be removed. The other consideration is the route of the surgery. If the procedure is abdominal, then removing the cervix might make the surgery longer and more difficult, increasing the risk of complications. If the route is through the birth canal, then the cervix has to be removed due to the procedure technique. Laparoscopic procedures can either leave or remove the cervix however it is much easier if the cervix is left in place.
What about the ovaries and tubes? The adnexal structures don’t have to be removed and again it depends on the reason for the surgery and the route. If the surgery is due to cancer, then removal all of the gynecologic organs are standard to minimize the risk of cancer spread. In women who have gone through menopause or are close to menopause then consideration should be given to removing both the ovaries and fallopian tubes. After menopause the ovaries are no longer functioning and the lifetime risk of ovarian cancer is about 2-3%, thus the adnexae should be removed for preventative purposes. If the route is via the birth canal, then removing these structures may not be easy and attempting to remove them may increase the risk of bleeding. In premenopausal women, strong consideration should be given to removing the fallopian tubes, even if the ovaries are left in place. There is compelling data to support this, as this appears to significantly reduce the risk of ovarian cancer in women who retain their ovaries.
A hysterectomy can be performed through a laparotomy incision on the abdomen, through the birth canal or laparoscopically. There are pros and cons to all routes and many factors to consider when choosing a route. The most important factor is the skill of your surgeon. Some gynaecologist can only perform a hysterectomy through an open technique using a laparotomy incision. There are others who can perform laparoscopy while some can perform pelvic surgery. Each surgeon selects the route she is most comfortable with and the one that minimizes risk to the patient. It is rare to find a surgeon who is highly skilled at all routes. Many good surgeons can perform all 3 procedures but their strength may lie in one approach over the other. Other factors in deciding the route include the size of the uterus, prior surgeries, the presence of malignancy, and what needs to be removed. Finally the availability of resources may also dictate the decision. The hospital may not have the necessary equipment to complete a laparoscopic procedure or there may not be a surgeon in proximity who can perform the surgery through alternative routes.
As you can see, the decision to have a hysterectomy doesn’t end with the decision to undergo surgery. You need to understand why you are having the surgery and your options for removing the cervix, ovaries and fallopian tubes. There are pros and cons to all and you should have a detailed discussion with your gynaecologist to make the decision that is right for you. It is imperative that you be involved in all decisions and understand exactly what will be done at the time of your surgery.
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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