Laparoscopic hysterectomy

About laparoscopic hysterectomy

A hysterectomy is an operation to remove your uterus (womb). We usually remove your cervix (neck of your womb). We may need to remove your ovaries at the same time.

Laparoscopic means it is done using a type of keyhole surgery. This is associated with less pain, less scarring and a faster return to normal activities.

Benefits

We will discuss with you why we recommend a laparoscopic hysterectomy for you.

A laparoscopic hysterectomy may cure or remove the following conditions:

• Heavy or painful periods not controlled by other treatments.
• Fibroids, where part of the muscle of your womb becomes overgrown.

The following are less common reasons for having a hysterectomy:

• Endometriosis, where the lining of your uterus grows outside your uterus.
• Adenomyosis, where the lining of your uterus grows into the muscle of your uterus.
• Chronic pelvic inflammatory disease, where inflammation of your pelvis leads to chronic pain and, often, heavy periods.
• Ovarian cysts.

A hysterectomy may cure or improve your symptoms. However, pain may continue, depending on what is causing it.

You will no longer have periods after a hysterectomy.

If we do not remove your ovaries, you may continue to have your usual premenstrual symptoms.

Alternative treatment

A hysterectomy is a major operation, usually recommended to women after simpler treatments have failed to control their symptoms.

For some women there may be no suitable alternatives and a hysterectomy may be recommended immediately, but this is unusual.

Heavy periods

• We can treat heavy periods using the following methods:
  • A variety of non-hormonal and hormonal oral (by mouth) medicines.
  • An IUS (intra-uterine system). This is an implant containing a synthetic form of the hormone progesterone that fits in your uterus.
  • ‘Conservative surgery’ which removes only the lining of your womb.

Fibroids

Depending on the size and position of the fibroids, we can give you medicine to try to shrink them and control the symptoms.

We can also use surgery to remove the fibroids, or shrink the fibroids by reducing their blood supply.

If you decide against the operation or it is delayed

You may prefer to put up with your symptoms, rather than have the operation. Your gynaecologist will talk to you about the risks of not having the operation.

We will monitor your condition and try to control your symptoms.

About the operation

We usually perform the operation while you are under a general anaesthetic (asleep). We can also use other anaesthetic techniques.

We may give you injections of local anaesthetic to help with pain, and antibiotics to help reduce the risk of infection.

During the operation [heavily edited]

We empty your bladder using a catheter (tube). We may examine your vagina.

We may insert an instrument called a manipulator through your cervix and into your uterus. This allows us to move your uterus so we can get a good view of your pelvic area.

We make a small cut on or near your belly button and several small cuts on your abdomen. We use these small cuts to insert ports (tubes) and instruments so that we can perform the operation. 

We may need to insert instruments through your vagina. We may need to make a cut around your cervix.

We may need to remove your ovaries, even if this was not originally planned. We will discuss this possibility with you before the operation.

Sometimes we may need to make a larger cut, usually on your ‘bikini’ line or downwards from your belly button (sometimes from above your belly button).This is so we can insert an instrument in your abdominal cavity to inflate it with gas (carbon dioxide).

If needed, we will place a temporary pack (like a large tampon) in your vagina. We may place a catheter in your bladder to help you to pass urine (wee).  We may insert a tube in your abdomen to drain away fluid that can sometimes collect.

The operation usually takes about 90 minutes.

After-effects of the operation

• Pain. We will give you medicine to control the pain. Take it as instructed so that you can move about and cough freely. After keyhole surgery, it is common to have some pain in your shoulders because a small amount of carbon dioxide gas may remain under your diaphragm (a muscle in the chest cavity). Your body will usually absorb the gas naturally over the next 24 hours. This will ease the symptoms.
• Unsightly scarring of your skin.
• You will no longer have periods.
• You will not be able to get pregnant.

Complications and risks

Any numbers which relate to risk are from studies of people who have had this operation. Your doctor may be able to tell you if the risk of a complication is higher or lower for you.

Some risks are higher if you are older, obese, have other health problems or you smoke. Health problems include diabetes, heart disease or lung disease.

Some complications can be serious and even cause death (risk: 4 in 10,000).

Your anaesthetist will be able to discuss with you the possible complications of having an anaesthetic.

Using keyhole surgery means it may be more difficult for your gynaecologist to notice some complications that may happen during the operation. When you are recovering, you need to be aware of any symptoms that may show you have a serious complication. Speak to your doctor if you need more advice.

General complications of any operation

• Feeling or being sick. Most women have only mild symptoms and feel better within 1 to 2 days without needing any medicine.
• Bleeding during or after the operation. Your healthcare team will try to avoid the need for you to have a blood transfusion, but we will give you one if you need one (risk: less than 1 in 100).
• Infection of the surgical site (wound). It is usually safe to shower after 2 days, but ask your healthcare team for advice. Let them know if you get a high temperature, notice pus in your wound, or if your wound becomes red, sore or painful. An infection usually settles with antibiotics, but you may need special dressings and your wound may take time to heal. In some cases another operation might be needed.
• Allergic reaction to the equipment, materials or medicine. Your healthcare team is trained to detect and treat any reactions that might happen. Let them know if you have any allergies or have reacted to any medicines or tests in the past.
• Developing a hernia in the scar. This appears as a bulge or rupture (burst) called an incisional hernia. If this causes problems, you may need another operation.
• Venous thromboembolism (VTE) (risk: 1 in 100). This is a blood clot in your leg (deep-vein thrombosis or DVT) or one that has moved to your lung (pulmonary embolus). DVT can cause pain, swelling or redness in your leg, or the veins near the surface of your leg to appear larger than normal. Your healthcare team will assess your risk for DVT and encourage you to get out of bed soon after the operation. They may give you injections, medicine or special stockings to wear. Let them know immediately if you become short of breath, feel pain in your chest or upper back, or if you cough up blood. If you are at home, call an ambulance or go immediately to your nearest Emergency department.
• Chest infection. Your risk will be lower if you have stopped smoking and are free of Covid-19 symptoms for at least 7 weeks before the operation.

Specific complications of this operation

Keyhole surgery complications

• Surgical emphysema (a crackling sensation in your skin caused by trapped carbon dioxide), which settles quickly and is not serious.
• Damage to structures such as your bowel, bladder or blood vessels when inserting instruments into your abdomen (risk: less than 3 in 1,000). The risk is higher if you have had previous surgery to your abdomen. If an injury does happen, you may need open surgery. About 1 in 3 of these injuries is not obvious until after the operation.
• Developing a hernia near one of the cuts used to insert the ports (risk: 1 in 100). Your gynaecologist will try to reduce this risk by using small ports where possible (less than a centimetre in diameter) or, if they need to use larger ports, using deeper stitching to close the cuts.
• Conversion to an abdominal hysterectomy (risk: 1 in 100). The operation may be too difficult for your gynaecologist to perform using keyhole surgery. In this situation, they may need to carry out the operation through a larger cut on your abdomen so they can complete it safely. Open surgery can increase your risk of some complications such as VTE (venous thromboembolism), bleeding and infection.
• Making a hole in your womb or cervix with possible damage to a nearby structure during placement of the manipulator (risk: less than 8 in 1,000). You may need to stay overnight for close observation in case you develop complications. You may need another operation (risk: less than 1 in 1,000).
• Gas embolism. This is when gas (carbon dioxide) gets into the bloodstream and blocks a blood vessel. This is rare, but can be serious.

Hysterectomy complications

• Pelvic infection or abscess (risk: 2 in 1,000). You will need further treatment. Tell your gynaecologist if you get an unpleasant-smelling vaginal discharge.
• Damage to structures close to your womb such as your bladder or ureters (tubes that carry urine from your kidneys to your bladder), bowel and blood vessels (risk: less than 1 in 100). Your gynaecologist will usually notice any damage and repair it during the operation. However, damage may not be obvious until after the operation and you may need another operation (risk: less than 4 in 100).
• Developing an abnormal connection (fistula) between your bowel, bladder or ureters and your vagina (risk: less than 1 in 1,000). You will need another operation.
• Developing a collection of blood (haematoma) inside your abdomen where your womb used to be (risk: less 1 in 100). Most haematomas are small and may cause only a mildly high temperature that may need treatment with antibiotics. If the haematoma is large and causing symptoms, we may need to drain it while you are under an anaesthetic.
• Vaginal cuff dehiscence, where the cut at the top of your vagina opens (risk: 5 to 13 in 1,000). You will need another operation.

Long-term complications

Most women who have a hysterectomy do not have any long-term problems. A small number of women may experience the following problems.

• Developing a prolapse (a bulge of your vagina caused by internal structures dropping down). This is because a hysterectomy can weaken the supports of your vagina. The risk of a prolapse increases if you had a degree of prolapse before the operation.
• Continued bleeding from your cervix (risk: less than 2 in 10). Your surgeon can use diathermy (a type of heat treatment) to try to stop the bleeding. If the bleeding does not stop, we might need to remove your cervix (risk: less than 2 in 100).
• Continuing pain.
• Difficulty or pain having sex.
• Tissues can join together in an abnormal way (adhesions) when scar tissue develops inside your abdomen. The risk is higher if you get a pelvic infection or haematoma (pooling of blood). Adhesions do not usually cause any serious problems, but can lead to complications such as bowel obstruction and pelvic pain. You may need another operation.
• Passing urine more often, having uncontrolled urges to pass urine or urine leaking from your bladder when you exercise, laugh, cough or sneeze (stress incontinence).
• Feelings of loss because a hysterectomy will make you infertile (you cannot become pregnant). This may be more important for you if you have not had children.
• Going through menopause even if your ovaries are not removed. We advise you to discuss hormone replacement therapy (HRT) with your GP.

Recovery after the operation

After the operation we will transfer you to the recovery area and then to the ward. We may give you fluid for 12 hours through a drip (small tube) in a vein in your arm.

You will probably feel some pain or discomfort when you wake and we may give you strong painkillers. Pain relief is an important part of your recovery. Tell your healthcare team if you are in pain.

If you have a drip, or a catheter or drain, we usually remove them after 4 to 6 hours. We will allow you to start drinking and eating light meals. Good nutrition will speed up your recovery.

We usually remove the drip and the pack in your vagina after 12 to 24 hours.

On the second or third day, you may get wind pains. These can last for 1 to 2 days, but we can offer you medicine to relieve them.

You will be able to go home when your gynaecologist decides you are medically ready, which is usually the same day or after 1 to 2 days.

You may get a slight discharge or bleeding from your vagina for the first 2 weeks. Tell your healthcare team if this becomes heavy. Use sanitary pads, not tampons.

Nutrition and exercise

We advise you to drink plenty of fluid and increase the amount of fibre in your diet to avoid constipation.

Your healthcare team may recommend exercises to help you to recover. It is important to get out of bed and walk. We may give you breathing or other exercises. Do these, even if you feel you do not want to. They will speed up your recovery.

Look out for symptoms when you return home

Be aware of the following symptoms as they may show that you have a serious complication.

• Pain that gets worse over time or is severe when you move, breathe or cough.
• A heavy discharge or bleeding from your vagina.
• A high temperature or fever.
• Dizziness, feeling faint or shortness of breath.
• Feeling sick or not having any appetite (and this gets worse after the first 1 to 2 days).
• Not opening your bowels and not passing wind.
• Swelling of your abdomen.
• Difficulty passing urine.

Returning to everyday activities

To reduce the risk of a blood clot, follow our instructions if we give you medicine or ask you to wear special stockings.

Rest for 2 weeks and continue to do the gentle exercises we give you. Try to take a short walk every day.

Regular exercise will help you to return to normal activities as soon as possible. Before you start exercising, ask your healthcare team or GP for advice.

Eat healthily, drink plenty of fluid and rest when you need to.

You can return to work once your doctor has said you are well enough to do so. For most people this is after 4 to 6 weeks, depending on the type of work they do.

Most people feel more or less back to normal after 2 to 3 months.

While you recover, do not:

• Do not drive or ride a bike until you are confident about controlling your vehicle, including in an emergency. Check your insurance policy first and speak to your doctor if you have concerns.
• Do not have sex, use tampons or get into the bath, swimming pool or hot tub for at least 12 weeks and before any bleeding or discharge has stopped. When you have sex again, it can be uncomfortable at first and you may need to use a lubricant.
• Do not stand for too long or lift anything heavy.

Menopause and HRT

If your hysterectomy is performed while you are still having periods and your ovaries are removed during the operation, it is likely you will have menopausal symptoms.

These may include hot flushes, night sweats, passing urine more often, a dry vagina, dry skin and hair, mood swings and lack of sex drive. You can usually treat these symptoms with HRT.

Your GP is likely to recommend that you take HRT until the time when you would have gone through menopause naturally (at about age 50 to 52) but you can carry it on for longer if you want. Discuss this with your GP.

Most women take HRT in tablet form but it is also available as patches, gels, nasal sprays, vaginal rings and implants. Your GP will be able to discuss these options with you.

If we do not remove your ovaries

Your ovaries should continue to produce the hormones you need until you have reached the normal age of menopause. However, there is some evidence to suggest that some women who have had a hysterectomy may start menopause 2 to 3 years earlier.

After a hysterectomy, it can be more difficult to know when you are in menopause, as your periods will have stopped. You may need blood tests.

If you develop flushes or sweats or other menopausal symptoms, talk to your GP about HRT.