By James Kolter, M.D., Main Line OB/GYN
More than one in four American women will have a hysterectomy by the time they are 60 years old, according to the Centers for Disease Control and Prevention.
A hysterectomy—surgical removal of the uterus—can be a life-saving operation for some women with certain types of cancer or excessive uterine bleeding. It can also improve the quality of life for women who experience abnormal uterine bleeding, uterine fibroids, endometriosis, or uterine prolapse (the falling of the uterus from its normal position into or outside of the vagina).
A hysterectomy is generally performed through an incision in the abdomen or the vagina. During the procedure, the whole uterus or just part of it may be removed. The fallopian tubes and ovaries may also be removed.
There are now a variety of surgical techniques for performing hysterectomies, which are discussed below. A physician and patient should determine together the ideal surgical procedure based on her particular medical history and the reason for surgery.
Approaches to Hysterectomy
The majority of hysterectomies are performed conventionally using an “open” approach with a large incision in the abdomen. Another method is a vaginal hysterectomy, which involves the removal of the uterus through the vagina, without any external incision. Surgeons most often use this preferred approach when the patient’s condition is benign and limited to the uterus and when the uterus is normal size.
Today, there are a number of advanced options that feature shorter or no hospital stays, less post-operative pain, negligible scars, and a quick return to normal activity and work.
One such approach is laparoscopic or minimally invasive hysterectomy where the uterus is removed using instruments, including a miniature telescope and camera (laparoscope), inserted through several small “keyhole” incisions in the abdomen.
Laparoscopically assisted vaginal hysterectomy allows the uterus (and ovaries if necessary) to be removed through the vagina in cases that otherwise would not be suited for a vaginal hysterectomy. This approach has enabled a broader base of women to have the procedure done vaginally, thus sparing a large abdominal incision. However, those who have very large fibroids, certain types of cancer, or multiple previous abdominal surgeries may not be appropriate candidates.
While the laparoscopic technique offers surgeons better visualization of the uterus and surrounding area, it can limit their precision and control due to the rigidity of the surgical instruments.
The da Vinci® robotic hysterectomy takes laparoscopic surgery to the next level, giving surgeons unmatched precision, vision, and control. The da Vinci hysterectomy is useful particularly when performing more challenging procedures like hysterectomy with lymph node sampling for gynecologic cancer and many of the surgeries that due to enlarged fibroids or pelvic adhesions would be done with a large abdominal incision. The potential benefits of robotic hysterectomy over traditional approaches include less pain, minimal blood loss and scarring, shorter hospital stay, and quicker recovery.
The robotic technique uses miniature instruments and a 3D camera inserted through a few tiny incisions in the abdomen. The surgeon sits at a nearby console to view a magnified, high-resolution, 3D image of the uterus. The system then seamlessly translates the surgeon's hand, wrist and finger movements into precise, real-time movements of surgical instruments inside the patient. The system does not perform the surgery – it simply enhances the surgeon’s skill through its precision.
While the da Vinci technology has revolutionized the approach to hysterectomy, not to mention many other surgical procedures outside of gynecology, it will take time before it appears in the offices of most physicians. For many doctors who are used to working with their hands and performing traditional surgeries, the da Vinci will present a new set of challenges and requires specialized training and consistent use to master.
But as the demand for more efficient and effective ways to perform surgeries continues to increase, this approach may become more widely available and could become the preferred method of doing most hysterectomies.
Not all hysterectomy patients are candidates for the robotic approach. The technique is especially well suited for obese patients, a modestly enlarged uterus and/or ovaries, and for the dissection of lymph nodes in the pelvis as part of cancer treatment.
As with any surgery, a hysterectomy is both patient- and procedure-specific. Before making any final decision, it’s important to be aware of and understand all the options available, as well as their risks and benefits, and the physician’s experience using each technique.
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