Uterus is a hollow, muscular, pear shaped organ often referred to as Womb since Biblical times. It has two tubes called fallopian tubes connected to it at one end and to the ovary at the other. When an egg cell is released from an Ovary it travels to the uterus via these fallopian tubes. It is a very remarkable organ capable of expanding to contain a full-grown baby and of shedding its lining up to 500 times during the life that is during the time of monthly period. The resultant stresses and strains on its supporting structures during pregnancies and the repeated shedding and re-growth of its lining may lead to problems.

Hysterectomy merely means surgical removal of uterus. It is the second most common major operation performed today. Hysterectomy involves removal of the uterus, and sometimes the ovaries too (oophorectomy). Often one or both ovaries and fallopian tubes are removed at the same time a hysterectomy is done. So depending upon what is removed, hysterectomy can be classified as :

Sub-total or partial hysterectomy

It involves the removal of Fallopian tubes and the upper two-thirds of the uterus only, preserving the cervix.

Hysterectomy with ovarian conservation

It involves the removal of the Fallopian tubes, uterus and the cervix, while preserving the ovaries.

Hysterectomy with oophorectomy

It involves the removal of the Fallopian tubes, uterus and cervix, together with one or both sets of ovaries.

Radical or Wertheim's hysterectomy

It involves the removal of the Fallopian tubes, uterus, cervix, ovaries as well as nearby lymph nodes and the upper portion of the vagina. This type of hysterectomy is used in the treatment of some gynaecological cancer cases.

Before having a hysterectomy, it is very important to discuss the implications you're your gynaecologist and partner. Your doctor may recommend a hysterectomy if none of the treatments for the various conditions have worked. Ofcourse in some cases, there is no other choice than hysterectomy.

Before the surgery

The doctor will once again examine the patient thoroughly. The blood will probably be tested for hormone levels and also a pelvic ultrasound scan may be recommended. If the scan shows any abnormalities or is unclear, the doctor may want to investigate further using hysteroscopy, a procedure in which a viewing device is inserted into the uterus. A sample of the lining of the womb (endometrium) may be taken. Endometrial sampling is done either as an outpatient procedure, or by D&C-dilatation and curettage, usually when under a general anaesthesia. In a D&C, the cervix is opened (dilatation) and the lining of uterus (the endometrium) will be systematically scraped (curettage) with a long, thin instrument. The strips of the lining will then be examined under a microscope.

Preparation for both vaginal and abdominal hysterectomy is similar. She will be given a suppository to empty the bowels the night before. She will be told not to eat or drink anything on the day of the surgery about 6 to 8 hours before the surgery. Anaesthesia is given. It can be general, epidural or spinal anaesthesia. A catheter (a narrow silicon tube) is inserted into the bladder to empty it. The operation area is cleaned thoroughly with antiseptic before the operation.

The surgery

The actual hysterectomy operation can be performed in several different ways. The method chosen will depend on the surgeon's skills, expertise and preference, the reason for the hysterectomy and the woman's characteristics (e.g. weight, previous pelvic surgery, if she has had children). There are presently following ways to perform a hysterectomy:

   * Abdominal hysterectomy
   * Vaginal hysterectomy
   * Laparoscopic method

Abdominal hysterectomy

Initially this used to be the only method to remove the uterus. Ofcourse now options like laparoscopy have become the preferred choice of surgeons all over the world. But in some cases this method is still employed e.g. When there is a need for extensive exploration (in the case of cancer)or if the uterus is enlarged or if the woman has never had children or is obese. This surgery requires a four to eight inch abdominal incision to remove the uterus, and ovaries, if needed. An abdominal hysterectomy can be performed in two ways, with a vertical incision or a bikini line cut. A vertical incision generally involves a cut from the navel to the pubic hairline. The bikini line cut, as its name suggests, is done horizontally, directly above the pubic hairline. It leaves a less obvious scar and results in a shorter recovery time. The presences of large fibroids, extensive adhesions or endometriosis are other examples where this procedure is often preferred.

The advantages of an abdominal hysterectomy are lower incidence of damage to the urinary tract and blood vessels. It also allows the repair of a prolapse at the same time. But it is the least preferred route by patients because of the hospital stay, abdominal scar, pain, and disability; but it is sometimes the only route possible.

Vaginal hysterectomy

This is the next most frequently employed technique of hysterectomy. The surgeon operates entirely through the vagina, pulling the uterus down through the vagina into view, disconnecting the cervix and then the rest of the uterus. To use the vaginal route, a woman must usually have had a baby or two which widens the vagina and relaxes the connections of the uterus so it can be pulled down into the vagina to do the operation. There is no abdominal scar. It usually requires only two days in the hospital and about two weeks away from work. Vaginal hysterectomy is always preferred route if all the specific requirements are met-i.e. small uterus, no cancer, and vaginal laxity. It can not always be done for massive uterus. It is also not always possible to remove the ovaries because they are attached much higher in the pelvis than the uterus and cannot always be pulled down into the vagina for surgical removal.

The advantages of this method are less pain, a shorter hospital stay and recovery time and the absence of a visible scar. A review of different surgical approaches to hysterectomy for non-cancerous conditions concluded that a vaginal hysterectomy should be performed in preference to an abdominal hysterectomy where possible.

Benefits and drawbacks of laparoscopic hysterectomy

One advantage of laparoscopic hysterectomy is that the incisions are smaller (1/2 inch) and much less uncomfortable than that of abdominal hysterectomy. So people are able to resume normal activity in about 2 weeks. So Laparoscopic hysterectomy has many advantages like:

   * Less postoperative pain
   * May shorten hospital stay
   * May result in a quicker return to bowel function
   * Quicker return to normal activity
   * Better cosmetic results