June 10, 2005

Technique eases pain of hysterectomy

Featured Image

The laparoscopic supracervical hysterectomy procedure involves several small incisions rather than one large one.

Technique eases pain of hysterectomy

Vanderbilt University Medical Center is one of a handful of centers offering a less invasive technique for performing hysterectomies, a relatively new surgical technique that uses laparoscopy alone to remove the uterus, but leaves the cervix intact.

Although Vanderbilt has been offering laparoscopic supracervical hysterectomy (LSH) for the past three years, the number of women who take advantage of this procedure is growing, says Barry Jarnagin, M.D., associate professor of Obstetrics and Gynecology.

With LSH, a small laparoscope and surgical instruments are inserted through tiny incisions in the navel and abdomen to separate the uterus from the cervix. Another device dices the uterus and it is removed through one of the incisions.

The procedure is less invasive than a traditional “open” hysterectomy where an incision is made in the abdomen, and was developed to reduce pain and trauma to the pelvic area, minimize scarring and shorten recovery time. Some women go home the day of surgery, although most Vanderbilt patients stay for 23 hours, Jarnagin said.

Hysterectomy is the most common, non-pregnancy related surgical procedure performed on women in the United States. Each year, about 600,000 are performed, a majority of which are through the traditional, open abdominal approach. More than one-third of women will have a hysterectomy by their 60th birthday. Hysterectomies are normally performed in two ways — total, removing the uterus and cervix; and supracervical, removing the uterus but leaving the cervix in place.

There are three different routes to get to the uterus — through an incision in the abdomen, through the vagina or through a laparoscope. “The laparoscope is a route to the pelvis, just like a big incision in the abdomen or going through the vagina are other routes. It's an avenue of getting where you want to go to do what you need to do,” Jarnagin said.

The medical community's thinking on hysterectomies has come full circle, he said. When they were first done, before the days of antibiotics, the cervix was left intact because of the risk of infection. Then it was believed that removing the cervix was a good idea, because removing it might help prevent cervical cancer. But now, with Pap smears and other means of monitoring for cervical cancer, it's believed that removing the cervix may diminish sexual function in some women, and that leaving it preserves the pelvic support of the vagina.

“We know that 60 percent of women who undergo a total abdominal hysterectomy by the age of 60 will have significant pelvic support problems. It is hoped that leaving the cervix would reduce that risk,” Jarnagin said.

There are practical reasons for recommending LSH to women who meet the criteria — less pain and a more speedy recovery.

“You turn a procedure that has a significant amount of post-op pain into a procedure that has relatively little pain and reduces the risk of surgery, the risk of bleeding, infection and injury,” Jarnagin said. “The bladder sits right on top of the cervix so there's less moving around of the bladder.” And about 1 percent to 4 percent of women have some injury to the ureter during a total hysterectomy, he said, so there is less risk of a ureteral injury.

A hospital stay for a total abdominal hysterectomy is two to four days, and women have significant discomfort and pain for several days, then limited activity for six weeks. With LSH, patients go home within 23 hours, some the same day, have minor post operative pain for one to five days, then can resume normal, non-strenuous activity within one to two weeks. Many women say they don't even have to take a pain pill, Jarnagin said.

Debbie Howard, 42, of Brentwood, Tenn., underwent the LSH procedure in January and was shocked at the short recovery time. After having the procedure performed by Jarnagin and Radhika Ailawadi, M.D., assistant professor of Obstetrics and Gynecology, she stayed in the hospital overnight, had little pain, and felt like herself within days.

“I've had two Caesarean sections and uterine surgery, and was out of commission for about six weeks with those,” she said. “With this, I was out of it for about three days and that was because of the anesthesia, and that was it. It was all I could do not to do things, like laundry, right away, which I couldn't do because of the lifting and pulling. It was amazing how easy the recovery was. I couldn't do things like heavy lifting for about four weeks after the procedure, but after about two weeks my family forgot I had even had surgery,” she said.

With a surgeon and an assistant working, one on each side, the uterus is detached from its attachments, down to the uterosacral ligaments, the major support system of the cervix and uterus. Those are left intact. By the time the surgeons are ready to remove the uterus, its blood supply is essentially cut off and the uterus is cut away from the cervix. Then the morcellator is inserted into the largest — normally a 12-mm — incision and the uterus is removed through a tube.

Jarnagin is one of three Vanderbilt physicians who perform the procedure. Ailawadi and Ted Anderson, M.D., assistant clinical professor of Obstetrics and Gynecology, also based at the Cool Springs practice, are also trained in LSH.