• Operative injury to surrounding organs such as the bladder, ureters (kidney tubes), intestines, and blood vessels
  
  
• Bleeding that may on occasion require transfusion
  
  
• Infection
  
  
• Anesthetic risks

Laparoscopic Assisted Vaginal Hysterectomy (LAVH)
This method of hysterectomy is the most common way that I choose to remove a patient’s uterus and cervix. Greater than 95% of hysterectomies I perform each year are completed this way. LAVH requires a patient to remain in the surgery center or hospital for 10 to 23 hours. Many patients are able to drive after one week and most of my patients can return to part-time work in 2 weeks and full-time work in 3 weeks. Sexual intercourse and normal exercise routines can be resumed in 6 weeks after LAVH.

With an LAVH, a small 1/4th inch camera is inserted into the belly button area, allowing me to visualize the uterus, ovaries, intestines, and other intra-abdominal structures. Two other smaller incisions will be made in the left lower abdominal area and above the pubic bone so other instruments can be used to assist in the surgery. Scar tissue from previous surgeries can be evaluated and removed, if necessary, and pelvic diseases such as endometriosis, abnormally enlarged ovaries, or other pelvic organ abnormalities can be visualized and treated prior to removing the uterus and cervix. The connections and blood vessels of the uterus and cervix to the pelvic area are carefully separated and blood vessels are sealed. I then remove the uterus and cervix through a small vaginal incision and close up the incision after removal of the uterus, cervix, and if necessary the tubes and ovaries with stitches, leaving the remainder of the vagina unchanged.

Total Abdominal Hysterectomy
This surgery is performed through an incision that is like a C-section incision, just above the pubic hairline. I reserve this procedure for women with very large uteri due to large fibroids, women with a lot of scar tissue due to previous surgeries, or women that I may be concerned have a cancer of the female organs. This method of hysterectomy will require a two day hospital stay and a full six weeks of recovery before a return to work. Sexual intercourse and normal exercise can be resumed in 6 to 8 weeks after surgery. Because recovery is much more difficult with an abdominal hysterectomy when compared to LAVH, I do all I can to avoid this method of uterus and cervix removal. About 5% of the time, I will need to convert an LAVH to an abdominal hysterectomy because of too much scar tissue or a very abnormal uterine shape that makes vaginal removal too dangerous.

Laparoscopic Supra-Cervical Hysterectomy
This is a type of partial hysterectomy that involves removing only the uterus and not the cervix. The abdominal incisions are similar in position to those used to perform an LAVH, however, they are slightly larger (approx 1/2 inch each). With an LSH, the uterine connections to the pelvic area are taken down and blood vessels are sealed. The uterus is disconnected from the top of the cervix and a device called a morcellator is used to remove the uterus from the abdomen in small pieces.

The main advantage to this surgery is that recovery is very fast. Most women can return to work in one week while sexual intercourse and exercise can resume in one month. There are other proposed but not proven advantages like increased support to the vagina and decreased infection risk to surgery. Drawbacks include the need for continued pap smears in the future, possible need for future surgery due to cervical cancer, and up to 10% risk of continued small periods from the cervical stump. However, for women with no history of abnormal pap smears, uterine cancer, and a desire to keep the cervix, LSH may be an option for them.

Hysterectomy Satisfaction
Long term satisfaction with a hysterectomy is very high. Most studies show that 90% to 95% of women will be happy with their choice of a hysterectomy. Sexual functioning for the vast majority of women is unchanged or improved. Women still experience orgasm and their partners are unable to notice a difference during intercourse. However, some long term issues can occur. For a very small amount of women, they experience difficulty with sexual intercourse causing pain. Some women also experience abdominal pain from scar tissue related to the healing process. Fortunately, this only occurs in a very small fraction of women (<5%).

TO REMOVE THE OVARIES OR NOT TO REMOVE THE OVARIES

The most common question women ask when considering a hysterectomy is, “Should I remove my ovaries?” There are advantages and disadvantages to either decision. Ultimately, it is the patient that will need to make her own decision after considering all the factors that may be important to her. The surgery performed to remove both ovaries and the fallopian tubes is called Bilateral Salpingo-oophorectomy (BSO).

The Case for Keeping the Ovaries
Ovaries are the organs that produce hormones for women. These hormones include estrogen, progesterone, and testosterone. Once a woman becomes menopausal, at an average age of 52 years old, her ovaries no longer produce estrogen and progesterone, but does make a small amount of testosterone. If only one ovary is removed, the remaining ovary will increase production of hormones to match the amount produced by two ovaries. So, if one ovary is removed, no real changes in hormone levels will occur. Hormones produced by the ovaries help keep bones strong, prevent heart disease, and prevent menopausal symptoms. On the other hand, if a woman keeps her ovaries, there is a risk for ovarian cancer or ovarian diseases that may require surgery in the future.

The Case for Removing the Ovaries
Ovarian removal at the time of hysterectomy can be accomplished very easily. There is only a very small difference in the surgery for a GYN surgeon to remove the ovaries. Surgical risk may be slightly increased but the cost difference to you or your insurance company is little to none.

There are some reasons why I may encourage ovarian removal for a patient:

• Endometriosis is a female pelvic disease associated with pelvic pain, intestinal cramping, and other less common symptoms. Endometriosis can only be cured with ovarian removal or menopause and can only definitively be diagnosed with visualization of lesions in the pelvis at the time of surgery. If a woman with endometriosis opts to retain her ovaries at the time of hysterectomy, there is approximately a 50-50 chance she will need future surgery to remove her ovaries due to pain, ovarian cysts, or scar tissue. If a woman opts to remove her ovaries in light of endometriosis, there is only a 4% risk of surgery in the future for continued pain.
  
  
• Family history of ovarian cancer is a situation in which ovarian removal may increase the life span of certain women. There are certain genetic risk factors that can be determined in families that markedly increase risk for death due to ovarian cancer. In this situation, when a woman has completed childbearing or reached the age of 35 years old, ovarian removal with hysterectomy may be warranted.
  
  
• Pain associated with recurrent ovarian cysts may be a reason for some women to desire ovarian removal.
  
  
• Premenstrual syndrome may cause significant disability for some women and may warrant ovarian removal with hysterectomy.
  
  
• Ovarian tumors if found at the time of surgery, will usually warrant ovarian removal if they cannot be removed off of the ovary.
  
  
• Hormonal or menstrual migraines can be treated with ovarian removal. Some tests may be necessary prior to hysterectomy to determine if ovarian removal will assist with migraines.
  
  
• Post-menopausal or near menopausal women may desire ovarian removal to markedly reduce the risk of ovarian cancer in the future

If a woman is less than 50 years old and elects to have her ovaries removed, I do highly encourage the use of estrogen/hormones until she is into her mid-fifties. Estrogen replacement in this group of women will decrease risk for heart disease, improve sexual functioning, strengthen bones, help maintain weight control, keep hair and skin younger appearing, and does not appear to increase risk for breast cancer. In studies, a woman who opts to use estrogen after hysterectomy and ovarian removal appear to live longer and do better than women who opt not to use hormones after hysterectomy and ovarian removal in this age group.