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Laparoscopic Hysterectomy

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A laparoscopic hysterectomy is a minimally invasive surgery for removing the uterus. The procedure, when compared to a traditional hysterectomy, offers less pain, lower cost and shorter recovery time. A doctor performing a laparoscopic hysterectomy inserts a lighted camera called a laparoscope and robotic surgical arms into the patient’s abdomen through small incisions.

A hysterectomy is a surgical procedure that removes the uterus, the female sex organ that facilitates childbirth. Surgeons have been performing hysterectomies since 1843. However, the procedure was revolutionized in 1989 when the first laparoscopic hysterectomy was performed. A laparoscopic hysterectomy is a minimally invasive way of performing the procedure.  Doctors make small incisions to insert a lighted camera called a laparoscope and robotic surgical arms into the patient’s abdomen. The result is less pain and recovery time for the patient.

An outpatient laparoscopic hysterectomy costs roughly $9,500, about $2,000 less than a traditional open hysterectomy. Traditional surgical techniques involve either a large incision in the abdomen, called an abdominal hysterectomy, or in the vagina, called a vaginal hysterectomy. Aside from the cesarean section (C-section), hysterectomies are the most commonly performed major surgery in American women. They account for roughly 600,000 procedures each year, and about 60 percent of those are open abdominal hysterectomies.

The hysterectomy process often starts with a gynecologist, obstetrician or urogynecologist — doctors who specialize in the female reproductive system and pregnancy. Some of these doctors are trained surgeons and will perform the laparoscopic hysterectomy themselves. In other cases, laparoscopic surgeons who specialize in these minimally invasive procedures perform the surgery.

There are two main types of laparoscopic hysterectomies — total and partial. In a total laparoscopic hysterectomy, doctors remove the uterus and the cervix. The cervix is the lower part of the uterus that connects it to the vagina. In a partial laparoscopic hysterectomy, surgeons do not remove the cervix. Both types of procedures remove the organs through a small incision in the abdomen.

To do this, sometimes surgeons will choose to use a power morcellator — controversial devices the U.S. Food and Drug Administration linked to the spread of leiomyosarcoma and other uterine cancers.

Indications for Laparoscopic Hysterectomy

Hysterectomy is a major surgery and is only encouraged in a few scenarios because it renders women unable to bear children. A small number of patients choose to have a hysterectomy voluntarily as a form of birth control. In most hysterectomy cases, however, the procedure treats or prevents larger health conditions.

Gynecologists typically recommend laparoscopic hysterectomies if the patient is facing:

  • Abnormal uterine bleeding
  • Fibroids or leiomyomata, or benign uterine tumors
  • Endometriosis, when the tissue lining the uterus grows on other pelvic organs such as the ovaries or bladder
  • Adenomyosis, when the tissue lining the uterus attaches to the uterine wall
  • Pelvic organ prolapse, when weakened muscles causes a pelvic organ to drop and push against the vagina
  • Precancerous or early cancerous uterus or cervix

Some patients should not have laparoscopic hysterectomies because of health risks.  Doctors don’t recommend it for obese women, women who have had multiple operations on their lower abdomen and women whose uterus is abnormally large.

How is Laparoscopic Hysterectomy Done?

Patients who undergo the procedure receive general anesthesia. The surgery takes two or three hours to complete. To begin, the surgeon makes a small incision in the bellybutton, roughly one inch or less in length. Then, the surgeon makes two or more incisions of the same size in other parts of the abdomen lower than the bellybutton.

The laparoscope, a thin tube with a light and camera on the end, and two or three thin robotic arms enters the incisions. The doctor uses the images from the laparoscope to maneuver the robotic arms and navigate the inside of the pelvis.

The elements of the procedure vary based on the type of hysterectomy. A total hysterectomy removes the uterus and the cervix. A partial hysterectomy, or supracervical hysterectomy, keeps the cervix in place.

In general, doctors consider the surgery faster and safer if the cervix remains in place. Women who have a history of normal Pap smears — a gynecological test that checks for cervical cancer — are good candidates for partial hysterectomies. Alternatively, doctors will recommend removing the cervix if the woman has cervical cancer, or her Pap smears have indicated precancerous cells and she has a family history of cervical cancer. Recent studies show removal of the cervix has no impact on sexual experience. Women who have a supracervical hysterectomy must continue getting regular Pap smears.

The hysterectomy may also include an additional procedure to remove both fallopian tubes, or both fallopian tubes and both ovaries — called a bilateral salpingectomy and a bilateral salpingo-oophorectomy, respectively. Doctors recommend these procedures when the fallopian tubes and the ovaries are at risk of developing cancer. For a patient who has a family history of ovarian cancer, a BS or BSO will dramatically reduce or eliminate her chances of contracting it. The ovaries store a woman’s eggs and produce the female sex hormone estrogen, so a BSO will make a woman sterile and trigger menopause. For the majority of women younger than 50 years old, a BSO is not recommended because it leads to early menopause and all of it symptoms, including mood swings, hot flashes and reduced bone density.

All laparoscopic hysterectomies typically require a lead surgeon and an assistant surgeon. While the assistant moves the uterus out of the way, the lead surgeon first cauterizes one fallopian tube to seal the blood vessels, preventing blood loss, before cutting the tube and repeating the process on the second tube. This step is different for a patient also having a BS or BSO. The process repeats again to separate the uterus from the vagina, either above or below the cervix depending on the type of laparoscopic hysterectomy.

Surgeons can be remove the uterus in two ways — through the vagina, called a laparoscopic-assisted vaginal hysterectomy, or through one of the incisions in the abdomen, called a laparoscopic abdominal hysterectomy. Once the uterus exits the body, the doctor sutures the incisions to complete the surgery.

Laparoscopic Hysterectomy with a Power Morcellator

Some laparoscopic abdominal hysterectomies involve the use of an additional laparoscopic tool called a power morcellator. A power morcellator is similar in shape to long, thin laparoscopes, however it has sharp blades on the end used to cut up a large piece of tissue such as the uterus. Once morcellated, or cut into small pieces, the tissue is then vacuumed out.

Power morcellators were originally preferred in laparoscopic hysterectomy procedures because the tool prevents doctors from making a large incision to remove the uterus, therefore reducing patient pain, blood loss and recovery time. However, recent scientific studies linked this tool to the spread of other cancers. Doctors often perform a hysterectomy to remove a uterus with fibroids, or benign tumors, which can sometimes contain cancerous cells that are difficult to detect. When a power morcellator shreds the uterus inside the body, these cells can spread throughout the abdominal cavity, possibly infecting other organs and leading to the upstaging of cancer.

Because of this discovery, several hospitals stopped using power morcellators in laparoscopic hysterectomies. More insurance companies are also denying coverage for procedures that use the tool.

 

Complications

Although surgeons prefer laparoscopic procedures because they reduce patient blood loss, pain and recovery time, the procedure still carries risks. The surgery itself presents certain risks, and other complications may also occur after the surgery has been completed.

Surgical laparoscopic hysterectomy complications include:

  • Excessive bleeding that may require a blood transfusion
  • Damage to the bladder, bowel or tubes that drain fluid from the kidneys
  • Conversion to an open surgery
  • Breathing or heart problems related to anesthesia
  • Death

Post-surgical laparoscopic hysterectomy complications include:

  • Ruptured sutures
  • Blood clot in the leg, which can travel to the lungs
  • Bowel obstruction
  • Hernia
  • Fever and infection
  • Scar tissue

Patients are encouraged to call their doctor immediately if they experience:

  • A fever more 100.4 degrees
  • Heavy vaginal bleeding that requires a new sanitary pad every hour
  • Severe abdominal pain that the medication does not treat
  • Heavy, dark brown vaginal discharge with a bad odor
  • Chest pain or difficulty breathing
  • Swelling, redness or pain in the legs
  • Pain with urination
  • Bleeding at the suture site

What to Expect After Surgery

Laparoscopic hysterectomies are popular with gynecologists because they require small incisions and minimize bleeding resulting in a faster patient recovery time. For this reason, some patients may stay in the hospital one night after their laparoscopic hysterectomy. Other surgeons may allow their patients to go home the same day, depending on their circumstances.

Patients typically only take pain medication — either ibuprofen or narcotic pain pills — for a few days post-surgery. To prevent blood clots developing in the legs, surgeons recommend their laparoscopic hysterectomy patients begin walking and resuming normal activities as soon they are able. Women who work desk jobs can return to work roughly one week after surgery. Those with more physically strenuous jobs are encouraged to stay home from work for two or three weeks after surgery.

Women can resume their normal exercise and sexual intercourse habits after two or three weeks of healing. During the recovery time, women who received a total hysterectomy or a laparoscopic-assisted vaginal hysterectomy may experience vaginal spotting or a light amount of discharge, which is normal.

Patients may also experience emotional changes during this time. Hysterectomies can remove a woman’s cancer, render her unable to bear children or cause her to stop producing estrogen, all of which can result in varying emotional responses.

Laparoscopic Hysterectomy vs. Traditional Hysterectomy

Since the development of laparoscopic hysterectomies in the 1980s, many gynecologists and hospitals have embraced the procedure. Typically these doctors tout a quick recovery time and reduced pain as two of the main advantages of laparoscopic hysterectomy.

In a traditional abdominal hysterectomy, the surgeon cuts a long horizontal incision along the woman’s bikini line. In some cases, the incision can also be a long vertical incision from the bellybutton to the pubic bone. This allows the surgeon to fully visualize the uterus, using clamps and sutures to seal off the fallopian tubes before cutting the uterus away and lifting it out. These incisions cut through skin and several layers of muscle which take longer to heal and can develop unsightly scars.  A traditional hysterectomy also causes more blood loss.

Comparatively, the laparoscope allows the surgeon to see inside the patient without fully opening her up, therefore only requiring a few small incisions. Small incisions cut through less muscle and skin, leading to shorter recovery times and a smaller likelihood of scar tissue developing. Laparoscopic tools also allow for thermal cauterizing of the flesh, which leads to less bleeding than the traditional procedure.

Many doctors and patients prefer laparoscopic hysterectomies because of the reduced recovery time. Studies show having the procedure done laparoscopically reduces the patient’s length of stay in the hospital by half. It also allows patients to return to work within 14 – 28 days, roughly seven days quicker than a traditional hysterectomy. For a family that relies on the patient’s income, this shorter recovery time is crucial.

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