In recent years, numerous professional and mostly lay publications have reported on "too many unnessary hysterectomies". Women have been encouraged to seek second and third opinions and look for alternative treatments. Who determines whether a hysterectomy is necessary or not?
Let us assume Mrs.X after many years of pain and misery and having tried other forms of treatment eventually had a hysterectomy. The pathologist reports "a normal-sized uterus without significant pathologic findings". A reviewer of the hospital record would have to come to the conclusion, this hysterectomy was "unnessary", because nothing abnormal was found about the uterus. Mrs.X on the other hand states after the operation that "this was the best thing that ever happened to me. I should have had this many years ago. I am finally enjoying my life again without misery, and my husband is happy too".
In contrast, a woman without any complaints whatever is found at routine yearly check-up to have a large fibroid uterus the size of a four months pregnancy. It is decided not to do anything, just to follow her every six months with pelvic examinations and sonograms. A consultant rendering a 2nd opinion urges the patient to have a hysterectomy by laparotomy (removing the womb through a large abdominal incision). Who is right and what is "necessary"?
The medical profession to this day has not come up with a clear definition of indications for or approach to hysterectomy. It is certainly necessary to remove the uterus in cases of cancer of the cervix or body of the womb to save the life of the patient. For benign pelvic disorders the most frequent indications for a hysterectomy are:
With recent advances in gynecology most of these conditions can be treated conservatively without hysterectomy:
A reasonable approach to whether a woman needs a hysterectomy is probably
If a hysterectomy is indicated four techniques are available
This leads us to the next question: what is the best approach for me and am I a candidate for a C*I*S*H*?
Once the decision has been made that a hysterectomy is the most appropiate approach to correct a pelvic disorder, as discussed in the previous section, in our experience more than 80% of patients can safely undergo a C*I*S*H* procedure provided
A few days before the planned surgery, the patient has the following pre-admission tests:
These findings are reviewed with the surgeon prior to the operation. He instructs her
In the hospital, nurses will go through the admitting procedure. Usually IV fluids are started. The anesthesiologist will review the patient's history as well as physical and laboratory findings. He will decide on the most appropiate anesthesia regime in each individual case. The best anesthesia method for a C*I*S*H* is general anesthesia with endotracheal intubation ( going to sleep and having a tube placed into the windpipe).
After transfer to the operating room, the patient is placed flat on the operating table with the legs slightly raised and separated (modified lithotomy position). Anesthesia is started using a quick acting intravenous injection of sodium pentothal or similar drug. A muscle relaxing drug is added, a tube passed down the windpipe, a gas mixture maintains anesthesia.
At the same time appparatus and instruments are checked by the nurses and surgeons. Laparoscopic surgery is a very technical method and takes extra time to set up. A catheter is placed into the bladder, a uterine manipulator is inserted into the womb cavity. The operating fields are prepped sterile and draped.
Interested readers may refer to the chapter on surgical technique for a detailed description of C*I*S*H*.
After the operation the patient is transferred to the recovery unit where specially trained nurses and members of the anesthesia team watch over the patient for several hours until she has stabilized and is trasnsferred to her room.
The physical and emotional response to injury differs widely from person to person, The extent of surgery and thus injury to tissues likewise differs from patient to patient. Therefore, the degree of recovery will vary. In general we observe that
After discharge from the hospital, we encourage our patients to resume their normal lifestyle gradually. Within two weeks vaginal drainage should cease and residual abdominal soreness disappears. At that point we have no further restrictions: normal housework, return to work, and resumption of sexual activity are left to the discretion of the patient ("do what you feel comfortable to do").
Three to four days after C*I*S*H* the patient visits the office. Skin staples are removed and the cervix is checked for the presence/absence of the SURGICEL plug (gauze-like material which is placed into the cervix at surgery to prevent bleeding and infection). The patient is instructed before discharge from the hospital about the SURGICEL plug. She might pass it spontaneously at home (it looks like a black tampon).
In one month from surgery the patient returns for a postoperative check-up. Healing should be completed at that time.
A six months check-up is recommended, including a Pap. smear. Thereafter yearly gynecologic examinations are encouraged. Provided Pap. smears before and after surgery have been normal and the cored-out specimen has not shown any abnormalities, Pap. smears in two to three years interval appear to be sufficient for protection against cervical cancer (risk only 0.02% or 1:5,000,000 after C*I*S*H*).
Prospective, randomized studies with a twelve months follow-up determining the emotional and psychologic acceptance of the loss of the uterus in young women of childbearing age have recently been published in Vienna, Austria. They have shown superiority of C*I*S*H* over traditional hysterectomies (abdominal, vaginal, and laparoscopy-assisted vaginal hysterectomy).
It appears that women who have had a C*I*S*H* recover quickly and have very little residual physical and emotional trauma: we are removing debilitating pelvic organs without interfering with the anatomy and function of healthy pelvic structures.
Patients deny feelings of disfigurement but acknowledge preservation of self-confidence. They enjoy better quality of life through C*I*S*H* despite hysterectomy.
It is the removal of the ovaries along with the uterus which changes the hormonal environment. In that case, it is recommended that women use appropiate estrogen/testosterone replacement to prevent menopausal changes and to protect themselves from future occurrence of osteoporosis and vascular accidents.
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P.F. Vietz, M.D.