• Kim Hood, MD

Hysterectomy: What, When, How, Who!

Updated: Dec 26, 2019

Many of my Hoodies have asked me to write about what to expect after having surgery like a hysterectomy or cesarean section. This will be more for those who are considering hysterectomy, but the risks and complications are similar for cesarean. Please be advised that this is educational and informational. This is not to be used as advice. Please talk to your doctor about any issues, questions, or concerns you have regarding your own procedure.

Hysterectomy is a procedure where your doctor will remove your uterus. This can also include removing your cervix, fallopian tubes, and your ovaries at times. Women who are in menopause (you have had no period for a year or more) or have medical conditions like endometriosis will often have everything removed to prevent the need for additional surgery in the future. Gynecologic experts recommend removing the fallopian tubes even if you are leaving ovaries because studies have shown removal of the tubes decreases the risk of ovarian cancer. The thought is that many ovarian cancers were actually fallopian tube cancers; the two cancers look alike and are hard to tell apart visually and under the microscope.

Women who have not gone through menopause and are having their hysterectomies for reasons like heavy periods that have not responded to conservative therapy will have just the uterus, cervix, and fallopian tubes removed. They will leave their ovaries to use for hormones. The average age of menopause is 51+ 2 years.

Most GYN's will remove the cervix on hysterectomies. It's likely a good idea because if you ever need it removed later in life, it can be difficult to do and result in injury to bladder, bowel, and ureters (the tubes that go from the kidneys to the bladder). There was a movement several years ago to leave the cervix in women with normal pap smears who are low risk for developing cervix cancer. The reason was to help support the vagina to prevent it from falling out. (Yes, that can happen although not from hysterectomy only.)

Going into the procedure, you need to be aware that it is surgery. Duh? I'm not insulting your intelligence, but I want to write this statement because I don't think people really understand that bad things beyond anyone's control can happen; therefore, you need to be thinking, "keeping my uterus and not having this surgery will make my life horrible such that I'm willing to risk bad things happening." Fortunately, these things don't happen very often.

What are some of the things that can happen? You could have a reaction to the anesthesia. One out of every 10,000 go to sleep for surgery and do not wake up. You could have a heart attack or a stroke. You could have a dental or throat injury from the tube that is used to help you breathe during the surgery. You could suffer a bowel injury that could result in the need for a colostomy and additional surgeries. You could have a bladder injury that could result in the need for additional surgery and use of a catheter for a long time. You could have your ureters cut. These are the tubes that go from your kidneys to your bladder. Their pathway goes right by the cervix that will be removed during your procedure, and it can be very easy to accidentally injure these. An injury would result in additional surgeries/procedures.

There are nerves in the pelvis that are cut during a hysterectomy. Usually women do well with this, but I have read about nerve pain that occurs afterwards. This could result in the need for pelvic physical therapy or chronic pain management. Some women have reported sexual dysfunction after a hysterectomy, likely due to nerves being cut.

Fistulas can form. This is a connection between the bladder and vagina or the rectum and vagina. If this occurs, it would result in urine or stool coming out of your vagina. You would require additional surgery, maybe even at a university level program by a board certified urogynecologic/pelvic reconstruction specialist.

Your arms and legs position during the procedure could lead to pinched nerves that can cause numbness and weakness. This usually resolves with time or physical therapy, but sometimes it doesn't.

You could also develop a DVT (deep venous thrombosis). This is a blood clot that forms deep within the pelvis or legs, sometime the arms. These can dislodge and go to your lungs and stop you from breathing. This is called a PE (pulmonary embolus). DVT's and PE's are caused from the trauma of the surgical procedure along with immobilization and can occur even when precautions are taken.

There can be bleeding during or even after the procedure. This is especially true for individuals with more complicated surgeries or major risks like adhesive disease from endometriosis or previous surgeries. A fibroid uterus or very large ovarian mass can increase the risk of emergent bleeding. Often, you are not awake enough to be involved in the decision to give blood and there is great concern for your life; therefore, you doctor will give you blood unless you have directed otherwise.

Now that you're completely terrified, I do want to say that these risks are low. GYN's would not provide surgical procedures if this happened all the time. It would make life miserable for you AND them! We DO NOT like our patients to have ANY complications. It makes us worry about you and feel TERRIBLE that we are responsible for causing you problems.

So which type of hysterectomy are you having? Yes, there are many ways to accomplish the GYN task of saving the world one uterus at a time. You can have an open hysterectomy. It can be done vaginally, laparoscopic vaginal, total laparoscopic or robotically. Prior to robotics, women who had never had children or had multiple abdominal surgeries, like C-sections, would be done by the open method. This results in your biggest risks and complications, a large scar on your abdomen, and requires the longest hospitalization. It is also the most painful.

If a woman had several children vaginally and/or had a great deal of prolapse (this is where the uterus sags down into the lower vagina), then she could have a vaginal hysterectomy. These are better because there is no scar on the belly and risk of poor gut function is lower after surgery. The patient still requires hospitalization, usually 1-2 days. It's also a challenge for a GYN to get the fallopian tubes and ovaries.

With a laparoscopic approach, a GYN could save women who did not have any prolapse or no children and even some women who had abdominal procedures, a major incision from an open approach. This lessens pain and the patient usually only has to stay overnight.

Robotics really revolutionized the world of GYN surgery. This became my preferred method of providing a hysterectomy for all of my patients! This machine has made it possible to do very complicated surgical procedures that in the past would have needed to be done open. Pain is very minimal. Gastrointestional function is minimally affected if at all. Patients can often go home the same day. Usually by 2 weeks out from surgery, most do not even feel like they've had surgery! When you are considering a hysterectomy, find a doctor that can do the least invasive approach for you, and be aware that not all doctors are good at laparoscopy and not all are robot trained, especially if they are older doctors (40's+).

Now, you have had your surgery, what next? The day of surgery, you are going to be groggy and tired. Make sure someone comes with you to drive you home if you have a procedure that allows for you to go home the same day. You will have pain immediately after you wake up. The recovery room nurses will work very hard to get your pain under control. There are ERAS (enhanced recovery after surgery) protocols that many GYN's are starting to use. The protocol uses meds to help reduce the amount of nausea and pain a patient has after surgery, and it has been shown to improve gastrointestional function after surgery. There are other benefits, but those are the main ones that I always liked. I would recommend a GYN that uses some form of an ERAS protocol.

The first 2-3 days after surgery are usually the worse. Your bowels are still trying to adjust; you may have waves of nausea; pain may become an issue if you've been active or haven't had pain meds in a while. You may have shoulder pain. This is because air is in the abdomen and has become trapped under the diaphragm. The air irritates the phrenic nerve and causes referred pain to the shoulder. Movement/repositioning yourself to try to get the air away from the diaphragm is the only way to make the pain stop. It can also feel like a heart attack. If you are not sure if it is a heart attack, be cautious and call your doctor or go to the ER. Also, anti-gas meds do not help. The gas is not in the intestines. It's in the abdominal cavity, outside of your intestines. Your body will absorb that gas over time.

The amount of bleeding you should expect is what 3-5 panty liners per day would take care of. When you start activity, you will get tired faster that normal. You may even find that you get up to shower, get dressed, and now you are sweating, dizzy, nauseated and need a nap. Rest when your body tells you. You just had surgery. You can go on walks, but start slowly; 10 minutes at first. Do not push yourself, and again, LISTEN to your body.

You should be able to go up and down stairs. You should not drive while taking any pain meds or while having any pain. You could have a wreck, hurt yourself or others, and even get sued.

You can eat what ever diet you followed prior to the procedure. You should not lift anything more than 10 pounds. That would be like a one gallon milk jug. Watch lifting things that you don't realize are heavier than you would think, like a basket of wet laundry. Avoid twisting motion like vacuuming or mopping; it can make you very sore.

DO NOT HAVE SEX or put anything in your vagina until your doctor tells you it is ok. This will infuriate your GYN. It should be common sense, but you would not believe the stories I have!!! Also, I would avoid repetitive bending motions, like trying on pants, at the store, ALL DAY! If you rip the stitches holding the top of your vagina closed, your bowels can spill out through your vagina, and that, my friends, is not good! If you have had an open procedure, bending too much or lifting heavier than you should can cause your abdominal opening to rupture and bowel come through that opening.

What symptoms would be a good sign of something bad? If you feel you have a fever, take your temp. If you do not have a thermometer, please get one. Do not call your doctor and tell her that you have a fever but you don't know what it is because you don't have a thermometer! Low grade temps can be normal from healing, but if your temp is 101.0 F, you need to call your doctor or go to the emergency room. You could have a UTI, a vaginal cuff infection, a pelvic abscess, a DVT, or a wound infection to name a few.

If you began to fill a large pad from edge to edge and all the way through in an hour or less and it's continuous, go to the ER. If you have foul smelling discharge from the vagina or your abdominal incision, call your doctor or go to the ER. If you have redness of your incision that appears to be spreading, call your doctor or go to the ER. Drainage from an abdominal incision can be normal, but it should never be heavy drainage or look like it has been mixed with vanilla pudding.

Pain/swelling of your calf muscle in one leg or difficulty breathing should prompt an ER visit. This could be a DVT or PE that I spoke of earlier. Also, pain and swelling of your upper arm could be a DVT. These conditions can be life threatening. You should have a very low threshold to go to the ER even if you are slightly concerned this may be a problem.

Bowels can be slow and constipation can occur from having surgery and not moving much, especially if you are taking any narcotics or anti-nausea meds. However, if you become significantly distended in the abdomen with nausea and/or vomiting, especially if you cannot keep anything down, call your doctor or go to the ER. Sometimes, these symptoms will require a readmission, IV meds, IV fluids, and bowel rest by not eating. This could also be a bowel obstruction, but most of the time, it is "slow return of bowel function."

This is all the information I have in my brain. I have dumped on this page for all my "Hoodies" to see. I hope you find this informative and helpful. I also hope that it will help you have the discussion with your doctor that is needed prior to making your decision about surgery and prompt questions for you to ask. My last bit of advice: take as long off as you can from work. Most places of employment allow 6 weeks of recovery. Take it. If you are doing well and can get back sooner, then good! You'll look like a boss!!!

Disclaimer: While I am a doctor, I am not your doctor. The information in this blog post is for information and entertainment purposes only and are not intended as medical advice!

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