Vaginal surgery is my forte and greatest interest. While I perform abdominal and laparoscopic surgeries of many sorts, I believe (as does ACOG) that a woman is best served if a procedure can be completed without abdominal incisions. I personally do not see a place for robotic surgery in my practice, as I can accomplish procedures more efficiently and cheaply and with less pain and fewer incisions without the robot. A vaginal hysterectomy, for example, is the cheapest, safest, and least painful way to accomplish hysterectomy in the hands of a confident, and careful, and experienced vaginal surgeon. Frequently this can be accomplished even in the case of a large fibroid uterus.
Total vaginal hysterectomy (TVH) means “removal of the entire uterus.” It does not mean removal of the tubes or ovaries. These organs certainly can be removed at the time of hysterectomy, but that is a separate consideration. In general, hysterectomy, especially vaginal hysterectomy carries with it very high patient satisfaction, but appropriate patient selection is very important. The procedure is usually accomplished in an hour or two, and involves one night’s stay in the hospital.
Laparoscopically assisted vaginal hysterectomy (LAVH) involves use of the laparoscope to assist with hysterectomy. The laparoscope is an effective tool which allows access to the upper pelvis without a large incision. The laparoscope may be useful if the uterus is more difficult to access vaginally, or if there is suspicion of significant pathology such as severe endometriosis or adhesions. Sometimes, the laparoscope is used to perform a supracervical hysterectomy (LSH), which means “removal of the uterus over the cervix,” (the part that bleeds and cramps.) LSH involves no vaginal incision at all. The body of the uterus is cut up and removed through several small incisions on the lower abdomen. Recovery after LSH is possibly easier and shorter than TVH. The disadvantages of LSH are the need for small abdominal incisions and a slight risk of light monthly bleeding from the cervical canal. LSH must be avoided if there is any suspicion for malignancy. Patient selection is limited to low risk patients. It is generally not recommended to leave the cervix if there is a history of cervical dysplasia.
Abdominal hysterectomy involves making an incision of several inches on the lower abdomen. The incision is either transverse or vertical, depending on the pathologic reason for the procedure. Abdominal hysterectomy is performed least frequently, since most of the time TVH, LAVH, or LSH can be performed leading to an easier and safer recovery.
Salpingectomy and oophorectomy
Removal of the tubes or ovaries can be accomplished at the time of hysterectomy, but this is a separate consideration. It is now generally recommended that the fallopian tubes be removed at the time of hysterectomy to reduce ongoing risk of ovarian cancer. (It turns out that around 40% of ovarian cancers are probably actually fallopian tube cancers.) Prophylactic removal of ovaries in an average risk patient is generally not recommended unless the patient is near or after menopause. Ovaries can be removed at any age if there is an appropriate reason to do so.
Laparoscopy is surgery performed using the laparoscope, a lighted telescope which can be attached to a camera for viewing on a screen. Laparoscopic surgery is sometimes termed “minimally invasive surgery,” because the incisions made are smaller than traditional laparotomy incisions. This generally leads to an easier and less complicated recovery for the patient. It should not, however, be inferred that the surgery being performed is not major surgery just because the incisions are small.
The laparoscope was first used by gynecologists to look into the pelvis to diagnose problems such as endometriosis and infertility. When I was in medical school, tubal ligation was the only therapeutic procedure performed with the laparoscope. Now there are a multitude of procedures performed this way, including diagnosis and treatment of pelvic pain and infertility, treatment of endometriosis, lysis of adhesions, removal of ovarian cysts, and hysterectomy.
Urinary dysfunction and complaints are so integral to pelvic care that I have focused here intentionally to be able to offer the best care available.