Hysterectomy

What it is

Removal of the uterus. A total hysterectomy takes the body of the uterus and the cervix and is the usual operation; a subtotal hysterectomy leaves the cervix in place; a radical hysterectomy, used mainly for cervical cancer, also removes the tissue beside the cervix (the parametrium), a cuff of the upper vagina and pelvic lymph nodes. The fallopian tubes are usually removed at the same time, and the ovaries may be removed with them (bilateral salpingo-oophorectomy) or left. The uterus can be taken out through the vagina, through keyhole incisions with or without a robot, or through a cut in the abdomen, depending on its size, the reason for surgery and previous operations. Periods stop afterwards and pregnancy is no longer possible.

Why it is done

• Heavy menstrual bleeding that has not settled with medicines, a hormonal intrauterine system or ablation
• Fibroids causing bleeding, pain or pressure on the bladder and bowel
• Endometriosis or adenomyosis with pain that other treatments have not controlled
• Prolapse of the uterus into the vagina, as part of a repair
• Cancer of the uterus, cervix or ovary, and risk-reducing surgery in people with a high inherited risk
• Gender-affirming surgery for trans men and non-binary people, sometimes with removal of the fallopian tubes and ovaries, which is decided individually, and sometimes before phalloplasty

Before the procedure

• A discussion of the alternatives and of the fact that the operation is permanent: fertility ends, so fertility preservation is raised first where it matters
• Decisions agreed in advance about the ovaries (removing them before the natural menopause brings on a surgical menopause) and about keeping or removing the cervix
• Blood count and group and save, with iron treatment beforehand if bleeding has caused anaemia; a pregnancy test where relevant
• Ultrasound, and sometimes MRI, to size fibroids and plan the route; staging investigations when the operation is for cancer
• Stopping smoking, weight and diabetes optimised, antibiotics at induction, clot-prevention stockings and injections, fasting and a general anaesthetic (some vaginal operations are done under a spinal)

Step by step

1. The bladder is emptied with a catheter and, for vaginal and keyhole routes, the legs are supported in the lithotomy position
2. Access is gained: an incision around the cervix from inside the vagina, small ports at the navel and lower abdomen with the abdomen inflated with gas, or a transverse incision along the bikini line (a midline cut for a very large uterus or cancer)
3. The round ligaments and the leaves of the broad ligament are divided and the bladder is pushed down off the front of the cervix and upper vagina
4. The blood supply is sealed and divided: the ovarian vessels in the suspensory ligament if the ovaries are being removed, or the ovarian ligament and tube if they are being kept, then the uterine arteries beside the cervix, where the ureter passes underneath the artery and is identified and kept clear
5. The uterosacral and cardinal ligaments are divided, the vagina is opened around the cervix and the uterus is delivered through the vagina, through the abdominal wound, or in pieces inside a retrieval bag at keyhole surgery
6. The top of the vagina (the vault) is closed and commonly suspended from the uterosacral ligaments to reduce later prolapse; the bladder, ureters and bowel are inspected, bleeding is checked and the wounds are closed
7. In a subtotal operation the uterus is divided at the level of the internal os and the cervix is left; in a radical operation the parametrium, a cuff of upper vagina and the pelvic lymph nodes are removed with the uterus

Afterwards

• The catheter and any vaginal pack come out within a day, and walking starts the same day with clot-prevention injections and stockings continued as prescribed
• Vaginal bleeding and discharge settle over a few weeks; nothing is put into the vagina and sex is avoided for about six weeks while the vault heals
• Periods stop and pregnancy is no longer possible; hormone replacement is discussed when the ovaries have been removed before the natural menopause
• Cervical screening is no longer needed once the cervix has been removed for a non-cancerous reason, samples from the vault are taken for a time after previous treatment for CIN, and screening continues as usual when the cervix has been left in place
• Heavy or fresh vaginal bleeding, offensive discharge, fever, a hot or painful calf, breathlessness, or difficulty passing urine are reported to the surgical team or to NHS 111 without waiting for the follow-up appointment

Recovery

Hospital stay is usually one to five days, shortest after vaginal and keyhole surgery. Recovery takes about six to eight weeks after an abdominal hysterectomy and is often quicker after the other routes; driving resumes once an emergency stop is comfortable, and heavy lifting is avoided while the tissues heal. Tiredness, a swollen abdomen and low mood in the first weeks are common and settle.