Demystifying Hysterectomy: What You Need to Know

Feb 01, 2022

Hey there 👋🏼! It's me, Dr. Kelly, Double Board Certified Pelvic Physio, and your go-to expert for all things pelvic health! Today, I want to dive into the nitty-gritty of hysterectomy. In this post, we'll answer the questions 'what is a hysterectomy?' 'what do they take out in a hysterectomy?' 'How do they take it out'" and more!

Let's start with "what is a hysterectomy"? In a nutshell, a hysterectomy involves removing the uterus due to pathology (cancer, excessive bleeding, pain, possibly to control leaks or pee urges).

The terminology can be overwhelming, so here's a quick guide:

Demystifying Hysterectomy Terminology

This earlier blog post teaches you about the different pelvic organs, so if you are unsure what a uterus, or cervix is, pop over to that post and read up, then return. I'll wait :)

If you prefer to read, the key parts of a pelvis with female anatomy are:
- Vulva vs vagina? In female anatomy, "if you can see it, it's the vulva, if someone, or something is inside of it, it's the vagina". This silly Instagram Post sums it up perfectly, if I do say so, myself!!
- Uterus: the organ for creating a baby
- Cervix: the part at the TOP of the vagina, just before the uterus. If you are pregnant, it closes with a mucous plug.
- Ovaries: the parts that hold eggs
- Fallopian Tubes: the parts that carry eggs to the uterus. FUN FACT: you CAN have one ovary removed, and still could have a fertile cycle each month!! It's true, if an ovary was removed, but the fallopian tube left behind, it could move around to "gather" an egg released from the other ovary!! Aren't bodies AMAZING!!! (& PSA to use birth control if this is you and your goal is NOT to have a child).

Now that we've go that out of the way...let's move on to Hysterectomy varieties...

Terms Used in Hysterectomy:

Hysterectomy

Surgical removal of the uterus. (...saying "I had a hysterectomy" really doesn't give us any more detail than that)...check out the further specifics...

Subtotal/Partial/Supracervical Hysterectomy:

The uterus is removed, leaving the cervix intact

Total/Complete Hysterectomy

Surgical removal of the uterus and cervix.

Radical Hysterectomy

Removal of not only the uterus & cervix, as well as ovaries, and fallopian tubes.

Hysterectomy with Salpingectomy

Surgical removal of the uterus and the fallopian tubes

Total Hysterectomy with Oophorectomy

Removal of the uterus, cervix and ovaries.

Phew!! So it IS worthwhile to know what they plan to take out, and why, and why they might change their mind and take out more when they're in there. Or, if it's been 10 years since your surgery, you can now read your report with greater insights and understanding!

K: Know I know what the terms mean...how do they take it out?

There are a variety of methods surgeons use to perform a hysterectomy

Transvaginal:

In this approach, there are still incisions in the abdomen, through which the surgical instruments and camera are placed, so the surgeon can see what they are doing. There is one camera, one device that fills the space around the uterus with a gas, so that the organs are more separated (which makes it easier for the surgeon to see, and operate), as well as the actual tools that will remove "whatever it is that they're removing."

In the transvaginal approach, the surgeon prepares the "parts to be removed" via abdominal incisions, then actually removes them through the vagina, then closes up the cervix or vagina when they are finished.

Transabdominal:

A more invasive method, than transvaginal removal, in a trans abdominal (or "open") hysterectomy, the organs are removed via an open incision through the abdominal region. This is required for more complicated procedures. It is more common in cancer surgeries.

The key is...while we love "less invasive"...if your surgeon feels that they need an "open" procedure to visualize and perform the procedure that is right for you...you ought to let them choose the approach that they need, to do the best job possible.

Pick your surgeon for their skill and appropriateness for your situation. Then trust their judgement.

Laparoscopic/Open/Robotic:

Utilizing small incisions or robotic technology for enhanced precision. Here, again, it is a surgeon preference. If YOU feel strongly about one approach, discuss this with your surgeon...but at the end of the day, the best laparoscopic surgeon in the world might be "new" to a robot...or vice versa...so please pick the surgeon whose skills fit YOUR SITUATION the best, and trust their judgement and approach.

Key in Hysterectomy: Stabilizing the Remaining Vagina:

The post-hysterectomy vagina requires internal support to avert prolapse.

In the "olden days" (>10 years ago), surgeons would NOT stabilize the remaining vagina...which lead to something like a 20% incidence of repeat surgeries being required to address post-operative pelvic organ prolapse!!! YIKES!!!

(Psst: THIS post is about what happens in a hysterectomy...THIS POST is about questions you should ask, if able, before your hysterectomy,to better understand the procedure and prepare, mentally)

Common techniques to stabilize the remaining vagina involve sacrocolpopexy, sacrospinous fixation, and uterosacral ligament support.

IMPORTANT NOTE: Hysterectomy, and vaginal stabilization, are important procedures...but your pelvic floor will OFTEN object to "something" being sutured to it/near it, so preoperative PT is a MUST. Schedule with me (online or in person) or with a Pelvic PT near you. 3 months is IDEAL, but even 1 week of prep is exquisitely helpful!!!

Here's what all that means:

Sacrocolpopexy

This is the most common way, with the best long term outcomes.

The surgeon secures the remaining vagina, via a Y-shape of mesh, to the front of your sacrum (your lowest backbone).

Sacrospinous Fixation

Secures the remaining vagina to the sacrospinous ligament

This is usually only done on one side. There are more pain complaints if it’s done on both sides.

🔴 If your vagina is 'more posterior', there are higher failure rates with this approach (so talk to your surgeon if you think this might be you).

Uterosacral Ligament Support

This is less common, and involves supporting the vagina bilaterally.

This procedure has a 4% risk of neuropathy, likely because of elevated tension on the pelvic nerves, so should be done for a very specific purpose, and not as a "matter of fact".

Post-Hysterectomy Considerations:

K--procedure is over. Great job to you, and your support team.

Vaginal support (which is 100% necessary to prevent future prolapse of the vag) may give rise to complications such as pelvic discomfort (pain in crotch, bike seat area, or tailbone), and can even lead to new pee leakage in 40% of people, post-operatively (studies actually show a range of 23-50% instance of new leaks AFTER hysterectomy, more on that later, though).

Thus Pelvic floor physical therapy (PT) emerges as a potent solution to address and alleviate these common post-operative symptoms effectively.

Pelvic Floor Physical Therapy ought to be a standard of care pre-operatively, to optimize tissue health, as well as resume post-operatively (usually at 6-weeks, earlier if there are complications) to ensure normal muscle function, even in the absence of patient functional complaints.

Posoperatively, it's important to focus on Dr. Kelly's "Big 2"--"exhale with exertion", and perform relaxed belly breathing, when sitting at rest, with focus on also relaxing your pelvic floor. I'll do a WHOLE post (& course, in fact) on post-hysterectomy care soon, but for now, focus on the big 2, and plan on seeing a pelvic physio online or in person, at about the 4 week post-op mark.

Empowering You with Knowledge About Your Hysterectomy!

Whether your hysterectomy is in 2 days, 2 weeks or was 30 years ago, understanding the basics of your hysterectomy empowers you to make informed decisions about your health.

Whether you have undergone surgery or are contemplating it, recognizing the pivotal role pelvic floor PT can play in the recovery process is crucial, and 1-3 pre-procedure visits with a Pelvic PT (in person or online) are vital to optimizing outcomes. Here’s how to find a Pelvic PT near you, or here’s my scheduling site if you’d like to work with me.

For those seeking alternative avenues, perhaps we’re not ready to see a Pelvic PT in person, consider a high-quality online course from a trusted professional (like me!). Pelvic Floored offers world-class streamable pelvic wellness programs, that you can work through at your own speed, in the comfort and privacy of your own home, for a fraction of the cost of one:one Pelvic PT. And yes, you can stream Pelvic Floored's courses from your computer, as well as from your phone or tablet (courtesy of the FREE Kajabi app, a blue K that you'll find wherever you download your apps from).

And lastly, if you are interested in Pelvic Floored's upcoming Hysterectomy Course, please be sure to join our mailing list via the form below, as VIP (Very Important Pelvis) e-newsletter subscribers always get FIRST NOTICE & BEST DEALS on courses.