Hysterectomy is the removal of the uterus. Many lay people consider a total hysterectomy one where the uterus and ovaries both are removed.  Medical personnel would consider a total hysterectomy just the removal of the uterus and the cervix (the mouth of the uterus). Doctors say "hysterectomy and bilateral oophorectomy" if the uterus and ovaries both are removed. Hysterectomies are usually done because of pain caused by the uterus or because of heavy periods, cramping with the periods and occasionally cancer of the uterus, ovaries or cervix. Sometimes, because of a drop in the uterus and incontinence or prolapse of the uterus, the uterus will have to be removed as part of the repair procedure. Most of the time the removal of the uterus is a decision that should be made by the patient herself, though the insurance companies now have a lot to say about whether or not an operation is "medically necessary" or not. When someone is having heavy bleeding with periods that require missing several days of work or cause her to be miserable from cramping for several days out of the month, even though this is not life threatening it certainly is life altering. In almost all cases I think treatment should be considered with medicines, either non-steroidal anti-inflammatory medicine such as Advil, Motrin or Anaprox or hormones such as Provera, Depo-Provera or birth control pills before surgery is considered. If these medicines are ineffective or are unacceptable because of side effects or other factors, then surgery may be the best alternative. Endometrial ablation may be tried to decrease the periods or to make the cramping more acceptable. If this is ineffective or inadvisable or if the surgery is being considered for other reasons, then, hysterectomy is probably the operation of choice.

In earlier years, hysterectomy was always done either by the vaginal route or abdominal. In vaginal hysterectomy, the surgeon goes through the birth canal and cuts around the mouth of the uterus, locates and ties the blood vessels and then removes the uterus through the vagina. It is more difficult to do if the uterus is large, if the ovaries have to be removed along with the uterus or if there is a lot of scar tissue or endometriosis. Abdominal hysterectomy is done by making an incision in the abdomen, usually a low transverse incision or "bikini incision". This is done if the uterus is larger, affected with a lot of adhesions, of the ovaries have to be retrieved at the same time or if there are other abdominal procedures that have to be done. Nowadays, there are very few reasons for doing a hysterectomy abdominally, if hysterectomy is the only procedure necessary. Unless the uterus is exceptionally large or the adhesions are exceptionally dense or some other problem is explained, the hysterectomy can usually be done either vaginally or laparoscopically.

In a laparoscopic hysterectomy, instead of making a large abdominal incision, several small ½ to 1-cm incisions are made and the operation is done with small instruments through these incisions. The uterus is then reduced in size if necessary and pulled through the vagina. Since most of the pain following a hysterectomy is because of the abdominal incision, this greatly decreases the amount of discomfort the person will have and the amount of disability she will experience. If other procedures, such as a bladder repair, repair of vaginal support, removal of endometriosis, removal of the ovaries or an appendectomy are planned, these can almost always be done through the same laparoscopic incisions.

Recently, a new instrument has changed the laparoscopic approach to hysterectomy.   If the patient has never had abnormal pap smears in recent years  or disease of the cervix and if she is willing to commit to annual pap smears even after the hysterectomy is done, another option presents itself.  This is the Laparoscopic Supracervical Hysterectomy.  In this procedure, the uterus is separated from the cervix about an inch from the opening into the vagina.  This means that the cervix is preserved for the vaginal support it may give.  Some people find that sex is more satisfying if the cervix is left in place.  There are fewer problems with the bladder during and after surgery if the cervix is left alone. Since the vagina is not cut, as in the abdominal, vaginal and laparoscopic vaginal hysterectomies, there is no pain related to the vaginal wound.  There is also less chance for infection since there is no contamination of the abdomen with vaginal secretions.  These factors speed recovery and lessen the risk of complications.  Since this procedure does not have an incision in either the abdomen or the vagina, there is the problem of how to get the uterus out.   This is solved with an instrument called a morcellator.   It has a cylindrical blade that reduces the uterus to small sections that can be pulled out through a laparoscopy port.  I believe that laparoscopic supracervical hysterectomy, or LSH for short, is the safest and easiest procedure for the patient.   It is rare to have more than a single overnight in the hospital and many will prefer to leave the hospital the afternoon after surgery.   Most people are back on their feet in a few days and can return to full activity in as little as two weeks.  I have done more than 95% of hysterectomies this way in the four years. I have published one paper on our experience with this operation and I am collecting data for another. 

In summary, if a hysterectomy is planned the first choice would usually be laparoscopic or  vaginal since this usually gives the quickest recovery. Vaginal is preferred if the cervix must be removed. Virtually all hysterectomies can be done in one of these two ways. The abdominal hysterectomy is the third choice and should be used only very rarely and when specific problems are anticipated. When we began doing laparoscopic hysterectomies in 1993, we found that we were doing approximately two vaginal hysterectomies for every one abdominal hysterectomy. In 1997 and 1998 we found that were doing approximately equal numbers of abdominal and vaginal hysterectomies and these were approximately 2/3 the number of laparoscopic hysterectomies. In the last couple of years The rate is well over 90% laparoscopic. Our hospital stay after surgery is now usually less than 24 hours. I  think that  now the abdominal hysterectomy is about as rare as an open gallbladder operation is today.