One of the biggest things to get your head around with this is all the choices. I always thought if you needed surgery you got surgery; I never thought I’d have to choose *if* I wanted surgery, and if I did *which sort* I felt would be best for me! I suppose that’s no bad thing though, it means I made sure I understood the options enough to make a choice.
Each type has various pros and cons, and how important they are depends on how much weight you give them personally.The most important thing is to be comfortable with the surgical route you are taking – don’t have the same surgery someone else did because *they* were happy with it if you aren’t sure. (Disclaimer: I had open surgery so I am generally positive about that choice).
The main choices are open surgery, laparoscopic surgery or vaginal surgery. (I’ll touch on robotic surgery at the end.)
Before I go into each I wanted to explain something generally about healing. How quickly you will heal is not really dependent on how big an incision you have. With a hysterectomy most of the work is going on inside, so there is a lot inside that needs to heal and you won’t be able to see any of it. From two tiny incisions to one large vertical one, there will always be a lot of healing to do inside, and you probably won’t feel back to your normal self in a couple of weeks regardless of which route you choose!
Everyone can imagine open surgery, it’s the stereotypical type of surgery for any treatment, and it’s also similar to a c-section (but not the same – read the article here).
These days I think women try to avoid open surgery, mainly because of scarring but also because I think it seems old-fashioned when compared to the more high-tech options available. As I chose it as an option I’ll present some of the more positive aspects to this type of surgery. With open surgery the surgeon gets a good view of everything, and they can check for any other potential issues. This may be a factor for you if there is a chance you have another concern (issues with ovaries etc.), or it may just be something you like the idea of (for me, I just liked the idea of the surgeon being able to see everything!).There is also more room for the surgeon to work, which may mean less chance of accidental damage to other organs (although that really shouldn’t happen at all). Generally it’s a fairly quick surgery, roughly 90mins, with low chances of a blood transfusion being required (I didn’t need one which I find amazing when I think about it… they cut me open and removed a major organ and didn’t have to give me any blood. The wonders of medicine!). It’s also the most straightforward way to remove the uterus; it just gets lifted out.
The biggest negative with open surgery is really the scar. For me, this isn’t a big deal. The scar sits so low that I could wear a low cut bikini and you still wouldn’t see it, which means it’s between me and my husband! I was however unfortunate enough to end up with a bump of internal scar tissue which runs along the length of the scar, just above it. It’s hard to say the exact cause but it means there is a small bump. It’s not very obvious but I know it’s there! This type of surgery also requires a longer hospital stay; usually 2 nights.
This can be done in various ways, the main difference being the method of removal for the uterus; it can be removed whole through the vagina (laparoscopically-assisted vaginal hysterectomy) or it can be cut into small pieces (‘morcellated’) and removed through the incisions. This cutting process used to be done mechanically with no protection but there were rare but serious complications if unknown cancer was present; the cutting of the tissue can spread the cancer to other organs. Now any morcellation should be done contained within a bag before pieces are removed (check with your surgeon but I’d be surprised if anywhere was doing this surgery and not using a bag).
This type of surgery has smaller ‘keyhole’ incisions and so a faster immediate recovery time, meaning less time in hospital. However it doesn’t always mean a faster recovery entirely. I have read some websites stating you can be back at work in two weeks… I’d be very wary of planning for that! As I said above there is a lot of healing going on internally that you can’t see, and you only get the chance to heal right once. Don’t rush it. I found my biggest issue was a general tiredness and lack of energy, and we all react differently to surgery, so be prepared for that.
The biggest issue I’ve seen talking about post-laparoscopic surgery is gas pain. When surgery is open the surgeon can see and access everything. When the surgery is laparoscopic they pump in gas to enlarge the abdominal area and allow everything to be visible and accessable. After the surgery that gas has to dissapate and this can result in some pain issues; weirdly the pain seems to frequently go to the shoulder area! It will pass, but can be very uncomfortable.
A hysterectomy performed entirely vaginally results in no external incisions or scarring, which might be very appealing! However it’s worth bearing in mind a few things: this type of surgery can take longer because it is more difficult to access everything. Like laparoscopic surgery there is still a lot of work going on inside that you can’t see; you need to be careful after surgery not to start doing too much just because outwardly you look fine!
The main concern with vaginal surgery is space. If you haven’t given birth naturally there may not be room in your vagina to carry out the procedure and remove the uterus, particularly if it’s large. It might be possible, but the surgeon may have to switch methods part way through (this was what was presented to me as a possibility – I hadn’t had children – which was one reason I opted for open surgery; I wanted to know exactly what was doing to happen, I didn’t like the idea of a mid-way switch). With this surgery it’s harder to check for other issues because there is no easy way to view other organs, so if you are concerned about other problems this probably isn’t the best choice for you.
And one last thing to consider; after surgery you may suffer from back or leg pain because of the position you’ll be in during surgery (in stirrups). If you have back issues this might be worth mentioning to your surgeon.
Robotic surgery (often called DaVinci surgery)
I find robotic surgery a little confusing. It is a type of laparoscopic surgery, where the surgeon uses a robot to control the surgical tools, rather than doing it themselves, and the tools are inserted through 5 small incisions. It might seem like the most “high-tech” option, but from what I have read there doesn’t seem to be any advantage to robotic surgery, and if you’re somewhere where money is a consideration when it comes to medical treatment it is more expensive than other options. It’s extremely similar to standard laparoscopic surgery except that generally it takes longer. In the end the surgeon’s skill is more important than the latest tech. If you have a complex situation it may be worth considering robotic surgery; the main benefit of this type of procedure is surgeons can perform more delicate and complex procedures which could be difficult or impossible with other methods. However for most women a hysterectomy does not require this level of complication!
Oh and why is it called ‘DaVinci’? Because the robotic system used to carry out the surgery is called DaVinci 🙂
Do you want to keep your cervix?
This is often a big factor in our surgery choice, usually without a lot of knowledge about what the cervix is and what it does! So to weigh up whether or not to keep your cervix please read the article on that specific topic; you’ll find it here.
Ultimately…. what factors are important to you?
This is where things get a bit more personal – and I don’t mean ‘intimate’ (let’s face it all this stuff is pretty intimate!) I mean about your own personal gut feelings about things. I’m a great believer that the way to get through this surgery is to feel comfortable about what is happening. Sure, ideally we’d choose no surgery at all, but if you need surgery, what option fits you best?
Are you worried about surgery? What is it that worries you?
Scarring: choose a less invasive surgery (vaginal/laparoscopic)
Potential for other issues: choose open surgery – the surgeon can see a lot better and spot other problems more easily.
Accidental damage: let’s be honest, this could happen with any surgery, but – and this is me speaking personally – there seems less chance of accidental damage to surrounding tissues/organs with open surgery – more room to work, more room to see.
Recovery time: this can be a bit misleading. Less invasive surgery can have a faster recovery time but this isn’t guaranteed; with every hysterectomy the majority of the work is being done inside, what you see on the outside is just a small part. Over the first few days it may make a difference (open surgery usually requires a longer stay in hospital and more caution moving around early on) but over the long term most of the healing happens where we can’t see it.
Dignity (ahem): this actually was a factor for me. I was offered vaginal or open surgery options, and I chose open for various reasons, one of which was that I hadn’t had children. I don’t like pap smears, never mind the thought of anything else, and picturing an undignified pose while my surgeon and assistants guddled around in there trying to get my uterus out just made me uncomfortable! It’s not rational, but it is real. I just felt far more comfortable with open surgery – it’s about finding the best choice for you.