Hysterectomy means removal of the uterus. Laparoscopic hysterectomy is removal of the uterus by laparoscopy. This procedure involves placement of 3-4 small tubes (cannulae) 0.5-1cm in diameter in the abdomen and passing a telescope along with specialized instruments through these cannulae for performing this surgery.
The uterus is fixed in the pelvis by cord or band like structures called ligaments. In the lower part it is closely adherent to the urinary bladder in front and the rectum behind. The uterus is attached to the top of the vagina and derives its blood supply from two large vessels (uterine arteries) running on either side of the uterus.
Laparoscopic hysterectomy involves separation of the uterus from its attachments (ligaments, Fallopian tubes and ovaries), dissection of the urinary bladder and rectum safely away from the uterus, cauterizing or suturing & cutting the blood supply (uterine arteries) and cutting the uterus from the top of the vagina. The uterus is removed through the vagina or through a machine called a morcellator which cuts the uterus into long strips. The vagina is sutured with absorbable sutures.
The Fallopian tubes are usually removed to prevent a hydrosalpinx (fluid filled swelling of the Fallopian tubes) later. The ovaries are removed (one or both) if they are diseased or have stopped functioning (menopause).
The indications of laparoscopic hysterectomy are:
- Heavy or abnormal uterine bleeding due to uterine pathology such as adenomyosis or fibroids
- Pelvic pathology such as endometriosis
- Uterine (endometrial) or cervical cancer
- Pelvic organ prolapse
- Along with surgery for rectal or colonic cancer
Hysterectomy is performed only when:
- Medical or conservative surgery (hormones, myomectomy or resection of endometrium) has failed or is contraindicated (suspected malignancy)
- Patient does not desire menses or childbearing
- To improve success of primary surgery (colonic cancer)
The contraindications for laparoscopic hysterectomy include:
- Severe cardiac or lung disease
- Ovarian cancer
Large uterine size or presence of adhesions (bowels getting stuck to the abdomen or uterus and bladder stuck to the uterus) is NOT a contraindication to laparoscopy.
In fact, laparoscopy has a major advantage over conventional laparotomy (open surgery) because:
- Magnification and superior visualization of deep structures
- The gas passing into the abdomen under pressure opens up normal tissue planes facilitating surgery
- Better visualization and precise dissection of vital structures such as the urinary bladder, rectum and the ureters
- Lesser blood loss in skilled and experienced hands
- Faster recovery with lesser morbidity, less pain and better cosmesis
- Precise separation of blood supply with lesser possibility of disturbing the blood supply to the ovary