The hysterectomy is the procedure through which the surgical removal of the uterus is performed. The uterus is a female organ with an internal cavity surrounded by a thick muscular layer that allows it to contract when required. This organ is located in the pelvis, bordering the bladder on its front side and the rectum on its back side.
The Hysterectomy can be accompanied by the removal of the annexes or ovaries (female gonads) and fallopian tubes. However, the hysterectomy can also be done keeping the adnexa, in the event that the reason for the intervention is not involved with the ovaries and these are healthy in a young patient.
The hysterectomy also be classified as total or subtotal. In the first case, it involves the complete removal of the uterus, while in subtotal hysterectomy, the uterine cervix is preserved.
The reason for leaving the cervix may be in cases where a shorter surgical time is required due to decompensation of the patient or due to technical difficulty in the approach, either due to adhesions or in some cases, due to an obstetric hysterectomy (that is, hysterectomy performed after the newborn is extracted, secondary to complications of labor or delivery).
Indications for hysterectomy
1. When there is vaginal bleeding that increases in quantity and frequency and does not correspond to menstrual cycles, it is known as abnormal uterine bleeding. It is originally treated medically, however, if this therapy fails, hysterectomy may be indicated. Abnormal uterine bleeding is secondary to:
· Endometriosis (endometrial tissue outside of where it is normally found)
· Adenomyosis (insertion of the endometrial glands into the uterine muscle)
· Endocervical or cavitary polyps.
· Endometrial hyperplasia
2. Pelvic organ prolapses.
3. Cancer of the cervix, endometrium, even as a protocol in the case of ovarian cancer.
4. Obstetric causes such as placental accreta, Couvelaire uterus (infiltration of the blood between the muscular fibers of the uterus) due to premature detachment of the placenta, uterine rupture, etc.
What are the approaches to perform a hysterectomy?
The hysterectomy may be performed abdominally or vaginally. There are also several surgical techniques:
1. Laparoscopic route: both abdominal and vaginal, being a minimally invasive surgery, it is performed by inserting punches or thin tubes through 3 small holes in the case of the abdomen, which allow surgical instruments such as receptacles, scissors, cautery, forceps and a camera that projects the image of the interior of the patient on a screen in the operating room, which allows the surgeon to have a clear vision for both diagnostic and therapeutic purposes. The indication for hysterectomy is generally performed for benign pathology, so in the case of oncological surgery the ability to study the sample adequately by pathological anatomy is lost. It has the advantage of a faster recovery compared to the other routes.
2. Open abdominal route: also known as laparotomy, which is performed through a mid-abdominal incision, allowing direct vision of the surgical team on the pelvic organs. It is preferred in the case of managing oncological criteria or giant myomatous uteri (due to fibroids, which are benign uterine tumors that can generate a large increase in the volume of the uterus).
3. Vaginal route: it is the hysterectomy that is performed through the vaginal orifice, with the advantage of having a quick recovery and not leaving visible scars, frequently used in patients with obesity. Likewise, it allows the approach to joint extraction of the ovaries (oophorectomy). It is an ideal approach in the case of patients with pelvic floor disorders, such as prolapse, incontinence due to bladder descent, short perineum, etc., because other complementary procedures can be performed to correct the rest of the anatomical defects.
4. Robotic route: it is a surgical technique that is used in benign and malignant pathology of the uterus, with good safety rates and a lower rate of complications, but with high costs because it uses high robotic technology, and requires trained and trained personnel in this technique.
5. It is important to finally clarify that whatever the indication, hysterectomy should be the last option to consider after there are no effective non-surgical therapeutic options. The choice of hysterectomy as an option must be preceded by a solid diagnostic protocol, which together with the characteristics of the patient allows the choice of the best approach.
It should be remembered that once the uterus is removed, there will be no menstruation again, and any subsequent vaginal bleeding should be considered pathological, the hormonal levels of estrogens and progesterones, however, not being affected if the ovaries are preserved.
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