Hysterectomy procedures by  James Purdy  MD FACOG


Dr. Purdy performs the following procedures with and without removal of the tube and ovaries. Since December 9, 2008, most of the hysterectomies performed have been robotic assisted hysterectomy due to decreased hospital stay (one day), decreased patient discomfort and decreased blood loss and as a result, faster recovery from surgery.

  • Abdominal hysterectomy (TAH)
  • Vaginal Hysterectomy (TVH)
  • Laparoscopic Assisted Vaginal Hysterectomy (LAVH)
  • Robotic Assisted Vaginal Hysterectomy (RAVH)  - newest advanced procedure

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Surgery type

Risk

What to expect

Recovery

Robotic surgery


Hysterectomy is the surgical removal of part or all of the uterus. Subtotal hysterectomy removes only the body (fundus) of the uterus and not the cervix. Total hysterectomy (the most frequent hysterectomy procedure) removes the cervix and the body (fundus) of the uterus. It is the second most common major surgery among women of child-bearing age. Over 600,000 hysterectomies are performed annually.

Hysterectomy is performed to treat the following pelvic or uterine symptoms/conditions:

  • Abnormal uterine bleeding
  • Endometriosis
  • Cancer of the cervix, uterus  or ovaries/tubes
  • Endometrial cancer - most common of uterine cancers
  • Menorrhagia (very excessive or heavy menstrual periods)
  • Painful periods (dysmenorrhea)
  • Pelvic Pain  - chronic pelvic pain
  • Pelvic support problems (such as uterine prolapse) or pelvic relaxation
  • Uterine fibroid(s) (leiomyoma)

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Total Abdominal Hysterectomy (TAH):

Dr. Purdy makes an incision (cut) through the skin and tissue in the lower abdomen to reach the uterus. The incision may be vertical or horizontal.  Abdominal hysterectomy requires a longer healing time than vaginal or laparoscopic surgery. 

This type of hysterectomy allows a unrestricterd view and access for Dr. Purdy of the uterus and other organs during the operation. Dr. Purdy would suggest this procedure if there are large tumors, if cancer may be present. or the uterus with fibroids is very large - greater than 20 week size uterus

Total Vaginal Hysterectomy (TVH):

Dr. Purdy removes the uterus and cervix (total) through the vagina. There is no abdominal incision. Recovery is faster and less uncomfortable.

Laparoscopic Assisted Vaginal Hysterectomy (LAVH):

With laparoscopically assisted vaginal hysterectomy (LAVH), Dr. Purdy removes the uterus through the vagina. LAVH involves the use of a small laparoscope connected to a 2 D high resolution video camera . The device is  placed into the abdomen through a small incision. The incision is called a surgiport  ranging in size from 5 mm - 8 mm to 12 mm in diameter  Dr. Purdy views the actual surgery on a screen while performing the surgery.

Additional small incisions (surgiports) are made in the abdomen to assist the surgery. The uterus is removed through the vagina. Recovery from LAVH is similar to vaginal hysterectomy.

Robotic Assisted Vaginal Hysterectomy (RAVH):

Dr. Purdy routinely performs the da Vinci Hysterectomy, one of the most effective, least invasive treatment options for a range of uterine conditions. da Vinci Hysterectomy is performed using the da Vinci Surgical System, which enables Dr. Purdy to perform with unmatched precision and control using only a few small incisions. da Vinci Hysterectomy also allows Dr. Purdy a  better visualization of pelvic anatomy, which is especially critical when working around delicate and confined structures like the bladder and ureters. This means that Dr. Purdy has a distinct advantage when performing a complex hysterectomy involving adhesions from prior pelvic surgery or non-localized cancer.. 

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Risks

The risk of problems related to hysterectomy is among the lowest for any major surgery :

  • Blood clots in the veins or lung(s) - Pulmonary embolus
  • Infection - deep pelvic abcess or superficial abcess
  • Bleeding during or after surgery
  • Bowel blockage - partial or complete intestinal obstruction
  • Hernia formation - usually in the abdominal wall
  • Injury to the urinary tract or nearby organs
  • menopause (if ovaries are removed)
  • Pneumonia or post op bronchitis
  • Urinary tract infection
  • Vaginal vault (cuff) rupture - rare  -slightly higher rate with robotic hysterectomy
  • Death rate is 1 out of 600,000 cases!

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What to Expect

Dr. Purdy will interview and obtain a past medical history and complete a physical exam a day or a few days before the surgery in order to accurately access the the patient's health. If a consultation is needed, there will be more time alotted. It is very helpful to know what to expect before any major surgery.

  • Blood and urine will be obtained for a CBC, chem profile, pregnancy testing and a urine check.
  • Over the age of 35, Dr. Purdy will order a chest x-ray and an EKG to check the heart!
  • The patient may be given one or more enemas or use at home Magnesium Citrate 80 cc for clearing of intestinal gas.
  • Dr.Purdy always orders Magnesium Citrate for a planned robotic hysterectomy.
  • The abdominal and pelvic areas will be partially shaved after the onset of anesthesia.
  • Antibiotic(s) will be given to prevent infection.
  • Monitors will be attached to your body before anesthesia  is given.
  • General anesthesia will used for any laparoscopic  procedure including RAVH. 
  • A regional anesthetic (spinal or epidural) that blocks pain sensations in the lower part of your body may be elected by the anesthesiologst for an open abdominal hysterectomy or simple vaginal hysterectomy.
  • A thin foley catheter will be placed in your bladder. The catheter will drain urine from your bladder during the surgery and the catheter will be removed the following early morning hours.
  • Recovery from surgery is in the immediate Post Anesthesia Recovery Unit (PARU) and later overnight stays or longer on the gyn floor.
  • An IV (intravenous soltion) will hydrate the patient until the patient is able to advance her diet. Usually the IV is removed the next morning.

What to Expect for robotic hysterectomy surgery and laparoscopic assisted vaginal hysterectomy:

  • Faster recovery from surgery
  • 90 percent discharged from the hospital in 24 hours - the patient is admitted as a outpatient and stays less than 24 hours.
  • Greatly reduced blood loss - usually a thimble full of blood (average 15 cc of blood loss compared to 100 - 150 cc for a vaginal hysterectomy and much more for an abdominal hysterectomy)
  • The intravenous fluid is may be stopped the evening of surgery and the Foley catheter may be removed in the evening of surgery.
  • Reduced pain intensity due to axial pivoting of the instruments in the surgiports  by the da Vinci robot  rather than multidirectional if held by a human hand.

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Post hysterectomy recovery:

  • Dr. Purdy recommends increased walking post op - especially at home as soon as possibible after  surgery. Walking keeps preserves local circulation - especially in the lower extremities and prevents leg blood clots. For high risk individual for deep vein thrombosis (DVT's), Dr. Purdy will give post op a low molecular weight Heparin (Lovenox) to help prevent blood clots.
  • The patient can expect to have some pain for the first few days after the surgery. She will be given medicines to relieve pain. Dr. Purdy usually does not need to send the patient home on heavy narcotic mediation for pain relief. Dr. Purdy will medicate with such drugs as  Ultram ( tramadol), Darvocet and NSAID  eg Cataflam, Aleve or Naproxin sodium. Rarely is a narcotic like Demerol or Morphine required. 
  • Robotic surgical hysterectomy patients rarely need a prolonged use of any pain killer post op at home.
  • The patient may need to wear a sanitary pad for protection for several days and up to 4 weeks.
  • Robotic surgical hysterectomy patient rarely has any post op vaginal bleeding.
  • Rest and avoid undue lifting and straining; Dr. Purdy recommends for 4 - 6 weeks no lifting of objects weight ing over 5 pounds and no sudden lifting of any object.
  • Dr. Purdy recommends showers rather than tub soaking baths after hysterectomy surgery for at least 6 weeks.
  • Dr. Purdy recommends no douching or insertion of any object into the vagina (tampons) for 6 weeks!
  • Dr Purdy recommends the avoidance of strenous physical activities for 6 weeks.
  • Dr.Purdy recommends no sexual intercourse for 6 weeks after a non robotic hysterectomy.
  • Dr. Purdy recommends  resumption of such activities as driving a car or shopping by 1  to 2 weeks after non robotic hysterectomy.

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For Robotic Assisted Vaginal Hysterectomy, Dr. Purdy recommends the following strict guidelines of home activities::

  1. Do not put anything into the vagina during the first 8 weeks. This includes no tampons and no douching.
  2. Strict avoidance of strenous physical activities for the first 8 weeks; the patient after a robotic surgery recovers very fast as regards to pain resolution. The patient is often tempted to do too much too early because she feels so good - remember that the tissue collagen density and strength are the same regardless of surgery type!
  3. Shower rather than bath for the first 8 weeks after robotic hsyterectomy!
  4. Do not drive a car for one week after surgery
  5. Do not walk on a sandy beach - shifting sands place undue stress on the pelvic floor.

Dr. Purdy will usually see the patient back for evaluation:

  • at one week for most hysterectomy procedures and at 6 weeks with a pelvic exam.
  • at two weeks for robotic surgery and at 8 weeks fora final complete pelvic exam.

Dr  Purdy helps the patient plan for her return to normal activities. As she recovers, she may slowly increase activities such as driving, sports, and light physical work. If the patient can do an activity without pain and fatigue, it should be okay. If an activity causes pain, the patient must call and discuss the situation causing pain with Dr. Purdy.

Even after your recovery, you should continue to see  Dr. Purdy for routine gynecologic exams.  Dr. Purdy recommends thin Pap tests routinely of the vaginal every two years after a hysterectomy. If certain cancers were treated (eg cervical or endometrial cancer), then Dr. Purdy may recommend annual thin prep Pap smears of the vaginal cuff.

The vaginal cuff (apex) can still be infected with Human Papilloma Virus (HPV) that may induce abnormal cell changes that can develop into vaginal cuff atypia, vaginal dysplasia or rarely vaginal cuff cancer. High risk sexual activity can place the female's vaginal cuff at cancer risk. Smoking increases the risk of cancer of the vaginal cuff.

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