Joan Bengtson, M.D., is assistant professor of obstetrics, gynecology and reproductive biology at Harvard Medical School and a member of the Department of Obstetrics, Gynecology & Reproduction at Brigham and Women's Hospital.

Question:

My doctor recommended a hysterectomy for uterine fibroids. He also recommends this be done in the traditional way, using an incision to remove the uterus. I'd prefer laparoscopic surgery. Are there circumstances that make one approach preferred over the other?

Answer:

A hysterectomy is the surgical removal of the uterus. It is the second most common operation in the United States after Caesarean section.

More than half a million women have hysterectomies each year through a variety of approaches. The uterus can be removed through a traditional incision, through the vagina, or through small, laparoscopic incisions.

Several factors help decide the best approach. The first is why the surgery is being performed. Hysterectomy is done to treat fibroids, abnormal bleeding, prolapse, endometriosis, cancer, and precancerous lesions of the genital tract.

Prolapse, a condition in which the uterus drops into the vaginal space due to the loss of pelvic support, is most often treated by a vaginal hysterectomy. A suspicion of cancer, on the other hand, often requires abdominal surgery. This lets the surgeon see if the tumor has spread to other pelvic organs.

The safest approach should always be taken. When all options are equally safe, other factors can be considered, such as which allows for the quickest recovery.

Laparoscopic surgery uses three or four small incisions. It is called minimally invasive because it's not as drastic a surgery as having one large incision. Laparoscopic surgery allows patients a much faster return to normal activities. Hospitalizations are shorter, there is less discomfort and, in properly selected patients, the risk of bleeding and infection is reduced.

Assessing the safest option includes weighing the risk of bleeding, injury to nearby organs, length of surgery, potential for infection, and anesthesia requirements. For example, fibroids that are very large or in a part of the uterus that is difficult to reach may require abdominal surgery because it is deemed safest. While a shorter recovery time is important, doing the surgery safely must always be the first consideration.