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:

How do doctors decide if a hysterectomy can be done vaginally or surgically?

Answer:

The surgical removal of the uterus, or womb, is called a hysterectomy. It can be performed three different ways: abdominally, vaginally, and through the use of a laparoscope. The surgeon chooses the best approach based on a number of factors. The most important reason is why the hysterectomy is needed.

The abdominal approach uses an incision in the lower abdomen. The advantage to this approach is that it provides the most room and best access to the pelvic and abdominal cavity. It is used when the uterus is significantly enlarged. as may occur with fibroids. The abdominal approach may also be chosen when scar tissue from prior surgery or inflammation is present. The scars (or adhesions) must be carefully removed before the hysterectomy is performed. If cancer is suspected the abdominal approach may be the best way to evaluate whether the cancer has spread to other pelvic organs.

Hysterectomy is done vaginally by removing the uterus through an internal incision at the top of the vagina. The recovery time and post operative discomfort is much less with this approach than for abdominal surgery. This is favored in any patient in whom it can safely be performed. The vaginal approach also allows the surgeon to correct any support defects in the pelvic floor, a condition called prolapse. Prolapse is common and often resulting from childbirth.

The use of minimally-invasive pelvic surgery done through tiny incisions using a fiberoptic telescope is rapidly developing. Newer techniques allow for this approach to be used for hysterectomy. The uterus is released from its attachments and then removed in small pieces through the scope. It can often be performed as an outpatient procedure, allowing for a quick return to normal activity. Because the uterus must be removed in pieces, this approach is not used when cancer is suspected.

The risks and benefits of all options should be discussed in detail with the patient and all of her questions and concerns addressed.