Laparoscopic subtotal hysterectomy (LSH)

Why you may prefer LSH.

LSH is the least invasive form of hysterectomy:

• Minimal scaring - Minimally invasive

• Most cosmetic - No large abdominal incision

• Less stress to your body

• Retention of the cervix - no scar to vagina and no shortening of the vagina

• More satisfactory sex life after surgery

LSH has the least impact on your life:

• Short hospital stay

• Short recovery time

• Return to normal activities in 1 to 2 weeks.

Laparoscopic subtotal hysterectomy (LSH) has been performed in Medfem Clinic since 1999. and up to date (October 2013) Dr Divanovic has been involved in more than 2000 of those procedures.

The vast majority of hysterectomies are done for the problems involving primarily the body of the uterus. These include excessive and abnormal uterine bleeding, endometriosis, adenomyosis and fibroids. Cervix (PAP smear) is usually normal, as well as are the ovaries.

By doing LSH, we remove the diseased area of the uterus and at the same time preserve the areas that are not affected by the disease.

LSH is much less invasive procedure than either abdominal or vaginal hysterectomy and leaves the cervix and its mucous glands in place thus avoiding vaginal dryness which can be one of the most common complaints that women have post hysterectomy.

Theoretically, with a subtotal hysterectomy the nerves of the cervix are preserved and the woman does not usually notice any impaired sexual function. It is thought that the cervix may play a more significant part in women’s experiences of orgasm and sex post hysterectomy than had previously been thought.

Also, the links which support the cervix and vagina are maintained, resulting in lower chances of prolapsed pelvic organs in the future.

Because the surgery is done through the small incisions in your abdomen, the recovery is fast and there is much less pain.

If done by experienced surgeon LSH carries much less risk of intraoperative injuries and complications then other types of hysterectomy.

Before the surgery:

If you have any medical problems, several tests may be done to make sure that you are fit for surgery. These may include blood tests, x rays, ECG and visit to the physician.

You will have to fast (no solids or liquids) at least 8 hours before the surgery.

Once admitted to the ward, you will be seen by the anesthetist who will examine you and give you necessary medication.

Surgery:

Once in the operating theatre, drip will be inserted in your arm and you will be given general anesthesia. Urinary catheter is inserted to unable the uninterrupted emptying of the bladder. Both drip and catheter will remain in place until next morning when they will be removed before leaving the hospital.

Four small incisions are made on your abdominal wall (one just below the navel and three above your pubic bone). The largest incision is in the midline above the pubic bone and is about 15mm. Other three incisions are around 5mm wide.

Abdominal cavity is filled with CO2 to expand it and enable the surgeon access to the uterus and at the same time move the bowels away, thus decreasing the risk of incidental injury.

Troacars (plastic tubular conduits) are inserted in the incisions so that laparoscope and necessary instruments are passed through them. The laparoscope transmits images to the screen thus giving your doctor a clear view of your organs. During the procedure, the diseased part of the uterus is detached from the cervix and the ovaries and removed through the largest incision.

When the procedure is finished, the instruments are removed, the incisions are closed and you will be transferred to the recovery room. When you are awake and the anesthetist is satisfied with your condition, you will be transferred to the ward.

After surgery:

In the ward after the surgery, you will be monitored by our nurses. They will make sure that you are comfortable, pain free, and that all your vital signs are normal. The drip will be running, making sure that you are well hydrated and that you receive sufficient amount of pain medication.

The surgery itself is not very painful. You might feel burning in the lower abdomen and period like pains, but all that is easily managed with minimal amount of drugs. The most of the discomfort will come from the small amount of gas that is left in your abdomen. You might feel discomfort in the upper abdomen and in your shoulders, but that is also easily managed.

Few hours after surgery, you will be allowed to drink fluids, and if you are not nauseous, light meal will be provided.

For the night, if required, you will be given a sleeping pill so that you can have a good night rest.

In the morning, the catheter will be removed, you will be asked to go to the toilet and pass urine, and if if all is normal, you will be able to go home.

Doctor will come to see you several times during the day of the operation to explain to you how the operation went and to make sure that you are ok. He will also come to see you the following morning to examine you and make sure that you are well enough to leave the hospital.

At home:

Make sure that you organize your setup at home in such a way that for the next few days you can rest. You are encouraged to walk around, as movements will decrease the risk of DVT. You are free to eat and drink whatever you like. Take your pain medication as prescribed. By taking your pain medication for a first few days after surgery even if pain is not strong, you will be able to move more freely and will recover quicker.

What are the signs that something is wrong:

Be assured that you will not be discharged from hospital if doctor is not happy with your recovery. Most of the complications manifest themselves in the first 24 hours and will be noticed by medical staff at the hospital.

If at any time you suspect that something might be wrong, call your doctor immediately.

Once at home, pay attention to the following:

* Pain should get gradually better and will be relieved by pain medication. If the pain is getting worse or pain medication is not helping, call your doctor.

* Urinary catheters can sometimes cause irritation of the bladder as well as bladder infection. If you have problem passing urine call your doctor.

* The small cuts on your abdomen can sometimes bleed. Most of the times, putting a bit of pressure on them will stop the bleeding. If that does not help, call your doctor.

* Nausea is common after anesthetic. If it does not subside or if you are vomiting, call your doctor.

* The gas left in the abdomen will make you feel bloated. Your tummy will be slightly distended, but it will be soft. If the abdomen becomes hard and you start having difficulty breathing, call your doctor.

* Fever and chills are sign of infection, call your doctor.

These are most common problems that you should look for. However, if you feel at any time that something might be wrong, please contact your doctor immediately. You will be given his mobile phone number where you can reach him at all times.

Follow-up visit:

You will be asked to return to your doctor’s office one week after the surgery. By then you should be feeling fine, apart from some remaining bloatedness that will be there for one more week on most occasions. You should need much less pain killers by now.

During this follow up visit, doctor will examine you and remove the stitches. The histology report will be ready by then and doctor will discuss the findings with you.

Recovery and return to activities:

The return to work will depend on what kind of work you do. If you work from an office at home, you will be able to resume it after few days. If work involves driving, wait for 10-14 days.

You can start light exercise 10-14 days after surgery. Do not push yourself! If you feel pain, slow down. You can resume full exercise one month after surgery.

Sex can be painful first few weeks after surgery, so do not resume sexual activity for at least three weeks.

Lots of patients feel tired for almost the whole month after surgery. That is normal.

Please remember that the absence of big cuts on your tummy does not mean that you had a minor surgery. You had a big surgery done through the small holes!!! So take it easy and allow your body some time to fully recover.

Vaginal bleeding after surgery:

Subtotal (supracervical) hysterectomy means that your cervix was not removed and is left in place. Because there is a small area of enometrium (uterine lining) present in the cervix, some women might experience cyclical spotting once a month. This bleeding will happen in less than 10% of women and is minimal, rarely requiring anything more than a panty liner. It is more common in women in their late thirties and early forties. If the bleeding is significant and poses a problem, discuss with your doctor how to manage it.

The risk of cervical cancer:

You cervix was not removed because it was normal at the time of surgery. The risk of you developing cervical cancer after having numerous normal Pap smears before surgery is 0,1%. So please make sure to continue doing your regular Pap smears and visit your doctor annual