Hysterectomy

Prevalence

Hysterectomy is the most frequently performed surgery in women. The difference in life time risk between countries probably reflect the mainly the attitude of the surgeon and the available techniques.

Indications
* Fibroma: a uterine volume of more than 14 weeks, or a smaller fibromatous uterus causing clinical symptoms as pain, bleeding or volume problems

* Bleeding problems: It should be realised that for a normal sized uterus, an endometrial ablation is the preferred treatment whereas also for a submucous myoma or a polyp hysteroscopic surgery is to be preferred.

* Pain: since the diagnosis of adenomyosis is difficult to make before treatment a tendency exist to remove the uterus when no other solution is found for persisting pain problems. It is clear that this is an open door for overtreatment when the diagnosis is not made carefully.

Techniques
* Laparoscopic Hysterectomy has replaced completely the abdominal hysterectomy, at least for a uterus of less than 1 kilo. A larger uterus can be operated if the surgeon has the expertise.

* The LAVH (laparoscopic assisted vaginal hysterectomy) combines laparoscopic and vaginal surgery. It is already a better solution than the abdominal hysterectomy, and is performed by less experienced endoscopists.

* A vaginal hysterectomy when a prolaps is present and the uterus is not too big. A vaginal hysterectomy can be associated with a vaginal repair of a prolaps.

* An abdominal hysterectomy is still indicated if the uterus is larger than 1000 grams. Larger uteri can be operated by laparoscopic surgery provided great experience by the surgeon.

Removal of the ovaries is unclear.
Leaving the ovaries has a 1/200 risk of developing later an ovarian carcinoma remains controversial . Removal of the ovaries before menopause causes immediate menopause ; removal of the ovaries after menopause also removes the androgen production of the ovaries which can cause a diminished well beeing.

Myomectomy
A myomectomy is indicated if the myoma is subserous, unique and/or pedunculated. For a polyfibromatous uterus a hysterectomy is indicated.

Laparoscopic myomectomy is the treatment of choice for myoma's less than 7-8 cm. Larger myoma's can be operated by laparoscopy depending upon localisation and expertise of the surgeon.

Intrauerine myoma's should be treated by hysteroscopy.

Website: http://www.gynsurgery.org