What is a Total Laparoscopic Hysterectomy?
It is a minimal access surgical procedure which facilitate the removal of non prolapsed uterus through vaginal route. Total Laparoscopic Hysterectomy (TLH) is an operation to remove the uterus with the aid of an operating telescope known as a laparoscope. This tiny instrument is inserted through a small cut within the abdominal wall and allows the surgeon to see inside patient's abdomen. The main benefit of this sort of hysterectomy is that patient will not need to possess a large cut in your abdomen as well as your recovery is generally much faster.
Cervix of the patient, or the neck from the womb, is also removed during this operation by laparoscopic technique. Uterine artery, Uterosacral ligament, cardinal ligament or Mackenrodt's ligament, all is dissected from above. Ovaries of patient might be removed based on wishes of gynecologists as well as patients condition.
Not every patient is suitable for this total laparoscopic hysterectomy. If it's suitable for the patient, Gynaecologist will decide type of hysterectomy require for the patient.
How many types of hysterectomies are there?
There are nine types of hysterectomy:
Garry and Reich classification
- Type 1 - diagnostic lap + VH
- Type 2 - lap vault suspension + VH
- Type 3 - LAVH
- Type 4 - LH (ligation of uterine art.)
- Type 5 - TLH
- Type 6 - LSH (Supracervical hysterect)
- Type 7 – LHL (hyst+ lymphadenectomy)
- Type 8 - LHL + O (hyst+ lymphadenectomy + omentectomy)
- Type 9 - RLH (radical lap hysterect)
What goes on throughout the surgery?
Surgery will be performed under a general anaesthetic. Carbon dioxide gas is going to be accustomed to inflate the abdomen through an isufflator and also to create space for that surgeon to operate. The gynecologist will insert the laparoscope with the umbilicus so the team can easily see what they are doing. The gynecologist will also make three small cuts within the abdomen to insert other instruments that are required for total laparoscopic hysterectomy surgery. A uterine is used from the vagina to elevate the uterus so that surgeon can perform surgery without damaging the surrounding bowel. Sometime if the uterine manipulator is not possible to introduce than myoma screw is used to manipulate the uterus. In the video which is showing above uterine manipulator is not used and a myoma screw is used.
The gynecologist will have a really clear view of the inside of patient abdomen and may use the image on screen to free uterus from the tubes, ligaments and arteries on each side. A cut may also be made round the cervix and into the vagina make it possible for the uterus to be removed through the vagina. The cut is going to be closed with absorbable stitches or stapled or glue.
If the ovaries and tubes should be removed simultaneously they will also be freed and removed through the vagina or through one of the port. The pelvic cavity is going to be beaten up having a sterile solution. The CO2 gas will be removed as much as possible and also the wounds closed with sutures.
Sometimes, a little drain tube is inserted through among the wounds to empty some blood stained fluid and gas after the operation. This is removed the very next day if everything is found normal.
How much time the TLH take?
The operation will often take the time between one and two hours.
After the operation what patient feel?
Patient will wake up with a tube inside bladder urinary catheter, an IV drip will be given to replace lost fluids, a drain tube, as well as an oxygen mask is required sometime. Generally after 4 hours patient will be offered something to drink, and from next day patient can start eating.
Patient will probably be able to eat breakfast the very next day. Additionally, patient will be able to shower and also have the drip and catheter removed. Most patients are discharged around the second day.
What are the complications of TLH?
All operations possess a small risk of complications. For many people the risks are higher. For instance, there is chance of experiencing complications increases if patient smoke, have cardiovascular disease, diabetes or else patient are overweight.
What are the general risks with Total Laparoscopic Hysterectomy?
- Wound infection - all patient generally receive antibiotics within the drip to lessen the chance of infection.
- Bleeding - half the normal women may require a blood transfusion during or following the procedure. Rarely, women will have bleeding following the operation will need to have another operation.
- Blood clots in legs known as deep venous thrombosis – this is rare but sometimes thrombus will break off and travel to the lungs known as pulmonary embolism. Most of the patient are offered medication to reduce the danger of DVT.
- As tissues heal inside the abdomen, loops of bowel or any other tissues may become stuck together known as adhesions, which occasionally is painful and may require further surgery to do adhesiolysis.
- Severe complication such as a heart attack due to strain on one's heart throughout the anaesthetic, as well as death is extremely rare.
What are the specific risks with laparoscopic hysterectomy?
- Urine infection which may require antibiotics.
- Damage towards the bladder or ureters.
- Bowel damage is 1 in 1000 or major circulation system damage is one in 3000 for all laparoscopies, which may require a laparotomy in order to correct these complication. It is unusual, but occasionally this problem won't be recognised for some time.
- If throughout the operation the surgeon decides that it is not safe to continue using the laparoscope it may be chose to convert to a regular abdominal open hysterectomy.
- If patient have her ovaries removed and she was not already menopausal, patient may start to experience hot flushes.
- A hysterectomy is irreversible so there is no chance of pregnancy following this operation.
How is the recovery after TLH?
Some pain is usual. patient may even experience a period-like, cramping sensation in the abdomen or pain in the shoulders. This is pain in shoulder is thought to be due the Co2 gas used to inflate the abdomen, which irritates the diaphragm. This, along with a sensation of bloating, usually lasts one or two days but in some cases it will last few weeks. In case of pain patient should try simple analgesics such as paracetamol, Panadeine or Naprogesic. Severe pain is unusual. It is quite normal to possess a a sore throat and some nausea after the operation. The a sore throat is due to the endotracheal tube used whilst you are anaesthetised. Analgesics and small quantities of fluids can help. Nausea and drowsiness is due to the anaesthetic itself.
What is wound care and dressings?
Patient should leave dressings intact unless they are soiled or wet, because the dressings are sterile. After a week patient may remove the dressing, and may leave the wounds open, or preferably cover with a Band-Aid. It is been shown that keeping wounds slightly warm and moist enhances healing. Patient should not apply antiseptic creams, Dettol, Betadine, methylated spirit etc towards the wounds without asking the gynecologists. These are unnecessary and in most cases bad for healing tissue. The easiest method to achieve a good scar would be to leave the wounds alone until healed. Sutures will need to be removed around five days in the date of operation.
Some redness of the wound is usual, especially around the site of the wounds. When the redness is spreading or even the wound is discharging, or else patient feel unwell or feverish, the gynecologist who has performed the surgery should be consulted.
After surgery showering is allowed or not?
Patient will get the wounds wet the day after the operation, but she should avoid spas/baths/swimming pools before the sutures are out.
Why there is Vaginal bleeding after TLH?
This is usually because of the colpotomy which was done during the procedure, and could last about few days. Upto four week after surgery patient should avoid sex, tampons and strenuous exercise whilst she continue to be bleeding. It is not uncommon that some women notice the stitch material (Vycril or PDS etc.) which is used to close the the vaginal opening inside the abdomen may fall out after a couple of weeks. It might look like a black bit of thread or fishing line. Patient should not be afraid after seeing this thread that what and why should this happen. Although she should not pull on any thread that seems attached inside the vagina.
Why there is dizziness or loss of concentration?
This can be because of the anaesthetic or analgesics agent used especially ones for example Panadeine or morphin. Patient should avoid operating machinery, making important decisions or driving a vehicle for at least 48hrs after surgery. Patient need to take a minimum of two weeks off work, or longer if her work involves strenuous physical activity or using machinery during her day to day work. Patient should also avoid strenuous exercise for around few weeks.
When should be post-operative review?
Patient will need to consult gynecologist again after seven days to achieve the stitches removed. Patient will be offered a scheduled appointment in the hospital in again around 6 weeks.