• Reference Number: HEY-240/2013
• Departments: Gynaecology
• Last Updated: 1 August 2013

Introduction

This leaflet has been produced to give you general information about your procedure. Most of your questions should be answered by this leaflet.  It is not intended to replace the discussion between you and your doctor, but may act as a starting point for discussion.   If after reading it you have any concerns or require further explanation, please discuss this with a member of the healthcare team caring for you.

What is a hysterectomy?

A hysterectomy is a commonly performed and generally safe surgical procedure. This can be carried out in a number of ways and your surgeon will discuss the most appropriate type of hysterectomy for you.

Abdominal hysterectomy

This is carried out by making a cut on the abdomen (stomach); which is usually a horizontal bikini line cut along the pubic hair line. It includes the removal of the womb and in some cases the removal of the neck of the womb (cervix). Depending on your age or reason behind the need for hysterectomy, the ovaries and fallopian tubes may also be removed.

Subtotal hysterectomy

The body of the uterus is removed but the neck of the womb (cervix) is left in place.

Total abdominal hysterectomy and bilateral salpingo-oophorectomy
This is when the womb, neck of the womb, both fallopian tubes and the ovaries are removed. This is usually performed if women are approaching or have gone through the menopause. For younger women it is normal for the ovaries to be left if they are healthy. If you require your ovaries to be removed and you have not reached the menopause it may be necessary to commence hormone replacement therapy (HRT). This will be discussed with you prior to surgery.

Laparoscopic assisted hysterectomy

This is when the womb is removed through four small cuts on the abdomen below the naval (belly button). This is also known as keyhole surgery. This is a surgical option which involves a laparoscope (an instrument through which structures within the abdomen and pelvis can be seen). Small surgical instruments are inserted through a tiny incision in the naval and abdomen. The surgeon uses the instruments to carefully separate the womb and remove it through the small incisions. Due to the intricate nature of this surgery only certain women are considered appropriate.

Laparoscopic assisted vaginal hysterectomy (LAVH)

This is a procedure using laparoscopic surgical techniques and instruments to remove the uterus (womb) and/or tubes and ovaries through the vagina.

Laparoscopic subtotal hysterectomy

This type of surgery is an operation to remove the body of the womb, the cervix is not removed. The doctor can remove the ovaries with this procedure as well. With this type of procedure there is a very small chance of light bleeding.

Vaginal hysterectomy

This type of hysterectomy involves the womb and neck of the womb being removed through the vagina. Due to the operation being performed vaginally there will be no cut on the abdomen and all the stitches are inside the vagina and will dissolve. This option is the operation of choice if you are having your hysterectomy for a prolapsed womb, heavy periods and where repair of the vaginal wall is required.

Why do I need a hysterectomy?

Hysterectomy may be indicated for a variety of reasons including:

• Heavy periods and other vaginal blood loss problems that do not respond to medical treatment. This is the most frequent reason that hysterectomy is performed whether or not there is a suspected cause such as fibroids.
• Pelvic pain associated with the womb, ovaries or fallopian tubes, is another common indication. This may be related to fibroids, endometriosis or pelvic inflammatory disease.
• Large fibroids when fertility is not required.
• Premenstrual syndrome. Removal of the ovaries and uterus may prove to be the last resort in treatment for severe premenstrual syndrome.
• Womb (uterine) prolapse.

Diagram (c)EMIS 2010 as distributed at http://www.patient.co.uk/health/Hysterectomy.htm, used with permission.

Can there be any complications or risks associated with a hysterectomy?

A hysterectomy is a commonly performed and generally safe surgical procedure. However, in order to make an informed decision and give your consent, you need to be aware of the possible side effects and the risk of complications. The recovery time post hysterectomy depends on the type of procedure, possible complications and the individual patient. Women who are overweight, for example, take longer to recover. Exercise and care with diet pre and post hysterectomy can speed up your recovery. With laparoscopic hysterectomy, many women have made a complete recovery within six weeks. When discussing the pros and cons of hysterectomy with your gynaecologist, you should take into account possible problems including side effects and complications.

The possible complications of hysterectomy surgery include the following.

Frequent risks include:

• Wound infection, pain, bruising, delayed wound healing or hard raised scar.
• Numbness, tingling or burning sensation around the scar (the woman should be reassured that this is usually self-limiting but warned that it could take weeks or months to resolve).
• Frequency of micturition (passing urine) and urinary tract infection.
• Ovarian failure. (When your ovaries stop producing hormones. A symptom of this may be your periods stop.)
• Bleeding.

Serious risks include:

• The overall risk of serious complications from abdominal hysterectomy is approximately 4 women in every 100 (common).
• Deep vein thrombosis (DVT) is a blood clot in the leg or pulmonary embolism (PE) a blood clot in the lung.
• Damage to the bladder and/or the ureter is 7 women in every 1000 and/or long-term disturbance to the bladder function (uncommon).
• Damage to the bowel in 4 women in every 10 000 (rare).
• Excessive bleeding during or after surgery (haemorrhage) requiring blood transfusion is 23 women in every 1000 (common).
• Return to theatre because bleeding/wound dehiscence (opening of a wound) is seven women in every 1000 (uncommon).
• Pelvic abscess/infection in 2 women in every 1000 (uncommon).
• Venous thrombosis or pulmonary embolism is 4 women in every 1000 (uncommon).
• Risk of death within 6 weeks in 32 women in every 100 000 (rare).
• Allergic reactions to the anaesthetic or other medications.
• Risk of laparotomy (an incision made in your tummy) for women having laparoscopic surgery.
• Increased risk of prolapse surgery (see below for information on vaginal wall prolapse).
• Residual ovary syndrome if ovaries conserved 3 women in 100 (development of a lower abdominal mass, lower abdominal pain, and occasionally painful sex following hysterectomy without removal of both ovaries).
• Bladder fistula (abnormal connection between the bladder and another organ) appearing 6 – 12 weeks post operation.
• Longer term: Earlier than expected menopause, which may necessitate use of hormone replacement therapy (HRT).

See: http://www.rcog.org.uk/abdominal-hysterectomy-benign-conditions

Further treatment such as returning to theatre to stop bleeding or damage to the bladder or bowel, antibiotics to treat an infection or a blood transfusion to replace lost blood may be needed.

Vaginal repair for anterior (front) and posterior (back) vaginal wall prolapse

A vaginal prolapse happens when the supporting sling (ligament) which holds the womb and other organs in their position, is no longer strong enough to do this (this could be described like a balloon when it has been blown up and has lost it elasticity). The womb can drop down into different positions and cause different types of prolapse. A prolapse may be described as ‘something coming down’ or a dragging sensation. The vagina is a hollow muscle which supports both the bladder and the bowel. Prolapse of the bladder wall may cause symptoms involving the passing of urine, for example; the frequency, urge and stress incontinence. Prolapse of the bowel may cause symptoms of constipation and other bowel symptoms.

What is a prolapse?

The vaginal wall and pelvic floor muscles can become weak over time causing them to collapse and move away from their normal position. This is due to various reasons but most common being pregnant and childbirth. Other causes may include being overweight, having a chronic cough or people with chest problems, constipation, continuous heavy lifting or due to the hormone effect of the menopause.

Why do I need a vaginal repair?

A vaginal repair operation is performed to correct a prolapse. It is possible to perform this at the same time as a hysterectomy. A vaginal repair is carried out in order to tighten and lift the weakened tissues allowing the bladder and bowel to return to their correct positions and reducing or alleviating symptoms. This surgery is carried out vaginally using dissolvable stitches to support the muscles.

Are there any alternatives to surgery?

It is not necessary for all women experiencing prolapse problems to proceed to surgery. The alternatives depend on the type of symptoms you present with.  Alternative treatment includes:

• Physiotherapy and pelvic floor re-education.
• Vaginal pessary (a plastic device inserted into the vagina to lift the womb
  back into place).

Can there be any complications or risks associated with a vaginal repair?

Frequent risks:

• Urinary infection, retention and/or frequency.
• Vaginal bleeding.
• Postoperative pain and difficulty and/or pain with intercourse.
• Wound infection.

Serious risks include:

• Damage to bladder/urinary tract – 2 women in every 1000 (uncommon).
• Damage to bowel – 5 women in every 1000 (uncommon).
• Excessive bleeding requiring transfusion or return to theatre – 2 women in every 100 (common).
• New or continuing bladder dysfunction (variable – related to underlying problem).
• Pelvic abscess – 3 women in every 1000 (uncommon).
• Failure to achieve desired results; recurrence of prolapse (common).
• Venous thrombosis – blood clot that can develop in the deep veins of the body, most often the leg (common) and pulmonary embolism – blood clot in the lungs (uncommon) may contribute to mortality.
• The overall risk of death within 6 weeks is 37 women in every 100 000 (rare).

See: http://www.rcog.org.uk/womens-health/clinical-guidance/vaginal-surgery-forprolapse

How do I prepare for the surgery?

Please read the information leaflet. Share the information it contains with your partner and family (if you wish) so that they can be of help and support. There may be information they need to know, especially if they are taking care of you following this examination.

Make sure that all of your questions have been answered to your satisfaction and that you fully understand what is going to happen to you.

Smoking

If you are a smoker, it would benefit you greatly to stop smoking or cut down before you have your operation. This will reduce the risk of chest troubles as smoking makes your lungs sensitive to the anaesthetic. If you need further information about stopping smoking please contact:

• Your GP.
• The NHS Smoking Helpline on 0800 1690169. A specialist adviser is available Monday to Friday 9am to 8pm, Saturday and Sunday 11am to 4pm.
• Hull and East Riding Stop Smoking Service on 0800 0915 5959.
  www.readytostopsmoking.org.uk.
• North East Lincolnshire and North Lincolnshire NHS Stop smoking services on 0845 6032166 (calls charged at local rate).
  www.freedomfromsmoke.org.uk.

Diet and exercise

You should also eat a healthy diet. If you feel well enough, take some gentle exercise before the operation as this will also help your recovery afterwards. Your GP, the practice nurse at his/her surgery or the doctors and nurses at the hospital will be able to give you further advice.

Before you come into hospital for your operation, try to make preparations for your return home. If you have a freezer, stock it with easy-to-prepare food. A microwave may be useful, if you do not already have one. Arrange for relatives and friends to do your heavy work such as changing your bedding, vacuuming and gardening and to look after your children or pets if necessary.

Pre-assessment Clinic

Prior to your surgery you will be asked to attend a pre-assessment clinic about one to three weeks before you are due to have your operation. At this clinic you will be seen by a nurse who will take some general information from you such as next of kin, medical history. You will have your blood pressure, pulse checked, urine test, MRSA swabs, blood tests and also possibly a chest X-ray. Depending on your age and your medical history you may also need an electrocardiogram (ECG) – this is a tracing of your heart patterns. Please bring a list of all your medication to the pre-assessment clinic.

Admission date

Your admission date will be confirmed at pre-assessment.

What will happen?

Admission to hospital

You will need to bring your nightwear, dressing gown, slippers, toiletries, tissues and a packet of sanitary towels into hospital with you, plus any medications that you are currently taking. You may also choose to bring in something to pass the time. It is important that you bring in all your medicines you are on when coming into the ward.

What happens on the day of the operation?

You will be admitted to the ward on the day of your operation. The ward clerk or one of the nurses will greet you and show you to your bed. If your bed is not ready, you will be given a seat on the ward until it becomes available.

You will meet the ward nurses and doctors involved in your care. The anaesthetist may visit you to discuss the anaesthetic and to decide whether you will have a ‘pre-med’ (tablet to relax you) before you go to the operating theatre. Any further questions you have can also be discussed at this time. For more information about your anaesthetic please see, You and Your Anaesthetic: Information to help patients prepare for an anaesthetic at: http://www.rcoa.ac.uk.

You will have been asked not to suck, eat or drink anything prior to your operation (including chewing gum or sucking boiled sweets). Your admission letter will inform you of the time which you need to stop eating and drinking. It is important to read this and follow instructions. You will be given a surgical gown to wear. All make up, nail varnish, false nails and jewellery (except wedding ring), dentures and contact lenses must be removed. You will be provided with some support stockings to help reduce the risk of blood clots during the operation. The nursing staff will advise and assist you if required.

What happens afterwards?

After your operation you will wake up in the recovery room before returning to the ward. You may still be very sleepy and be given oxygen through a clear face mask to help you breathe comfortably immediately after your operation.

On rare occasions a drain (tube) is inserted into your wound during your operation. This is so that any blood or fluid that collects in the area can drain away safely and will help to prevent swelling. The drain will be removed when it is no longer draining any fluid, which could take several days.

During your operation a catheter (tube to drain urine away) may be inserted into your bladder. The catheter may need to stay in post operatively. Once it has been removed we need to make sure that you have emptied your bladder completely. We do this by measuring how much urine you are passing or by scanning your bladder to see if it is completely empty. On your first attempt at passing urine, sit on the toilet with your feet on the floor and give yourself plenty of time. Do not try to strain or use force. If you had a vaginal repair, you will have a vaginal pack inserted. This will be removed by the nursing staff whilst you are in hospital.

How will I feel after my operation?

Please tell us if you are in pain or feel sick. We have tablets/injections we can give you so that you remain comfortable. You may have a self-administering device which is used to control your pain yourself. This is known as a Patient Controlled Analgesia (PCA) which will be through an intravenous drip. You will be shown how to use it. The PCA is removed once you are able to tolerate painkillers by mouth or by suppositories after 12 – 24 hours.

Emptying your bowels

When you have your first bowel movement you may find some extra support will make you more comfortable. Try holding a wad of toilet paper or a sanitary pad firmly in front of the back passage – supporting the wound with a folded towel may also help. You may have trouble opening your bowels or have some discomfort due to wind for the first few days after the operation. This is temporary and we can give you laxatives, hot peppermint water and painkillers if you need them. Moving and walking around the ward will help to relieve wind. Putting your feet on a footstool and breathing out as you move your bowels may help.  Do not strain to open your bowels.

Vaginal Bleeding

You should expect some vaginal bleeding in the first few days following surgery. The bleeding normally turns to a red/brownish discharge before disappearing completely and can last anything from a few days to a few weeks. If the bleeding becomes heavier than a period or smells very offensive, let your doctor know as it may indicate infection. We advise you to use sanitary towels whilst the bleeding persists. Please do not use tampons as these increase the risk of infection.

Physiotherapy

Early mobilisation is important following your surgery and you will be encouraged to get out of bed the day after your operation which will help to prevent chest complications and improve circulation. Gentle leg and breathing exercises are recommended immediately after your operation and exercises to help your recovery can be found in the Fit for Life physiotherapy booklet which can be found by clicking on this link: http://www.csp.org.uk/sites/files/csp/secure/acpwh-ffsurgery.pdf

Caring for the wound area

It is important to keep your wound clean. A daily bath or shower is advisable paying particular attention to the genital area and the area around the wound. Avoid the use of highly scented soaps, bubble bath and vaginal deodorants while you are in hospital. Your wound will be looked at daily to ensure it is healing. Some surgeons glue the wound so there are no stitches to be removed. If you do have stitches they will be removed on or around day three and if you have staples they will be removed on day five.

When can I go home?

You will be in hospital approximately one to three days, depending on the type of operation you have had, your individual recovery, how you feel physically and emotionally and the support available at home. This will be discussed with you before you have your operation and again whilst you are recovering.

When can I get back to normal?

It is usual to continue to feel tired when you go home. It can take up to one to three months depending on your operation, to recover fully. However, your energy levels and what you feel able to do will usually increase with time. This is individual, so you should listen to your body’s reaction and rest when you need to. This way, you will not cause yourself any harm or damage.

Things to remember

• Avoid lifting or carrying anything heavy (including children and shopping). Vacuuming and spring-cleaning should also be avoided for six weeks after your operation, or until you have had your check-up at the hospital.
• Rest as much as possible, gradually increasing your level of activity. Continue with gentle activities such as making cups of tea, light dusting and washing up. Generally, within one to three months you should be able to return to your normal activities but you can discuss this further on your return to the followup clinic.
• You will go home wearing support stockings and are advised to wear them for at least six weeks, until you are back to your full mobility.
• You should also avoid long periods of travel for four weeks after your operation to reduce your chances of developing a blood clot.
• Continue with any exercises that you were advised to do in hospital. You may find that you get tired quite quickly at first, this is normal and will improve along with your general fitness level.

How to tell if you have a blood clot?

There are certain signs to look out for after your operation that could mean you have a blood clot. You should contact your healthcare professional immediately if you experience any of the following in the days or weeks after your operation:

• You have pain or swelling in your leg.
• The skin on your leg is hot or discoloured (red, purple or blue), other than bruising around the operation site.
• Your feet are numb or tingling.
• The veins near the surface of your legs appear larger than normal or you notice them more.
• You become short of breath.
• You feel pain in your chest, back or ribs which gets worse when you breathe in deeply.
• You cough up blood.

What about exercise?

Continue with the physiotherapy exercises that can be found in the Fit for Life advice booklet for at least six weeks after your operation. The Fit for Life advice booklet can be found by clicking on this link: http://www.csp.org.uk/sites/files/csp/secure/acpwh-ffsurgery.pdf

It is important to continue with gentle exercises for at least six weeks after your operation. Ideally, you should carry on doing them for the rest of your life, particularly the pelvic floor exercises. You may be able to resume swimming after your six weeks post operation check. Avoid all high impact exercise until at least 12 weeks after your surgery.

The medical and nurses staff will be happy to give advice on your individual needs.

When can I start driving again?

We advise you not to drive for at least four to six weeks after your operation. However, this will depend on the extent of surgery you have had and your individual recovery. You will be able to discuss it further with your doctor at your appointment. We advise you to contact your car insurance company for advice on driving following your surgery.

When can I return to work?

Your recovery is individual to you and returning to work will depend upon the type of work you do and how you feel physically and emotionally. The type of surgery you have will also determine how quickly you can return to work. Most women need approximately four to twelve weeks away from work to fully recover before returning to work or their usual routine. However, this will depend upon your recovery, and you might wish to discuss it further with your GP or Occupational Health Department.

Remember – the return to normal life takes time and is a gradual process and involves a period of readjustment and will be individual to you.

What about exercise?

It is important to continue with gentle exercises for at least six weeks after your operation. Ideally, you should carry on doing them for the rest of your life, particularly the pelvic floor exercises. Avoid all aerobic exercise, jogging and swimming until advised, to allow the muscles cut during your operation to heal. The medical staff and nurses will be happy to give advice on your individual needs.  See Fit for life booklet

When can I have sex?

After a hysterectomy or vaginal surgery you may not feel physically or emotionally ready to start having sex again for a while. We normally advise women not to have sexual intercourse for six weeks until you have had a follow up appointment at the hospital/GP.

Follow up treatments and appointments

Will I need to visit the hospital again after my operation?

The majority of patients will not need a follow up appointment. If an appointment is necessary you will receive a letter in the post.

Should I continue to have cervical smears?

This will depend on the type of surgery you have had. If you still have your neck of the womb (cervical), smear tests are necessary after your operation. You should continue with them until you are advised not to.

Step by step guide to recovery:

It is important to take enough rest, however you should start some of your normal daily activities when you get home.

Step 1: Day 1 – 4 after leaving hospital

• No domestic chores whatsoever. Lie down for at least one hour a day.
• Listen to your body/mind/spirit – if it wants to go to sleep then do so for you will have less energy than you thought.
• No stretching or lifting anything heavier than a kettle with water in it for one cup/mug full.
• Try to maintain your gentle mobility exercises.
• Enjoy a daily bath/shower.
• Go to bed early.

Step 2: Day 5 – 7 after leaving hospital

• Lie down for at least one hour a day.
• Help with washing up and or dusting but avoid stretching or lifting.
• Go for a five minute walk.
• Try to maintain your gentle mobility exercises.
• Enjoy a daily bath/shower.
• Go to bed early.

Step 3: Weeks 2 – 3 after leaving hospital

• Gradually increase walking. Stop if you feel tired.
• Decrease the rest period rather than resting most of the time and being occasionally active.
• Light shopping.
• No lifting of shopping, suitcases, furniture, full saucepans.
• Try to maintain your gentle mobility exercises.
• Enjoy a daily bath/shower.
• Go to bed early.

Step 4: Week 3 – 4 after leaving hospital

• Start moderate activity – going to the shops and some light shopping.
• Help with washing up and/or dusting.
• Go to the hairdresser.
• Rest if you feel tired.
• No lifting of shopping, suitcases, furniture, full saucepans.

Step 5: Weeks 5 – 6 after leaving hospital

• Light house work such as vacuuming in an upright position.
• Driving a car is possible, providing you have checked with your insurance company and can do an emergency stop.
• Listen to your body/mind/spirit if it feels tired then rest.
• Start bending gently.

Useful websites and contact numbers:

Hysterectomy Association: www.hysterectomy-association.org.uk

Royal College of Obstetricians and Gynaecologists: www.rcog.org.uk/womens-health/patient-information

Should you require further advice on the issues contained in this leaflet, please do not hesitate to contact:

Gynaecology Outpatients – Women and Children’s Hospital – (01482) 607829

Women’s Health Outpatients – Castle Hill Hospital – (01482) 624045

Ward 30 Cedar ward (Gynaecology Ward) – Women and Children’s Hospital – (01482) 382739/604387

Ward 14 – Castle Hill Hospital – (01482) 623014

General Advice and Consent

Most of your questions should have been answered by this leaflet, but remember that this is only a starting point for discussion with the healthcare team.

Consent to treatment

Before any doctor, nurse or therapist examines or treats you, they must seek your consent or permission. In order to make a decision, you need to have information from health professionals about the treatment or investigation which is being offered to you. You should always ask them more questions if you do not understand or if you want more information.

The information you receive should be about your condition, the alternatives available to you, and whether it carries risks as well as the benefits. What is important is that your consent is genuine or valid. That means:

• you must be able to give your consent
• you must be given enough information to enable you to make a decision
• you must be acting under your own free will and not under the strong influence of another person

Information about you

We collect and use your information to provide you with care and treatment. As part of your care, information about you will be shared between members of a healthcare team, some of whom you may not meet. Your information may also be used to help train staff, to check the quality of our care, to manage and plan the health service, and to help with research. Wherever possible we use anonymous data.

We may pass on relevant information to other health organisations that provide you with care. All information is treated as strictly confidential and is not given to anyone who does not need it. If you have any concerns please ask your doctor, or the person caring for you.

Under the General Data Protection Regulation and the Data Protection Act 2018 we are responsible for maintaining the confidentiality of any information we hold about you. For further information visit the following page: Confidential Information about You.

If you or your carer needs information about your health and wellbeing and about your care and treatment in a different format, such as large print, braille or audio, due to disability, impairment or sensory loss, please advise a member of staff and this can be arranged.