Hysterectomy
"Hysterectomy is the last and final option in most benign gynecological conditions," Dr. Obianwu said. "There are more than 600,000 hysterectomies done in the U.S. each year and the largest single reason is fibroids and abnormal bleeding in about 40-to-50 percent of the cases."
Other reasons include such conditions as uterine prolapse, endometriosis, uncontrolled uterine bleeding or cancer in the pelvic region.
There are two types of hysterectomy: supracervical or a total/complete hysterectomy. The supracervical procedure removes all of the uterus, without the cervix, the lower portion or "mouth" of the womb. The total or complete hysterectomy removes the uterus and cervix. (Removal of the ovaries and Fallopian tubes, sometimes accompanying a total hysterectomy, is called a salpingo-oophorectomy.)
"When the final medical conclusion is reached that a patient needs a hysterectomy, I discuss with her the different types of procedures, the surgical options on how they are done (from open hysterectomy to laparoscopic to robotic-assisted methods), and the risks, advantages and benefits of each procedure" said the physician.
"If you are facing a hysterectomy that can be done open or abdominally it can be done laparoscopically, or in many cases even better with the robot. This is especially true for cases that could not have been done or completed laporoscopically. I am favoring robotic surgery, when appropriate, because of the advantages and better outcomes for my patients; moreover, you often can go home the same day and recovery time is much shorter."
Among the decisions involved in removal of the uterus is whether or not to leave in place the lower portion of the organ, the cervix, sometimes called the "mouth" of the womb. "A supra cervical hysterectomy means you remove the uterus and leave the cervix," said Dr. Obianwu.
"Controversy does exist in our medical literature as to whether or not to remove the cervix, if normal. Some think, for example, that leaving the cervix may help structurally and may provide pelvic support and prevent prolapse or it may preserve sexual function and satisfaction. The down side may be possible spotting and bleeding from endometrial cells and the potential risk of cervical cancer and precancerous lesions in the future."
"If you have a benign disease and no precancerous lesions, I discuss this with you and review what the literature shows and let you make the choice. If you have risk factors or precancerous cervical disease I recommend removal."
A total hysterectomy does not always involve removal of the ovaries and Fallopian tubes, he said. If there are precancerous lesions, or a strong family history or risk of ovarian cancer, it may be best to remove the ovaries. But if menopause is in the distant future and the woman can benefit from ovarian function, it may be best left intact.
"Once we decide what kind of hysterectomy we are to do, I usually offer the patient the minimally invasive approach, which is a laparoscopic or robotic approach. We discuss the risks and options and make sure they understand everything so they have good informed consent."
While the surgery itself may range from up to two hours, the process leading up to the procedure is deliberate and involved. Dr. Obianwu takes a detailed history and determines if the patient has any medical conditions that might affect the surgery. He may require a medical evaluation by the primary care physician. For example, if a patient is diabetic or has hypertension or other major medical illness, he requires that patients have their disease stabilized before surgery. A heart condition may require prophylactic antibiotics to avoid bacterial endocarditis, while a person with previous blood clots may need special preparation.
All patients must do a bowel prep, a pre-surgery prep to clean out the bowel that helps prevent infection in case of bowel injury and provides more room in the abdomen and pelvic region for surgical maneuvers.
Because of they often have severe pelvic bleeding, hysterectomy patients are often are put on iron therapy weeks or months before surgery to raise their blood count, or they may require medication to control their bleeding.
"When the patient is discharged, I write their prescriptions and tell them to see me in a week I, at which point they are usually driving on their own to my office. I check their incisions and we talk about the experience and go over their pathology results."
