Abdominal hysterectomy

Abdominal hysterectomy

Department of Gynaecology
It has been recommended that you have a hysterectomy. This leaflet explains some of the benefits, risks and alternatives to the operation. We want you to have all the information you need to make the right decision.

What is a hysterectomy?
A hysterectomy is an operation to remove your womb (uterus). After the operation you will no longer be able to have children. If you have not yet gone through the menopause, you will no longer have periods.

Why do I need a hysterectomy?
A hysterectomy is used to treat conditions that affect the female reproductive system, such as heavy periods, long-term pelvic pain, non-cancerous tumours fibroids and cancer of the ovaries, womb, cervix or fallopian tubes.

Other procedures that is available
Your gynaecology doctor will have discussed alternative treatments with you if they are appropriate; for instance, Mirena or endometrial ablation for heavy periods.

The operation
There are different types of hysterectomy. The type you have depends on the reason for your surgery and how much of the womb and surrounding reproductive system can safely be left in place. The main types include:

• Total hysterectomy: this is the most commonly performed operation. The womb and cervix (neck of the womb) are removed.
• Subtotal hysterectomy: the main body of the womb is removed leaving the cervix (neck of the womb) in place.
• Total hysterectomy with bilateral salpingo-oophorectomy: the womb, cervix, fallopian tubes (salpingectomy) and the ovaries (oophorectomy) are removed.
• Radical hysterectomy: the womb and surrounding tissues are removed, including the fallopian tubes, part of the vagina, ovaries, lymph glands and fatty tissue.

There are three ways to perform a hysterectomy:

• Vaginal hysterectomy: the womb is removed through a cut in the top of the vagina.
• Abdominal hysterectomy: the womb is removed through a cut in the lower abdomen.
• Laparoscopic hysterectomy (keyhole surgery): the womb is removed through a number of small cuts in the abdomen.

You have been recommended to have an abdominal hysterectomy.

Things to consider:

Removal of the cervix (total/radical hysterectomy)
If you have cancer of the cervix, the ovaries or the womb, you may be advised to have your cervix removed to prevent the cancer from spreading. Even if you do not have cancer, removing the cervix means that there is no risk of developing cervical cancer in the future.

Many women are concerned that removing the cervix will lead to a loss in sexual function, but there is no evidence that this is the case. Some women are reluctant to have their cervix removed because they want to retain as much of their reproductive system as possible. If you feel this way, you should talk to your surgeon about any possible risks of keeping your cervix.
If you do not have your cervix removed, you will need regular screening for cervical cancer (cervical smears).

Removal of the ovaries (salpingo-oophorectomy) and early menopause
If you have had your ovaries removed, it is likely that you will start experiencing menopausal symptoms (hot flushes, sweating, vaginal dryness and disturbed sleep) soon after having your operation. This is because the menopause is triggered once a woman stops producing eggs from her ovaries. Although your hormone levels drop after the menopause, your ovaries continue to produce testosterone for up to 20 years. In some women testosterone is an important part of the stimulus for sexual desire and sexual pleasure.
Your surgeon may recommend removal of the ovaries if you have a family history of ovarian or breast cancer, to prevent cancer occurring in the future. Your surgeon will be able to discuss the benefits and disadvantages of removing your ovaries with you.
If your ovaries are removed, your fallopian tubes will be removed also.

If you have already gone through, or are close to the menopause, some surgeons recommend removing the ovaries regardless of the reason for your hysterectomy. This is because it is a good way to protect against the possibility of ovarian cancer developing in the future. Other surgeons feel it is best to leave healthy ovaries in place if the risk of ovarian cancer is small, for example if there is no family history. This is because the hormones produced by the ovaries can help to protect against conditions such as osteoporosis and in some they also play a part in feelings of sexual desire and pleasure. If you would prefer to keep your ovaries, make sure that you have discussed this with your surgeon and made it clear before your operation. You may still be asked to give consent for your ovaries to be removed if an abnormality is found during the operation. Think carefully about this and discuss any fears or concerns you have with your surgeon.

Hormone replacement therapy (HRT)
If you have your ovaries removed, you may be offered hormone replacement therapy (HRT). This is to replace some of the hormones that your ovaries used to produce and relieve any menopausal symptoms.

It is unlikely that the HRT you are offered will exactly match the hormones previously produced by your ovaries. It is not possible to tailor HRT exactly to an individual because people vary greatly in the amount of hormones they produce. Many women try different doses and brands of HRT before they find one that feels suitable for them.

Not everyone can take HRT. It is not recommended for women who have had a hormone-dependent type of breast cancer or liver disease. Make sure your surgeon is aware of any conditions you have suffered from in the past.

If there are no reasons why you should not take HRT and both of your ovaries are removed, it is important to take HRT until the normal age of the menopause (50 years of age).

Complications of a hysterectomy
Most people will not experience any serious complications from their surgery but as with all types of surgery, having a hysterectomy can lead to complications. You will be cared for by a skilled team of doctors, nurses and other health-care workers who are involved in this type of surgery every day. If problems arise, we will be able to assess them and deal with them appropriately.

Risks from general anaesthesia
There are several serious complications associated with having an anaesthetic, but they are very rare. Complications include nerve damage, allergic reaction and death. Being fit and healthy before an operation reduces the risk of complications.
Anaesthesia will be discussed in more detail later on in this document.

Bleeding
With all operations, including a hysterectomy, there is a small risk of heavy bleeding.
This may mean a blood transfusion is needed.

Damage to the bladder or bowel
Very rarely women will suffer damage to other abdominal organs, such as the bladder or bowel. This can cause problems such as infection, incontinence or a frequent need to urinate.
It may be possible to repair any damage during the operation. You may need to have a temporary catheter to drain your urine or (very rarely) a colostomy to collect your bowel movements.

Infection
There is always a risk of infection after an operation. This can be a urinary tract infection (UTI), chest infection or vaginal infection. These are not usually serious and can be treated with antibiotics.

Thrombosis
A thrombosis is a blood clot that forms in a vein and interferes with the circulation of the blood and oxygen around the body and can be dangerous. The risk of getting a blood clot increases after operations and periods of immobility.

You will be encouraged to start moving around as soon as possible after your operation. You will also be given support stockings and a blood thinning drug to reduce the risk of clots forming.

Your pre-surgery assessment visit
You will need to have a pre-assessment appointment a few weeks before your operation. The aim of this visit is to record your current symptoms and past medical history, including any medication you are taking, including any non-prescription or herbal remedies. This might involve having some blood tests and a general health check to make sure that you are fit for surgery. Please bring your operation consent form (which you may have been given in Outpatients), making sure that you have read and understood the form before you visit the clinic. You can also use your pre-assessment appointment as an opportunity to discuss any concerns or ask any questions about your hysterectomy.

How to prepare for the operation
To help you recover from your operation and reduce your risk of complications it helps if you are as fit as possible beforehand. As soon as you know you are going to have a hysterectomy operation, consider the following:

• If you smoke, giving up for several weeks before the operation reduces the risk of breathing problems and makes your anaesthetic safer. The longer you can give up beforehand, the better. If you cannot stop smoking completely, cutting down will help.
• If you are overweight, reducing your weight will reduce many of the risks of having an anaesthetic. However, starvation or ‘crash’ diets should be avoided
• If you have loose or broken teeth or crowns that are not secure, you may want to visit your dentist for treatment. This may reduce the risk of damage or dislodgement during anaesthesia
• If you have long-standing medical problems, such as diabetes, asthma, bronchitis, thyroid problems, heart problems or high blood pressure, you should ask your GP if you need a check-up.

There is a risk that your procedure will be cancelled if there is a chance of very early pregnancy. In order to be sure you are not pregnant at the time of the procedure you must not have sex or you must use reliable contraception between the first day of the last NORMAL period to the date of procedure.

Your anaesthetic
We will usually carry out your surgery under a general anaesthetic. This means that you will be asleep during your operation and you will feel nothing. When you are admitted to hospital, the anaesthetist will come to see you and ask you questions about:

• Your general health and fitness
• Any serious illnesses, past or present
• Any problems with previous anaesthetics
• Medicines you are taking, including non-prescribed and herbal medicines
• Allergies

Your anaesthetist will discuss with you the different methods of anaesthesia that can be used. He or she will also talk about methods of pain relief following your hysterectomy. After talking about the risks, benefits and your preferences, you can then decide together what is best for you.
Nothing will happen to you until you understand and agree with what has been planned for you.
You have the right to refuse if you do not want the treatment suggested or if you want more information or more time to decide.

Anaesthesia-risks
All forms of anaesthetic have advantages and disadvantages. There are risks of side effects and complications.

In modern anaesthesia, serious problems are uncommon. Risk cannot be removed completely, but modern equipment, training and drugs have made anaesthesia a much safer procedure in recent years.
Anaesthetists take a lot of care to avoid all the risks given in this section. If you need more information about side effects, complications and risks, your anaesthetist will be happy to discuss your queries.
When discussing the risk of certain complications or side effects, it is worth explaining some terms used:

‘Very common’ = may occur in about 1 in 10 patients
‘Common’ = may occur in about 1 in 100 patients
‘Uncommon’ = may occur in about 1 in 1000 patients
‘Rare’ = may occur in about 1 in 10,000 patients
‘’Very rare’ = may occur in about 1 in 100,000 patients

Types of Anaesthetic which may be offered to you
General anaesthetic
Local anaesthetic
Spinal or epidural

General anaesthesia (“GA”)
General anaesthesia is a state of controlled unconsciousness during which you feel nothing and may be described as ‘anaesthetised’.

Most women having an abdominal hysterectomy will have a general anaesthetic. General anaesthesia usually starts with an injection of medicine into a vein. You will be unconscious for the whole of the operation. The anaesthetist will continuously monitor you throughout the operation. At the end of the operation, you will wake up from the anaesthetic and be taken to the recovery room.

Advantages: You will be unconscious during the operation
Disadvantages: GA alone does not provide pain relief after the operation. You will need strong pain-relieving medicines afterwards, such as morphine. You may decide to have a spinal anaesthetic as well as a GA

Side effects and complications of general anaesthesia
Very common and common

• Nausea and vomiting (can be treated with ‘anti-sickness’ medicine, or ‘anti-emetics’), sore throat, dizziness, shivering, blurred vision, headache, minor damage to lips or tongue, itching, backache or general aches and pains, confusion or memory loss (more common in the elderly and usually temporary).

Uncommon

• Chest infection, slow breathing (depressed respiration), damage to teeth, an existing medical condition getting worse, or awareness (becoming conscious during a general anaesthetic). Awareness happens if you do not receive enough anaesthetic to keep you unconscious. To reduce the risk of awareness, monitors are used during your operation to record how much anaesthetic is in your body and how much your body is responding to it. These normally allow your anaesthetist to judge how much anaesthetic you need to keep you unconscious.

Rare or very rare

• Damage to eyes, heart attack or stroke, serious allergy to drugs, nerve damage, vomit getting into your lungs, equipment failure, death
• Deaths caused by anaesthesia are very rare. There are probably about 5 deaths for every million anaesthetics in the UK

Local anaesthesia or local anaesthetic nerve block
A local anaesthetic numbs a small or superficial part of the body. It can help to numb part of the operation site and may mean you need less pain relief after the operation.
An example is a ‘TAP’ block which numbs the nerves leading to the front of the tummy. This usually consists of 2 injections either side of the tummy while you are under GA.

Advantages – you should need less morphine after the operation and should therefore have less side effects from morphine, such as drowsiness and sickness
Disadvantages – Numbs only the uppermost tissues of the operation and so you will still require some strong pain killers.

Complications include a failed block i.e. the TAP block does not work as well as hoped for, bruising at the injection site, accidental injection into the wrong tissue e.g. bowel, liver, blood vessel. Local anaesthetic toxicity is uncommon.

Spinal or epidural Anaesthesia
Local anaesthetic drugs are injected through a needle into the small of the back to numb the nerves leading to the lower body. It can be performed awake (the skin of the back will be numbed first with local anaesthetic) or sometimes under general anaesthetic. Your anaesthetist will discuss this with you

Spinal anaesthetic being inserted into a patient’s back

Advantages (compared to GA + morphine)
Usually, good pain relief immediately after the operation as the spinal/epidural should have numbed the operation site. The numbness from a spinal usually wears off in 2-4 hours but you will still have some pain relief for several hours after this. You should require less morphine in the first few hours after the operation, and so should therefore be less drowsy, and this may enhance your recovery. By reducing the amount of morphine you might require, a spinal or epidural reduces side effects from morphine. This may be particularly helpful in some patients e.g. those with chest disease or those with an intolerance to morphine.
There may be less risk of deep vein thrombosis (clot in the leg)

Disadvantages – there are side effects and complications associated with a
spinal/epidural.

Very common or common

• Discomfort during the injection (tell the anaesthetist if there is any pain during the spinal/epidural injection as it may indicate irritation to one of the nerves in the back).
• Weak legs while the spinal or epidural is working.
• Low blood pressure (your blood pressure will be measured frequently. A low blood pressure can be treated with medicines and fluids in your ‘drip’).
• Itching or ‘pruritis’ (a side effect of the morphine-like drug which is used as part of the spinal or epidural. If you let the nursing staff know about it, it can be treated).
• Difficulty passing urine, or ‘urinary retention’ while the spinal/epidural is working (most women will be catheterised following a hysterectomy and so this side-effect is not often a problem).
• Headache (there are many causes of headache including the GA itself, dehydration and anxiety. Most headaches get better within a few hours and can be treated with pain-relieving medicine. Severe headache can occur after a spinal or epidural. If this happens to you, your nurse should ask the anaesthetist to see you as you may need further measures to treat it, sometimes another injection in the back).
• Nausea and vomiting (can be treated with anti-sickness drugs).
• Inadequate pain relief (sometimes spinals and epidurals do not work as effectively as we would like. If this is the case, you will be kept comfortable with other forms of pain relief e.g. morphine)

Rare

• Infection in the spine.
• Blood clot in the spine.
• Nerve damage or paralysis-this is a rare complication of spinal and epidural anaesthetics. Temporary loss of sensation, pins and needles and sometimes muscle weakness may last for a few days or even weeks, but almost all of these make a full recovery in time.
  Permanent nerve damage is very rare.

Pain relief afterwards
Good pain relief is important. It prevents suffering and helps you to recover more quickly. It also helps prevent complications.
If you can breathe deeply and cough easily after your operation, you are less likely to develop a chest infection.

If you can move around freely, you are less likely to get blood clots (deep-vein thrombosis or DVT).
Your anaesthetist will already have discussed various methods of pain relief with you before the operation, so you can make an informed decision about which you would prefer.
Here are some ways of giving pain relief:

Pills, tablets and liquids to swallow-you need to be able to eat, drink and not feel sick for these drugs to work.

Suppositories- these waxy tablets are put into your back passage (rectum) The pellet dissolves and the drug passes into the body. They are useful if you cannot swallow or if you might vomit.

Patient Controlled Analgesia (PCA)
PCA allows you to control your pain relief yourself.
You will be connected to a pump containing a pain-relieving medicine, usually morphine. The pump is linked to a handset that has a button. When you press the button, you receive a small dose of medicine painlessly into your cannula. The pump will be programmed for you individually, both to ensure that you receive an effective dose of pain relief, and also to ensure that you will not receive an overdose of medicine, no matter how often you press the button.
Do not give the button to anyone else to press-you alone decide if you need pain relief or not.

A PCA pump

Spinals and epidurals
These can give good pain relief for hours, sometimes longer, after the operation. You should require less amounts of strong pain-relieving drugs such as morphine if you have had a spinal or epidural anaesthetic.

On the day of your operation

What should I take into hospital?

• a change of night clothes
• something comfortable to wear
• comfortable knickers
• sanitary towels
• toiletries
• your usual medication
• a book, magazine, iPod and other things to help pass the time during recovery
• important phone numbers

It is advisable not to take valuables, jewellery or large sums of money into hospital with you. You could ask a friend to look after your valuables if you do not want to leave them at home.

Being admitted to the ward
You will usually be admitted on the day of your surgery. We will welcome you to the ward and check your details. We will fasten an armband containing your hospital information to your wrist.

Nothing to eat and drink (nil by mouth)
It is important that you follow the instructions we give you about eating and drinking. We will ask you not to eat anything (including chewing gum or sucking sweets) for six hours before your operation. This is because any food in your stomach could come up into the back of your throat and go into your lungs while you are being anaesthetised. You may drink clear fluids i.e. water, dilute squash, black tea or black coffee up to two hours before your operation.

Your normal medicines
Continue to take your normal prescribed medicines up to and including the day of your surgery. It is helpful if you bring your usual medicines with you. If we do not want you to take your normal medication, your surgeon or anaesthetist will explain what you should do. It is important to let us know, before you are admitted, if you are taking anticoagulant drugs (for example, warfarin, aspirin or clopidogrel).

We will need to know if you don’t feel well and have a cough, a cold or any other illness when you are due to come into hospital for your operation. Depending on your illness and how urgent your surgery is, we may need to delay your operation as it may be better for you to recover from this illness before your surgery.

Your anaesthetic
When it is time for your operation, a member of staff will take you from the ward to the operating theatre. They will take you into the anaesthetic room and the anaesthetist will make you ready for your anaesthetic.
To monitor you during your operation, your anaesthetist will attach you to a machine to watch your heart, your blood pressure and the oxygen level in your blood.

Abdominal hysterectomy
During an abdominal hysterectomy a cut is made in your abdomen. The cut is either made along the bikini line (horizontal) or vertically from the belly button to the bikini line.

A vertical incision is usually made when there are large fibroids in the womb or for some types of cancer. The womb is removed through the incision, and the incision stitched up. The operation takes about an hour.

After your operation
You will be looked after in the Recovery Area of theatres until you are ready for discharge back to the ward. Recovery staff will be with you at all times to monitor your postoperative progress.

You may have a drip in your arm and a catheter (a small tube to drain urine from your bladder, which passes into a collection bag). There will be a dressing covering any wounds from your operation. The day after the operation you will be encouraged to take a short walk. This encourages your blood to flow normally, which will reduce the risk of complications such as blood clots in your legs (deep vein thrombosis). Once your catheter has been removed you should be able to pass urine normally. Any stitches that need removing will be taken out between five and seven days after the operation.

Recovery time
How long it takes before you are well enough to leave hospital will depend on your age and general health. Women who have had an abdominal hysterectomy can usually leave after two to five days.

A follow-up appointment may be arranged 6 to 12 weeks after your operation to check your progress. Increasingly, a follow-up with your surgeon does not occur and your care will be taken over by your GP after you are discharged from hospital.

It takes about six to eight weeks to recover fully from an abdominal hysterectomy. During this time, you should rest as much as possible and not lift anything heavy, such as bags of shopping. You need time for your abdominal muscles and tissues to heal. If you live by yourself, help may be available from your local authority while you are getting better. Hospital staff should be able to advise you about this.

Side effects
Bowel and bladder disturbances
After your operation you may experience some changes in your bowel and bladder functions when going to the toilet. Some women get urine infections or find they get constipation, both of which can easily be treated. It is recommended that you drink one to two litres of fluid a day and increase the fruit and fibre in your diet to help with your bowel or bladder movements.

Vaginal discharge
After a hysterectomy you will experience some bleeding and discharge. This is less than a period but may last up to six weeks. If bleeding is heavy, you start passing blood clots or you have an offensive discharge, you should inform your GP.

Getting back to normal
Returning to work
How long it will take for you to return to work will depend on how you feel and what sort of work you do. If your job does not involve manual work or heavy lifting, it may be possible to return after four to eight weeks.

Driving a car
You should not drive a car until you are comfortable wearing a seatbelt and can perform an emergency stop. This can be anything from three to eight weeks after the operation. You may want to check with your GP that you are fit to drive before you start. Some car insurance companies require a certificate from a GP stating that you are fit to drive. You should check this with your car insurance company.

Exercise and lifting
You should be given some information after your operation on suitable forms of exercise during your recovery period. Walking is always recommended and you can swim after your wounds have healed. You should not try to do too much as you will probably feel more tired than normal.
You should not lift any heavy objects during your recovery. If you lift light objects you should make sure that your knees are bent and your back is straight.

Sex
It is generally recommended that you do not have sex until your vaginal discharge has stopped, and you feel comfortable and relaxed, or after a minimum of six weeks have passed.
You may experience some vaginal dryness, especially if you have had your ovaries removed and you are not taking HRT.

Many women also experience an initial loss of sexual desire (libido) after the operation, but this normally returns once they have fully recovered.
Studies show that pain during intercourse is reduced, and orgasm, strength of orgasm, libido (desire for sex) and sexual activity all improve following a hysterectomy.

Contraception
Contraception to prevent pregnancy is no longer required after you have had a hysterectomy. You will still need to use condoms to protect yourself against sexually transmitted infections.

After you leave hospital
You should contact your GP or the ward immediately if you experience any of the following:

• Persistent bleeding from the vagina that is smelly or becomes heavier than a normal period and is bright red.
• Pain or burning on passing urine, or the need to pass urine frequently, as this may indicate a urinary tract infection.
• Increasing nausea.
• Increasing abdominal pain with vomiting.

Contact details
If you have any specific concerns that you feel have not been answered and need explaining, please contact the following:

The secretary who is working with your consultant, via hospital switchboard.

Worcestershire Royal Hospital
Gynaecology Nursing Staff, Lavender Ward (phone 01905 760586)
Hospital Switchboard (phone 01905 763333)

Alexandra Hospital
Gynaecology Nursing Staff, Ward 14 (phone 01527 512100)
Hospital Switchboard (phone 01527 503030)

Kidderminster Treatment Centre
Ward 1 Nursing Staff (phone 01562 512356)
Hospital Switchboard (phone 01562 823424)

Other information
The following internet websites contain information that you may find useful.

• www.nhs.uk
  Information on many aspects of healthcare
• www.rcoa.ac.uk
  Information leaflets by the Royal College of Anaesthetists about ‘Having an anaesthetic’
• www.worcsacute.nhs.uk
  Worcestershire Acute Hospitals NHS Trust
• www.rcog.org.uk/recovering-well
  Royal College of Gynaecology

If your symptoms or condition worsens, or if you are concerned about anything, please call your GP, 111, or 999.

Patient Experience
We know that being admitted to hospital can be a difficult and unsettling time for you and your loved ones. If you have any questions or concerns, please do speak with a member of staff on the ward or in the relevant department who will do their best to answer your questions and reassure you.

Feedback
Feedback is really important and useful to us – it can tell us where we are working well and where improvements can be made. There are lots of ways you can share your experience with us including completing our Friends and Family Test – cards are available and can be posted on all wards, departments and clinics at our hospitals. We value your comments and feedback and thank you for taking the time to share this with us.

Patient Advice and Liaison Service (PALS)
If you have any concerns or questions about your care, we advise you to talk with the nurse in charge or the department manager in the first instance as they are best placed to answer any questions or resolve concerns quickly. If the relevant member of staff is unable to help resolve your concern, you can contact the PALS Team. We offer informal help, advice or support about any aspect of hospital services & experiences.

Our PALS team will liaise with the various departments in our hospitals on your behalf, if you feel unable to do so, to resolve your problems and where appropriate refer to outside help.

If you are still unhappy you can contact the Complaints Department, who can investigate your concerns. You can make a complaint orally, electronically or in writing and we can advise and guide you through the complaints procedure.

How to contact PALS:
Telephone Patient Services: 0300 123 1732 or via email at: wah-tr.PALS@nhs.net

Opening times:
The PALS telephone lines are open Monday to Friday from 8.30am to 4.00pm. Please be aware that you may need to leave a voicemail message, but we aim to return your call within one working day.

If you are unable to understand this leaflet, please communicate with a member of staff.

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