Hysterectomies are the most common type of gynecological surgery
in the United States, with around 600,000 procedures being performed
every single year for a variety of different reasons.
In today's video, with the help of the cadavers
here in the lab, we're going to discuss the different types of hysterectomies,
as well as the different surgical approaches that doctors and patients
may elect to take. It's going to be a fascinating one.
Let's do this.
A hysterectomy, which literally means womb removal,
is an extremely effective and life changing procedure that can help those
with abnormal menstrual bleeding, adenomyosis, endometriosis,
multiple types of cancers, uterine prolapse, and even gender affirmation.
However, simply having one of those conditions doesn't
necessarily mean that a hysterectomy is the best course of action.
Which is why, as with everything,
it's so important that you speak with your doctor as to all viable treatments.
It's important to note that there are multiple different types
of hysterectomies.
But to best understand them, let's first take a look at this incredible prosection
that we have in front of you.
So you're looking at an anterior view of the internal female reproductive system.
This would be a superior aspect of the uterus
and this would be the inferior aspect.
Now, those aren't technically accurate
because the uterus can actually be slanted and in different positions.
But from an instructional standpoint, I think that's okay to say.
So that makes this — and you can see that we've cut; made an incision
that allows us to see the internal anatomy
— this portion here is the upper aspect of the vagina.
And then up here we call this the fundus, and fundus
means “end.” So this is the end of the uterus.
Then this larger, thicker, more muscular
portion is what's known as the body of the uterus.
And then down here we can see even part of an opening to it.
This is what's known as the cervix, which is just the neck of the uterus.
And it's what connects the vagina to the uterus.
As we go laterally,
we can see the broad ligament here, which is really cool to see.
You can see that's a really well named tissue.
And then over here we have the round ligament.
And those who've been pregnant might be familiar with the round ligament
because round ligament pain is very common in pregnancy,
but that makes sense as the uterus just grows bigger, that that's going
to put tension on the round ligament and everything that comes with it.
Now up here we can see the uterine tube
as it's then transitioning into the fimbrae,
which are these little appendages that come off the uterine tube. Now,
some of you may have heard or probably have heard of fallopian tube instead.
Anatomists have been steering away from fallopian tube
because it's just not very descriptive.
It's just named after the doctor who discovered it.
It's not telling you what it does.
While “uterine tube” is telling you that it's a tube that is actually connected
to the uterus, but it's in close
proximity to this structure here, which is known as the ovary.
What's really cool
to come over to this side, we can see some of the internal anatomy of the ovary.
In fact, the donor that provided this uterus was 95 years old.
And when you become post-menopausal,
the reproductive system kind of starts to get smaller — it starts to atrophy.
The body, with everything, is in a “if you don't use it, you lose
it”, type of mentality.
There's no sense in sending resources to maintain structures
in tissues that are just not really in use anymore.
So what that means is, as small as this is,
and I'll even place my hand next to it so you can get a good idea
is how big this entire female reproductive system is.
It would actually be — it would be somewhat bigger.
The body of the uterus would be a little bit bigger,
and in comparison to the cervix
in someone that is of reproductive or in their reproductive age.
So between puberty and menopause.
So I do think that's important to note.
But I just love looking, and this is such
a cool peosection here, just to be able to see the inside.
And we can see that lateral anatomy.
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The first type of hysterectomy
is what's known as a partial or subtotal hysterectomy.
This is where they remove the body of the uterus,
but they leave the cervix, the upper portion of the vagina,
the supporting and connective tissues, the uterine tube and the ovary.
All of those will remain.
The only thing that is removed is going to be the body of the uterus.
Now, the reason that they decide, at least historically speaking,
to leave the cervix in place is because it's thought or has been thought
to improve or help retain bladder control as well as sexual function and enjoyment.
And in preparation for this video, I looked over a lot of different
data, and the literature had some conflicting aspects to it.
Some were saying, “yes, you do retain better
bladder control and sexual function”, and other parts of the literature
were saying, “no, it's not all that different to just removing the cervix.” So
this is why you're going to hear me say multiple times on this video,
you want to speak with your doctor.
If you're someone who is considering getting a hysterectomy,
you'll want to speak with your doctor because they're likely aware
of a lot more of literature, a lot more data around this than I am.
Just understand, though, that a partial or subtotal hysterectomy
is just going to be the removal of the body of the uterus.
Next up, we have a total hysterectomy, and this is where they're going to remove,
again, the body of the uterus, but also the cervix of the uterus.
They'll leave everything else in place.
So the upper aspect of the vagina, the supportive and connective tissues,
the uterine tube and the ovaries.
Now this is meant to treat fibroids, endometriosis,
uterine and cervical cancers.
So this can be extremely effective and still being able
to leave a lot of the tissue in place.
So next up, we have a radical hysterectomy.
And as the name suggests, they're going to be removing a lot of tissue.
So in a radical hysterectomy, they're going to remove the body
just as we've seen before.
They're also going to remove the cervix.
And this time they're also going to remove the upper aspect of the vagina.
It can be anywhere from one third to one half of the vagina.
But they're also going to be removing
a significant amount of the surrounding supportive and connective tissues,
as well as lymph nodes
that we unfortunately just can't see in this particular dissection.
And the idea behind removing all of that
is that you're helping to fight again, kind of similar to a total hysterectomy,
fibroids, endometriosis, but also the cancers.
So not just uterine and cervical cancers, but the seeding of cancers,
because cancers can get into the vagina, cancer can get into those surrounding
the supportive connective tissues, and obviously the lymph nodes.
So again, this goes to show that depending on your needs,
the type of
hysterectomy you may require would be different.
Now, it's important to understand, though, at least as far as I've always taught
this, that the removal of the uterine tube
and the ovary isn't really included in a hysterectomy
because the hysterectomy, again, is definitionally going to be
a “womb removal.” And these are not the womb itself.
The procedure that removes the uterine tube is what's known as a salpingectomy
and then the procedure that removes the ovary is an oophorectomy.
However, there are those that will classify those along
with the hysterectomy.
So you may hear of an ultra radical hysterectomy or a pan hysterectomy.
These are just different ways to kind of include these additional structures.
But you always want to leave tissue whenever possible.
The whole point, well, I guess, of any surgery
is you only do what you absolutely need to.
Now, a lot of the data starting to suggest that removing the uterine tubes may be a
really smart choice in regards to cancer, because many different types of cancer
can actually seed inside of that uterine tube.
But if you remove the ovaries, you're affecting the hormones quite dramatically.
And then that patient is going
to have to have hormone replacement for the rest of their life.
So you never want to remove them unless you absolutely have to.
But if, say, someone is suffering from multiple different conditions,
maybe they have cervical cancer as well as ovarian cancer,
then it makes sense to remove or do, I guess, an ultra
radical hysterectomy where you're going to be taking these additional structures.
But again, technically, a radical hysterectomy is where it ends
and then you're just adding on additional procedures on top of it.
Now, as I mentioned earlier, there are different techniques
for actually performing the various types of hysterectomy.
The first one I want to discuss is seen by many to be the most preferred method,
mainly because it's the least invasive of them all, and some say comes
with the least amount of complications, and that is the vaginal hysterectomy.
So basically what will happen is the patient is placed
in the dorsal lithotomy position, so they're on their back,
their legs, can be raised and placed into stirrups.
And this is going to do two things.
First off, it's going to make
for easy viewing for the surgeons, but it's also going to have the intestines
pull away from the uterus to provide surgical space for the procedure itself.
The surgeons will then give, anticoagulants,
antibiotics and anesthesia, and the procedure will go on as normal.
There are some potential contraindications, such as morbid obesity,
but it really depends on the surgical team and what they're operating with.
Next up, we have the abdominal hysterectomy.
Now, this is the most classic type of hysterectomy.
At least it's the one that most people are aware of.
And it has a very similar approach, or at least it can have a similar approach
to a C-section,
which is why many patients will elect to have them done at the exact same time.
So same as before, anticoagulants,
antibiotics and anesthesia will be given to the patient.
But this time they're going to make a vertical,
or they can make a horizontal cut into the abdomen.
Now, if they're making a vertical cut,
this may be because, let's say if they're doing an oophorectomy at the same time.
So maybe they're doing an ultra
radical hysterectomy and say there's this giant cyst on there,
or maybe if there's an enlarged uterus, they may have no choice
but to do the vertical cut to be able to even pull it out.
But a C-section is typically going to be done
with a transverse cut on the skin and then a vertical cut
through the abdomen, the abdominal muscles.
So it really just again, depends on why you need the hysterectomy,
because, again, the surgeons are always going to want
to make the least amount of cuts they possibly can,
because one of the biggest issues with an abdominal hysterectomy
is the possibility of adhesions.
And we've discussed adhesions in multiple different videos.
I myself have a vertical cut going up my abdomen where they had to
treat a bowel obstruction
and simply making that incision to treat my bowel obstruction
makes me more susceptible to more bowel obstructions,
because whenever you make an incision, you're going to create scar tissue.
And considering there's all the intestines in the abdominal cavity, it's possible
for the scar tissue to adhere to the intestines and pinch them off.
And then you find yourself years down the road
with a whole set of other problems.
Now, that's not a guarantee.
It's not to say that
just because you've got an abdominal surgery, that's going to happen,
but it is far more likely to happen, which is, again, why
many will prefer the vaginal hysterectomy over the abdominal.
But again, you may have to get an abdominal hysterectomy
depending on the reasons why you're going under the knife in the first place.
And lastly, we have the laparoscopic hysterectomy.
Now, this is actually preferred
by many surgeons, even over the vaginal hysterectomy,
and that is because you have the option of doing it
manually or through the assistance of a robot.
Now, laparoscopic surgeries are where small incisions
are made, and then instruments are inserted into those incisions,
and then the procedure is performed essentially through a computer screen.
So what'll happen is multiple incisions will be made into the abdomen,
including one that will deliver carbon dioxide
gas into the abdominal cavity, creating what's called a pneumoperitoneum.
This will actually lift the abdominal wall away from the intestines.
So then the surgeons have space to conduct the procedure.
If it's robotically assisted, it's actually kind of cool,
the surgeon will go over to a completely different area.
They'll step away from the patient and then they will
almost it's almost like a three dimensional experience
where the surgeon feels — maybe not literally feels — but
it appears to them that they're inside of the abdominal cavity.
And then through the use of their fingers,
they're using very precise instrumentation to make all the necessary cuts.
But you can also do it by just simply inserting the instruments
through these ports that are going to be in the made in the cuts.
And then you can do it that way.
Again, this is going to be seen to be better by pretty much everyone
then when you compare it to an abdominal hysterectomy,
but still you're making incisions, meaning that there is
an increased likelihood of complications.
However, though,
again, this is where it comes
down to the surgical team and your doctor and everyone in their opinions, because
you also have a higher level of precision with the robotically assisted procedure.
So it really just depends and this is again, why it's so important
for you to speak with your doctor about all the viable treatment options,
considering there are so many different types
of hysterectomies and surgical techniques to perform them,
it's very difficult to give you the outcomes of a hysterectomy,
especially when you take into account things like the patient's age
as well as their overall health.
If they're obese, things are going to probably be more complicated
than it would be if they are, say, an elite athlete or something like that.
I know obviously those are the extremes,
but I think you understand what I'm saying here.
But generally speaking, the outcomes are pretty good.
But this is again, why so important to speak with your doctor
and understand all of your potential risks,
all of your potential complications, everything that goes with it.
Because at the end of the day, you are still removing a part of your body
and it's best to understand everything that can potentially come with that.
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