An Hysterectomy operation can be performed in several different ways -abdominally, vaginally or with the use of a laparoscope. The method chosen depends on the surgeon’s preference, the reason for the hysterectomy and the woman's characteristics (eg. weight, previous pelvic surgery, if she has had children).

Abdominal

An abdominal hysterectomy is conducted when there is a need for extensive exploration (in the case of cancer), if the uterus is too enlarged, there are extensive adhesions, if the woman has never had children or is obese. An abdominal hysterectomy can be performed in two ways, with a vertical incision or a bikini line cut.

A vertical incision generally involves a cut from the navel to the pubic hairline. The bikini line cut, as its name suggests, is done horizontally, directly above the pubic hairline. It leaves a less obvious scar and results in a shorter recovery time.

The main advantage of an abdominal hysterectomy as against a laparoscopic hysterectomy is a lower incidence of damage to the urinary tract and blood vessels. The disadvantages are more pain or discomfort, a lengthier hospital stay and longer recovery time.

Vaginal

A vaginal hysterectomy involves making an incision in the upper portion of the vagina and removing the uterus through the vagina. Any prolapse of the genital organs can be corrected at the same time. The advantages of this method are less pain, a shorter hospital stay and recovery time and the absence of a visible scar. A vaginal hysterectomy is performed in preference to an abdominal and laparoscopic hysterectomy whenever possible.

Uterine size, presence of adhesions, descent and vaginal size are some of the criteria evaluated to judge if a vaginal approach is possible. If the patient is multiparous, laxity of pelvic supports provides easy manoeuverability to the vaginal surgeon even in the presence of significant uterine enlargement. In fact, many cases of laparoscopic hysterectomies would have been easily operated vaginally anyway.

Laparoscopic

The term is used to describe a hysterectomy in which any part of the operation is performed laparoscopically. Laparoscopic surgery involves making three or four small incisions in the abdomen. A laparoscope (an instrument that allows the interior of the abdomen to be viewed) is inserted through one of the incisions into the abdominal cavity. The surgeon is then able to view the pelvic organs on a video screen and insert surgical instruments through the other incisions. The primary focus and intention of laparoscopic hysterectomy is to convert selected abdominal hysterectomies to a vaginal approach.

Laparoscopic procedures have been promoted as being advantageous due to a shorter hospitalisation and recovery time as there is much less pain than for an abdominal hysterectomy. There are 2-3 very small incisions on the abdomen of 0.5-1.0 cm as compared to 10-15cms in a conventional procedure . The disadvantages include a possible longer operating time, higher costs and an increased risk of damage to the urinary tract.

The laparoscopic route is not ideal for severe pelvic adhesions, very large uterine fibroids (bigger than 20 cm) and adnexal masses. Moreover, in laparoscopic hysterectomy the uterus may not be removed entirely through the abdominal route - vaginal surgery completes the procedure