Many operations on the uterus, ovaries and fallopian tubes are performed through the abdomen. The type of operation (for example, removing a fibroid or a cyst) and the route used to reach the organs are separate decisions: the same operation may be performed laparoscopically or as open surgery, depending on the situation. Some operations are performed without an abdominal incision, through the vagina or through the inside of the uterus (hysteroscopy).
Laparoscopy (keyhole surgery)
Laparoscopy is usually performed under general anesthesia. Gas is introduced into the abdomen through a small incision in or just below the belly button so that the organs can be seen more clearly. A thin camera (laparoscope) inserted through the same incision transmits the image to a screen. Surgical instruments are inserted through a few additional small incisions in the abdomen. If needed, an instrument may be placed into the uterus through the vagina to move it into view. At the end of the operation, the gas is released and the incisions are closed.
Open surgery (laparotomy)
In open surgery, a horizontal or vertical incision is made in the lower abdomen and the organs are reached directly. The incision is larger than in laparoscopy, so pain after surgery is usually greater, and the hospital stay and recovery are longer. On the other hand, open surgery may be preferred for a very large uterus or mass, extensive adhesions, masses that may be malignant and need to be removed intact, or situations in which laparoscopy is not suitable.
Which operations are they used for?
- Myomectomy: removal of fibroids while preserving the uterus (details on the Uterine Fibroid Treatment page).
- Ovarian cyst surgery (cystectomy): removal of the cyst while preserving ovarian tissue (details on the Ovarian Cysts page).
- Endometriosis surgery: removal of endometriosis lesions and endometriomas and division of adhesions.
- Hysterectomy: removal of the uterus; described separately below.
- Operations on the fallopian tubes: treatment of an ectopic pregnancy, and tying or removing the tubes for permanent contraception.
- Diagnostic laparoscopy: examination of the inside of the abdomen in situations such as long-term pelvic pain, difficulty getting pregnant or a mass whose cause cannot be determined. If a problem is found, it can often be treated during the same operation.
Some operations for urinary incontinence and organ prolapse can also be performed laparoscopically; these topics are described on their own pages.
Hysteroscopy: working inside the uterus
For problems inside the uterine cavity, such as polyps, fibroids extending into the cavity and adhesions, surgery can be performed without an abdominal incision, using a thin camera (hysteroscope) passed through the vagina and cervix. Hysteroscopy is a different method from laparoscopy; it is used to examine the uterine cavity, take tissue samples and treat certain problems.
Comparing the two approaches
In comparative studies of benign gynecological conditions, laparoscopy has been associated with less pain after surgery, a shorter hospital stay, fewer wound infections and an earlier return to daily life than open surgery. Because the incisions are small, the scars are also smaller. On the other hand, laparoscopic surgery can take longer in some situations and requires special equipment and experience in this field; in some operations (for example, hysterectomy), urinary tract injury is slightly more common. No single approach is suitable for every situation; the choice is made according to the person’s circumstances.
Factors that influence the choice of approach
- The size and location of the uterus or the mass
- The possibility that the mass is malignant
- Previous surgery and adhesions inside the abdomen
- General health and anesthesia considerations (for example, excess weight or other medical conditions)
- Whether the situation is an emergency
- The person’s preference, the surgical team’s experience and the available equipment
Even when an operation starts laparoscopically, switching to open surgery may become necessary because of an unexpected finding, bleeding or another problem. This possibility is discussed before surgery.
Assessment before surgery
An examination and ultrasound are carried out, and MRI is requested if needed. Blood tests, current medicines (particularly blood thinners) and an anesthesia assessment are part of planning the operation. Fasting is required for a set time before surgery, and some medicines may need to be paused; because smoking can slow healing, stopping is advised. What the operation will involve, possible additional procedures and the risks are discussed, and written consent is obtained.
After the operation
For a few days after laparoscopy, there may be tenderness at the incision sites, bloating and shoulder pain caused by gas remaining in the abdomen; this pain goes away on its own. A sore throat from the breathing tube and nausea related to anesthesia may occur. After minor procedures, most people go home the same day or the next day; after more extensive operations such as hysterectomy, the hospital stay and recovery take longer. After open surgery, the hospital stay and full recovery are usually longer than after laparoscopy. When to return to daily activities and work is decided at the follow-up examination according to the operation performed. Walking early helps prevent blood clots in the legs.
Possible risks
As with any operation, bleeding, infection, blood clots in the legs (and a clot traveling to the lungs) and problems related to anesthesia may occur. Injury to the bowel, bladder, ureter or major blood vessels is a less common but serious risk; in that case, the injury may need to be repaired during the same operation, the operation may need to be converted to open surgery, or a blood transfusion may be needed. Some bowel injuries may not be noticed during the operation and may cause symptoms in the following days. Bruising, wound infection, wound opening and a hernia may develop at the incision sites. Adhesions may form inside the abdomen over time. Excess weight, previous surgery, extensive disease and other medical conditions increase the level of risk.
Hysterectomy (removal of the uterus)
A hysterectomy can be performed vaginally, laparoscopically or as open surgery. In laparoscopic hysterectomy, the uterus is detached using a camera and special instruments inserted through small incisions in the abdomen and is usually removed through the vagina. When suitable, vaginal hysterectomy is considered the first option. Compared with open surgery, laparoscopy usually means a shorter hospital stay, and the return to daily life may be earlier. On the other hand, the operation takes longer and the risk of injury to the ureter (the tube that carries urine from the kidney to the bladder) is slightly higher. The size of the uterus, previous surgery, adhesions inside the abdomen and general health affect the choice of method; in some cases, vaginal or open hysterectomy may be more suitable. The method is chosen according to the person’s situation.
When is it considered?
Hysterectomy may be considered for fibroids, abnormal uterine bleeding that continues despite medication, adenomyosis, endometriosis, uterine prolapse and certain precancerous conditions. In most cases, medication or options that preserve the uterus are considered first. After a hysterectomy, pregnancy is not possible and menstrual periods stop. After operations in which the cervix is left in place, some women may continue to have light cyclical bleeding.
The cervix, fallopian tubes and ovaries
The cervix may be removed together with the uterus (total hysterectomy) or left in place (subtotal hysterectomy). When the cervix is left in place, or when the uterus is too large to be removed through the vagina, the uterus is often cut into small pieces inside the abdomen so that it can be removed. Rarely, the uterus contains a previously unknown malignant tumor; in that case, cutting it into pieces can spread the disease. This risk is discussed before surgery.
Hysterectomy does not mean that the ovaries are also removed. Whether the ovaries are preserved is decided separately according to age, risk factors and the type of condition. Removal of the fallopian tubes may also be recommended to reduce the risk of ovarian cancer.
Preparation and recovery specific to hysterectomy
Before surgery, cervical screening results are reviewed; where necessary, a biopsy is taken from the lining of the uterus. Light vaginal bleeding or discharge may occur for a few weeks after the operation. The return to daily activities is gradual. After operations in which the cervix is removed, intercourse and heavy lifting are postponed for a time so that the stitches at the top of the vagina can heal; this period is determined at the follow-up examination. Sexual activity can be resumed once healing is complete; questions and concerns about this can be discussed during the consultation.
If the cervix was also removed and the operation was not done because of a cervical condition, routine smear tests are usually no longer needed. If the cervix was left in place, or if a precancerous change of the cervix was found in the past, screening continues.
Risks specific to hysterectomy
Injury to the bladder, the ureter or the bowel and separation of the stitches at the top of the vagina are less common risks. Ureter injury is slightly more common with laparoscopy than with open surgery. If the ovaries are also removed before menopause, menopausal symptoms begin. The level of risk varies with the person’s health and previous surgery.