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What hysterectomy options do I have if I have never given birth?

I recently had a patient who was told that because she had never given birth vaginally before, she would require an open, abdominal hysterectomy.

This is incorrect, because alternative options are available. There are different surgical approaches to hysterectomies and not all choices are appropriate for all women. Here we give an overview of hysterectomy techniques and what type of hysterectomy should be offered to what conditions.  

Generally, open hysterectomy should be avoided if possible. An open hysterectomy should be reserved to patients with ovarian cancer, for patients with large, complex pelvic masses or patients with a uterine size of 20 cm or larger.

LACE

If the opening of your abdomen is recommended (especially for a benign condition), I suggest you look for a second opinion before taking this option. Some surgeons are not able to perform every surgical technique for hysterectomy therefore they can only offer certain options.  

A vaginal childbirth naturally broadens the vagina allowing for the width necessary to perform a vaginal or vaginally assisted hysterectomy. Many hysterectomies are performed vaginally and have clear advantages over an open surgical approach, such as fewer complications, shorter hospital stay, quicker recovery and shorter healing time.

If the vaginal width is indeed too small, the patient had abdominal surgery previously (e.g., caesarean sections) or the uterus is distinctly enlarged, based on high-quality research a laparoscopic hysterectomy should be performed over open, abdominal surgery.

When choosing the right surgical approach consider the following:

Open, abdominal hysterectomy: Generally, an open hysterectomy is outdated for women requiring removal of the womb for benign conditions and should only be performed in exceptional circumstances. The overall rate of surgical complications is at least 30% higher in patients who have an open, abdominal hysterectomy compared to a laparoscopic hysterectomy. There are even higher risks for women who are obese. The risk of infection is much higher with open surgery. If you have been advised your uterus is enlarged or have never given birth naturally, this is not reason alone to have an open hysterectomy .

Vaginal hysterectomy:  Not having a vaginal birth can often make this approach difficult. In those circumstances, a laparoscopic hysterectomy should be considered. Vaginal hysterectomy is still the surgical approach of choice in women who have their hysterectomy primarily for pelvic floor repair. It is not suitable for women who require the removal of ovaries or the fallopian tubes. 

Laparoscopic hysterectomy (keyhole surgery): It is suitable for almost all patients, even those with previous surgery (e.g. caesarean), or obese patients. Laparoscopic hysterectomy is possible in women who have never given birth vaginally before. Laparoscopic hysterectomy has fewer complications, shorter hospital stay, quicker recovery and shorter healing time compared to open, abdominal hysterectomy.

Robotic hysterectomy: Whilst gaining popularity in the U.S, robotic surgery hysterectomy is not established in Australia (read our previous blog on robotic surgery in Australia). Research suggests that patient outcomes are comparable for both robotic and laparoscopic hysterectomy but uptake is driven by marketing of robotic surgical device companies. The costs of robotic hysterectomy are still prohibitive for many women. The absence of advantages in the presence of significant costs has not helped the uptake of robotic hysterectomy by gynaecological surgeons in Queensland or Australia. 

It is essential for women to be well informed about the different surgical techniques for performing a hysterectomy, so they can be confident they have made the right choice for themselves.

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