Laparoscopic Hysterectomy: Keyhole Removal of the Uterus

Laparoscopic hysterectomy removes the uterus through a few small cuts in the abdomen instead of one long incision. For women who need a hysterectomy and cannot have it vaginally, the Cochrane review finds that keyhole surgery speeds recovery compared with open surgery, at the price of a longer operation and a higher chance of injury to the urinary tract. This article explains when it is advised, what the operation involves and what the main risks are.

What laparoscopic hysterectomy is

In a laparoscopic hysterectomy, a small telescope with a camera is passed into the abdomen through the navel, and two or three further small cuts are made for instruments. The uterus, including the cervix in a total hysterectomy, is detached under camera view and removed, usually through the vagina. Removing the ovaries is a separate, optional decision that you agree on before the operation.

Other routes exist: vaginal hysterectomy (through the vagina with no abdominal cuts) and abdominal or open hysterectomy (through a lower abdominal incision). The route is chosen according to the reason for surgery, the size and mobility of the uterus, previous surgery and the surgeon's training.

Why it is done

Hysterectomy treats conditions of the uterus when other options have not helped or are not suitable. The consent form issued by the NHS England GIRFT programme lists the aims as:

• stopping abnormal bleeding, including heavy or irregular periods and bleeding after the menopause;
• reducing bleeding, pain or pressure symptoms from fibroids;
• relieving pelvic pain thought to come from the uterus, ovaries or ovarian hormones;
• treating cancer or pre-cancer of the uterus.

Hysterectomy ends periods for good and ends the ability to carry a pregnancy. It is a decision to be made after a full discussion, not in a hurry.

What the guidelines say

Source	Document	Relevant position
Cochrane	Surgical approach to hysterectomy for benign gynaecological disease	63 randomised trials with 6,811 women. Vaginal hysterectomy should be done whenever possible. When it cannot, laparoscopic hysterectomy has advantages over the abdominal route but a greater risk of ureter injury. Evidence is mostly low or moderate certainty.
NICE	Heavy menstrual bleeding, NG88 (as applied in the Evidence-Based Interventions programme)	Hysterectomy should not be first-line treatment for heavy periods alone. It is considered when other treatments have failed or are not suitable, or when a fully informed woman wants periods to stop permanently or no longer wishes to keep her uterus or fertility. The levonorgestrel intrauterine system is the first option in many cases.
NHS England GIRFT	Consent form: total laparoscopic hysterectomy (2022)	Sets out the aims, the alternatives to discuss and the serious and frequent risks to be explained before consent.
NHS Greater Glasgow and Clyde	Minimising urinary tract injury at gynaecological surgery	Lists risk factors for bladder and ureter injury and prevention steps, including identifying the ureter before clamping and getting a urology opinion when it cannot be identified.

RCOG/BSGE consent advice specific to laparoscopic hysterectomy was not opened for this article, so the risk wording comes from the GIRFT consent form and the Cochrane review. The full text of NG88 also would not open, so its position is taken from the Evidence-Based Interventions summary.

Laparoscopic, vaginal or open surgery?

The Cochrane review compared the three routes.

• Laparoscopic compared with open: women return to normal activities about 13 days sooner (28 trials of 3,431 women overall; the recovery figure comes from 7 trials and 618 women, with low certainty). The authors report better results for hospital stay, wound infection, fever and transfusion, and a longer operating time.
• Urinary tract injury: more likely after laparoscopic surgery than after open surgery (odds ratio 2.16; 18 trials, 2,594 women; moderate certainty). Ureter injury was higher with the laparoscopic route.
• Vaginal compared with open: recovery is also quicker after vaginal hysterectomy, by about 11 days (4 trials, 274 women, moderate certainty).
• Laparoscopic compared with vaginal: the review is uncertain whether the groups differ on the main outcomes, and serious complications were rare in both.

The authors' conclusion is that the vaginal route should be used when feasible, and keyhole surgery is the better option over open surgery when it is not. The best route for you depends on your anatomy, scars from previous operations, the reason for surgery and your surgeon's experience.

What to expect

1. Before. You discuss the alternatives, the type of hysterectomy, whether the ovaries and tubes are removed, and the risks. If you have large fibroids, scans may be done in advance. Be sure to ask whether the operation could need to be converted to open surgery.
2. The operation. Under general anaesthesia, the surgeon makes a cut at the navel and two or three smaller cuts. The bladder and ureters are identified, the blood supply to the uterus is sealed and divided, and the uterus is separated and removed, usually through the vagina. The top of the vagina is closed with stitches.
3. After. The length of stay varies between hospitals, and many women go home within a few days. Expect abdominal and shoulder-tip discomfort, and some vaginal bleeding like a light period for a couple of weeks. Use pads, not tampons. Moving about early lowers the risk of blood clots.
4. Recovery. Avoid sex for the first 6 weeks while the vaginal closure heals, as in the GIRFT advice, and follow the advice your own team gives about driving, lifting and work.

Risks

The GIRFT consent form lists these.

• Injury to nearby organs (bladder, ureters, bowel or major blood vessels). A serious injury may need open surgery, a stoma, a catheter or a ureteric stent. A local NHS study of almost 1,000 hysterectomies quoted bladder injury in 1.3% and ureteric injury in 1.9%, and a wider analysis of laparoscopic benign surgery gave 3.3 urinary tract injuries per 1,000.
• Blood clots (deep vein thrombosis or pulmonary embolus), about 1 in 300.
• Heavy bleeding, which can need transfusion or conversion to open surgery. Conversion is more likely with obesity or previous surgery.
• Fistula, an abnormal connection leaking urine or faeces through the vagina, and bowel obstruction from adhesions or a port-site hernia.
• Common effects (more than 1 in 20): wound or urine infection, bloating and slow bowels, vaginal bleeding and shoulder-tip pain.
• Early menopause, with about twice the risk compared with not having a hysterectomy. Removing the ovaries causes menopause directly.
• Rare but serious: chest, heart, stroke and kidney complications, and death.

Risk factors for urinary tract injury include a high body mass index, previous pelvic surgery or caesarean section, endometriosis, pelvic abscess and cancer. Contact your hospital or seek urgent care for fever, worsening abdominal pain, heavy bleeding, leaking urine or faeces from the vagina, or calf pain with breathlessness after discharge. This is general advice.

Alternatives to consider first

For heavy menstrual bleeding with no major abnormality, or with small fibroids, the Evidence-Based Interventions summary of NICE advice suggests starting with a levonorgestrel intrauterine system, then tranexamic acid or anti-inflammatory drugs, then hormonal treatments. Fibroids of 3 cm or more call for specialist assessment, and options include medicines, myomectomy, uterine artery embolisation, endometrial ablation where suitable and hysterectomy. Hysteroscopic removal is considered for fibroids that bulge into the uterine cavity. If you want to keep your fertility, hysterectomy is not an option.

Frequently asked questions

Does the cervix or ovaries have to come out?

In a total hysterectomy the cervix is removed with the uterus. Removing the ovaries is optional and decided with you beforehand, because it brings on menopause and changes your long-term health risks.

Will I have periods afterwards?

No. Without a uterus there are no periods and no pregnancy. If the ovaries stay, they keep making hormones.

Is keyhole surgery always possible?

No. A very large uterus, extensive adhesions or bleeding may mean the surgeon switches to an open operation. This is more likely with obesity or previous surgery.

How long is recovery?

In the Cochrane review, women returned to normal activities about 13 days sooner after laparoscopic than after open hysterectomy. As an illustration from the review, if open surgery takes 37 days to recover from, keyhole surgery would take roughly 22 to 25 days. Your own recovery depends on your health and what was done.

Sources

This article is educational and does not replace individual medical advice. Details were taken from the pages below; some points rely on summaries, so confirm exact recommendations against the originals before clinical use.

• Cochrane review: Surgical approach to hysterectomy for benign gynaecological disease
• Cochrane review full text (CD003677)
• NICE NG88: Heavy menstrual bleeding
• Evidence-Based Interventions: Hysterectomy for heavy menstrual bleeding
• NHS England GIRFT consent form: Total laparoscopic hysterectomy
• NHS GGC: Minimising urinary tract injury at gynaecological surgery for benign disease

Laparoscopic Hysterectomy: Keyhole Removal of the Uterus

Laparoscopic hysterectomy removes the uterus through a few small cuts in the abdomen instead of one long incision. For women who need a hysterectomy and cannot have it vaginally, the Cochrane review finds that keyhole surgery speeds recovery compared with open surgery, at the price of a longer operation and a higher chance of injury to the urinary tract. This article explains when it is advised, what the operation involves and what the main risks are.

What laparoscopic hysterectomy is

In a laparoscopic hysterectomy, a small telescope with a camera is passed into the abdomen through the navel, and two or three further small cuts are made for instruments. The uterus, including the cervix in a total hysterectomy, is detached under camera view and removed, usually through the vagina. Removing the ovaries is a separate, optional decision that you agree on before the operation.

Other routes exist: vaginal hysterectomy (through the vagina with no abdominal cuts) and abdominal or open hysterectomy (through a lower abdominal incision). The route is chosen according to the reason for surgery, the size and mobility of the uterus, previous surgery and the surgeon's training.

Why it is done

Hysterectomy treats conditions of the uterus when other options have not helped or are not suitable. The consent form issued by the NHS England GIRFT programme lists the aims as:

• stopping abnormal bleeding, including heavy or irregular periods and bleeding after the menopause;
• reducing bleeding, pain or pressure symptoms from fibroids;
• relieving pelvic pain thought to come from the uterus, ovaries or ovarian hormones;
• treating cancer or pre-cancer of the uterus.

Hysterectomy ends periods for good and ends the ability to carry a pregnancy. It is a decision to be made after a full discussion, not in a hurry.

What the guidelines say

Source	Document	Relevant position
Cochrane	Surgical approach to hysterectomy for benign gynaecological disease	63 randomised trials with 6,811 women. Vaginal hysterectomy should be done whenever possible. When it cannot, laparoscopic hysterectomy has advantages over the abdominal route but a greater risk of ureter injury. Evidence is mostly low or moderate certainty.
NICE	Heavy menstrual bleeding, NG88 (as applied in the Evidence-Based Interventions programme)	Hysterectomy should not be first-line treatment for heavy periods alone. It is considered when other treatments have failed or are not suitable, or when a fully informed woman wants periods to stop permanently or no longer wishes to keep her uterus or fertility. The levonorgestrel intrauterine system is the first option in many cases.
NHS England GIRFT	Consent form: total laparoscopic hysterectomy (2022)	Sets out the aims, the alternatives to discuss and the serious and frequent risks to be explained before consent.
NHS Greater Glasgow and Clyde	Minimising urinary tract injury at gynaecological surgery	Lists risk factors for bladder and ureter injury and prevention steps, including identifying the ureter before clamping and getting a urology opinion when it cannot be identified.

RCOG/BSGE consent advice specific to laparoscopic hysterectomy was not opened for this article, so the risk wording comes from the GIRFT consent form and the Cochrane review. The full text of NG88 also would not open, so its position is taken from the Evidence-Based Interventions summary.

Laparoscopic, vaginal or open surgery?

The Cochrane review compared the three routes.

• Laparoscopic compared with open: women return to normal activities about 13 days sooner (28 trials of 3,431 women overall; the recovery figure comes from 7 trials and 618 women, with low certainty). The authors report better results for hospital stay, wound infection, fever and transfusion, and a longer operating time.
• Urinary tract injury: more likely after laparoscopic surgery than after open surgery (odds ratio 2.16; 18 trials, 2,594 women; moderate certainty). Ureter injury was higher with the laparoscopic route.
• Vaginal compared with open: recovery is also quicker after vaginal hysterectomy, by about 11 days (4 trials, 274 women, moderate certainty).
• Laparoscopic compared with vaginal: the review is uncertain whether the groups differ on the main outcomes, and serious complications were rare in both.

The authors' conclusion is that the vaginal route should be used when feasible, and keyhole surgery is the better option over open surgery when it is not. The best route for you depends on your anatomy, scars from previous operations, the reason for surgery and your surgeon's experience.

What to expect

1. Before. You discuss the alternatives, the type of hysterectomy, whether the ovaries and tubes are removed, and the risks. If you have large fibroids, scans may be done in advance. Be sure to ask whether the operation could need to be converted to open surgery.
2. The operation. Under general anaesthesia, the surgeon makes a cut at the navel and two or three smaller cuts. The bladder and ureters are identified, the blood supply to the uterus is sealed and divided, and the uterus is separated and removed, usually through the vagina. The top of the vagina is closed with stitches.
3. After. The length of stay varies between hospitals, and many women go home within a few days. Expect abdominal and shoulder-tip discomfort, and some vaginal bleeding like a light period for a couple of weeks. Use pads, not tampons. Moving about early lowers the risk of blood clots.
4. Recovery. Avoid sex for the first 6 weeks while the vaginal closure heals, as in the GIRFT advice, and follow the advice your own team gives about driving, lifting and work.

Risks

The GIRFT consent form lists these.

• Injury to nearby organs (bladder, ureters, bowel or major blood vessels). A serious injury may need open surgery, a stoma, a catheter or a ureteric stent. A local NHS study of almost 1,000 hysterectomies quoted bladder injury in 1.3% and ureteric injury in 1.9%, and a wider analysis of laparoscopic benign surgery gave 3.3 urinary tract injuries per 1,000.
• Blood clots (deep vein thrombosis or pulmonary embolus), about 1 in 300.
• Heavy bleeding, which can need transfusion or conversion to open surgery. Conversion is more likely with obesity or previous surgery.
• Fistula, an abnormal connection leaking urine or faeces through the vagina, and bowel obstruction from adhesions or a port-site hernia.
• Common effects (more than 1 in 20): wound or urine infection, bloating and slow bowels, vaginal bleeding and shoulder-tip pain.
• Early menopause, with about twice the risk compared with not having a hysterectomy. Removing the ovaries causes menopause directly.
• Rare but serious: chest, heart, stroke and kidney complications, and death.

Risk factors for urinary tract injury include a high body mass index, previous pelvic surgery or caesarean section, endometriosis, pelvic abscess and cancer. Contact your hospital or seek urgent care for fever, worsening abdominal pain, heavy bleeding, leaking urine or faeces from the vagina, or calf pain with breathlessness after discharge. This is general advice.

Alternatives to consider first

For heavy menstrual bleeding with no major abnormality, or with small fibroids, the Evidence-Based Interventions summary of NICE advice suggests starting with a levonorgestrel intrauterine system, then tranexamic acid or anti-inflammatory drugs, then hormonal treatments. Fibroids of 3 cm or more call for specialist assessment, and options include medicines, myomectomy, uterine artery embolisation, endometrial ablation where suitable and hysterectomy. Hysteroscopic removal is considered for fibroids that bulge into the uterine cavity. If you want to keep your fertility, hysterectomy is not an option.

Frequently asked questions

Does the cervix or ovaries have to come out?

In a total hysterectomy the cervix is removed with the uterus. Removing the ovaries is optional and decided with you beforehand, because it brings on menopause and changes your long-term health risks.

Will I have periods afterwards?

No. Without a uterus there are no periods and no pregnancy. If the ovaries stay, they keep making hormones.

Is keyhole surgery always possible?

No. A very large uterus, extensive adhesions or bleeding may mean the surgeon switches to an open operation. This is more likely with obesity or previous surgery.

How long is recovery?

In the Cochrane review, women returned to normal activities about 13 days sooner after laparoscopic than after open hysterectomy. As an illustration from the review, if open surgery takes 37 days to recover from, keyhole surgery would take roughly 22 to 25 days. Your own recovery depends on your health and what was done.

Sources

This article is educational and does not replace individual medical advice. Details were taken from the pages below; some points rely on summaries, so confirm exact recommendations against the originals before clinical use.

• Cochrane review: Surgical approach to hysterectomy for benign gynaecological disease
• Cochrane review full text (CD003677)
• NICE NG88: Heavy menstrual bleeding
• Evidence-Based Interventions: Hysterectomy for heavy menstrual bleeding
• NHS England GIRFT consent form: Total laparoscopic hysterectomy
• NHS GGC: Minimising urinary tract injury at gynaecological surgery for benign disease