Hysterectomy involves removal of the uterus (womb). Both the body of the uterus and the cervix (mouth of the womb) are removed. In certain instances, a supra-cervical hysterectomy may be performed, removing only the body of the uterus and leaving the cervix. The tubes and ovaries may or may not be removed at the same time as a hysterectomy. The general public sometimes uses the terms complete or total hysterectomy to indicate removal of the uterus, tubes, and ovaries and partial hysterectomy to denote removal of just the uterus.
Hysterectomy can be done using one of several techniques or a combination of these techniques.

• The most common technique many gynecologists now use is the laparoscopically assisted vaginal hysterectomy (or LAVH).
• Hysterectomy may also be performed entirely through a larger incision in the lower abdomen (TAH or total abdominal hysterectomy).  Occasionally, the initial approach to hysterectomy may be laparoscopic or vaginal, and the surgery may have to be completed through an abdominal incision due to adhesions or scar tissue, bleeding, the size of the uterus or other factors that prevent the procedure from being completed laparoscopically or vaginally.  
• The hysterectomy may be done entirely through the vagina (TVH or total vaginal hysterectomy).

Choosing which technique depends on a number of factors such as:

• the size of the uterus relative to the size of the pelvis (birth canal)
• whether or not the tubes and ovaries are to be removed
• whether or not endometriosis or scar tissue is suspected
• the presence of cancer
• whether or not other procedures are to be performed at the same time as the hysterectomy. Complete or partial removal of other abdominal and pelvic organs such as ovaries, fallopian tubes, and appendix may be completed along with hysterectomy as well as repair of the bladder, rectum and vagina.
• the skill of the surgeon. Some physicians are particularly skilled at laparoscopic or vaginal surgery, making recovery much easier and quicker. If your physician suggests you have surgery through a large abdominal incision, ask if it is possible to complete the procedure either laparoscopically or vaginally.

LAVH involves the use of a laparoscope to perform most of the surgery. The tissue is then removed through the top of the vagina. The LAVH is appropriately used in place of the abdominal hysterectomy; it is not meant to replace procedures that can be easily accomplished entirely through the vagina. Occasionally, the entire procedure is completed laparoscopically (or laparoscopic hysterectomy) and the tissue removed through a lower abdominal incision approximately 1 inch long.

After a hysterectomy a woman will not be able to become pregnant and will no longer have menstrual periods. If the ovaries are also removed, a woman will become estrogen deficient if she has not already gone through the menopause. Pros and cons of hormone replacement therapy should be discussed with your physician.  Common questions asked regarding the effects of hysterectomy include the likelihood of weight gain, mood changes, increased hair growth, or change in sexual function. Although prior experience suggests the occurrence of any of these is low, these should be discussed with your physician.
Many patients after having a laparoscopically-assisted or vaginal hysterectomy are able to leave the hospital in less than 24 hours (if a larger abdominal incision is necessary, the usual stay is several days, and return to normal activity is delayed by at least 2-4 weeks.

"There is something fascinating about science. One gets such wholesome returns of conjecture out of such trifling investments of fact." Mark Twain, Life on the Mississippi

Supra-cervical vs. Total Hysterectomy

Over the past several years, laparoscopic supra-cervical hysterectomy has become a more popular procedure – mainly due to promotion by a company that sells surgical equipment necessary to perform the procedure. Before physicians and patients embrace this procedure, certain questions should be answered. What are the advantages of this procedure? Are there any disadvantages? What are the costs? Are the costs justified?

Total hysterectomy (as noted above) indicates removal of the entire uterus, including the body of the uterus and the cervix (so-called mouth of the womb). Total hysterectomy can be performed with or without removal of the tubes and ovaries. The surgery can be performed through a large abdominal incision (total abdominal hysterectomy), by a vaginal approach (total vaginal hysterectomy), at laparoscopy (total laparoscopic hysterectomy), or through a combination of laparoscopic and vaginal incisions (laparoscopically-assisted vaginal hysterectomy). Recovery is easier if a large abdominal incision can be avoided. The choice of approach to total hysterectomy depends on the reason for the surgery and the skills of the surgeon.

Supra-cervical hysterectomy specifies removal of the body of the uterus without removal of the cervix. This procedure was popular many years ago before the advent of modern antibiotics to reduce the risk of infection, which resulted from bacterial contamination from the vagina. With modern antibiotics, postoperative infection after total hysterectomy is unusual. Supra-cervical hysterectomy can be performed through a large abdominal incision or at laparoscopy (LSH or laparoscopic supra-cervical hysterectomy). Again, recovery is easier if a large abdominal incision can be avoided. In order to complete the surgery at laparoscopy, an instrument called a morcellator is used to cut the tissue into small pieces so it can be removed through a smaller laparoscopic incision. The morcellator adds cost to the procedure. Improper use of the morcellator can result in significant risk of complication.

Invalid arguments for considering supra-cervical hysterectomy over total hysterectomy include:

• Improved sexual function – A number of recent well-designed medical studies have shown sexual function is improved equally with supra-cervical and total hysterectomy.
• Improved pelvic support with less urinary incontinence – Over fifty percent of women over the age of fifty have some degree of uncontrollable urinary loss, frequently associated with decreased support of the bladder. Some medical studies show improvement in urinary function with both supra-cervical and total hysterectomy. One study showed more women had urinary incontinence after undergoing supra-cervical than those having total hysterectomy.
• Decreased surgical complications – The incidence and type of complications for supra-cervical and total hysterectomy are similar.

Cyclic bleeding occurs in up to 20% of women after supra-cervical hysterectomy. The upper part of the cervix that is left with supra-cervical hysterectomy may contain tissue that responds to hormones, resulting in bleeding. Additionally, 25% of women having supra-cervical hysterectomy will require further surgery due to abnormal bleeding or abnormal PAP smears of the cervix.

Laparoscopic supra-cervical hysterectomy may offer a slight benefit of quicker initial recovery, but for most women removal of the cervix along with the body of the uterus is the preferred procedure when hysterectomy is indicated. You should discuss your options with your physician.