Inpatient Procedures

Marsupialisation of Bartholin Cysts

If the mouth of the Bartholin's gland of the vulva becomes blocked, the secretion (a vaginal lubricant) causes the gland to swell forming a cyst. It may then occasionally become infected when it forms an abscess.

Where is Bartholin's Gland?

There is a gland on either side in the posterior third of the labium majus (large lips). It was first described by the anatomist Caspar Bartholin and is now known by his name. Its function is to produce a mucus secretion for lubrication of the vagina.

How does it form a cyst?

The mouth of the gland is just inside the vaginal opening. This can sometimes get blocked. The secretion of the gland does not stop and so the gland swells like a balloon. It may get to the size of a hen's egg. It is not painful but the lump may be a nuisance.

And an abscess?

Wherever there is a secretion that does not flow, germs may enter and multiply. This then forms an abscess which is, in effect, a huge boil. It is extremely painful and may prevent you sitting down! Antibiotics often do not penetrate the mucus well and have little effect.

What can be done?

The treatment of choice is called "Marsupialisation". It is usually performed under general anaesthetic. The gland is lanced just inside the vagina and opened to about the size of a little finger. The gland lining is then stitched to the skin making a new mouth to the gland and allowing the secretion to flow. At this stage it is like a pouch, hence the name. Soon the gland shrinks back to its original size leaving a tiny punctum (hole). Sometimes a gauze pack is used overnight. The cyst may be marsupialised to prevent abscess formation. An abscess will usually be marsupialised as an emergency.

Are there risks to the operation?

This is not a painful operation. In fact, the pain goes when the pus of an abscess is released. There will be some remaining discomfort for a short while. The infection may clear without antibiotics just by allowing drainage but antibiotics are usually administered to prevent spread into the tissues. Any operation might be followed by a water infection. There are, of course, risks to anaesthesia when the marsupialisation is done as an emergency without proper preparation. Otherwise, anaesthesia these days is very safe.

When can I go home?

Usually you are ready to go home the same day or the next.

Laparoscopy

There are 2 ways of looking into the abdomen. In years past and for major problems, one will frequently use laparotomy ("lapar-" : belly, "-tomy" : cut), meaning a large cut and a traditional type of operation. However, there are many advantages to using laparoscopy ("lapar-" : belly, "-scopy" : look inside).

Diagnostic laparoscopy enables the surgeon to see the womb, the fallopian tubes and the ovaries and the pelvic wall surrounding them. He may see there adhesions, possibly due to old inflammation or endometriosis. 
This involves a narrow telescope, normally inserted through a small cut in or just below the navel. The instrument itself is called a laparoscope. This can give a very clear image of the pelvis with the womb, the tubes and the ovaries and the areas surrounding them. Also, using closed circuit TV cameras, the view can be greatly magnified and displayed on a screen.
In order to see past the loops of bowel which normally fill the tummy, it is inflated with carbon dioxide (CO2). This gas is normally released at the end of the operation but a small quantity will stay in the tummy. This is seldom of any problem as it is absorbed into the blood stream and then breathed out like the CO2 produced normally in the body.
Although the small incision is generally not painful, we will usually use a general anaesthetic because of the pressure of the gas in the abdomen. The patient is also tipped head-down so that the bowels "fall upwards" against the diaphragm. These can make an unpleasant experience for the patient who is not asleep. Some surgeons use a gasless technique, supporting the belly wall on special retractors and allowing air from the operating theatre to take the place of CO2
Sometimes another instrument is inserted through a separate incision to manipulate structures so that the surgeon can see behind them. For a diagnostic laparoscopy there is seldom need for more than these 2 incisions but for surgery for treatment there may well be 3 or even 4 ports (tubes through which the instruments are passed)..

Diagnostic Laparoscopy and dye studies:   The Surgeon can also check that the fallopian tubes are not blocked. This is done by injecting a blue dye through the cervix (neck of the womb) which can be seen, through the laparoscope, to flow out of the ends of the fallopian tubes. Sometimes when the laparoscope is withdrawn from the body, some blue dye comes out after it and is seen at the navel. Dye which has been injected into the body is absorbed into the blood stream and passed out through the kidneys in the urine. Blue dye in yellow urine can make it a bright green.

Operative laparoscopy also known as minimal access surgery, or keyhole surgery, can have great advantages over the older types of operations which require large incisions. This technique has been used over 40 years by gynaecologists to sterilise women, firstly by coagulating the fallopian tubes with diathermy and more recently, with a variety of rings and clips designed to block the fallopian tubes. The patient has only 2 incisions of between 5 and 10 mm and can usually go home from hospital the same day.
Many other operations are performed laparoscopically: Simple division of adhesions around the fallopian tubes, drilling ovaries in the treatment of polycystic ovarian syndrome, draining ovarian cysts or destruction of minor endometriotic deposits by laser or diathermy. Many ectopic pregnancies are nowadays treated laparoscopically.
Some surgeons have the skills and training to perform much bigger operations laparoscopically such as cutting out ovarian cysts or even hysterectomy and new operations are frequently being introduced.

Are there any serious risks?
Pain: This is usually more related to the extent of the internal surgery rather than the laparoscopy. However, it is impossible to remove all the gas at the end of the operation. Carbon dioxide (CO2) is very soluble and so it is dissolved in the blood and carried to the lungs where it is breathed out. Whilst there is still a bubble in the tummy, it will rise up under the diaphragm, when you sit up, and irritate it. This is felt as pain in the shoulder and possibly down the arm. Lie down and the bubble goes to the navel and the pain goes.
Bleeding: This is very unlikely to be serious. Scraping the inside of the womb at the time of a laparoscopy will cause a little bleeding. It is extremely rare to have internal bleeding of dangerous amount unless there is extensive internal surgery.
Infection: The most common infection is probably a water infection which is usually easily treated with antibiotics.
Deep Vein Thrombosis: This is very rare after a short diagnostic operation. If the operation is a longer operative laparoscopy, it would be wise to take precautions against this.
Damage to Bowel or other internal structures: The technique of gas insufflation and tipping the patient head down makes this very rare but if it is suspected, laparotomy and careful inspection of the bowel is mandatory.  This may involve an open operation (Laparotomy)

When can I go Home?
After a diagnostic laparoscopy, or laparoscopy and dye studies, you can usually go home the same day.  However, if there is extensive internal surgery the period of observation in hospital is often longer.  (I would let my laparoscopic hysterectomy patients go home if all was well at 36 hours after the operation)
The incisions are usually closed with absorbable material and so stitches do not need to be removed.   Sometimes the knot protrudes through the skin but this should not worry you. Once the suture has done its job beneath the skin and has been dissolved by the body, the protruding piece will fall off. If it is causing a nuisance it can be snipped off by a nurse or even the patient. Occasionally the body recognises the knot as a foreign body (as if it was a splinter or something like that), forms a little boil and ejects the knot after which the wound heals well.
Normal activity can be resumed within a day or two, though because there might still be gas within the abdomen, it is recommended that one does not fly even in a commercial aeroplane for a week following a laparoscopy (the low pressure in the aeroplane may result in expansion of the gas and discomfort).

Laparoscopic Division Of Adhesions

Sometimes adhesions in the belly can cause pain which is cured by dividing them

How are Adhesions Caused?

Anything which causes inflammation in the peritoneal cavity (the belly is lined with peritoneum which lubricates the bowel allowing it to move around) can result in adhesions. Common reasons are: surgery, infections such as appendicitis, and endometriosis. Inflamed bits stick together and when they pull apart, strands may form like glue or chewing gum. These are called adhesions.

Laparoscopic Division of an Adhesion


What Problems do they Cause?

Most adhesions cause no problem. However sometimes even very fine adhesions can pull on a particularly sensitive area and cause pain. Some cause the bowel to get "kinked" so causing a temporary obstruction with pain as the bowel tries to force its contents through. Adhesions can limit the movement of the Fallopian Tubes or even block them causing subfertility.

Can We Prevent Adhesions?

Meticulous attention to bleeding can be helpful. Sometimes we will cover a raw area with a special layer of material designed to prevent adhesions. (e.g. Tubal Reanastomosis) Alternatively, we might leave a quantity of fluid in the peritoneal cavity so that the pieces upon which we have operated can "float about" and not stick together.

How Do We Correct Adhesions?

In order to reduce the risk of further adhesion formation, we prefer to operate with a laparoscope and very fine instruments. Some adhesions are not amenable to this form of surgery and an open operation is necessary. We use several different instruments to divide adhesions. Commonly, scissors are used which can pass an electric current through the blades (diathermy). This seals any blood vessels in the adhesion.

Are there any expected complications?

For the possible complications of Laparoscopy, see the article on Laparoscopy.
Complications of this procedure in particular, will be related to the use of scissors and diathermy. This is rare. Whenever an electric current is used, there is a risk that it will take an unexpected path to earth. This can cause burns to nearby structures such as the bowel. Metal touching the skin can cause burns. Piercings and rings must be removed or insulated. Touching a metal part of the operating table also could be risky.

Laparoscopic Female Sterilisation

It is important to realise that this operation is not reversible. If a woman is not totally sure that she will never, in any circumstances, want children in the future, she should not opt for sterilisation and should rely upon one of the other very reliable methods of contraception. The operation is usually performed by applying a clip to block the tube on either side or by burning (diathermy) the tubes, both of which damage the tubes as well as blocking them and it will therefore never be possible to repair the tubes to their original state.
It is also important to realise that it is not possible to guarantee permanent sterilisation and the procedure can fail at any time in the first year or after 15 years. The failure rate is estimated to be about 1 in 200 and because patients have sued their doctors in the past when they have conceived after sterilisation, all doctors will make a very definite point of telling their patients that the operation is not guaranteed to be permanent.
If the operation does fail, the pregnancy may be situated as normal in the womb, or in a tube. A pregnancy in a tube is called ectopic and may be life-threatening. If a woman misses a period after being sterilised, she must seek help from GP straightaway as:

  • - She may wish to terminate the pregnancy
  • - As there is the risk of an ectopic pregnancy, it is best investigated as soon as possible.
What Is The Procedure Of The Operation?

You will be given a general anaesthetic and positioned on the operating table with your legs slightly raised and apart. It is a good idea to tell the doctors if you have back, knee or hip problems so that they can be careful to avoid strain. The bladder is emptied with a catheter and an instrument is placed in the womb to move it about. The operating table is then tilted head down and a fine needle is passed into the stomach through the navel or just above the pubic bone. Carbon dioxide gas is passed through this needle to blow the stomach out, making it safer to pass the telescope (laparoscope) through a small cut in the navel (umbilicus).
The womb, tubes and ovaries are inspected via the laparoscope and then a second tube is inserted. If clips are being applied, they are applied to the thinnest part of the tube. Sometimes the tubes are coagulated with an electric current and then divided with scissors. Water is then squirted onto the tube where it has been burnt, to cool it down so that it doesn't cause heat damage to the bowel when released.
The other tube is dealt with in the same way and then both tubes are carefully inspected to ensure the clips are applied correctly or the tubes have been divided correctly. A second surgeon checks that the sterilisation has been performed correctly.
The gas is then released from the abdomen and the laparoscope removed. A dissolving stitch is placed in the wounds. The instruments are removed from the womb and the operation is over. A pain-killing suppository is placed in the back passage to provide pain relief on waking. The sterilisation is immediately effective.

Is the Operation Safe?

Yes it is, but like any surgical procedure, there are a few points to bear in mind so that you can give your informed consent to the operation.
Failure:  The failure rate is assessed at about 1 in 200 to 1 in 300
Pain: This is usually more related to the extent of the internal surgery rather than the laparoscopy. However, it is impossible to remove all the gas at the end of the operation. Carbon dioxide (CO2) is very soluble and so it is dissolved in the blood and carried to the lungs where it is breathed out. Whilst there is still a bubble in the tummy, it will rise up under the diaphragm, when you sit up, and irritate it. This is felt as pain in the shoulder and possibly down the arm. Lie down and the bubble goes to the navel and the pain goes.
Bleeding: This is very unlikely to be serious. Scraping the inside of the womb at the time of a laparoscopy will cause a little bleeding. It is extremely rare to have internal bleeding of dangerous amount unless there is extensive internal surgery.
Infection: The most common infection is probably a water infection which is usually easily treated with antibiotics.
Deep Vein Thrombosis: This is very rare after a short operation. If the operation is a longer operative laparoscopy or laparotomy, it would be wise to take precautions against this.
Damage to Bowel or other internal structures: The technique of gas insufflation and tipping the patient head down makes this very rare but if it is suspected, laparotomy and careful inspection of the bowel is mandatory.There is a very small chance you may need a larger cut in your tummy because

  • - If we could not see the tubes down the laparoscope, we would make a small cut in the hair line and do the sterilisation through that

OR

  • - In the very unlikely event of any of the instruments causing injury to any of the structures in the tummy, we would make a proper incision to put things right.
How Long Do I Need To Stay In Hospital?

If the operation is performed in the morning, you will be allowed home in the afternoon. If performed in the afternoon, you will be allowed home in the early evening. You should feel back to normal 24-48 hours later. If you have been taking the pill, continue taking it to the end of the packet. Other methods of contraception can be stopped straightaway. The dissolving stitches usually fall out by the seventh day, if not they can be removed by the practice nurse at your doctor's surgery.
Some people believe that being sterilised will lead to an hysterectomy in due course. If this happens it is not because of the operation. The periods which occur after sterilisation where a coil has been removed from the woman at the time of operation tend to be lighter than before. The periods when oral contraception has been stopped tend to be heavier. It is not uncommon for women to have problems with their periods in their 40s and if she has been sterilised the woman's problems would not be masked by taking the oral contraceptive p
ill. There are many operations which may reduce heavy periods short of hysterectomy but a woman who has been sterilised has already made the decision not to use her womb again and therefore may be more able to take the decision to have an hysterectomy than others.


Are there Alternatives to Laparoscopic Sterilisation?
Yes.  Some surgeons can offer a technique in which the Fallopian Tube is blocked by inserting a tiny plug or “superglue” through the womb using a Hysteroscope.  The failure rate of this technique is said to be the same as for tubal clipping.
Are there Alternatives to Sterilisation?

There are 2 main alternatives:

  • - The progesterone-containing coil (Mirena) - this takes about 5 minutes to fit into the womb and is as effective a method of contraception as being sterilised but carries much less risk and it can be reversed. The progesterone coil is particularly helpful if your periods are heavy because it can significantly reduce the blood flow in the majority of women. It lasts 5 years.
  • - Vasectomy - this is a much safer operation than female sterilisation. It is usually performed using local anaesthetic and most importantly, the failure rate is 10 times lower than that of female sterilisation.

Laparotomy

This simply means opening the abdomen (Lapar: "belly", Tomy: "cut"). We will usually indicate what we expect to do inside but often the operation is exploratory in order to find out what is wrong.
The operation will usually involve a General Anaesthetic.
The incision used may be the "Bikini line" favoured by Gynaecologists but if we suspect something large or complicated inside, we will use a vertical cut between the navel and the pubis. It may even be necessary to extend the cut above the navel.

Before The Operation

If time allows, it may help speed your recovery if you are able to get as fit as possible before the operation with regular exercise and if you are overweight, try to get your weight down to normal. If you are using the contraceptive pill, it will be necessary to stop taking it 4-6 weeks before the operation, remembering to use barrier contraception and if you smoke, try to stop or cut down as much as possible. Think about how you will manage after the operation - if you have young children, you may need to organise some extra help for when you come home from hospital.

Coming Into Hospital

Some of the things to bring into hospital with you include:

  • - Nightclothes
  • - Wash bag/towel/hairbrush/makeup
  • - A small amount of cash - please do not bring large quantities
  • - Any drugs you are taking
  • - Any medical results or x-rays you may have

When you arrive in hospital, a nurse or doctor will explain the operation again to you and ask any questions that you might have. You will be asked to sign a consent form. Samples of urine and blood will be taken for testing. The doctors will usually administer antibiotics at the start of the operation to reduce the risk of infection and you should mention any allergies to antibiotics beforehand. Precautions will be taken against the risk of deep vein thrombosis which may involve an injection the night before the operation.
On the day of the operation, you may have a small amount of your pubic hair shaved and you will have been asked not to eat or drink for about 12 hours before. You may be given a "pre-med" in the form of a tablet or injection which will make you feel drowsy and may make your mouth dry. When you arrive in the theatre, the anaesthetist will put a needle into the back of your hand and inject a drug to make you go to sleep. In some circumstances, it may be possible to have a spinal anaesthetic, but in any case, there will be an opportunity to discuss the anaesthetic with the anaesthetist before your operation. Once you are asleep a catheter (narrow tube) will be inserted into your bladder to empty it and this will remain in place until your bladder is working again after the operation.

Complications

Pain:  This occurs with every operation.  You will be given medication to control it.  Sometimes this is in the form of an intravenous morphine like drug over which you have control.  You get more pain relief by pressing a button.  The equipment prevents any chance of an overdose.  It is called "Patient Controlled Analgesia" or PCA.
Bleeding:  During any operation in which you are cut, you will bleed. However, major blood loss, for which a blood transfusion is required, is uncommon (risk less than 3 per 1,000).  We respect the beliefs of Jehovah’s Witnesses.
Sometimes the blood collects in the layers of the abdominal wall or in the pelvis. (Risk about 5 per 100).  Most of these collections are small and may cause no more than a rise in temperature.  Some will drain by themselves; occasionally an operation to drain it will be needed.
Infections:  These may occur in your bladder, your wound (normally due to the germs that you brought with you), or your lungs (mainly due to smoking and not coughing after the operation). They occur in about 15 per 1,000 operations and are usually treated easily with antibiotics.  It is our practice to give a large dose of Augmentin at the start of the operation to minimise this risk.  (if you are allergic to this antibiotic, please mention it and another can be used)
Blood clots (DVT):  The types of surgery most likely to have clots form in the calf veins are those operations on the leg or in the pelvis.  Without preventative measures, they are probably very common (though undiagnosed and of no consequence in many cases).  We recommend "Below knee graduated compression stockings" sometimes called "TED". These should be worn until you are really mobile.  Also we use injections of the blood thinning drug clexane.  The risk of DVT is less than 1 per 100.
Ileus:  Sometimes, after exposing the small bowel to the elements, it refuses to work properly for a short time. This is called ileus. It is much less likely after laparoscopic surgery.
Damage to internal organs:  The bladder, ureters, bowel and blood vessels lie very close to the womb and may be stuck to it.  Usually the surgeon will notice any damage and repair it during the operation.  Occasionally, damage may not be obvious until after the operation and may need another operation to correct the problem. (Risk about 1 per 125 operations)
Unsightly scarring:  This is more likely with repeated opening of the same wound, with midline rather than 'bikini line', with infection and with black skin (keloid formation).
Death:  This will usually be due to the cause for which the laparotomy is being done, e.g. cancer, or due to other disease from which the patient suffers.  Risk about 2 per 10,000.
If you start bleeding heavily after your discharge from hospital or experience abdominal pain, contact your GP or surgeon as soon as possible as it may mean that you have a slight infection that needs to be treated with antibiotics. You may feel a bit depressed, tearful and moody, but this is true of any major operation, and these feelings will not usually last beyond 6-8 weeks by which time you will be feeling stronger physically and more like your old self.

After The Operation

You may feel some pain or discomfort for 48 hours after the operation and painkillers will be available to alleviate this. You may still have a drip in your arm to provide your body with extra fluids and any drugs you might need. Your pulse and blood pressure will be checked regularly. A physiotherapist will visit to show you how to breathe properly, do some simple exercises and the easiest way to get out of bed. Your surgeon may visit you to explain how the operation went and when you can expect to start eating and drinking again. You should start to move around as soon as possible under the supervision of the nurses. You will have a slight discharge or bleeding from the vagina, for which sanitary towels will be provided. You may experience griping wind pains caused by bowel and stomach gas but medicines can be provided to help with this if necessary.

Recovering

How long you need to spend in hospital depends very much on how you feel and may be affected by the extent of the operation you had. You will be given a follow-up appointment to see your specialist for 6-8 weeks after your operation.

Going Home

For the 2-3 weeks at home you should rest, relax and continue to do the exercises you were shown in hospital. Try to take a short walk every day and drink plenty of fluids. Avoid standing for too long and lifting anything heavy for the first 3 months. You should be able to start driving again after 4 weeks or so and may feel ready to go back to work in 6-12 weeks, depending on the sort of work you do. You will probably feel back to normal in about 3 month
Recovery, as always, depends on many factors. One important factor is the nature of the problem, and of the surgery required.

What is the difference between Laparotomy and Laparoscopy?

Both terms indicate the technique by which we aim to get access to the abdomen or pelvis. Laparotomy involves a large cut so that good access is achieved to surgically correct the problem.  Laparoscopy involves a small cut at the navel to insert a scope so that we can see what is wrong.  In some cases, we can then operate through more tiny cuts whilst seeing what we are doing with the laparoscope (Laparoscopic surgery sometimes called "Keyhole surgery"). The recovery from laparoscopic surgery can be much quicker that that after open laparotomy.

About Your Hysterectomy

Hysterectomy might be recommended to you for many reasons. It is an operation the name of which causes great distress to some. However, I hope that a better understanding will alleviate this.

Why has an Hysterectomy been advised?

You may be considering hysterectomy or it may have been recommended for a variety of reasons including:
Heavy, painful periods: may be due to hormonal imbalance and hormone tablets can sometimes, but not always correct this
Fibroids: non-cancerous lump of muscle which grows out of the wall of the womb
Endometriosis: when tissue that usually lines the womb grows outside the womb causing pain at the time of a period
Pelvic Inflammatory Disease: infections of the pelvic organs
Prolapse: a torn pelvic floor (often through childbirth), causing the womb to drop down into the vagina
Cancer: this is rare, but a hysterectomy can be life-saving
Your specialist will have carefully considered all the factors involved in your treatment, for example, if medical rather than surgical treatment would be appropriate, your age, your wishes regarding children etc.

How would an Hysterectomy be performed?

There are several different methods by which the operation is performed, the choice of which will depend on the reason for the operation, your physical build and the size of your womb and your personal choice. The main differences are discussed below:
Abdominal Hysterectomy A cut is made in the abdomen, this may be vertical or, more commonly, horizontal - called a Pfannenstiel or bikini cut - and the womb is taken out through this cut
Vaginal Hysterectomy The womb is taken out through the vagina, not needing a cut in the abdomen
Laparoscopic-assisted vaginal hysterectomy (LAVH) Part of the operation is performed through small cuts in the abdomen, approximately 1 cm long and the womb is taken out through the vagina.


"Laparoscopic view of insertion of one lateral port and division of the ovarian pedicles"


"Division of the uterine pedicles "


"Closing the abdominal wall at the end of the operation"

Total Abdominal Hysterectomy Involves both the body and the neck of the womb
Sub-Total Hysterectomy The cervix (neck of the womb) is left in place and only the body of the womb is removed. This means that you must continue to have cervical smears
Hysterectomy and BSO (Bilateral salpingo-oophorectomy) Both ovaries and fallopian tubes are removed at the same time as the womb
Extended or Radical Hysterectomy (Wertheim's) This is usually used to treat cancer and as well as the womb and fallopian tubes, the upper part of the vagina and surrounding fat and lymph glands will be removed

What Should I do before the Operation?

If time allows, it may help speed your recovery if you are able to get as fit as possible before the operation with regular exercise and if you are overweight, try to get your weight down to normal. If you are using the contraceptive pill, it will be necessary to stop taking it 4-6 weeks before the operation, remembering to use barrier contraception and if you smoke, try to stop or cut down as much as possible. Think about how you will manage after the operation - if you have young children, you may need to organise some extra help for when you come home from hospital.

Coming Into Hospital

Some of the things to bring into hospital with you include:

  • - Nightclothes
  • - Wash bag/towel/hairbrush/makeup
  • - A small amount of cash - please do not bring large quantities
  • - Any drugs you are taking
  • - Any medical results or x-rays you may have

When you arrive in hospital (or at a “Pre-Admission Clinic”), a nurse or doctor will explain the operation again. Please ask any questions that you might have. You will be asked to sign a consent form if this has not been completed in the earlier consultation. Samples of urine and blood will be taken for testing. The doctors will usually administer antibiotics at the start of the operation to reduce the risk of infection and you should mention any allergies to antibiotics beforehand. Precautions will be taken against the risk of deep vein thrombosis which may involve an injection the night before the operation.
On the day of the operation, you may have a small amount of your pubic hair shaved and you will have been asked not to eat or drink for about 12 hours before. You may be given a "pre-med" in the form of a tablet or injection which will make you feel drowsy and may make your mouth dry. When you arrive in the theatre, the anaesthetist will put a needle into the back of your hand and inject a drug to make you go to sleep. In some circumstances, it may be possible to have a spinal anaesthetic, but in any case, there will be an opportunity to discuss the anaesthetic with the anaesthetist before your operation. Once you are asleep a catheter (narrow tube) will be inserted into your bladder to empty it and this will remain in place until your bladder is working again after the operation.

After The Operation

You may feel some pain or discomfort for 48 hours after the operation and painkillers will be available to alleviate this. You may still have a drip in your arm to provide your body with extra fluids and any drugs you might need. Your pulse and blood pressure will be checked regularly. A physiotherapist will visit to show you how to breathe properly, do some simple exercises and the easiest way to get out of bed. Your surgeon may visit you to explain how the operation went and when you can expect to start eating and drinking again. You should start to move around as soon as possible under the supervision of the nurses. You will have a slight discharge or bleeding from the vagina, for which sanitary towels will be provided. You may experience griping wind pains caused by bowel and stomach gas but medicines can be provided to help with this if necessary.

Recovering

How long you need to spend in hospital depends very much on how you feel and may be affected by the type of operation you had. Patients recovering from a laparoscopic-assisted vaginal hysterectomy (LAVH) sometimes feel well enough to go home after 2 or 3 days but you may need to spend a week or so in hospital. You will be given a follow-up appointment to see your specialist for 6-8 weeks after your operation.

Going Home

For the 2-3 weeks at home you should rest, relax and continue to do the exercises you were shown in hospital. Try to take a short walk every day and drink plenty of fluids. Avoid standing for too long and lifting anything heavy for the first 3 months. You should be able to start driving again after 4 weeks or so and may feel ready to go back to work in 6-12 weeks, depending on the sort of work you do. You will probably feel back to normal in about 3 months.

Are there any Complications?
As with any operation, complications do occasionally happen.  Here are the important ones to consider.

Pain:  This occurs with every operation.  You will be given medication to control it.  Sometimes this is in the form of an intravenous morphine like drug over which you have control.  You get more pain relief by pressing a button.  The equipment prevents any chance of an overdose.  It is called "Patient Controlled Analgesia" or PCA.
Bleeding:  During any operation in which you are cut, you will bleed. However, major blood loss, for which a blood transfusion is required, is uncommon (risk less than 3 per 1,000).  We respect the beliefs of Jehova's Witnesses.
Sometimes the blood collects in the layers of the abdominal wall or in the pelvis. (Risk about 5 per 100).  Most of these collections are small and may cause no more than a rise in temperature.  Some will drain by themselves, occasionally an operation to drain it will be needed.
Infection:  These may occur in your bladder, your wound (normally the germs that you brought with you), or your lungs (mainly due to smoking and not coughing after the operation). They occur in about 15 per 1,000 operations and are usually treated easily with antibiotics.  It is our practice to give a large dose of Augmentin at the start of the operation to minimise this risk.  (if you are allergic to this antibiotic, please mention it and another can be used)
Blood clots (DVT):  The types of surgery most likely to have clots form in the calf veins are those operations on the leg or in the pelvis.  Without preventative measures, they are probably very common (though undiagnosed and of no consequence in many cases).  We recommend "Below knee graduated compression stockings" sometimes called "TED". These should be worn until you are really mobile.  Also we use injections of the blood thinning drug clexane.  The risk of DVT is less than 1 per 100.
Damage to internal organs:  The bladder, ureters, bowel and blood vessels lie very close to the womb and may be stuck to it.  Usually the surgeon will notice any damage and repair it during the operation.  Occasionally, damage may not be obvious until after the operation an may need another operation to correct the problem. (Risk about 1 per 125 operations)
Unsightly scarring:  This is more likely with repeated opening of the same wound, with midline rather than 'bikini line', with infection and with black skin (keloid formation).
Death:  This will usually be due to the cause for which the hysterectomy is being done, e.g. cancer, or due to other disease from which the patient suffers. Risk about 2 per 10,000.
If you start bleeding heavily after your discharge from hospital or experience abdominal pain, contact your GP or surgeon as soon as possible as it may mean that you have a slight infection that needs to be treated with antibiotics. You may feel a bit depressed, tearful and moody, but this is true of any major operation, not just hysterectomy, and these feelings will not usually last beyond 6-8 weeks by which time you will be feeling stronger physically and more like your old self. There is no reason why having a hysterectomy should make you put on weight, as long as you are careful to eat healthily and take regular exercise.

Your Sex Life Post-hysterectomy

After your hysterectomy, you will obviously not have any more periods, so if painful periods were a reason for your operation, you may find sex more enjoyable and, of course, there will be no worries about an unwanted pregnancy.
It is probably best to avoid sexual intercourse until just before your post-operative check- up and you may find it more comfortable to use a lubricant such as K-Y jelly for the first few times.

Hormone Replacement Therapy

If you have your ovaries removed, you will almost certainly need HRT (Hormone Replacement Therapy) and you should discuss the therapy most suited to you with your GP or specialist. If your ovaries were left in place, you can start HRT when you begin to have menopausal symptoms which may be a few years earlier than if you have not had your womb removed. In this case, you will need to take only one hormone, oestrogen.

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