Laparoscopic Hysterectomy (TLH) TOTAL LAPAROSCOPIC HYSTERECTOMY LEAFLET (For patients, relatives and hospital personnel) Information for patients having Total Laparoscopic Hysterectomy (TLH) You have been given this information sheet because it is recommended you have a hysterectomy. What is a hysterectomy? A hysterectomy means removal of the uterus. The fallopian tubes and ovaries can be removed at the same time when necessary. A hysterectomy is the most commonly performed gynaecological major operation. Types of hysterectomies: You have had all the relevant tests, weighed up your options and decided that having a hysterectomy is the best solution for you. Now you must come to an agreement with your doctor as to how the operation is to be performed. The uterus can be removed in one of four ways: A big cut on the abdomen (bikini-line or vertical) Vaginally A combination of laparoscopic and vaginal operating Totally laparoscopic (key hole surgery) Option 1 is the most commonly used approach to remove the uterus. While it is a safe technique overall, its disadvantages include longer hospital stay (usually 3 to 5 days), longer recovery and longer time to return to work (usually 6 -12 weeks), need for more pain medication and a relatively high rate of wound complications (especially in overweight/obese and cancer patients). A vaginal hysterectomy or a combination of a laparoscopic operation with a vaginal hysterectomy (options 2 and 3) mean the hospital stay and recovery time are shorter and less pain medication is required than with the first option. This technique is often not feasible for patients who are very overweight or who have not had vaginal childbirths. Option 4 - a Total Laparoscopic Hysterectomy (TLH) - this means the whole operation is performed by keyhole. After TLH, if there are no complications, patients usually stay in hospital for 24-48 hours and they are back to work after 2-6 weeks. Obviously, this would depend on the type of job. The overall complication rate is one third when compared to the first option, and the need for painkillers is reduced by 90% when compared to a major cut on the abdomen and 50% when compared to a vaginal hysterectomy. This technique is often not feasible for patients with a large uterus. In about 5% of patients where a TLH is planned, the operation has to be converted to a laparotomy (a major cut on the abdomen). The reasons for this could be intraoperative complications (which are rare) or extremely difficult surgery where the continuation of a laparoscopic technique would increase the risk of complications. This information is for you if you are about to have, or you are recovering from total laparoscopic hysterectomy. You might also find it useful to share this information with your family and friends. Every woman has different needs and recovers in different ways. Your own recovery will depend upon: how fit and well you are before your operation, the reason you are having the hysterectomy, how smoothly everything goes and whether there are any complications. Total Laparoscopic Hysterectomy is an operation to remove your uterus (womb) and cervix (neck of womb) by keyhole surgery (minimally invasive surgery). In addition you may require removal of one or both or your ovaries and fallopian tubes (salpingo-oophorectomy). You may also need to have lymph nodes removed (lymphadenectomy). Before the operation Pre-operation assessment: Before your operation your surgeon will have discussed with you what the operation involves. You will also meet a nurse, junior doctor and an anaesthetist and have the opportunity to ask questions. You will see these people either at the pre-operative assessment clinic or when you are admitted to the ward. Routine blood tests and heart monitoring (ECG) will also be performed during the preoperative assessment. Preparation: It is important that you are as fit as possible. If you smoke try to give up as soon as possible as smokers are much more likely to develop chest infections after surgery. Many women suffer from constipation after surgery. We advise that you buy ducosate from your local pharmacy. Docusate is a laxative, which takes 1-2 days to achieve effect. Take one capsule (100mg) three times a day. This keeps the bowel motion soft, so that there should be less need to strain to open your bowels in the post- operative recovery period. You should start to take this, 3 days before your operation and afterwards until normal bowel function returns. Prior to surgery you may be given an enema or suppository (medicine which is given via the rectum). This will empty the lower bowel, which makes the operation easier. What to expect after the operation Hospital stay: In most instances you will be admitted to hospital on the day of your operation. Most patients will be discharged the following day after surgery. Very rarely, you may need to stay a bit longer than 24 hours especially if your operation was very difficult or if there were complications. Anaesthetic and pain relief The operation is usually performed under a general anaesthetic. There ia usually no need for a spinal anaesthetic. Immediately following your operation, you may feel more tired and sleepy than usual. For the first few hours a strong painkiller (morphine) may be given as an injection into your muscle or vein. Usually, you will only need this on the day/night of your operation. By the following day, your pain will usually be controlled by taking painkiller tablets, which you will also be given to take home. Drip, drain and catheter: On return from the operating room you will usually have an intravenous drip with fluids and you may have a drainage tube from the wound. You may also have a catheter (tube) in your bladder to allow drainage of your urine. Usually, these are all removed either at night or on the morning following your operation. Eating and Drinking: The nursing staff will advise you when you are able to drink and eat. You will be offered a drink of water or cup of tea and something light to eat. If you are not hungry initially, you should drink fluid. Try eating something later on and your appetite will gradually return. Abdominal and shoulder pain: You can expect pain and discomfort in your lower abdomen for at least the first few days after your operation. You may also have some pain in your shoulder. This is a common side effect of laparoscopic surgery. When leaving hospital, you will be provided with painkillers, take them when needed if you have discomfort, don’t wait for pain and do not exceed the stated dose. Taking painkillers as prescribed to reduce your pain will enable you to get out of bed sooner, stand up and move around – all of which will speed up your recovery and help to prevent the formation of blood clots in your legs or your lungs Trapped wind: Following your operation your bowel may temporarily slow down causing air or ‘wind’ to be trapped. This can cause some pain or discomfort until it is passed. Getting out of bed and walking around will help. Peppermint water may also ease your discomfort. Once your bowels start to move, the trapped wind will ease. Scars, stitches and dressings: You will usually have four small scars on different parts of your abdomen. This may be more if your operation was slightly difficult. Each scar will be between 0.5 cm and 1 cm long. If you have had your cervix removed, you will also have a scar at the top of your vagina, which will be out of sight. Wounds will be closed with stitches that dissolve by themselves. Initially, your wounds will be covered with a dressing. Very often, the dressings will be taken off before you are discharged home, otherwise, you should be able to take this off about 24 hours after your operation and have a wash or shower. After that try to keep your wounds clean and dry. Any stitches in your vagina will not need to be removed, as they are dissolvable. Washing: The day after your operation, you should be able to have a shower or bath and remove any dressings. Don’t worry about getting your scars wet – just ensure that you pat them dry with clean towel or disposable tissues or let them dry in the air. Keeping scars clean and dry helps healing and reduces the risk of infection. Vaginal bleeding: You can expect to have some vaginal bleeding for 1 to 2 weeks after your operation. This is similar to a light period and is red or brown in colour. Some women have little or no bleeding initially and have a sudden gush of old blood or fluid about 10 days later. This usually stops quickly. You should only use sanitary towels, not tampons, as using tampons could increase the risk of infection. Recovering after an operation is a very personal experience What may help your recovery? Relax and rest as much as you can for the first few days but it is important not to remain in bed and to stay mobile as this reduces your risk of developing blood clots. You will be able to do light activities around the house within a few days. It is safe for you to climb stairs the day you go home. Establish a daily routine and keep it up. Eat a healthy balanced diet: This will ensure your body has all the nutrients it needs to aid recovery. A healthy, high fibre diet (fruit, vegetables, wholegrain bread and cereal) with up to 2 litres a day of fluid intake, mainly water, is recommended. Keep your bowels working. Your bowels may take time to return to normal after your operation. Your motions should be soft and easy to pass. You may initially need to take laxatives (e.g. ducosate) to avoid straining and constipation. Stop smoking. This will benefit your health in all sorts of ways such as lessening the risk of a wound infection or chest problems after your anaesthetic. By not smoking, even if it is just while you are recovering, will bring immediate benefits to your health What can delay your recovery? It can take longer to recover if -1) there were any complications during your operation; 2) you had health problems before your operation, for example, women with diabetes may heal more slowly and may be more prone to infections; 3) you smoke; women who smoke are at increased risk of getting a chest or wound infection during their recovery since smoking can delay the healing process; 4) you were overweight at the time of your operation, if you are overweight it can take longer to recover from the effects of anaesthesia and there can be a higher risk of complications such as infection and blood clots; 5) occasionally, due to difficulties encountered during surgery, it may be necessary to complete the operation through a larger cut on the tummy (laparotomy). This leads to a longer hospital stay (3-5 days) and a longer recovery (2-3 months). Complications: All operations carry some degree of risk and complications do occur. Heavy bleeding (haemorrhage) at the time of surgery is rare. Blood loss is usually less than 200 mls, however, blood loss requiring a blood transfusion occurs in 1% of patients. A collection of blood (haematoma) at the top of the vagina may occur. Most patients do not require treatment, although antibiotics are sometimes needed. Very rarely these collections of blood require surgical drainage. When you are at home after the operation the loss should be light, like the end of a period, and getting less and less each day. If it becomes very heavy or smelly, please contact either the hospital or your GP. Infection – surgery is covered with antibiotics, but infection may occur in 10% of patients. Infection can occur in the chest, urine, scars or pelvis and are usually easily treated with antibiotics. Blood clots in the legs and lungs can occur after surgery, though the risk is small (less than 1%). Specific steps are taken to minimize this risk such as use of compression stockings and blood thinning injections. By staying active and well hydrated you can further reduce the risk of clots. Rarely during the operation, damage to other structures (e.g. bowel, bladder, ureters) may occur which may make additional surgery necessary. This may require a large cut on the tummy (laparotomy). Getting back to normal: Work - Everyone recovers at a different rate, so when you are ready to return to work will depend on the type of work you do, the number of hours you work and how you get to and from work. After any operation, you may experience more tiredness than normal, so your return to work should be like your return to physical activity, with a gradual increase in the hours and activities at work. Some women are fit to work after 2 to 3 weeks. Many women are able to go back to normal work after 4 to 6 weeks if they have been building up their levels of physical activity at home. Driving -In general, it can take 2 to 4 weeks before you are ready to drive. Before you drive you should be free from the sedative effects of any painkillers and able to sit in the car comfortably and work the controls. You should be able to wear the seatbelt comfortably and make an emergency stop. You also should be able to comfortably look over your shoulder to manoeuvre. Please contact your insurance company to confirm the details of your policy, although most will be happy for you to drive once declared medically fit. Sex - You should usually allow 4-6 weeks after your operation to allow your scars to heal. It is then safe to have sex – as long as you feel comfortable. If you experience any discomfort or dryness (which is more common if your ovaries have been removed at the time of the hysterectomy) you may wish to try a vaginal lubricant. Hormone replacement therapy (HRT) -If your ovaries have been removed during your operation you may be offered HRT. Your gynaecologist will discuss this with you and together you can decide the best way forward. Follow up -Follow up and/ or additional treatment will be offered and arranged for you if needed depending on your histology results (laboratory test of the tissues removed). Some women who have had a laparoscopic hysterectomy will need to continue to have cervical cancer screening tests (smear tests). You will be advised if this applies to you. When to seek medical help-advice? 1. Burning and stinging when you pass urine or pass urine frequently This may be due to a urine infection. Drink plenty, cranberry juice (or tablets) and barley water can help, as can a teaspoon of bicarbonate of soda dissolved in a glass of water each day. Take a urine sample and contact your GP. If a urine infection is detected this is easily treated with a course of antibiotics. 2. A swollen leg, shortness of breathe, chest pain or coughing up blood There is a small risk of blood clots forming in the veins in your legs and pelvis (deep vein thrombosis) after any operation. These clots can travel to the lungs (pulmonary embolism), which could be serious. You can reduce the risk of clots by: (a) being as mobile as you can as early as you can after your operation; (b) doing exercises when you are resting, for example: - pump each foot up and down briskly for 30 seconds by moving your ankle - move each foot in a circular motion for 30 seconds -bend and straighten your legs, one leg at a time, three times for each leg You may also be given other measures to reduce the risk of a clot developing, particularly if you are overweight or have other health issues. These may include: a daily injection of a blood thinning agent and /or graduated compression stockings that should be worn day and night until your mobility has improved. 3. Red and painful skin around your scars This may be caused by a wound infection. Treatment is with a course of antibiotics. 4. Heavy or smelly vaginal bleeding You will experience some degree of vaginal bleeding after surgery. However, if this becomes increasingly heavy or smelly and especially if you also feel unwell with a temperature (fever), this may be because of an infection or a small collection of blood at the top of the vagina. Treatment is usually with a course of antibiotics. Occasionally you may need to be admitted to hospital for the antibiotics to be administered by a drip. Rarely, the bleeding may need to be drained. 5. Increasing abdominal pain If you have increasing pain along with a temperature (fever), loss of appetite or vomiting, this may be because of damage to your bowel or bladder, in which case you will need to be admitted to hospital.