Gynaecology Leaflet: Your Road to Recovery - Lap Hysterectomy

Leaflet Details

Patient Information

This information is for you if you are about to have, or you are recovering from, an open hysterectomy (an operation to remove your uterus (womb) by an incision on your abdomen). You might also find it useful to share this information with your family and friends

About this information

You should read this information together with any other information you have been given about your choices and the operation itself. This information gives general advice based on women’s experiences and expert opinion. Every woman has different needs and recovers in different ways.

Your own recovery will depend on:

• how fit and well you are before your operation
   
• the reason you are having a hysterectomy
   
• the exact type of hysterectomy that you have
   
• if your hysterectomy is performed at the same time as other surgical procedures
   
• how smoothly the operation goes and whether there are any complications.

Within this information, we may use the terms ‘woman’ and ‘women’. However, it is not only people who identify as women who may want to access this information. Your care should be personalised, inclusive and sensitive to your needs, whatever your gender identity.

Introduction

We look forward to welcoming you to Ashford and St. Peter’s Hospitals for your operation.

Our aim is for you to come into hospital as strong as possible, ready for your surgery, and to make a quick recovery.

Surgical Information

Before you agree to surgery and sign your consent form, your surgeon will discuss what is planned (this is called an informed consent). Your surgeon will discuss the risks of surgery with you during your consultation.

What is a laparoscopy?

A laparoscopy (also known as keyhole surgery) is performed under a general anaesthetic. 3-4 small cuts (half to one centimetre in length) are made in the abdomen which allows your surgeon to insert a small telescope so that they can see inside your abdomen and your reproductive organs directly. Your abdomen will be filled with gas to allow us some space to gain a clear picture and if necessary, to treat any problems as agreed with you before your operation. At the end of surgery as much gas as possible is released from the abdominal cavity and the incisions are closed.

Types of hysterectomy

There are several different types of hysterectomy, including:

• total hysterectomy, where both the uterus and cervix (neck of the womb) are removed
   
• subtotal hysterectomy, where just the uterus is removed and the cervix is not
   
• hysterectomy with salpingo-oophorectomy (removal of one or both or your ovaries and your fallopian tubes) at the same time.
   
• hysterectomy can also be performed with operations to the bowel, bladder, ureters (tubes that connect kidneys and bladder), omentum (fat that is attached to the bowel) depending on the reason that you require the surgery

Some laparoscopic hysterectomies are done entirely by keyhole surgery. Others are done partially through your vagina (sometimes called a laparoscopic assisted vaginal hysterectomy or LAVH). If you are having an LAVH, you might find helpful information in Recovering well: information for you after a vaginal hysterectomy, https://www.rcog.org.uk/for-the-public/browse-our-patient-information/laparoscopic-hysterectomy-recovering-well/.

The type of hysterectomy will depend on your personal circumstances and will be discussed with you by your gynaecologist before your operation.

Why do you need a laparoscopic hysterectomy?

You have been offered a laparoscopy because conservative or medical treatment of your problem has failed or are not suitable. Laparoscopy is commonly used in the treatment of various problems which include:

• Endometriosis
   
• Ovarian cysts
   
• Fibroids
   
• Adhesions (this is where internal organs are stuck to each other)
   
• Heavy periods
   
• Persistent post-menopausal bleeding
   
• Pre-cancerous changes / Cancer of the lining of the womb

Advantages of a laparoscopic hysterectomy over open surgery:

• Quicker recovery
   
• Smaller incisions
   
• Less pain following procedure
   
• Shorter hospital stays
   
• Less scar formation under the abdomen

Anaesthetic

You will need an anaesthetic for a laparoscopic hysterectomy. This will be a general anaesthetic and/or a regional anaesthetic (spinal or epidural).

Length of operation

A laparoscopic hysterectomy takes between 1-2 hours but will be longer if there is an additional procedure or extensive surgery planned.

Scars

You will have between two and four small scars on different parts of your abdomen. Each scar will be between 0.5cm and 1cm long. If you have had your cervix removed, you will also have a scar at the top of your vagina.

Risks and Complications

Whilst every effort will be taken to ensure your wellbeing, no surgery is without its risks. There are some risks associated with this particular kind of surgery. These are listed over the next 2 pages, with average chances of these happening. Your personal risk of these issues will depend on how complicated your surgery is, and your surgeon will be able to advise you further.

Pain

It is quite normal to experience pain or discomfort, but this can be controlled effectively with painkillers.

Shoulder tip pain is common after laparoscopy as this is caused by small amounts of gas left in the abdomen after surgery. Early mobilisation after surgery is the best way to improve this type of pain.

Bleeding

This can occur during or after surgery. Major bleeding requiring blood transfusion is uncommon (less than 3 in 100).

Potential to proceed to open surgery

In certain circumstances, the surgeon may feel that it would be safer to proceed with open surgery. This will mean you may need to remain in hospital longer and your recovery will be longer.

Infection

This can occur in the wound (15 in 100), urine or chest. If an infection occurs you will be given antibiotics.

Risk of return to theatre / transfer to St Peter’s hospital

If you are unwell after surgery at Ashford hospital, you may be transferred to St Peter’s hospital for further monitoring or investigation. This would also happen if you need to return to theatre for a second operation to deal with any complications, such as bleeding or infection.

Risk of blood clots

Having laparoscopic surgery increases your risk of blood clots in the legs (deep vein thrombosis) or lung (pulmonary embolus), with the overall risk being about 1 to 5 in 1000. This risk is higher if you have other risk factors, including immobility and if you are overweight.

This risk will decrease by weight loss and smoking cessation prior to your operation and quick mobilisation after the operation.

You will be given support stockings to wear to help prevent clots and given a blood thinning injection if you stay in hospital overnight. Depending on your risk factors, you may be taught how to give yourself these injections at home for a few days / weeks after the operation.

Damage to internal organs

The average risk of serious complications at laparoscopy is about 2 in 1000. This includes injury to the bladder, ureters (tubes that pass from the kidneys to the bladder), bowel, and blood vessels. This would be dealt with and repaired when they are identified, usually at the time of operation.

However, damage may not be obvious until after the operation and in 15 out 100 cases of bowel injury, this may not be obvious at the time of surgery. However, when identified, all measures will be taken to act in your best interest and repair the injury. There is about a 1 in 100 chance of hernia at the site of entry (the incision sites on your abdomen)

Hormone Replacement Therapy

If your operation involves the removal of both ovaries, you may need to consider taking hormone replacement therapy (HRT) at least until the age of 50 to prevent your bones from becoming weak and fragile (osteoporosis) and to help control mood swings and hot flushes. The need for HRT, its benefits and risks should be discussed with your medical team prior to leaving hospital. It may be advisable to delay the start of HRT until a few weeks after your operation (as you may have an increased risk of developing a blood clot immediately following surgery). However, you should be made aware which type of HRT you need and when to start taking it prior to leaving hospital.  

Pre-Operative Information

Having seen your doctor and agreed to surgery, you will need to think ahead and plan your life whilst waiting for the operation and for your recovery afterwards. Your surgeon will discuss what to expect during your recovery period and how long you will be off work.

You will receive an appointment to attend pre-operative assessment clinic. The purpose of this clinic is to prepare you for your admission and discharge from hospital. At this clinic we will have the opportunity to discuss your home circumstances for safe discharge, assess your fitness for anaesthesia and give you a chance to ask any questions you may have. During this appointment the staff will discuss any other illnesses you may have (e.g., diabetes), record your blood pressure and record your height and weight. All patients are checked for MRSA (skin swab sample) prior to their operation so any infection can be treated before surgery. The team may arrange blood tests, ECG (heart recording) and/or to see an anaesthetist before your operation date.

Pre-assessment will also review any medications that you take regularly and will look to see if these will interfere with your operation (e.g. blood thinning medications).

Please bring in all of your medications and a note of any allergies with you. Only stop the medications you have been advised.

Consent

You will be asked to sign a consent form which confirms you have agreed to the procedure. If you do not understand anything or would like someone with you, please let the doctor taking the consent know before you sign. Signing this form does not stop you from asking questions or changing your mind.

Eating and drinking

You will be advised when you need to stop eating and drinking prior to the procedure depending on the type of anaesthetic.

Bowel preparation

It is not routine for bowel preparation medication to be given to those undergoing a laparoscopy, but in some circumstances it is appropriate. If you do require bowel preparation medication, you will be given information on how to take it correctly in pre- assessment.

Contraception

If you are sexually active and having regular periods, it is important you are not pregnant at the time of the operation. Please ensure you are using some form of contraception and see your GP for advice about this if needed.

You may be asked to stop your hormonal contraception for a few weeks before the operation if it contains oestrogen (such as the Combined oral contraceptive pill, NuvaRing etc.), as this may increase the risk of developing blood clots after the operation. If it is not possible to stop your contraception, please let your surgeon know. Please use condoms as contraception if you stop hormonal contraception before your surgery.

We will perform a urine pregnancy test on the day of the procedure, and your surgery will be cancelled/postponed if you are pregnant.

Preparing for Admission

It is important for you to be thinking about planning your discharge now, before you go into hospital. You can help yourself by arranging help and support before you come into hospital such as:

• Make sure you know who can come and collect you from hospital. Please bring their contact details with you.
   
• Ask friends and relatives if they can come to stay or visit to help around the house when you get home.
   
• Arrange for a friend or relative to do some shopping for you or make extra portions of food to freeze.
   
• Get up to date with any housework before you come into hospital, this will help reduce the load when you get home.
   
• Arrange additional childcare or help with the school runs where necessary.

In most instances, you will be admitted to hospital on the day of your operation. You may be able to go home within 24 hours or, depending on your circumstances, you may need to stay in hospital for one to three days.

When you are discharged, you will need to make arrangements for transport home and that someone is at home to help you for the first 24 hours following surgery.

After your operation

Immediate recovery - Once your operation is over, you will be taken to the theatre recovery unit. You may wake up with an oxygen mask over your face.

Painkillers will be provided but please tell the nurse or doctor if any pain is not relieved by the painkillers you are given.

You may be given fluids through a drip in your arm. Once you are able to take fluids by mouth you will be encouraged to start drinking and eat light meals. Good nutrition is important to your recovery. If you are not hungry initially, you should drink fluid. Try eating something later on. A good fluid intake (1.5-2 litres in 24 hours) and increase in fibre in your diet will minimise the risk of constipation.

To achieve this, we use an Enhanced Recovery Programme to optimise your nutrition, mobility and pain relief around the time of your operation. There is strong evidence that by following an Enhanced Recovery Programme you will recover faster from your operation, with fewer problems.

Enhanced Recovery involves staff caring for you (Doctors, Anaesthetists, Nurses, and Physiotherapists), helping you to follow a clearly defined programme. Most importantly it requires your help and involvement to make it work.

Together, we will use as many parts of the programme suitable for you to achieve the best recovery. The key parts are:

• Having specific nutritional high energy drinks before and soon after your operation leading to an early return to your normal diet.
   
• Having good pain relief following your operation.
   
• Being able to get out of bed and having assistance to walk soon after your operation.
   
• Getting back to the comfort of your own home soon as possible.

After-effects of general anaesthesia

Most modern anaesthetics are short lasting. You should not have, or suffer from, any after-effects for more than a day after your operation. Having a general anaesthetic can make you very groggy. You might feel less co-ordinated or that it's difficult to think clearly. This should pass within 24 hours. In the meantime, don't drive, drink alcohol, operate machinery or sign anything important.

Catheter

You may have a catheter (tube) in your bladder to allow drainage of your urine. This is usually for up to 24 hours after your operation until you are easily able to walk to the toilet to empty your bladder. If you have problems passing urine, you may need to have a catheter for a few days.

Vaginal bleeding

You can expect to have some vaginal bleeding for one to two weeks after your operation. This is like a light period and is red or brown in colour. Some women have little or no bleeding initially, and then have a sudden gush of old blood or fluid about 10 days later. This usually stops quickly. You should use sanitary towels rather than tampons as using tampons could increase the risk of infection.

Pain and discomfort

You can expect pain and discomfort in your lower abdomen for at least the first few days after your operation. When leaving hospital, you should be provided with painkillers for the pain you are experiencing. Sometimes painkillers that contain codeine or dihydrocodeine can make you sleepy, slightly sick and constipated. If you do need to take these medications, try to eat extra fruit and fibre to reduce the chances of becoming constipated. Taking painkillers as prescribed to reduce your pain will enable you to get out of bed sooner, stand up straight 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

Washing and showering

You should be able to have a shower or bath and remove any dressings the day after your operation. Don’t worry about getting your scars wet - just ensure that you pat them dry with clean disposable tissues or let them dry in the air. Keeping scars clean and dry helps healing.

Stitches and dressings

Cuts on your abdomen will be closed by stitches or glue. Glue and some stitches dissolve by themselves. Other stitches may need to be removed. This is usually done by the practice nurse at your GP surgery about five to seven days after your operation. You will be given information about this. Your cuts will initially be covered with a dressing. You should be able to take this off about 24 hours after your operation and have a wash or shower (see section on washing and showering). Any stitches in your vagina will not need to be removed, as they are dissolvable. You may notice a stitch, or part of a stitch, coming away after a few days or maybe after a few weeks. This is normal and nothing to worry about.

Packs

You may have a pack (a length of gauze like a large tampon) in your vagina after the operation to reduce the risk of bleeding. A nurse will remove this after your operation while you are still in hospital. Check with your nurse that this has been done before you go home.

Formation of blood clots - how to reduce the risk

You can reduce the risk of clots by:

• being as mobile as you can as early as you can after your operation
   
• 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:

• daily heparin injections (a blood-thinning agent) - you may need to continue having these injections daily when you go home; your doctor will advise you on the length of time you should have these for
   
• graduated compression stockings, which should be worn day and night until your movement has improved and your mobility is no longer significantly reduced
   
• special boots that inflate and deflate to wear while in hospital

Discharge

You will be given a discharge letter containing details of your operation, medications and advice on who to call if you have any problems once home.

Cervical screening (smears)

Some women who have had a sub-total hysterectomy will need to continue to have smears. Check with your GP or gynaecologist whether this applies to you

Follow-up appointment

We do not routinely book follow up appointments if a patient’s surgery is uncomplicated and they do not need ongoing care. This practice is built on our experience and evidence that follow up appointments often do not add to the patient's care. However, if a patient has complications afterwards or needs ongoing care, we will make an appointment and the same is mentioned on the discharge letter.

Feeling unwell after your surgery?

Expected recovery period

While it is important to take enough rest, you should start some of your normal daily activities when you get home and build up slowly. You will find you are able to do more as the days and weeks pass. If you feel pain, you should try doing a little less for another few days. It is helpful to break jobs up into smaller parts, such as ironing a couple of items of clothing at a time, and to take rests regularly. You can also try sitting down while preparing food or sorting laundry.

For the first one to two weeks, you should restrict lifting to light loads such as a one litre bottle of water, kettles or small saucepans. You should not lift heavy objects such as full shopping bags or children or do any strenuous housework such as vacuuming until three to four weeks after your operation as this may affect how you heal internally. Try getting down to your children rather than lifting them up to you. Remember to lift correctly by having your feet slightly apart, bending your knees, keeping your back straight and bracing (tightening or strengthening) your pelvic floor and stomach muscles as you lift. Hold the object close to you and lift by straightening your knees.

Exercise - While everyone will recover at a different rate, there is no reason why you should not start walking on the day you return home. You should be able to increase your activity levels quite rapidly over the first few weeks. There is no evidence that normal physical activity levels are in any way harmful and a regular and gradual build-up of activity will assist your recovery.

If you are unsure, start with short steady walks close to your home a couple of times a day for the first few days. When this is comfortable, you can gradually increase the time while walking at a relaxed steady pace. Many women should be able to walk for 30- 60 minutes after two or three weeks. Swimming is an ideal exercise that can usually be resumed within two to three weeks provided that vaginal bleeding and discharge has stopped.

If you build up gradually, the majority of women should be back to previous activity levels within four to six weeks. Contact sports and power sports should be avoided for at least six weeks, although this will depend on your level of fitness before surgery.

Driving - You should not drive for 24 hours after a general anaesthetic. Each insurance company will have its own conditions for when you are insured to start driving again. Check your policy.

Before you drive you should be:

• free from the sedative effects of any painkillers
   
• able to sit in the car comfortably and work the controls
   
• able to wear the seatbelt comfortably
   
• able to make an emergency stop
   
• able to comfortably look over your shoulder to manoeuvre.

In general, it can take two to four weeks before you are able to do all of the above. It is a good idea to practise without the keys in the ignition. See whether you can do the movements you would need for an emergency stop and a three-point turn without causing yourself any discomfort or pain. When you are ready to start driving again, build up gradually, starting with a short journey.

Time off work - If you require a fit note, please tell the ward team. We would normally provide a fit note for 6 weeks following this surgery. If you feel unable to return to work after this time, please discuss with your GP.

Travel plans

If you are considering travelling during your recovery, it is helpful to think about:

• the length of your journey - journeys over four hours where you are not able to move around (in a car, coach, train or plane) can increase your risk of deep vein thrombosis (DVT); this is especially so if you are travelling soon after your operation
   
• how comfortable you will be during your journey, particularly if you are wearing a seatbelt
   
• overseas travel: Would you have access to appropriate medical advice at your destination if you were to have a problem after your operation? Does your travel insurance cover any necessary medical treatment in the event of a problem after your operation?
   
• whether your plans are in line with the levels of activity recommended in this information. If you have concerns about your travel plans, it is important to discuss these with your GP or the hospital where you have your operation before your operation.

Having sex

You should usually allow four to six 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. You can buy this from your local pharmacy.

Returning to work

You may experience more tiredness than normal after any operation, so your return to work should be like your return to physical activity, with a gradual increase in the hours and activities at work. If you have an occupational health department, they will advise on this. Some women are fit to work after two to three weeks and will not be harmed by this if there are no complications from surgery. Many women are able to go back to normal work after four to six weeks if they have been building up their levels of physical activity at home.

Returning to work can help your recovery by getting you back into your normal routine again. Some women who are off work for longer periods start to feel isolated and depressed. You do not have to be symptom free before you go back to work. It is normal to have some discomfort as you are adjusting to working life. It might be possible for you to return to work by doing shorter hours or lighter duties and build up gradually over a period of time. Consider starting partway through your normal working week so you have a planned break quite soon. You might also wish to see your GP or your occupational health department before you go back and do certain jobs - discuss this with them before your operation. You should not feel pressurised by family, friends or your employer to return to work before you feel ready. You do not need your GP’s permission to go back to work. The decision is yours.

Useful Information

• Day Surgery Unit, St. Peter’s Hospital: 01932 722167 (8AM - 5PM)
   
• Day Surgery Unit, Ashford Hospital: 01784 884127/1375 (Mon-Fri between 8AM - 5PM)
   
• Kingfisher Ward: 01932 722380 (Mon-Sun)
   
• Ashford Hospital: 01784 884488 (Mon-Sun)
   
• St. Peter’s Hospital: 01932 872000 (Mon-Sun)

Further information regarding the CEMIG team can be found at https://cemig.info/