Hysterectomies are one of the most commonly performed surgeries in the United States. Many are still performed with a total abdominal hysterectomy (TAH) procedure. TAH is the traditional approach to accessing and removing the uterus through the abdomen.

But experts now concur that a minimally invasive hysterectomy is the "procedure of choice" for most women today. These MIP may include either a vaginal hysterectomy or one of the various laparoscopic hysterectomy techniques.

Compared with those treated with TAH, women treated with MIP for hysterectomy typically experience the following:

• Shorter hospital stays
• Faster recovery and return to normal activities, including sexual intercourse
• Less pain and scarring
• Fewer complications and infections
• Less blood loss

There are two major types of MIP for hysterectomy.

Vaginal Hysterectomy ^{1, 2, 7}

Vaginal hysterectomy (VH) is the first option to consider for any woman requiring hysterectomy. It is the quickest procedure to perform, and it offers the most clinical and patient benefits.

VH involves removing the uterus and cervix (although typically not the ovaries) through a small incision made at the top of the vagina. Because the VH incision is much smaller than that used in the total abdominal procedure, it heals more quickly and causes less pain and visible scarring.

VH is not feasible for all patients. Some women may have an oversized uterus, a constricted vagina, a narrow pubic arch, or other conditions that make vaginal removal difficult or impossible.

(Flash animation: MIP vaginal hysterectomy)

Laparoscopic Hysterectomy Techniques ^{2, 4, 26}

When a vaginal hysterectomy is not feasible, the second option to consider is a laparoscopic hysterectomy (LH). Although LH generally requires about the same operative time as TAH, it offers women the benefits of fewer infections, less blood loss and pain, and much quicker recovery. Instead of the three to four days of hospitalization required with an open procedure, for example, LH usually means a one-night stay.

Contraindications include ovarian neoplasms that cannot be excised or removed intact through a vaginal incision or laparoscopic bag and anatomy that precludes peritoneal access.

There are various approaches to using laparoscopy for hysterectomy.

Laparoscopically Assisted Vaginal Hysterectomy (LAVH) ^{2, 4, 22, 26}

With LAVH, part of the surgery is done vaginally and part is done through a few small laparoscopic incisions. Generally, the uterus and surrounding structures are detached and divided into small portions using the laparoscopic instruments inserted through these small ports. Then, as with a VH, the uterus is removed through a small incision at the top of the vagina.

LAVH provides all the usual recovery advantages of a minimally invasive procedure, while allowing for the removal of ovaries and larger uteri that once required a lengthy abdominal incision. It may also be an excellent MIP option for obese women.

(Flash animation: MIP hysterectomy versus an open procedure)

Total Laparoscopic Hysterectomy ⁴

With a total laparoscopic hysterectomy, every step, including uterus removal, is performed through a few small abdominal incisions.

In some cases, a laparoscopic supracervical hysterectomy may be performed. This is a laparoscopic hysterectomy during which the uterus is removed while leaving the cervix and supportive tissues in place. Some women prefer this option because it preserves more of their anatomy. Theoretically, it may also deter pelvic floor defects and incontinence and may preserve sexual function, but it is not an option for women with cervical or uterine cancer or those unwilling to continue annual pap smears.

As with all operative procedures, be sure to discuss surgical risks with your patients.

(Flash animation: Laparoscopic Surpracervical Hysterectomy)