Hysterectomy: cost, duration, types, and step by step

• Hysterectomy is a surgery that consists of the partial, total or radical removal of a woman's uterus. The removal of this organ can be carried out by three different methods: abdominal incision, vaginal incision or laparoscopy. 
• A hysterectomy is performed to prevent and treat various conditions of the female reproductive organs such as fibroids, uterine cancer or endometriosis. 
• Cases requiring a hysterectomy are very common in the gynaecological field and although it is a complex surgery, the degree of success is assured and recovery in most patients is short and bearable.

Hysterectomy is the removal of the uterus or womb. Hysterectomy may be combined with the removal of other reproductive organs such as the fallopian tubes and one or both ovaries.

Abdominal hysterectomy can be performed through a horizontal incision, just above the pubic bone, or a vertical incision from the navel to the pubic bone. The type of incision will depend on several factors, such as the patient's medical condition, the size of the uterus, and the surgeon's preference.

It is important to note that abdominal hysterectomy is major surgery and requires general anaesthesia. The recovery period may vary depending on the patient and the extent of the surgery, but generally involves a period of hospitalisation and a period of rest and postoperative care.

Hysterectomies are very common in the gynaecological field, as they prevent and treat pathologies such as cervical cancer, uterine cancer and are recommended in the case of ovarian cancer.

Another of the reasons why hysterectomy is most frequently performed is when a woman has haemorrhages or pain in the uterus that considerably affect her quality of life. 

It is also a valid treatment for other conditions such as the appearance of fibroids, endometriosis, pelvic inflammation, heavy menstruation without a diagnosed cause and in cases of prolapse of the uterus.

There are three methods of hysterectomy, the main differences being the length of hospital stay, the reason for the treatment, the size of the uterus, the recovery time after surgery, and the surgeon's experience and preference.

• Abdominal hysterectomy: The abdominal approach hysterectomy operation involves the removal of the uterus through a surgical incision in the lower abdomen. This procedure allows access to the entire reproductive structure and is chosen in cases where the uterus must be removed along with ovaries, fallopian tubes, etc.
• Vaginal hysterectomy: In this case, the approach is through the vaginal canal, making an incision inside the vagina to remove the uterus. It is a less invasive procedure than abdominal hysterectomy and as a result has fewer complications, less chance of infection and a quicker recovery.
• Laparoscopic hysterectomy: In this case, the hysterectomy operation is performed through small incisions through which the laparoscope is inserted without opening the patient. This technique allows a more detailed exploration of the organs. It is also characterised by the fact that it is a minimally invasive surgery that heals quickly.

Below we explain in more detail what each of these procedures consists of, how long it takes and the cost of each intervention.

On the day of the surgery, the patient comes to the hospital where she will hand in the corresponding documentation at the admissions desk and will then be accompanied to a pre-surgical room where she will be instructed to change into her operating clothes. 

After that, she will be taken to the operating theatre and the operation will begin.

In the operating theatre, the patient will be placed on the operating table and anaesthesia will be administered. When the anaesthesia takes effect and the patient is stable, the abdominal wall will be cleaned and the surgery will begin:

• First, an incision will be made in the abdomen in a transverse direction and below the navel (this is generally the most common type of incision). Through this incision, the surgeons will dissect and coagulate the blood vessels and other tissues of the abdominal wall until they reach the abdominal cavity.
• Once in the abdominal cavity, the gynaecological surgeon will proceed to check the organs in the cavity to ensure that they are in good condition. A surgical retractor will then be placed to hold the incision open on its own and the small and large bowel will be moved to the upper side so that the pelvic cavity can be seen in the best possible way.
• The next step is to locate the uterus and grasp it with two forceps with a slight upward traction.
• The next step is to locate the ligaments and blood vessels that nourish and form the uterus. In this case it is very important to locate and ligate or suture the round ligament, the utero-ovarian ligaments, locate the ureter to avoid its section and the location and section or ligation of the uterine vessels.
• The bladder must be located and separated from the uterus by dissecting the walls of both, which are usually glued together.
• The next step is to locate and dissect the uterus in relation to the rectum, in a similar way to the bladder.
• Then, once the uterus is free of surrounding structures, the next step is to locate the cervix. This will, at this point in the operation, be the only part of the woman's body that joins the uterus. At this point the cervix is clamped with a pair of blunt scissors in the middle portion and the uterus is cut free.
• The cervix is then sutured. Many techniques have been described for this part of the surgical procedure. The individual characteristics of the uterus and its cervix as well as the experience of the gynaecological surgeon will be key in the choice of one or the other.
• Once the uterus has been removed and the cervix closed, the rest of the structures of the pelvic and abdominal cavity are checked to ensure that they are in perfect condition. Washing with physiological saline solution is usually carried out to eliminate any bleeding that may have occurred inside both cavities during the operation.
• Finally, both cavities and the abdominal wall are closed layer by layer in reverse order.

After performing all the necessary stitches, the anaesthetist will proceed to wake the patient up. She will then be transferred to the resuscitation room until the anaesthesia is completely eliminated from her body. 

At this point, when you have fully recovered from the anaesthesia and your vital signs are restored, you will be taken to your room.

After admission to the hospital, the patient is transferred to the operating room where the anaesthesiologist, the gynaecological surgeon with whom the consultation was carried out and one or two members of the nursing team are waiting for her.

Once the patient is anaesthetised and under control, she will be placed in the surgical position required to perform the vaginal hysterectomy. Generally, the patient will be placed in the supine decubitus position with the legs open and elevated to a height above the horizontal axis of the body.

Next, before the actual surgery begins, the cervix is fixed using a type of surgical clamp called a Pozzi clamp. With this type of clamp it is possible to mobilise the uterus as required during the surgical procedure.

After preparation of the surgical field and bladder catheterisation, the surgical procedure begins:

1. Anterior pericervical incision: This type of incision is made in the anterior and upper part of the vagina and is used by the gynaecological surgeon to access one of the spaces within the pelvic cavity called the "vesicovaginal space" so that the bladder, ureters and the ligaments that join them to the uterus can be accurately located for subsequent exeresis (removal).
2. Posterior pericervical incision: This incision is made in the vaginal vault in the region posterior to it until it joins the previous incision, this is one of the ways of accessing another important space such as the "rectovaginal space".
3. Section of the supravaginal septum: The supravaginal septum is a set of fibres that holds the uterus and vagina in place along with other adjacent structures. The section of these fibres allows the uterus to be freed from the elements that keep it anchored and fixed to the pelvic-abdominal cavity. To do this, one of the gynaecological teams must use the surgical forceps to pull the cervix downwards and push the valve placed in the vesicovaginal space upwards.
4. Dissection of the bladder and displacement of the ureter: The bladder and ureters are displaced towards the upper part of the abdomen by traction of the valve in the vesicovaginal space in order to minimise possible damage to the urinary tract during the vaginal hysterectomy operation. This traction allows visualisation of other fibrous structures that anchor the female reproductive system, which can be ligated and cut as a further step to free the uterus from the other structures.
5. Opening of the cul-de-sac of Douglas: This is achieved by pulling the cervix upwards, opening an opening that communicates the peritoneal cavity and dissecting the uterine attachment ligamentous fibres.
6. Section of the parametrium (uterosacral ligaments): Making use of the open opening in the anterior space (the pouch of Douglas), some of the strongest uterine attachment fibres, such as the uterosacral ligaments, are located and dissected after prior ligating them.
7. Opening of the anterior peritoneum: Using the space generated during access to the space of Douglas, the peritoneal cavity is entered and the ovarian adnexa, fallopian tubes and uterine vascularisation (arteries, veins, etc.) are located.
8. Clamping of the uterine vessels: With a slight lateral traction of the uterine fundus and cervix, and by placing a flap on the lateral vaginal wall, the uterine vascular structures, the utero-ovarian pedicle, the tube and the round ligament can be easily visualised. These structures are then clamped, ligated and finally sectioned.
9. Uterine flip: A turning manoeuvre in which the aim is to face the last fibres that hold the uterus in place and place the uterus in position for extraction.
10. Clamping of the utero-ovarian and round uterine pedicles.
11. Extraction of the piece and control of haemostasis: The uterus is extracted along with the rest of the attached elements that may have been removed and it is observed that there is no intraoperative bleeding.
12. McCall's culdoplasty: This is a technique that allows the dome of the vagina to be held in place by means of a fixation point in the pelvis to prevent the vagina from descending through its entrance in the future, which could lead to its prolapse.
13. Closure of the peritoneum layer by layer to ensure proper closure of the peritoneal cavity. This prevents the possible development of hernias or reopening of the surgical wound.
14. Closure of the vagina: Closure of the vagina is performed with interrupted stitches or slow-absorbing continuous suture to allow proper healing of the vaginal surgical wound. Once the vagina is closed, the fixation stitches are knotted on the vaginal vault.

After closure of the vagina, a gauze soaked in antiseptic fluid is placed at the bottom of the vagina to allow for more correct haemostasis, while decreasing the risk of infection from the vaginal hysterectomy surgery. This will remain in place for about 12 hours after the surgery.

The anaesthesiologist then proceeds to awaken the patient. The patient will remain in the operating theatre until she regains consciousness, is able to speak and move. 

The patient will then be taken to the resuscitation room where she will remain until she is fully recovered from the anaesthesia and can be transferred to her room.

When the patient is admitted to the hospital and it is time for surgery, she will be taken to the surgical area. Once inside the operating theatre, the abdominal wall will be cleaned with antiseptic substances. 

Previously, a peripheral venous catheter will have been inserted for the administration of drugs through the veins and, if necessary, certain parts of the body will be shaved.

Once the patient is fully prepared for surgery, the surgical procedure is started. In general terms, the laparoscopic technique can be described in the following steps:

• Prior to anaesthetic induction, the patient is placed in the supine decubitus position (facing the ceiling), with the legs open and flexed at the level of the knee joint, so that the abdominal wall and the hip remain at the same level.
• Anaesthetic induction and monitoring of vital signs is then performed.
• Once the operating field has been prepared, the bladder is catheterised with a Foley catheter and an intrauterine manipulator is placed, which will allow the uterus to be mobilised from the outside to help the surgeon remove it.
• The intra-abdominal field is then prepared so that the laparoscopic instruments can be inserted into the pelvic cavity to allow the surgery to be performed. To do this, an incision is made in the abdominal wall with dissection of the different layers that compose it until the peritoneum is reached. At this point, one of the trocars is inserted and air is infiltrated into the abdominal cavity, creating an enlarged abdominal cavity in which a virtual air-filled space called the pneumoperitoneum has been created. Subsequently, two more incisions will be made in order to include two more trocars with their corresponding surgical instruments that will help and allow the gynaecological surgeon to accurately manipulate the abdominal viscera.
• Once the appropriate pneumoperitoneum has been created and after a detailed examination of the abdominal organs, the patient is placed in the Trendelenburg position, i.e. with the head slightly lowered over the rest of the body at approximately 35º to the horizontal line. This position is intended to facilitate the recognition of the pelvic organs and their positioning, providing a better view of all the components of the abdominal and pelvic cavity.
• The next step, with slight variations according to each case, is a technique very similar to abdominal hysterectomy, although instead of clamping, cutting and ligating the uterus, it is usually performed by coagulating the surrounding structures using the bipolar forceps that form part of the components of the laparoscopic technique. In sequence, the procedure is usually performed in the following order: first the round ligaments, second the opening of the anterior and posterior peritoneum, third the pelvic infundibulae and finally the uterine vessels.
• Subsequently, with a hook loaded with coagulation capacity in another of the laparoscopic surgical components, the cul-de-sacs are sectioned or opened above the uterosacral ligaments, preserving the entire endocervical fascia and allowing the uterus to be released almost in its entirety, i.e. the uterus is separated from any nearby structures.
• After this step comes the vaginal step in which the uterus is removed through the vaginal vault. In uteruses larger than 300 grams or those that are difficult to pass through the vagina, "morcellation" may be necessary, i.e. the uterus is divided into pieces to facilitate its exit.
• Closure of the vagina is generally performed with suture of synthetic origin of ample thickness and is usually performed vaginally with a continuous suture, or laparoscopically with separate stitches or continuous suture.
• The final haemostasis check, observing the abdominal cavity and the presence or absence of bleeding once all the sutures have been performed, is one of the advantages of the laparoscopic technique over the vaginal technique.

After finishing the stitches, the anaesthesiologist wakes the patient up. The patient will remain in the operating theatre until she regains consciousness, is able to speak and move. The patient will then be taken to the resuscitation room where she will remain until she is fully recovered from the anaesthesia and can be transferred to her room.

Abdominal hysterectomy

The duration of the abdominal hysterectomy operation is between 60 and 80 minutes, depending on the particular characteristics of each case.

The length of hospitalisation after surgery is 3 days, and the patient's full recovery takes 2 weeks.

Vaginal hysterectomy

The duration of the vaginal hysterectomy operation is between 45 and 80 minutes, depending on the characteristics of the patient and the pathology indicated.

The length of hospitalisation after surgery is 2 days, and the patient's full recovery takes between 2 and 4 weeks.

Laparoscopic hysterectomy

Laparoscopic hysterectomy surgery lasts approximately 60 to 80 minutes, depending on the characteristics of the patient and the associated pathology.

The length of hospitalisation after surgery is 2 days, and the patient's full recovery takes between 1 and 2 weeks.

Abdominal hysterectomy

Everything mentioned above regarding the cost of the abdominal hysterectomy operation is based on the way Operarme, specialists in surgery, works. 

Our interventions include everything necessary to carry out the surgical treatment of uterus removal with the greatest possible safety and effectiveness for the patient, providing an all-inclusive fixed price of 5.190 €

In this way, the patient knows the final cost of the operation from the outset. Below you will find a breakdown of what is included in the price of the abdominal hysterectomy surgery at Operarme:

• Booking and use of the operating theatre
• Single room with a spare bed for 3 days.
• Stay in the post-surgical recovery room, monitoring and necessary treatments.
• Preoperative tests (blood tests, electrocardiogram and chest x-ray according to medical indication).
• Complementary tests related to the process
• Post-operative visits until medical discharge
• Medical fees
• Anaesthesiologist fees
• Nursing team fees
• Surgical material necessary for the surgery

In addition, the company offers the patient a free transfer service for the day of admission and discharge from hospital, thus avoiding the need to take the car. Similarly, the patient has continuous access to our patient care department, with whom he/she will be able to resolve any queries or setbacks.

Vaginal hysterectomy

Everything mentioned above regarding the price of the vaginal hysterectomy surgery is based on the way Operarme, specialists in surgery, works. Our interventions include everything necessary to carry out the surgical treatment of uterus removal with the greatest possible safety and effectiveness for the patient, providing a closed all-inclusive price of €4,690.

In this way, the patient knows the final cost of the operation from the outset. Below you will find a breakdown of what is included in the price of the vaginal hysterectomy operation at Operarme:

• Booking and use of the operating theatre
• Single room with a spare bed for 2 days.
• Stay in the post-surgical recovery room, monitoring and necessary treatments.
• Preoperative tests (blood tests, electrocardiogram and chest x-ray according to medical indication).
• Complementary tests related to the process
• Post-operative visits until medical discharge
• Medical fees
• Anaesthesiologist fees
• Nursing team fees
• Surgical material necessary for the operation

In addition, the company offers the patient a free transfer service for the day of admission and discharge from hospital, thus avoiding the need to take the car. Similarly, the patient has continuous access to our patient care department, with whom he/she will be able to resolve any queries or setbacks.

Laparoscopic hysterectomy

Everything we have said about the price of the laparoscopic hysterectomy surgery is based on the way we work at Operarme, specialists in surgery. Our interventions include everything necessary to carry out the surgical treatment of uterus removal with the greatest possible safety and effectiveness for the patient, providing a closed all-inclusive price starting from 6,190 €.

In this way, the patient knows the final cost of the operation from the outset. Below you will find a breakdown of what is included in the price of the laparoscopic hysterectomy operation at Operarme:

• Booking and use of the operating theatre
• Single room with spare bed for 2 days.
• Stay in the post-surgical recovery room, monitoring and necessary treatments.
• Preoperative tests (blood tests, electrocardiogram and chest x-ray according to medical indication).
• Complementary tests related to the process
• Post-operative visits until medical discharge
• Medical fees
• Anaesthesiologist fees
• Nursing team fees
• Surgical material necessary for the operation

In addition, the company offers the patient a free transfer service for the day of admission and discharge from hospital, thus avoiding the need to take the car. Similarly, the patient has continuous access to our patient care department, with whom he/she will be able to resolve any queries or setbacks.

If you have any questions about the hysterectomy process or you are thinking of having surgery with us, you can request a free surgical assessment consultation with our specialist in gynaecological surgery and obstetrics.

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