Surgeons gain access to, and remove, one or more of the reproductive organs in a number of ways. This is the basis for another method of classifying hysterectomy.
If the reproductive organs are accessed through the vagina, the operation is called a vaginal hysterectomy. This approach may be considered when:
• a woman has a prolapse and her uterus, bowel or bladder has already started to intrude into her vagina
• there are fibroids that are small enough to enable the uterus to be pulled down and out through the vagina
• the ovaries are to be left intact.
Vaginal hysterectomy is unsuitable when the uterus is very large or contains one or more sizeable fibroids. It is more difficult to perform than abdominal hysterectomy and should always begin and end with a laparoscopic inspection of the pelvis. This helps ensure that any abnormalities, such as ovarian cysts, are identified prior to surgery and alerts the surgeon to any bleeding that has occurred during the operation. Bleeding must be contained or the patient will form large blood clots in the pelvis which may lead to adhesion formation and infection. Removal of any clots will involve another trip to the operating theatre and an extra two to three days in hospital.
The debate among doctors about the relative merits of abdominal and vaginal hysterectomies is ongoing. Proponents of the vaginal approach argue that it involves less post-operative pain, is less costly and requires a shorter hospital stay. Some research has suggested it may be safer than the abdominal approach, resulting in fewer deaths and a lower complication rate but analysis of Australian hospital data indicates that this is not necessarily so. Nevertheless it is argued that the vaginal approach could be used for most hysterectomies if appropriate training programs for doctors were available.
In contrast, doctors who favour the abdominal approach claim that the types of complications more likely to affect women having a vaginal hysterectomy are a cause for concern. They claim post-operative infection and large blood losses necessitating transfusions are more common with the vaginal approach; and they suggest that there is an increased risk of damage to other pelvic organs due to the confined space in which the surgery is performed. Repairing this damage entails further surgery. They also say that vaginal hysterectomy is more likely than abdominal hysterectomy to result in a vaginal prolapse, where the upper part of the vagina collapses inwards. The upshot is that at present in the US, UK and Australia, about 25% of hysterectomies are performed vaginally.