Dr. Kenneth A. Thomas, MD, JD

More and more, gynecologic surgery is moving towards the use of minimally invasive surgery. Minimally invasive surgery uses several small incisions and tiny tools and scopes to perform the operation, rather than one large opening. While it is not appropriate in every case, minimally invasive surgery can lead to less scarring, less blood loss, faster recovery, and a lower chance for infection. Minimally invasive gynecologic surgery may be performed with a laparoscope, a thin tube with a camera on the end that allows the surgeon to see inside the body. It may also be performed robotically, using even smaller tools and cameras that a surgeon controls from a computer. Robotic surgery allows even better vision, precision, and control than laparoscopic surgery.

Over the course of a lifetime, many women need pelvic surgery to stay healthy. Qualified gynecologic surgeons will have the right tools at their disposal to provide care with a minimum of discomfort.

It is important to note that having any of these conditions does not necessarily mean that a hysterectomy is necessary. There are other available treatment options in most cases.

Although the uterus is responsible for a period, it is the ovaries that control the hormonal changes that women go through every month. So if a woman has a hysterectomy but keeps her ovaries, she might still experience hormonal swings every month even if she no longer has a period. Alternately, if a younger woman has a hysterectomy where her ovaries as removed, she will essentially be in immediate menopause.

A hysterectomy can be performed traditionally through one large cut in the abdomen, laparoscopically using tiny incisions and small tools, or through the vagina. Full recovery may take four to six weeks. After a hysterectomy, patients might experience sexual changes such as vaginal dryness or a change in libido. It is common to experience strong emotions after a hysterectomy, including both grief and relief. If a patient's ovaries were removed, they may be at higher risk for certain diseases, such as heart disease and osteoporosis. Taking hormonal birth control might reduce this risk.

The choice of treatment for pelvic organ prolapse depends on the severity of the condition. Mild to moderate prolapse may be managed by doing pelvic floor strengthening exercises, taking hormone replacement therapy, or using pessaries. Pessaries are small devices inserted into the vagina to help support the pelvic organs. Pessary fitting is a quick procedure done in a doctor's office. For severe prolapse, surgical treatment may be necessary. Pelvic organ prolapse surgery repairs the following:

• Cystocele or bladder prolapse, where the bladder sags into the vagina. The surgeon repairs a cystocele by strengthening the front wall of the vagina using stitches so that the bladder will no longer sag.
• Enterocele or small bowel prolapse, which occurs when the small bowel descends towards the vagina. To correct an enterocele, the tissues between the small bowel and the vagina are sewn together, allowing them to provide more support.
• Rectocele or posterior prolapse, which is the bulging of the front wall of the rectum into the back wall of the vagina. Surgery to repair a rectocele removes the excess stretched tissue between the rectum and vagina.
• Uterine prolapse, which occurs when the uterus slips down to the vagina. To treat a uterine prolapse, the surgeon may secure the neck of the uterus (called cervix) to a ligament in the pelvis using stitches. Another option for this type of prolapse is a vaginal hysterectomy, which is the removal of the uterus.

Each of these procedures is performed through a vaginal incision, but an enterocele repair may use the abdominal approach as an alternative. If two or more pelvic organs have prolapsed, a combination of any of these procedures may be performed during the same surgical session.

For women who no longer wish to have intercourse, an operation called colpocleisis

may be a surgical option as well. By closing the vaginal canal, colpocleisis treats pelvic organ prolapse and eliminates any risk of its recurrence.

In most instances, pelvic organ prolapse surgery only requires a hospital stay of one day. Patients may experience vaginal bleeding for the first few weeks following surgery. If this happens, patients should use sanitary pads rather than tampons, as a higher risk of infection is associated with the use of tampons. To further help with recovery, patients should begin doing gentle pelvic floor strengthening exercises a few days after surgery. Doing these exercises at least three times a day as a routine tightens the pelvic floor muscles and prevents the recurrence of prolapse.