Robotically assisted Total Laparoscopic Hysterectomy (TLH)

What is a robotically assisted TLH?

Laparoscopic surgery is also often called keyhole surgery. It is carried out using several small incisions called keyholes.

For this operation, your surgeon will make 4 to 5 small incisions (cuts) to your abdomen (tummy). These incisions will be about 1 cm in length.

Robotic assisted surgery is a laparoscopic technique that uses a robotic console to help your surgeon during the operation. Your surgeon will be in the same room and will control the robotic arms to perform the operation. It is important to understand that the robot is not performing the surgery. The surgeon still carries out the procedure, but the robotic console allows more controlled and precise movements during the operation.

The robot has four arms. One holds a high-magnification 3D camera, which is inserted into your abdomen through one of the keyholes. This allows your surgeon to see inside your abdomen.

What are the benefits of having a robot-assisted laparoscopic hysterectomy?

A robot-assisted laparoscopic hysterectomy provides you with many benefits over traditional surgery:

• Less blood loss
• Fewer complications
• Your stay in hospital will be shorter
• Your long-term recovery is quicker
• Your pain should be significantly less than with a traditional operation
• You are able to return to normal activity and work sooner

Why am I having a robotically assisted TLH?

Common reasons for robotically assisted TLH surgery are endometrial or early-stage cervical cancer. Your doctor will explain why you are having this surgery.

Before the surgery

You should carry on taking your usual medications, unless told otherwise. We strongly advise that you stop smoking before your surgery. If you develop an illness before your surgery or have any questions, please contact your consultant’s secretary.

Pre-operative assessment

You will be invited to the hospital any time up to 2 weeks before your surgery for a pre-operative assessment. During this assessment we will check your fitness for general anaesthetic and surgery. This will include recording a full medical history, any current medication and arranging any investigations needed. Please tell the nurse practitioner or doctor if you have had problems with any previous surgery, anaesthetic or if you have any allergies – this is very important.

At this visit you will have the opportunity to discuss what to expect before, during and after your surgery. We will also tell you what you will be able to do during your recovery time. Your admission details should be confirmed with you at this visit.

Will I have to sign a consent form?

You will be asked to sign a form giving your consent to the surgery. The consent form gives your gynaecologist the right to do only what is written on this form.

The only exception to this is if during the surgery there is an unforeseen problem, you have then consented to have this corrected. Please feel free to ask any questions about the surgery that you do not understand before signing the consent form.

The medical terms commonly used on the consent form are:

• Total Laparoscopic Hysterectomy (TLH) - removal of the womb which includes the cervix (neck of the womb)
• Oophorectomy - removal of one ovary
• Bilateral oophorectomy - removal of both ovaries
• Salpingectomy - removal of one fallopian tube
• Bilateral salpingectomy - removal of both fallopian tubes
• Salpingo-oophorectomy - removal of one ovary and fallopian tube
• Bilateral salpingo-oophorectomy - removal of both ovaries and fallopian tubes

When should I stop eating and drinking?

Detailed instructions will be included in your admission letter about this. It is very important that you follow the instructions otherwise your surgery may need to be put off until a later date. This will be discussed at your preoperative assessment appointment.

Day of the surgery

An anaesthetist and your surgeon (or a senior member of the team) will explain to you what will happen during your operation.

We want you to fully understand why you are having the surgery and what the possible risks are. You will be asked to sign a consent form, if you have not already done so, and you will have the opportunity to ask any questions.

During the surgery

Robotically Assisted TLH is normally carried out under a general anaesthetic (while you are asleep). A narrow plastic tube called a cannula will be inserted into a vein in your arm or hand using a needle; this is used to give you fluids and medications. After you have been given a general anaesthetic and you are asleep, a catheter (a tube for urine drainage) will be inserted into your bladder.

Your abdomen will be filled with gas and an optical instrument, called a laparoscope, will be inserted to allow the internal organs to be viewed before 4 further small cuts, about 1 cm each, are made on your abdomen at about the level of the umbilicus (bellybutton). These cuts are for other instruments to be inserted.

Your ovaries and fallopian tubes may or may not be removed depending on the reason for your surgery. In most cases the uterus and cervix are removed through the vagina. If the uterus is too large to remove vaginally, or the vagina is too narrow, a slightly larger cut will be made on the abdomen and it is taken out that way.

The wounds will be closed with dissolvable stitches. The procedure will take about 1 to 2 hours, but you can expect to be in theatre and recovery for 3 to 4 hours.

After the surgery

You will normally wake up in the recovery area of the operating theatre, but you may not remember much until you are back on the ward. You will be given medication during your surgery to relieve the pain when you wake up. You may have some discomfort following the surgery but we will try to control this in the best way possible using a variety of pain relief.

Risks

Minor risks

• Infections (such as chest, wound or bladder)
• Bruising to any wound on the abdomen or in the vagina
• Haematoma (blood collecting in the wound)
• Hernia
• Adhesion (tissue sticking together)

More serious risks

• Bleeding
• Blood loss can sometimes be heavy during the surgery and this may mean that you need a blood transfusion
• Blood clots in the chest (Pulmonary Embolism, PE) or Deep Vein Thrombosis (DVT) of the legs. Preventative treatment will be discussed
• Injuries to the bladder, ureters (narrow tubes between the bladder and the kidneys), bowel or blood vessels, requiring further surgery
• Anaesthetics carry a small risk and you will be asked by your doctors about any medical problems that might increase those risks

The specific risks for a robot-assisted laparoscopic hysterectomy are:

• Carbon dioxide (used during surgery) could become trapped in your abdomen. This can cause pain in one or both shoulders, but disappears as the gas is reabsorbed by your body
• The need to convert to open surgery

Will I need a catheter?

Immediately after a hysterectomy some women find it difficult to pass urine. The catheter mentioned earlier on this page, allows the bladder to stay empty until you are completely awake from the anaesthetic and more mobile. The catheter is usually removed the day after your surgery.

When can I resume my normal diet?

You may be able to drink a few hours after your surgery, until then you will be given extra fluid via your cannula. You will usually be eating and drinking normally within a day of the surgery.

How long will I be in hospital?

You may be discharged on the day of your surgery, 1 or 2 days after your surgery, but if you have had additional surgery, you may be in hospital for longer. If you have any concerns about going home after your surgery, please discuss these with the staff at the Pre-operative Assessment Clinic.

Follow up

You may be given a follow-up appointment to be seen at the hospital or you may be asked to make an appointment to see your GP.

Going home

You may still have some discomfort when you leave hospital but you will be given a supply of pain relief medication which you should take regularly for the best effect. You may also be given some laxatives to take home as minor bowel problems are common after hysterectomy.

After the surgery you may experience ‘wind pains’; this is from having medical air inside your abdomen. These should stop within a few days. Drinking a small amount of peppermint oil in warm water can help. Peppermint oil can be bought in supermarkets and health food shops.

You may notice some weight gain during the first few weeks following surgery this is because you are less active. Hysterectomy itself does not cause weight gain.

You may have some light vaginal bleeding (spotting) for up to 6 weeks after the surgery, this is normal.

Returning to normal

You may feel more tired in the weeks following your surgery if you do too much. You may also experience a slight aching discomfort at the wound sites.

In some cases, this can carry on for some months after the surgery, but most women are able to resume normal activity in terms of exercise and daily tasks within 4 to 8 weeks. It is advisable not to swim until all the wounds have healed and any vaginal discharge has cleared up.

When can I go back to work?

We suggest that you stay off work for 4 to 8 weeks; this depends on the nature of your job. Please talk about this with your consultant or GP.

What about my sex life?

The area at the top of the vagina where the cervix was will have stitches which will need about 6 weeks to heal before intercourse is resumed. You will tend to know when you feel ready to resume intercourse, you should find that there is no alteration in the sensation, but there may be discomfort if you are over enthusiastic. If you experience any pain, please seek advice from your GP.

When can I drive?

You should not drive until you feel able to perform an emergency stop comfortably and are not taking regular pain medication. This usually means about 6 weeks without driving. We recommend you discuss this with your insurance company.

Will I need hormone replacement therapy (HRT)?

HRT will have been discussed with you in the Out-patient Clinic before your surgery. Whether it is offered to you will depend on whether your ovaries are removed during the surgery and your age.

If you have not yet reached the menopause and your ovaries are left in place there is a possibility that they may stop working at an earlier age than normal. If you do develop hot flushes or other menopausal symptoms before the age of 45 you should seek advice from your GP about the possible need for HRT to prevent osteoporosis (premature thinning of the bones).

If your ovaries are removed at the time of the hysterectomy, before you reach the menopause, you will be offered oestrogen replacement therapy until the age of 50. This will depend on your diagnosis.

If you have already reached the menopause before your surgery your need for HRT will not change. If you were not taking it before the surgery, you should not need it afterwards.

You may wish to have a discussion about the advantages and possible disadvantages of HRT with the gynaecology team or with your GP before, or shortly after your surgery.

If it has been decided that you will need HRT after your surgery you will be given a month’s supply to take home. Further supplies can be obtained from your GP.

Contact information

If you have any problems or concerns after going home, please contact your GP for advice.