**6. Implications and general advice**

The hospital stay after hysterectomy is usually 3 days. Postoperatively, prophylactic anticoagulation should be administered for about 10 days, and may be for longer in cases of hysterectomy due to cancer. Post hysterectomy, it may take 4–6 weeks to recover. The age and overall health will influence recovery time. In general, after a hysterectomy, an individual should not drive for 2 weeks, and not lift heavy objects for 6 weeks. Recovery may be aided by gentle exercise and gentle cleaning of the abdominal surgical incision. At follow-up, except for subtotal hysterectomy, the vaginal vault is checked for any granulation tissue, and if present it could be touched with silver nitrate.

When deciding on the route of hysterectomy, it has to be taken into account that, compared with abdominal hysterectomy, vaginal hysterectomy, as well as laparoscopic hysterectomy, are associated with less blood loss, shorter hospital stay, less post-operative pain, quicker return to usual activities and fess abdominal incisional infections [13–15].

Because of these findings, a recent review advocated that vaginal hysterectomy is preferable to abdominal hysterectomy. Furthermore, when vaginal hysterectomy is neither advisable nor practical, then laparoscopic hysterectomy should be considered [6].

In general, vaginal hysterectomy is not as expensive as abdominal hysterectomy, but it can be more difficult if adnexal masses are present, or in women with previous abdominal surgery or endometriosis. In addition, vaginal hysterectomy can be more challenging in cases of minimal uterine descent and patients with a narrow sub-pubic arch.

The adoption of the laparoscopic approach for the performance of hysterectomy has been slow. This, in part, has been attributed to the need for specialized highly technical equipment that is more delicate than those used in conventional surgery, and is in more need for routine maintenance. In addition, training programs lack a requirement that trainees need to have performed a certain number of laparoscopic procedures before graduating [16, 17].

For postoperative care, the best analgesic regimens are those that offer broad coverage, safe and are easy to administer. For moderate to severe pain, a centrally acting synthetic opioid analgesic with lower opiate-like dependence than Morphine would be appropriate. Non-steroidal anti-inflammatory drugs that possess analgesic and anti-pyretic activity are equally suitable. For nausea and vomiting patients are given the appropriate prophylactic and therapeutic antiemetics, such as dexamethasone and ondansetron [18–20].

After laparoscopic hysterectomy, it is normal to have some shoulder or back pain that is caused by the pneumoperitoneum. Patients tend to get tired easily or have less energy that lasts for several weeks after surgery, and may take about 4 to 6 weeks to fully recover. It's important to avoid lifting while recovering. Patients are advised to be active where walking is a good choice, and to rest when feeling tired. Diet should be normal. In cases of an upset stomach, bland, low-fat foods and yogurt is advisable. Drinking plenty of water may avoid constipation.

To avoid venous thromboembolism, antiplatelet medication, in the form of acetylsalicylic acid, or low molecular heparin should be prescribed.

Abdominal incisions could be washed daily with warm, soapy water, and patted dry. Hydrogen peroxide or alcohol should be avoided as they can slow wound healing. The area may be covered with a gauze bandage that should be changed daily, if it oozes any discharge or rubs against clothing.

Follow-up after hysterectomy is mandatory. Light vaginal bleeding is not unusual. Patients should use sanitary pads if needed and avoid vaginal douches or the use of tampons. Intercourse is not allowed for six weeks, and after being cleared at the follow-up check.

Bilateral oophorectomy in premenopausal women would cause an abrupt loss of ovarian hormones which may alter some fundamental aging processes at the cellular and system levels [21]. An association of bilateral oophorectomy with increased DNA methylation has been reported [22].

Other than DNA methylation studies, further new research is needed to investigate the association of bilateral oophorectomy with aging using brain imaging, in addition to physical and functional measures of balance, gait, limb strength, cognitive function, markers of Alzheimer's disease and of cerebrovascular disease [23].

#### **7. Present day issues**

Nowadays, newer surgical options and techniques include laparoscopic incisions, single umbilical incisions, and robotic-assisted procedures. Such minimallyinvasive hysterectomy approaches require a shorter hospital stay, with full recovery in four to six weeks.

Regarding hysterectomy for heavy and prolonged menstruation, endometrial curettage has been proven ineffective as a treatment as a reduction in bleeding

#### *Hysterectomy: Past, Present and Future DOI: http://dx.doi.org/10.5772/intechopen.103086*

may last for only one menstrual period and not after this. Curettage is utilized as a diagnostic procedure to determine the cause of the heavy bleeding.

The need to curette the uterus for histopathological purposes could be replaced by endometrial sampling where a fine plastic tube is passed inside the uterine cavity as an outpatient procedure. Vaginal ultrasound and hysteroscopy are the most commonly used procedures for reaching a histopathological diagnosis.

Endometrial ablation of the uterus is a day procedure, where a slightly lower proportion of women perceive improvement in bleeding symptoms, but it results in an improvement in pictorial blood loss assessment charts compared to their baseline score. Repeat surgery resulting from the failure of the initial treatment is more likely to be required after endometrial ablation than after hysterectomy, and the satisfaction rate is lower after endometrial ablation [24].

Regarding morbidity, it is more likely after hysterectomy. Women after endometrial ablation are less likely to experience sepsis, blood transfusion, pyrexia, vault hematoma and wound hematoma before hospital discharge, and a higher rate of infection after hospital discharge [24].

Unfortunately, not many clinicians are proficient in performing endometrial ablation, Alternatives to surgery include tranexamic acid in the first few days of heavy bleeding each month, progestogen tablets and progesterone impregnated intrauterine devices. In additions oral contraceptive pills and anti-prostaglandins may result in a sizable reduction in bleeding.

Second to menorrhagia, the most common reason for the hysterectomy is the presence of fibroids. Alternatives to hysterectomy that should be considered are laparoscopic myomectomy, myolysis and laparoscopic uterine artery ligation, and radiological uterine artery embolization. Hysterectomy remains an option for a small percentage where other modalities would have failed.
