A hysterectomy removes the uterus through one of several surgical approaches, each involving different incision locations, recovery times, and levels of invasiveness. The specific method depends on why the surgery is needed, the size of the uterus, and your surgeon’s expertise. Here’s what actually happens before, during, and after the procedure.
Types of Hysterectomy
Not every hysterectomy removes the same organs. The type you have determines what stays and what goes, which has real consequences for hormones, cancer screening, and recovery.
- Supracervical (partial) hysterectomy: Removes only the upper portion of the uterus, leaving the cervix in place. Because the cervix remains, you’ll still need regular Pap smears. The ovaries and fallopian tubes may or may not be removed at the same time.
- Total hysterectomy: Removes both the uterus and cervix but leaves the ovaries. This is the most common type.
- Total hysterectomy with bilateral salpingo-oophorectomy: Removes the uterus, cervix, both fallopian tubes, and both ovaries. If you haven’t already gone through menopause, losing both ovaries triggers it immediately.
- Radical hysterectomy: Removes the uterus, cervix, fallopian tubes, ovaries, the upper portion of the vagina, surrounding tissue, and nearby lymph nodes. This is typically reserved for cancer cases.
Three Surgical Approaches
Regardless of which organs are removed, the surgery itself is performed through one of three routes: abdominal, vaginal, or laparoscopic. Both vaginal and laparoscopic approaches are considered minimally invasive because they avoid a large abdominal incision, which generally means shorter hospital stays and faster recovery.
Abdominal (Open) Hysterectomy
The surgeon makes an incision across the lower abdomen, typically along the bikini line or vertically from the navel downward. This gives the widest view of the pelvic organs and the most room to work, which is why it’s often chosen when the uterus is very large, when there’s significant scar tissue from previous surgeries, or when cancer is suspected and the surgeon needs to examine surrounding tissue closely. The tradeoff is a longer recovery and more post-operative pain compared to minimally invasive options.
Vaginal Hysterectomy
The entire surgery is performed through the vaginal canal with no external incisions at all. The surgeon makes a cut at the top of the vagina, detaches the uterus from its supporting ligaments and blood supply, and removes it through the vaginal opening. This approach works best when the uterus is a normal size and the reason for surgery is benign. It typically causes the least post-operative pain and leaves no visible scars.
Laparoscopic and Robotic Hysterectomy
In a standard laparoscopic hysterectomy, the surgeon inserts a thin camera and specialized instruments through several small incisions in the abdomen, each roughly 1 to 2 centimeters long. The camera provides a magnified view of the pelvic organs on a screen, and the surgeon works through these small ports to detach and remove the uterus.
Robotic-assisted hysterectomy uses the same small incisions but adds a layer of technology. The surgeon sits at a console a few feet from the patient, viewing a high-definition 3D image of the surgical area while controlling robotic arms that hold the instruments. These arms replicate the surgeon’s hand, wrist, and finger movements with greater range of motion and steadiness than the human hand alone. This added precision can be particularly useful for complex cases that would otherwise require an open approach. Every maneuver is still controlled entirely by the surgeon.
What Happens During the Surgery
You’ll be under general anesthesia for the procedure. Once the surgical approach is established, the core steps are similar regardless of the route. The surgeon works through a careful sequence of isolating, sealing, and cutting the structures that hold the uterus in place.
First, the blood supply is addressed. The uterus receives blood from the uterine arteries and from vessels running through the surrounding ligaments. The surgeon seals these blood vessels using heat (cauterization) before cutting through them. The round ligaments, which anchor the uterus to the pelvic wall, are cauterized and cut on both sides.
If the fallopian tubes are being removed, the surgeon carefully separates them from the nearby ovarian blood vessels. If the ovaries are being preserved, the connections between the ovaries and the uterus are isolated and cut while keeping the ovarian blood supply intact. If the ovaries are being removed, a different set of ligaments carrying the ovarian blood supply is sealed and divided instead.
Throughout the procedure, the surgeon monitors the location of the ureters, the thin tubes that carry urine from the kidneys to the bladder. These run very close to the uterine blood vessels, and pulling the uterus upward during key steps increases the distance between them, reducing the risk of accidental injury.
Once all supporting ligaments and blood vessels have been sealed and divided, the surgeon makes a circular incision at the top of the vagina (called a colpotomy) to separate the uterus from the vaginal canal. The uterus is then removed, either through the vagina or, in laparoscopic cases, sometimes through one of the abdominal ports after being divided into smaller pieces. Finally, the top of the vagina is stitched closed.
Risks and Complications
Hysterectomy is one of the most commonly performed surgeries and is generally safe, but it does carry risks. The most closely tracked complication is accidental injury to the ureters or bladder. A large review of over 223,000 hysterectomy patients found ureteral injury occurred in about 0.78% of cases. The risk varies by approach: vaginal hysterectomy carries the lowest rate (0.02% to 0.5%), abdominal falls in the middle (0.03% to 2.0%), and laparoscopic has the widest range (0.02% to 6.0%, though a systematic review narrowed this to 0.02% to 0.4%).
Other possible complications include infection, bleeding requiring transfusion, blood clots, and reactions to anesthesia. These risks are relatively low for all approaches but tend to be lower overall with minimally invasive methods.
Hormonal Effects After Surgery
If both ovaries are removed and you haven’t yet gone through menopause, you’ll enter what’s called surgical menopause immediately. This can cause hot flashes, mood changes, vaginal dryness, and other menopausal symptoms, often more abruptly and intensely than natural menopause because hormone levels drop suddenly rather than gradually.
If the ovaries are left in place, the picture is more nuanced than many people expect. Ovarian function is preserved, so in theory the hormonal impact should be minimal. However, research tells a more complicated story. One study of 104 women who had a hysterectomy without ovary removal found they experienced higher rates of severe menopausal symptoms (about 2.4 times more likely) and sleep disturbances (about 1.75 times more likely) compared to women who hadn’t had the surgery. Some evidence also suggests the procedure may be associated with earlier onset of natural menopause, though this remains debated.
Preparing for the Procedure
Before surgery is scheduled, you’ll go through pre-operative testing to confirm you’re healthy enough for the procedure and anesthesia. This commonly includes blood tests to check kidney function and blood cell levels, a swab test to rule out infections, and an ECG to check heart health. Depending on your age and medical history, you may also have lung function tests or a chest X-ray. The specific workup varies, but the goal is to catch any issues that could complicate surgery or recovery before you’re on the operating table.
Recovery Timeline and Restrictions
Recovery differs significantly based on the surgical approach. After an open abdominal hysterectomy, most people stay in the hospital for one to two nights and need six to eight weeks before returning to normal activities. Minimally invasive approaches (vaginal, laparoscopic, or robotic) typically involve a shorter hospital stay, often just one night or even same-day discharge, with a return to normal activities in three to four weeks.
Regardless of approach, the restrictions during recovery are similar. For at least six weeks, you should not lift anything over 10 pounds. That includes laundry baskets, grocery bags, children, and pets. Pushing heavy doors or grocery carts and vacuuming also fall into this category. Nothing should be placed in the vagina for at least six weeks after surgery, including tampons, and sexual intercourse is off limits during this period as well. This allows the incision at the top of the vagina to heal fully.
Walking is encouraged early and often, usually starting the day of surgery. Most people can drive again once they’re off pain medication and can comfortably check their blind spot, which is typically one to two weeks after minimally invasive surgery and closer to three to four weeks after an open procedure.