by drseckin.com | Posted on May 14, 2020
by Tamer Seckin, MD
Endometriosis Excision Surgeon & Founder of Seckin Endometriosis Center (SEC)
Our specialists work with patients to understand symptoms, diagnosis, and treatment options for endometriosis.
With over three decades of experience in the field of GYN surgery, the Seckin Endometriosis Center is one of the pioneers in laparoscopic hysterectomy surgery while ensuring minimal invasion. We have been at the forefront of not only providing the proper technique for hysterectomies but also warning doctors and patients alike that the removal of the uterus should be performed with extreme diligence and only when absolutely necessary. They are performed in cases of multiple fibroids (40.7%), dysfunctional uterine bleeding (20%), uterine prolapse (14.5%), uncontrollable painful periods (10%), uterine cancer (9.2%), abnormal thickening of the endometrium, termed endometrial hyperplasia (2.7%), etc.. With endometriosis, a hysterectomy is necessary if the uterus is heavily involved with the disease, a condition called diffuse adenomyosis. However, it is common to see patients treated with an unnecessary hysterectomy by prior surgeons, only to experience persistent symptoms as lesions are left behind in the peritoneum, bowels, etc. It should be considered only by patients who do not respond to conservative surgical therapy (such as excision of endometriosis implants) and do not want to preserve fertility [2,3]. In other words, a hysterectomy should be a last resort and only performed if absolutely necessary and unavoidable. Regardless of whether a hysterectomy is necessary, it is imperative to also perform laparoscopic excision in order to examine and remove all other adhesions outside of the uterus. Laparoscopic excision of endometriosis lesions outside the uterus is the gold standard treatment and ensures patients their highest chance of symptom relief and recovery.
It is the surgical removal of the uterus (womb). A total hysterectomy includes the removal of the cervix. A supracervical hysterectomy preserves the cervix. Either way, it is a definitive surgical option and causes menstruation to cease.
The uterus, the source of monthly menstruation, also houses a developing fetus. In the absence of pregnancy, a typical woman has about 400 menstrual cycles during her reproductive life. The ovaries are the sites where egg development and subsequent ovulation take place, along with the production of estrogen and progesterone. Whereas estrogen prepares the lining of the uterus for pregnancy in the first 14 days of the cycle, progesterone then matures and prepares the endometrium between days 14 to 28 of a cycle for the first step of pregnancy, implantation. When an egg is fertilized by a sperm, the newly develop embryo travels down the fallopian tube and implants into the mature uterine lining. Then, the pregnancy continues to develop and is housed in the uterus for an average of nine months and ten days.
It is a commonly believed misconception that key reproductive hormones are made in the uterus. This is not true. The uterus is not responsible for the production of estrogen, progesterone, or any other hormones. The ovaries produce estrogen and progesterone and then feed these hormones into the uterus.
The removal of a uterus eliminates the function it serves, which is to host pregnancy development. Without the uterus, a woman will no longer have menstrual periods nor bear children.
According to the Center for Disease Control and Prevention (CDC), the United States has the highest rate of hysterectomy surgeries in the world, with more than 600,000 performed each year. In fact, approximately 300 out of every 100,000 women will undergo a hysterectomy at some point in their lives .
While a hysterectomy rate of 0.3% may not seem like such a large number, it is the second most common surgery performed on women in the United States after a C-section. Some of the most experienced surgeons in the world argue that hysterectomies are amongst some of the most overperformed surgeries in women’s health. A great number of hysterectomies are performed in order to ensure a patient will no longer suffer from disorders such as endometriosis. However, in most cases, a hysterectomy will not treat a patient's endometriosis. An endometriosis patient should always pursue laparoscopic excision surgery should first, and should only consider a hysterectomy if absolutely necessary. However, many doctors lack the experience, skill, and knowledge to perform laparoscopic excision surgery and thus settle on performing a hysterectomy. This is not a testament to how “good” or “bad” the doctor is, as they may not even be aware of this form of treatment. Nevertheless, this lack of knowledge is one of the primary reasons why hysterectomies are so common. If you decide to have a hysterectomy, it is crucial for you to make sure you have exhausted all other surgical methods and that there are no remaining endometriosis lesions in your body.
A hysterectomy should have justifiable indications. Pelvic pain, after all, may have multiple causes. In the absence of uterine disease, doctors and patients should be cautious in proceeding with a hysterectomy. In addition, pre-operative tests like MRIs do have false sensitivity in detecting uterine pathologies such as endometriosis or adenomyosis, thus any believed need for a hysterectomy based on such disorders should be confirmed with laparoscopic surgery. Nevertheless, there are several conditions where a hysterectomy is unavoidable:
|Endovaginal and abdominal sonogram||Intravaginal and abdominal ultrasound imaging will help confirm the presence and location of adenomyosis and fibroids, as well as help to determine the condition of the ovaries.|
|MRI and contrast||An MRI produces high-quality images of the body, which can give confirmation for a presumptive diagnosis of endometriosis, adenomyosis, and fibroids. This test allows your surgeon to visualize the status of the ureters, which serve as the kidney outlet to the bladder.|
|Dilation and curettage (D&C)||In the operating room, a surgeon will look inside your uterus with a video camera in order to rule out cervical or uterine cancer, diffuse adenomyosis, submucosal fibroids, or any other findings that call for a hysterectomy.|
The first laparoscopic hysterectomy was performed by Harry Reich in 1988 . Since then, the technique has evolved to ensure minimal invasion. Hysterectomies are performed via either the vagina or abdomen. An abdominal hysterectomy (with a surgery route through the abdomen) requires varying lengths of visible incisional scarring. A vaginal hysterectomy (with a surgery route through the vagina), provides almost no abdominal scarring and is today considered the best surgery route for a hysterectomy. However, not all uteruses can be removed via vaginal hysterectomy as the uterus may be too large, or the status of the ovaries and peritoneal disease may be unknown. There are limitations to vaginal hysterectomies. Nevertheless, in hysterectomy surgery, a laparoscope is used to visualize the uterus, ovaries, and pelvic cavity via very small incisions made through the abdomen. These incisions allow for the uterus to be removed from the vagina. The laparoscopy gives a surgeon complete visualization of the pelvic anatomy, allowing them to remove any believed abnormal pathology outside the uterus involving the ovaries and fallopian tubes that would not have been visualized if a normal vaginal hysterectomy was performed. Proper pelvic floor suspension techniques are also performed during this time in order to lower the chance of prolapse. This technique is called laparoscopically assisted vaginal hysterectomy (LAVH).
Many patients are surprised to hear that there are several different forms of hysterectomies. The uterus can be removed via the abdomen or vagina. However, aside from the route through which the hysterectomy is performed, there are specific techniques as to how the uterus is removed. While your doctor should always provide the best recommendation for your particular case, you should remember that you always have a choice. A hysterectomy is a very personal and emotionally-taxing surgery, and you should feel comfortable discussing your best option. Here are a few options that your surgeon may suggest if a hysterectomy is the right procedure for you.
A common misconception among patients concerns the difference between a partial and total hysterectomy. It is commonly believed that a partial hysterectomy involves the removal of the uterus while preserving the ovaries. A total hysterectomy is then believed to be complete removal of the uterus, along with the ovaries. However, what patients refer to as a total hysterectomy is what surgeons call a total hysterectomy with bilateral salpingo-oophorectomy (the removal of the fallopian tubes and uterus). In other words, the removal of the ovaries is not part of a hysterectomy procedure, unless specified. When patients hear the term hysterectomy, they should not be concerned about losing their ovaries unless bilateral salpingo-oophorectomy is specified. Nonetheless, doctors still use the term partial hysterectomy, but it refers to the removal of the upper half of the uterus, with the cervix preserved. To surgeons, a total hysterectomy means the removal of the uterus in its entirety, which includes the cervix. Therefore when a surgeon uses the terms “partial” vs. “total” hysterectomy, it is to identify whether or not the cervix will be preserved, as opposed to the public misperception of whether or not the ovaries are removed. In both partial and total hysterectomies, the ovaries are preserved unless specified.
One of the side effects of a hysterectomy is that a woman will no longer menstruate. However, this end to menstruation can bring on different symptoms depending on the form of hysterectomy surgery. When a partial or total hysterectomy is performed and the ovaries are preserved, estrogen and progesterone levels remain the same, and in turn “surgical menopause” takes place. A woman’s period stops due to the removal of the uterus, but menopause symptoms such as hot flashes, vaginal dryness, and mood swings do not occur as the ovaries remain. Because of the ovaries, female reproductive hormone levels are normal, and menopause symptoms do not surface. This is not the case in hysterectomies with bilateral salpingo-oophorectomies, where the ovaries are not preserved. Removing the ovaries means the loss of estrogen and progesterone levels, thus normal hormonal menopause begins. Strong consideration should be given to conserving normal ovaries when possible, so it is imperative to carefully consider whether to seek an oophorectomy with your hysterectomy.
The hysterectomy technique that is performed the day of your surgery can have consequential effects on the amount of scarring left behind and how long your hospital stay and recovery time maybe. Taking these factors into account, here is a list of the most successful hysterectomy surgeries arranged from most preferred to least:
No. A hysterectomy is not always necessary to achieve a comprehensive treatment for endometriosis. This is a common misconception among many physicians and we cannot stress it enough. First and foremost, the primary treatment of endometriosis should always be laparoscopic excision of all endometriotic lesions. Only in cases of endometriosis with diffuse adenomyosis, multiple fibroids with recurrence even after a myomectomy, and/or cervical or uterine cancer, is a hysterectomy needed. For a definitive treatment of endometriosis when hysterectomy is indicated, the operation should be tailored to relieve all symptoms and not just symptoms of suspected uterine origin. In other words, many surgeons misguidedly conduct hysterectomies in order to ensure the patient no longer suffers from further spreading of endometriotic tissue. However, the endometriotic lesions that have already spread throughout the body will go unremoved and therefore untreated. In cases of endometriosis requiring a hysterectomy, it is crucial that all extrauterine superficial and deep endometriosis is excised before a hysterectomy is conducted. This ensures that all possible causes of a patient's symptoms are treated.
The surgical choice for treatment of endometriosis with a hysterectomy depends on many factors, including the patient’s age, the severity of her symptoms, and whether she wants to have children. These are all key factors in decision-making. A thorough history and physical exam is warranted for determining many of these factors, as well as gauging the areas that may be affected in the pelvis. Diagnostic testing, such as ultrasound imaging and MRI, are also useful tools in determining if a hysterectomy is required, which is strictly in instances of diffuse adenomyosis with anterior and posterior cul-de-sac obliteration. Nevertheless, a hysterectomy alone will not definitively cure endometriosis if the tissues with endometriosis in the pelvis are not also removed. Only in cases where women with endometriosis no longer wish to have children, and conservative laparoscopic surgery has already been performed, is the definitive option made for a total hysterectomy with bilateral oophorectomy. But even in these cases, it is still crucial that their excision surgery is performed for all visually recognized and suspected endometriosis tissues along with the hysterectomy. Depending on the excision expertise of the surgeon, ovarian conservation may also be considered.
Once you and your physician have come to an agreement that a hysterectomy is the right surgery for you, you must prepare for the day of surgery. Any trip to the operating room can be a bit intimidating, so we like to inform our patients about what to expect before coming in for your hysterectomy.
Improper procedureIt is crucial to pick a hysterectomy procedure that suits your particular case. It is key to find a doctor who will have the patience and personability to have this type of discussion with you, while at the same time give you choices.
Many Large incisionsThe best surgeons can perform a hysterectomy while ensuring minimal invasion. Having small and few incisions are always more preferred over large and many as it gives a lower chance of post-surgical scarring.
Avoid Robotics!Never get sucked into the new and innovative treatments. Choose the best surgery: one that has the highest chance of success, while guaranteeing minimal invasion and high quality of care. In the case of cutting-edge technological treatments such as robotic surgery, there is a lower rate of success with larger incisions, and a higher number of incisions, than excision surgery performed in the hands of an experienced laparoscopic surgeon.
Inexperienced surgeonYour surgeon should have great experience in hysterectomies. Any experienced surgeon will not only be able to perform the right hysterectomy procedure for you, but also make you feel comfortable while doing so.
It usually takes a maximum of 6-8 weeks for a patient to heal following hysterectomy surgery, whether supracervical or total hysterectomy. Evidence has consistently shown that the majority of women have unchanged or improved sexual function 1 to 2 years after hysterectomy . Your surgeon should always go over proper postoperative care measurements in order to ensure you have a successful and time-efficient recovery period.
As one of the pioneers in the field of proper hysterectomy use, and with over three decades of experience, we have mastered our technique in order to ensure minimal invasion. We have found that the laparoscopic visualization required in proper uterus removal, can be done without large or many incisions to the abdomen. Our technique ensures minimal invasion, in great part due to our world-renowned expertise in the field. We do not resort to invasive techniques such as robotic surgery. By not using robotics, we are able to perform quicker, less risky, and overall more productive surgery. Our results are nearly scarless.
Another component of our hysterectomy technique that makes our approach so unique is our expertise in performing laparoscopically assisted vaginal hysterectomies (LAVH). Most surgeons are not able to do this, especially when it comes to cases of endometriosis, due to the great skill and experience it requires to be done successfully and without complications. Before the uterus can be removed, a vaginal hysterectomy requires a surgeon to separately detach the uterus from the ovaries, fallopian tubes, upper vagina, as well as all the blood vessels and connective tissue that support it. Even in cases of endometriosis and diffuse adenomyosis, we perform all hysterectomies vaginally if possible. We do this by first excising all endometriosis lesions we can find throughout the pelvic and abdominal cavity. By performing laparoscopically assisted vaginal hysterectomies, we are able to see above the uterus anatomically, giving us the ability to identify endometriosis lesions that would not normally be seen through a simple vaginal hysterectomy. Using this technique, we evaluate the peritoneum, cul-de-sac, and the uterus’s relationship with ovaries and bowels. Additionally, by removing the uterus through the vagina, we are ensuring minimal invasion. When an abdominal hysterectomy is performed, a greater number of incisions that are larger in size must be made in order to remove the uterus through the abdomen. We have worked tirelessly to master the technique of vaginal hysterectomy so we can ensure minimal invasion.
We firmly believe that whenever a hysterectomy is needed in cases of endometriosis, thorough laparoscopic excision surgery should precede this hysterectomy. If a patient is found to have believed endometriosis adhesions upon laparoscopic examination, all lesions should be excised out completely before the hysterectomy is conducted. We cannot tell you how many patients come in after having hysterectomies, only to find that their symptoms and pain have not been treated. If a patient has endometriosis, simply removing the uterus does not address the many other regions where endometriosis may remain. In fact, the patient will most likely continue to experience their symptoms as the disease spreads and pain worsens. We take the time in the operating room to ensure that all lesions and signs of endometriosis are excised, even before we begin to remove the uterus. When we go into surgery our primary goal is to not only remove the uterus but also ensure we are not doing so in vain. Our primary focus is always ensuring our patients their highest chance of symptom relief, and laparoscopic deep excision of endometriosis is the best way to do so, with a hysterectomy conducted only if needed.
The final aspect that makes our expertise in hysterectomy so unique is our strong belief that hysterectomies should only be performed when necessary. As stated before, so many surgeons perform hysterectomies without treating or even recognizing the multitude of areas where endometriosis lesions can still exist, grow, and spread. Not only do we recognize the futility of such procedures, but we also understand the emotional tax this can have on both the body and mind. Once the uterus is taken out, it cannot be put back in, and a woman can longer have children. This is why it can be such an emotionally difficult surgery to undergo and is why we use it as an absolute last resort. This same conservative practice determines what specific type of hysterectomy we determine is right for you. We always look to preserve the ovaries if possible. There is a potential increased risk of cardiovascular issues and bone loss in premenopausal patients with prophylactic bilateral salpingo-oophorectomy . As a result, hysterectomy and bilateral salpingo-oophorectomy is our last option. Nevertheless, this procedure can sometimes be needed. But even in those rare instances, we always have our patients' approval, understanding, and consent. We always want our patients to know that they have a choice when it comes to the sensitive field of hysterectomies.
Unfortunately, many surgeons who are not well versed in endometriosis, especially those with no experience or even awareness of deep-excision surgery, do not have this mindset. They simply tell their patients that the only solution to their ailment is to remove the uterus, which in many cases is either not true or not the full story. While these may seem like small nuanced details to the average physician, to an experienced laparoscopic excision surgeon they mark the difference of a pointless hysterectomy procedure versus a highly successful excision surgery, with the possibility of preserving the uterus. This meticulous attention to detail makes a monumental difference in not only patient symptom relief following surgery but also in the fact that a patient can be reassured if they are told a hysterectomy is required, as this decision is made after thorough examination and removal of all endometriosis lesions in the pelvic and abdominal cavity. To put it simply, there are no pointless hysterectomy procedures performed at Seckin Endometriosis Center.
Our goal is to always ensure that all endometriosis is excised out of the body. We want our patients to have the highest chance of symptom relief and recovery, both physically and mentally. We are extremely cautious in performing hysterectomies. No patient wants to hear that a hysterectomy is the only option for them. They want to be reassured that a hysterectomy is deemed necessary only after all other options have been considered. We want to work with you to obtain a comprehensive and thorough understanding of your particular case in order to see if a hysterectomy is truly the right option for you, and the first step is through communication.
E.L was a patient in her early 40’s who quietly struggled with adenomyosis for nearly two years. After consulting with two other physicians, she underwent successful supracervical hysterectomy treatment at Seckin Endometriosis Center. Learn about E.L’s story here.
You can read more stories of patients who received hysterectomies, at varying stages, in our testimonial section.
Medically reviewed by Tamer Seckin, MD on September 20, 2019
There aren’t enough stars for Seckin Endometriosis. They deserve 100/ 5. I want to make sure every woman right now who is looking for help, who is looking for a doctor and is scared and confused knows this is where you need to be. It doesn’t matter if you have to come from the other side of the United States or from the other side of the world, I can guarantee it will be worth it. Every member of their…
I’ve seen many obgyns over the years explaining my monthly symptoms during my period...but eventually it became a daily struggle with these pain. It feels like a poke here and there near my right pelvic region. I was given birth control pills for the past ten years but honestly, it didn’t help at all. I was in bed whenever I had my period. I was previously sent to GI doctors for possible appendicitis but it was ruled out from imagings…
Dr.Seckin is so much more than a surgeon. His passion for helping endometriosis sufferers and determination to improve the quality of life in all of his patients is undeniable. I remember when my gynecologist first told me I needed a laparoscopy. Her exact words were "I can do the surgery, but if you were MY daughter- I'd send you to him." From the first day I met him he took the time to explain endometriosis to me since I knew…
I was there for hysterectomy but then I found out that I also had endometriosis.My both surgeries went excellent and I feel great!.I am so thankful to Dr.Seckin and all his team for making my journey smooth!
I am a physician who suffered from deep infiltrative endometriosis. I needed laparoscopic surgery, so I went to see my former gynaecologist and he performed the procedure (a surgery which he supposedly does hundreds of times a year) last November. I had severe pain again when I had my period in January and was advised to go on taking a low hormone dose anticoncipient pill. My symptoms came back quickly and got worse in a few months’ time. I went…
After years of excessively painful periods, a serious loss of quality of life, and a series of uninformed and uninterested doctors, Dr. Seckin and Dr. Goldstein turned my life around. I was told I woke up from my surgery almost a year ago with a smile on my face, and I haven't stopped since. Before I heard of Dr. Seckin, I was experiencing almost daily terrible pain to the point where I had difficulty walking, inability to eat, inexplicable weight…
Dr Seckin and his team gave me back my life! Tomorrow will be 1 month since my surgery and I feel great. Dr. Seckin, Dr Liu, and Dr Goldstein are not only beyond words talented and amazing Doctors, but they are also genuinely wonderful and caring people. I cannot say enough great things about Holly, Asiye and Kim as well. They were all caring, kind, patient, and took the time to listen to me and explain anything I needed to…