Laparoscopic hysterectomy Information for patients, relatives and carers Introduction This information sheet has been provided to help answer some of the questions you may have about laparoscopic hysterectomy.

What is a laparoscopic hysterectomy? Laparoscopic hysterectomy is the surgical removal of the uterus (womb) where all the surgery is performed through three or four very small incisions (cuts). Sometimes your ovaries may need to be removed. This will be discussed with you by your hospital doctor. This is also known as keyhole surgery. It is done to help women who have: heavy periods or irregular bleeding, when other treatments have failed benign (non-cancerous) growths in the womb severe and/or recurrent pelvic infections endometriosis, when other treatments have failed cancer of the womb, ovaries or cervix (neck of womb)

What are the risks associated with laparoscopic hysterectomy? As with any operation, there are risks. Specific to this operation, there is a risk of: Minor infection Wound breakdown, i.e. when the wound does not heal well. This is temporary Wound haematoma (bruising under the skin) Haemorrhage (internal bleeding) Injury to the bladder or ureter Deep vein thrombosis (DVT) , also known as blood clots Pulmonary embolism (blood clot on the lungs) p1

Injury to the bowel Having to convert the operation into a laparotomy, which is an ‘open’ operation where a larger cut is made across the lower abdomen (tummy) The incisions are very small and therefore there is much less pain after surgery compared to an open operation. This makes it easier for you to start moving around again afterwards and get back to normal more quickly. We take many steps to keep the risks we have described to a minimum. For example: We give you antibiotics to prevent infection and the procedure is carried out in sterile conditions We ask you to wear special support stockings and to take medication to thin the blood, as this helps to prevent the formation of blood clots Your anaesthetist (a specialist doctor) will see you before the operation to check that you are fit for the operation and the anaesthetic.

Are there any alternatives to keyhole surgery? This varies from woman to woman, as not all patients can have keyhole surgery. If this is the case, the alternative procedure is an open operation (laparotomy) where a larger cut is made across the lower tummy. Please discuss the options available to you with your hospital doctor.

Will there be a scar? There will be three or four very small cuts on your tummy (one at your navel - belly button - and the other two or three lower down, just above the pubic hair line). The wounds will be closed together after the operation using stitches or dissolvable sutures.

What about losing my fertility? If both ovaries and the womb are removed, this will result in loss of fertility. At any age, having to have your ovaries removed can affect the way a woman feels about herself, particularly if this occurs at an early age. The loss of fertility can have a huge impact if you planned to have children and you have an operation that takes that choice away. Depending on the extent of your surgery, you may want to make sure that you have explored all your options. It is important that you have the opportunity to discuss this with the hospital doctor/surgeon or the gynaecological specialist nurse (also known as key worker) before your operation. If appropriate, advice is also available from our specialist fertility team and premature menopause team. If you wish, we can also refer you to other support organisations, as well as to a counsellor.

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Will I need hormone replacement therapy (HRT)? You may be offered HRT if you have both your ovaries removed and you have not already been through the menopause. HRT is available in many forms – as an implant, patches (similar to nicotine replacement patches), tablets, gels, sprays and vaginal creams. Potential symptoms can also be managed using ‘alternative’ remedies such as herbal based medication. Please discuss the options available to you either with the gynaecology team, before you are discharged from hospital, or with your GP.

What happens before my operation? Make sure that all your questions have been answered to your satisfaction and that you fully understand what is going to happen to you. You are more than welcome to visit the ward during visiting hours and meet the staff before you are admitted to hospital. Just ask your gynaecological specialist nurse/key worker or a clinic nurse to arrange this for you. An enhanced recovery programme (ERP) has been established at Imperial College Healthcare NHS Trust for patients undergoing surgery. It aims to reduce complications and the length of your hospital stay. An important part of this programme of care is your understanding of how you, and possibly your family and friends, can play an active part in your recovery. An appointment at the pre-admission assessment clinic will be arranged with you a week before your operation date. The pre-admission assessment appointment is to ensure that you are medically fit for the operation. This will involve taking a full medical history and ordering any tests that you may require to prepare you for your operation, such as a blood test, chest x-ray or ECG (recording of your heart). If you take blood-thinning medications (such as warfarin or aspirin) and/or you are allergic to any medications, please tell the doctor or nurse at your pre-admission assessment appointment. If you are a smoker, it would benefit you greatly to stop smoking or cut down before you have surgery. This will reduce the risk of chest problems as smoking makes your lungs sensitive to the anaesthetic. You should also eat a balanced diet and if you feel well enough, take some gentle exercise before the operation as this will help your recovery afterwards. Your GP, his/her practice nurse or the doctors and nurses at the hospital will be able to give you further advice about this. You may be referred to a dietitian if you are having problems eating or maintaining your weight. Before you come into hospital, try to organise things ready for when you return home. If you have a freezer, stock it with easy-to-prepare food. Arrange for relatives and friends to do your heavy work (such as housework, changing your bed sheets, vacuuming, gardening and shopping) and to look after your children if necessary. You may wish to discuss this further with the gynaecological specialist nurse/key worker if this is a problem. A social services assessment may be suggested if you feel you need further support at home to recover from the operation.

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Consent You will be asked for your consent before your treatment begins. Your doctor and/or gynaecological nurse specialist/key worker will carefully explain the procedure involved. Details will vary according to each individual case. No medical treatment can be given without your written consent. If you do not understand what you have been told, let the staff know straight away, so they can explain again. You may also find it useful to write a list of questions before your appointment and to have a relative or friend with you to help you remember the discussion when the treatment is explained. All clinical communications copied to your GP may also be sent to you at your request, please discuss this with your gynaecological nurse specialist/key worker.

What happens on the day of the operation? On the day of your admission, please bring all the medication that you take regularly. You will be admitted to hospital on the day of your surgery, unless your hospital doctor recommends you should be admitted the day before due to a medical reason (such as diabetes, heart problems etc.). Your temperature, pulse, blood pressure, breathing rate, height, weight and urine will be measured. A blood sample will be taken to check that you are not anaemic. The anaesthetist (specialist doctor) who will be putting you to sleep for the operation will also come to see you. He/she may prescribe a ‘pre-med’ for you to take one hour before surgery to help you relax and make you sleepy. We will give you special stockings to wear and start you on heparin injections to prevent blood clots (DVT) from forming in your legs following surgery. This will be discussed with you by your hospital doctor. The physiotherapists will also show you some useful exercises to do after surgery. You may be given an enema (a small sachet of medication) or suppository to help you empty your bowels. We will ask you not to eat or drink anything for at least six hours before your operation is scheduled to take place. This will be discussed further with you at the pre-admission assessment clinic. Please have a shower or bath before going to the operating theatre. All make-up, nail varnish, jewellery (except wedding rings, which can be taped onto your finger), body piercings and dentures must be removed. One of the nurses will then take you to the operating theatre.

What happens after the operation? You will wake up in the recovery room before you are taken back to the ward. It is common to have some discomfort in the shoulder tip. This is due to the gas that was introduced into your abdomen during the operation pressing on the nerve pathway to the shoulder. Any discomfort will go over the next few days as the gas is absorbed or passed naturally by your body. p4

You may also have trouble opening your bowels for the first few days after the operation. This is temporary and we can give you laxatives if you need them. You may feel light-headed or sleepy after the operation. This is due to the anaesthetic and may continue until the next morning. You may have a ‘drip’ attached to your hand/arm to provide you with fluids and prevent dehydration in the meantime. It is important that you start to drink and eat a few hours after your operation and we will encourage you to walk to the ward dining room for all meals. There is no restriction on the type of food you can have. You will also have protein or milk drinks every day until you are ready to go home to help you recover and your wound heal better. A catheter (tube) may be inserted into your bladder to drain urine away and allow you to rest more easily. This will need to stay in for one day. You may have some light vaginal bleeding, but this does not usually last for more than a few days. You may also have a blood-stained discharge, which may last for up to two weeks. You may have a sore throat for two or three days after having a general anaesthetic. This sometimes happens because the anaesthetist has to pass a tube down your windpipe to give you the anaesthetic gases that keep you asleep during the operation. You will have a 1cm (half an inch) wound in your umbilicus (‘belly button’) and two or three smaller wounds on your tummy. The wounds will have been closed with sutures (stitches), which will dissolve. We will encourage you to do gentle leg and breathing exercises to help with circulation and prevent chest infections. The physiotherapist will help and advise you with this. He/she will also encourage you to get out of bed and start moving around as soon as possible, as this will help with your recovery. Pain Please tell us if you are in pain or feel sick. We have tablets/injections that we can give you as and when required, so that you remain comfortable and pain free. However, the anaesthetist (specialist doctor) may suggest that you have a device which you use to control pain yourself. This is known as a ‘PCA’ (patient-controlled analgesia) pump and you will be shown how to use it. The anaesthetist (specialist doctor) may also discuss the use of an epidural as an option. This is a method of pain relief commonly used during childbirth and also for people with back pain, and is an injection in the back.

Is it normal to feel weepy or low in mood afterwards? Yes. It is a common reaction to the diagnosis, the operation and to being away from your family and friends. Advice and support of your friends, family, GP, gynaecological specialist nurse/key worker or support groups may be able to help you. If these feelings persist, please speak with your nurse who can put you in touch with a counsellor or other relevant services. Details of these can be found in the back of this booklet.

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When can I go home? You will be in hospital for one to two days after your operation. You will be supplied with anti-clotting injections to take home. You will be shown how to inject yourself before you leave. Please discuss this with the nurse. Please arrange for someone to come and collect you by car or accompany you in a taxi on the day of your discharge home, as you will not be able to drive yourself or travel on public transport. If you have been prescribed medication during your stay in hospital, the nursing staff will give you a supply of this to take home with you.

Is there anything I need to watch out for at home? Please contact your GP, gynaecological specialist nurse/key worker or go to your nearest accident & emergency (A&E) department if you have: excessive redness or discharge around the wound site a high temperature or fever (38°c or above) heavy vaginal bleeding a smelly discharge from the vagina or wound pain or swelling in your calves or the veins in your legs difficulty in breathing

What happens when I leave the hospital? After a laparoscopic hysterectomy, you can quickly return to most of your usual activities. It is normal to feel tired when you go home. However, your energy levels and what you feel able to do will increase with time. This is individual, so you should listen to your body’s reaction and rest when you need to. This way, you will not cause yourself any harm. Avoid lifting or carrying anything heavy (including children and shopping) for about four to six weeks after your operation. Vacuuming and spring cleaning should also be avoided until you have had your check-up at the hospital. You should avoid aerobic exercise, jogging and swimming until advised otherwise, but should continue with the exercises that the physiotherapist showed you. Try to eat a balanced diet and rest as much as possible, accepting all help that is offered to you. Continue with gentle activities, such as making drinks, light dusting and washing up, gradually increasing your level of activity. Gentle exercise such as walking is an important part of your recovery after surgery.

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When can I start driving again? You can start to drive again once you are able to do an emergency stop without discomfort. This is usually between ten days and two weeks after the operation It is important to inform your insurance company that you have had an operation to ensure that you are covered in the event of an accident. You should also make sure that you are not drowsy from any painkillers and that your concentration is good.

When can I return to work? Most women feel able to return to their normal activities two to three weeks after surgery and are back at work within a month. However, this depends on your individual recovery, how you feel and the type of work and activities you normally do.

When can I have sex? We advise you not to have sex until you have your first check-up or for at least four weeks after surgery. During this time, it may feel important for you and your partner to maintain intimacy (such as kissing, stroking etc.), despite refraining from sexual intercourse.

Will I need to visit the hospital again? Yes, for a check-up in the outpatient clinic about two to six weeks after your operation. We will either give you an appointment before you leave or post one to you. You will receive an appointment to attend the gynaecological outpatient department to check your wound is healing well, give you your final results and discuss whether further treatment is needed. Routine cervical smear tests are usually not necessary after the hysterectomy operation as the cervix will have been removed. It is important that you make a list of all medicines you are taking and bring it with you to all your clinic appointments. If you have any questions at all, it may help to write them down as you think of them. It may also help to bring someone with you when you attend your outpatient appointments.

Chaplaincy services Hospital chaplains representing the major world faiths are appointed by the Trust. The chaplaincy service provides pastoral and spiritual support for patients, relatives, friends and staff. Please tell your key worker if you would like a chaplain of your faith to visit you. For details of chapel services, please contact the chaplaincy service on 020 3313 4574.

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Contacting the hospital Gynaecological cancer nurse specialists/key workers Monday to Friday, 9.00-17.00 020 3313 3317 020 3313 5133 020 3313 5291 If the nurse is not available to take your call, please leave a message on the answerphone. We aim to reply within 24 hours of receiving a message. If you leave a message after 4 pm, we will reply the next day. Macmillan counsellor

Monday to Friday, 9.00-17.00 Charing Cross Hospital 020 3311 1629 Hammersmith Hospital 020 3313 4194 Victor Bonney ward 020 3313 5117 Gynaecology outpatient clinic Monday to Friday, 8.30-16.30 020 3313 5125 Reproductive medicine Monday to Friday, 7.00-17.00 020 3313 8187

Other sources of information Macmillan Cancer Support Helpline This is a free line for people affected by cancer who have questions about cancer, need support or just someone to talk to. It is open from Monday to Friday, 09.00 – 20.00 (interpretation service available). Telephone: 0808 808 0000 Gynae C Gynae C aims to support women with any form of gynaecological cancer, their partner, family and friends. This charity offers confidential, emotional support via a telephone helpline, email, letters and website to all contacts: Website: www.gynaec.co.uk/ Telephone: 01793 491116 Macmillan Cancer Information and Support Service at Charing Cross Hospital The information centre provides vital emotional and practical support to anyone affected by cancer, every step of the way. Our highly skilled and dedicated Macmillan information specialist is p8

here to answer your questions about cancer. We can also signpost to other ways of getting the support you need. The service is set in a warm, friendly and confidential environment and is located on the ground floor of Charing Cross Hospital. The centre is open (except bank holidays): Monday and Friday 9.00-17.00 Tuesday, Wednesday, Thursday 9.00-16.00 Telephone: 020 3313 0171 Maggie’s Cancer Caring Centre Maggie’s is a cancer charity that provides emotional, practical and social support that people with cancer may need. The centre combines striking buildings, calming spaces, professional experts offering professional support, and the ability to talk and share experiences with a community of people who have been through similar experiences. Maggie’s West London is located in the grounds of Charing Cross Hospital, but please note it is independent of our hospital. The centre is open Monday–Friday, 9.00-17.00. For more information please call 020 7386 1750.

How can I make a comment about my procedure or hospital stay? We aim to provide the best possible service and staff will be happy to answer any questions you may have. However, if your experience of our services does not meet your expectations and you would like to speak to someone other than staff caring for you, please contact the patient advice and liaison service (PALS) on 020 3313 3322 or 020 3313 0088 (Charing Cross and Hammersmith hospitals), or 020 3312 7777 (St Mary’s Hospital). You can also email PALS at [email protected]. The PALS team are able to listen to your concerns, suggestions or queries and are often able to help sort out problems on behalf of patients. Alternatively, you may wish to express your concerns in writing to: The chief executive Imperial College Healthcare NHS Trust Trust Headquarters The Bays, South Wharf Road London W2 1NY

Alternative formats This leaflet can be provided on request in large print, as a sound recording, in Braille, or in alternative languages. Please contact the communications directorate on 020 3312 5592.

Gynaecology and reproductive medicine Published: July 2012 Review date: July 2015 T0117 © Imperial College Healthcare NHS Trust

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