Answer: Hysterectomy (from the Greek word for womb, hustera) is the second most frequent surgery performed on women in the United States. Cesarean section for child birth is the most frequent. In the Asheville area, some 800 women each year undergo hysterectomy to remove an unhealthy uterus or cervix or as part of pelvic reconstructive surgery (repair of fallen or leaking bladder).

Many patients leave this decision solely to their surgeon which, depending on training or experience, leads to the more traditional route of hysterectomy about 75 percent of the time. Although easier for the surgeon to perform, it generally is more painful, takes longer, has a higher complication rate, leaves more wound scar, requires more time in the hospital and leads to a longer recovery period.

The main indications for the TAH route are invasive cancer or extremely large tumors or cysts of the pelvic organs, which are actually the least common reasons for needing a hysterectomy.

In 1992, technological advances in surgical devices such as laser, fiber optics and video laparoscopy (a narrow tube inserted through the abdominal wall with a lens and camera attached) allowed local gynecologists to perform the first LAVH in North Carolina here in Asheville.

This became the next most common route and is less invasive than the TAH (four small abdominal stab wounds compared to a 4-inch incision), thus reducing post-operative pain, hospital stay and recovery time.

The new procedure increased cost and operating room time and didn't decrease the complication rate. But some surgeons who became skilled with this procedure soon learned that the laparoscope was really a tool to help them become better vaginal surgeons and thus proceed in the first place to the least invasive of all the routes, the vaginal hysterectomy.

The LAVH is still indicated when there is severe endometriosis or extensive scarring in the pelvis. The most current studies on routes of hysterectomy don't support using the laparoscope just to leave the cervix (the opening of the uterus) behind (laparoscopic supracervical hysterectomy).

The resurgence of interest in the vaginal hysterectomy has been driven by more informed patients who realize that for the most common indication, excessive bleeding and cramping from fibroids, the vaginal route offers the only noninvasive approach to the surgical site (no incision or abdominal stab wounds).

Historic objections to this route such as previous Cesarean sections, absence of a vaginal birth and the need to remove ovaries at the same time are no longer valid. Even if the uterus is very enlarged from tumors, it still can be removed through the vagina by using a technique called morcellation (removing the uterus in small pieces) without damaging the vagina.

Today, experienced vaginal surgeons can utilize this route the majority of the time and provide improved safety and cosmetic results while decreasing pain, expense, complication rates, operating room, hospital and recovery time.

The public is invited to submit questions to Ask the Doctor, c/o Buncombe County Medical Society, 304 Summit St., Asheville, NC 28803 or by e-mail to askthedoctor@bcmsonline.

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