Go Minimally Invasive for Most Hysterectomies : Taking a vaginal or laparoscopic approach is best, except in a few specific, defined circumstances.

December 1, 2010|Family Practice News

Indeed, both AAGL and ACOG – as well as the American Board of Obstetrics and Gynecology – are exploring ways to improve training at the residency level, where currently the amount of exposure to minimally invasive hysterectomy procedures varies considerably from one program to the next, and is often quite low. This contrasts with general surgery, where completion of a didactic and clinical program “Fundamentals of Laparoscopic Surgery” is now a requirement of residency training.

“Developing something similar for gynecology is one of the AAGL's current initiatives,” Dr. Loffer said.

Movement also could come from the payer side. AAGL has had discussions with private insurers expressing interest in such approaches as “incentivizing” patients via lower co-pay to choose surgeons who do minimally invasive procedures. The AAGL provides a registry of qualified surgeons, the Council of Gynecologic Endoscopy (www.aagl.org/CGE

Dr. Iglesia noted that on the Medicare side, a recent change in the hysterectomy CPT codes giving a greater relative value unit for removal of uteri greater than 250 grams either vaginally or laparoscopically means higher payment. “That should incentivize a bit. … They are trying.”

According to the AAGL statement, the 66% abdominal hysterectomy rate in the United States contrasts dramatically with some European countries in which the proportion is less than 25%. Some insight to the attitudes of American practitioners can be found in the results of an online/paper survey conducted by Dr. Jon I. Einarsson of Brigham and Women's Hospital, Boston, and his associates (J. Minim. Invasive Gynecol. 2010;17:167-75).

Of the 1,500 randomly sampled practicing obstetrician-gynecologists surveyed, 376 responded. Among those, the most commonly performed hysterectomy procedure in the previous year was AH (84%), followed by VH (76%). But when asked to rank which hysterectomy approach they would prefer for themselves or their partner, 56% ranked VH as their first choice and 41% ranked LH as their first choice, with only 8% opting for AH.

When asked about barriers to performing minimally invasive procedures, the most common ones reported for VH included technical difficulty, potential for complications, and personal caseload. For LH, respondents cited lack of training, technical difficulty, personal surgical experience, and operating time as barriers.

Nonetheless, when asked about their ideal goal for mode of access, the respondents felt on average that minimally invasive techniques should comprise 79% of all hysterectomy procedures.

Not surprisingly, the survey also revealed that gynecologic surgeons who had a high surgical volume were more likely to feel comfortable offering a minimally invasive hysterectomy to their patients.

“This suggests that more emphasis needs to be placed on training opportunities … given the desire among practicing gynecologists to change their surgical mode of access,” Dr. Einarsson and his associates concluded.

Dr. Loffer declared that he owns stock in Johnson & Johnson and Interlace Medical. Dr. Iglesia, and Dr. Einarsson and his coauthors all stated that they had no disclosures.