Determining the best route for hysterectomy
Once a hysterectomy is indicated for the treatment of gynecologic disease, the surgeon must determine the safest and most efficient route—abdominal, vaginal, or laparoscopic-assisted vaginal. Here, the authors outline each approach, including patient selection, technical pearls, and advantages and disadvantages.
Kovac reported a standard protocol for selecting the route for hysterectomy. Uterine size, other pelvic pathology (endometriosis, adnexal disease, chronic pain, etc.), and uterine and adnexal accessibility (bony architecture, uterine support, and vaginal diameter) were each considered in the decision-making. A simplification of Kovac’s guidelines applicable to women undergoing hysterectomy for benign indications is summarized in Figure 3. Using these guidelines, Kovac reported a 99% (608/611) success rate for women assigned to VH or LAVH. The laparoscope was deemed necessary in only 19% of those assigned to the LAVH group, and ultimately only 9 patients required AH, yielding a 1:68 ratio for AH to VH.14
Gynecologists should seek alternatives to AH given its less favorable outcome in terms of morbidity and recovery. However, the surgeon who is competent with AH better serves the patient by performing the procedure via this route than by attempting an alternative procedure without the necessary proficiency. In other words, pelvic surgeons must be cognizant of their abilities and practice within that realm. Ultimately, the final selection of hysterectomy route should be based on the surgeon’s experience, the indication for surgery, and the patient’s anatomy.
FIGURE 3Guidelines to determine route of hysterectomy.
The authors report no financial relationship with any companies whose products are mentioned in this article.
