Reader discussions regarding trends in minimally invasive hysterectomy

“CAN WE REDUCE THE USE OF ABDOMINAL HYSTERECTOMY AND INCREASE THE USE OF VAGINAL AND LAPAROSCOPIC APPROACHES?”
ROBERT L. BARBIERI, MD (EDITORIAL; NOVEMBER 2015)

Choose the best approach for the patient
I cannot decrease the number of abdominal hysterectomies I perform—all of them are indicated. 
Richard Hatch, MD
Augusta, Georgia

Supracervical hysterectomy: simplest is best
Supracervical hysterectomy (SCH) via a Pfannenstiel incision in women with a body mass index less than 25 kg/m² is a great procedure for uterine pathology. SCH addresses only the uterine pathology and preserves the cervix, is a sterile procedure, requires no ancillary equipment, should take less than 30 minutes, preserves the full length of the vagina, requires only an overnight hospitalization, and has a short learning curve.

Removal of the cervix in any hysterectomy is the procedure that results in bladder and ureter injury and infection from contamination. Patients should be driving and back to nonphysical jobs in less than 1 week. As medical care becomes a truly transparent market-based business, patients will opt for SCH over higher priced alternatives. Sometimes the simplest procedures are still the best.
Joe Walsh, MD
Philadelphia, Pennsylvania

Continue to teach abdominal hysterectomy
No one can disagree with the statistics of shorter recovery and less morbidity for laparoscopic and vaginal procedures. In fact, what separates a gynecologist from other surgeons is the ability to operate in and through the vagina. There is still a place for abdominal hysterectomy for benign disease in modern gynecology.

Most programs produce good laparoscopic surgeons but ill prepared abdominal and vaginal surgeons. No gynecologist should be operating in the pelvis unless he or she is comfortable going into the retroperitoneal space if necessary. Many of the total laparoscopic hysterectomies that are performed could be done vaginally without abdominal incisions.

Now we have a generation of gynecologic surgeons who believe a robotic hysterectomy (at great extra expense) offers the patient an advantage, despite longer anesthesia and procedure times. We know morbidity has a direct correlation to operating and anesthesia time. Although I am impressed with what the next generation can do through a laparoscope, I would hate to let them continue without the experience or the ability to do an open abdominal procedure.
Allan N. Boruszak, MD
Washington, North Carolina

Dr. Barbieri’s response
I appreciate the perspectives of Drs. Hatch, Walsh, and Boruszak on the important issue of improving hysterectomy outcomes. Dr. Hatch raises the important point that gynecologists routinely select the best surgical approach for the unique needs of their patients. Based on a given gynecologist’s panel of patients and their unique medical issues, it may be difficult to change the distribution of surgical approaches to hysterectomy. Dr. Walsh advocates for a “minimally invasive” abdominal SCH, which is a valid approach to improving the outcomes of the abdominal approach. Dr. Boruszak rightly highlights the importance of teaching gynecologists to access the retroperitoneum, paravesical, and pararectal spaces in order to improve patient outcomes.

“VAGINAL HYSTERECTOMY WITH BASIC INSTRUMENTATION”
BARBARA S. LEVY, MD (OCTOBER, 2015)

Appreciates the instrument review
Dr. Levy’s article on vaginal hysterectomy using basic instruments is really wonderful. The segment on uterine reduction strategies will be especially useful. I appreciate her preference to use the Ligasure vessel-sealing device over suturing pedicles. Before we take steps to debulk the uterus, it is always essential, and better, to ligate uterine vessels, as this minimizes blood loss and makes the surgical field clearer.
R. Sasirekha
Puducherry, India

Skill should be rewarded
When I trained, vaginal hysterectomy was reserved for prolapse. After joining the Army, my eyes were opened by physicians who could morcellate a 16-week uterus or perform a 20-minute vaginal hysterectomy on a nulliparous woman for sterilization (which, of course, is controversial).

Once in private practice, incorporating these new skills into my own techniques was challenging and rewarding. Imagine my disappointment when I found out that reimbursement was a disincentive. It is easy to be altruistic, but one has to consider the incentives, too. Skill should be rewarded.
Mark B. Vizer, MD
Lansdale, Pennsylvania

A long-time proponent of vaginal hysterectomy
I appreciate the articles by Drs. Levy and Gebhart on vaginal surgical techniques. I have long been a proponent of vaginal hysterectomy as the preferred route for removal of the uterus (and tubes and ovaries, if indicated). I do most of my hysterectomies vaginally, with salpingectomies and oophorectomies if indicated. As an older surgeon, I now refer patients with uteri larger than 16 weeks, endometriosis, or suspected cancer.
Doug Tolley, MD
Yuba City, California

Share your thoughts! Send your Letter to the Editor to rbarbieri@frontlinemedcom.com. Please include your name and the city and state in which you practice.