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Hysterectomy: Which route for which patient?

The vaginal route—with or without laparoscopic assistance—is often preferable to laparotomy, but much less common.


  • Editorial We are at the tipping point



  • Moderator Mickey Karram, MD, Director of Urogynecology, Good Samaritan Hospital, Cincinnati, and Professor of Obstetrics and Gynecology, University of Cincinnati, Ohio.
  • Tommaso Falcone, MD, Professor and Chairman, Department of Obstetrics and Gynecology, Cleveland Clinic, Cleveland, Ohio.
  • Thomas Herzog, MD, Director, Division of Gynecologic Oncology, Physicians and Surgeons Alumni Professor, Columbia University Medical Center, New York City.
  • Barbara S. Levy, MD, Medical Director, Women’s Health Center, Franciscan Health System, Federal Way, Wash. Dr. Levy serves on the OBG MANAGEMENT Board of Editors.
The vast majority of hysterectomies are for benign conditions—for which minimally invasive approaches would seem appropriate—yet the ratio of abdominal-to-vaginal hysterectomy is 3 to 1 or higher.1,2 Approximately 800,000 US women undergo hysterectomy each year.

Why the continued reliance on the abdominal approach despite convincing evidence that vaginal and laparoscopicassisted vaginal hysterectomy (LAVH) offer faster recovery, better cosmesis, and, in many cases, a shorter operation with fewer complications?

OBG Management convened a panel of experts in different aspects of gynecologic surgery to explore this issue. They discuss the reasons most physicians prefer the abdominal approach, how residency programs affect the choice of hysterectomy route, indications for LAVH and supracervical hysterectomy, the issue of ovarian conservation, and management of uterine fibroids.

Why the abdominal route remains the old standby

Physicians use the procedure they are most comfortable with, and residents lack sufficient hands-on experience with laparoscopic and vaginal surgery. Medicolegal risk and reimbursement also have an impact.

KARRAM: Hysterectomy is one of the most widely performed surgeries in the United States, but approximately 60% to 80% of these surgeries still involve the abdominal route.2 Why do you think that is?

FALCONE: Most physicians practice in the manner they were trained, and most residency programs train residents to perform abdominal hysterectomy.

LEVY: I agree. Residents in obstetrics and gynecology have a limited time frame in which to learn and become facile with surgical gynecology. The requirements for primary care training and continuity clinics leave little time for the resident to become comfortable with endoscopic and vaginal surgery. However, they do get substantial exposure to abdominal surgery, both in obstetrics (with cesarean sections constituting 27.5% of all deliveries in the United States3) and gynecologic oncology rotations.

Furthermore, the volume of benign gynecologic surgery is low and the technical skills required for laparoscopic and vaginal surgery are more challenging than “slash and gash” abdominal surgery, so residents don’t get enough exposure to develop a comfort level with these procedures.

HERZOG: This trend is likely to change in the future because recent and current trainees have much more exposure to the laparoscopic approach than in the past, and the equipment has continued to improve. However, I have serious doubts about whether adequate amounts of vaginal surgery are performed in training programs to educate the next generation of vaginal surgeons.

LEVY: Another factor is the type of practice physicians enter after training. Most join practices in which the bulk of their income for many years derives from obstetrics. Without a mentor in the practice who is skilled at minimally invasive surgery, most of these young physicians appropriately resort to the hysterectomy approach for which they have the most comfort and skill: the abdominal route.

HERZOG: Secondary barriers to nonabdominal procedures are lower reimbursement and heightened medicolegal risk, since time and complications are greater for laparoscopic surgery and, to a lesser degree, vaginal procedures. Surgeons are not adequately compensated for either the increased time or risk.

Patients also tend to have higher expectations when the planned approach is minimally invasive. When conversion to laparotomy is necessary, the patient and her family may have trouble understanding why.

KARRAM: I agree that there is a serious lack of training in simple and complicated vaginal hysterectomy. Many inaccurate perceptions have been handed down over the years about its absolute and relative contraindications, such as the belief that any history of pelvic infection, endometriosis, or cesarean section is a contraindication for the vaginal approach.


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