Clinical Review

UPDATE: MINIMALLY INVASIVE SURGERY

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New data and the guidance of our professional societies are bringing us closer to clarity in understanding the superiority of minimally invasive techniques of hysterectomy


 

References

Dr. Garcia serves as a consultant to IOGYN, Minerva Surgical, Conceptus, Ethicon EndoSurgery, and Ethicon Women’s Health & Urology. She is a speaker for Conceptus.

Two-thirds of the almost one-half million hysterectomies performed annually in the United States for benign conditions take the abdominal route—even though less invasive transvaginal and laparoscopic approaches are available. Compared with abdominal hysterectomy, vaginal and laparoscopic hysterectomies are, on the whole, associated with less morbidity, a shorter hospital stay, and more rapid return to physical activity.

Over the past year, our understanding of the comparative advantages and risks of the various approaches to hysterectomy has been deepened by new research and by guidance from AAGL. Here is what we’ve learned, and here is how our surgical practices ought to be evolving for the long-term good of our patients.

Hysterectomy should be performed only rarely abdominally

AAGL Position Statement: Route of hysterectomy to treat benign uterine disease. J Minim Invasive Gynecol. 2011;18(1):1–3. [To link to the AAGL Position Statement, click here.]

In 2011, AAGL, which has been an international leader in promoting minimally invasive gynecologic surgery for longer than 40 years, issued a position statement on hysterectomy for the treatment of benign disease. AAGL’s position is a clear assertion that, when vaginal hysterectomy is not possible, laparoscopic hysterectomy should be performed—thus leaving few clinical indications for an abdominal hysterectomy.

Historically established contraindications to vaginal or laparoscopic hysterectomy—prior cesarean delivery, need for oophorectomy, an enlarged uterus—have been invalidated by recent studies. In competent hands, ovarian removal can be accomplished in 65% to 98.5% of vaginal hysterectomies.1 Vaginal morcellation techniques can facilitate removal of a large uterus vaginally and mechanical tissue morcellators enable laparoscopic removal.

In 2011, ACOG reaffirmed its 1999 Committee Opinion on Gynecologic Practice,1 which recommends that the vaginal approach for hysterectomy be the preferred route. ACOG asserts that, when vaginal hysterectomy is impossible, the laparoscopic and abdominal routes are alternatives.

How do these positions differ?

The difference in the AAGL Position Statement and the ACOG Committee Opinion lies in the surgeon’s ability to perform laparoscopic or vaginal hysterectomy. Although it might seem admirable for a surgeon to choose abdominal hysterectomy because he, or she, lacks the training and skills to perform the procedure laparoscopically or vaginally, AAGL does not hold this position. AAGL has established the expectation that, if a surgeon is unable to perform a hysterectomy safely vaginally or laparoscopically, he should refer the patient to a gynecologic surgeon who can.

Furthermore, AAGL recommends that abdominal hysterectomy be reserved for four broad situations, when:

  • a patient has a medical condition, such as cardiopulmonary disease, in which the risk of general anesthesia or increased intraperitoneal pressure that is associated with laparoscopy is deemed unacceptable
  • morcellation is known, or likely, to be required for vaginal or laparoscopic hysterectomy and uterine malignancy is either known or suspected
  • hysterectomy is indicated but there is no access to surgeons or facilities required for vaginal or laparoscopic hysterectomy and referral is not feasible
  • anatomy is so distorted by uterine disease or adhesions that the vaginal and laparoscopic approaches are deemed unsafe or unreasonable by a recognized expert in vaginal or laparoscopic hysterectomy techniques.

When hysterectomy is necessary, therefore, the demonstrated safety, efficacy, and cost-effectiveness of vaginal and laparoscopic approaches to surgical removal of the uterus mandate that these procedures be 1) the ones of choice and 2) presented as options to all appropriate candidates.

WHAT THIS EVIDENCE MEANS FOR PRACTICE

Whenever feasible for benign disease, perform hysterectomy vaginally or laparoscopically. Make the effort to facilitate these approaches based on the underlying principles of 1) informed patient choice and 2) preferential provision of minimally invasive options.

If you have not had the requisite training or learned the skills required to perform vaginal or laparoscopic hysterectomy, you should enlist the assistance of colleagues who do or refer your patients to those colleagues for surgical care. You should also, for the long term, seek to acquire those skills through formal training.

Quality of life improves after laparoscopic hysterectomy—more than it does after abdominal hysterectomy

Nieboer T, Hendriks J, Bongers MY, Vierhout ME, Kluivers KB. Quality of life after laparoscopic and abdominal hysterectomy: a randomized controlled trial. Obstet Gynecol. 2012;119(1):85–91.

Nieboer and colleagues have presented their long-term data from a prospective, randomized evaluation of quality of life (QOL) after abdominal hysterectomy compared with QOL after laparoscopic hysterectomy. Other researchers have compared hysterectomy approaches, but most of those studies focused on such outcome measures as operation time, surgical intraoperative and postoperative complications, hospital stay, and rate of recurrence of the condition that prompted the surgery. This is the first study to address QOL parameters that are more patient-centered —using a validated questionnaire and having a median follow-up of 4.7 years (range, 188 to 303 weeks).

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