Clinical Review

UPDATE: MINIMALLY INVASIVE SURGERY

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In 2007, investigators published the findings of a randomized comparison of QOL measures after total laparoscopic hysterectomy and total abdominal hysterectomy. Their assessment in that study utilized eight QOL measures from the RAND-36 Measure of Health-Related Quality of Life (the Dutch version of the validated QOL questionnaire, the SF-36 Health Survey)2 (TABLE).


8 key RAND-36 measures of quality of life in women who have had a hysterectomy

  • Bodily pain
  • Emotional role
  • General health
  • Mental health
  • Physical functioning
  • Physical role
  • Social functioning
  • Vitality


The current (Nieboer and co-workers) study evaluated 59 randomized patients from the 2007 work: 27 to laparoscopic hysterectomy and 32 to abdominal hysterectomy. The overall response rate after 4 years was 83% (N=49).

The QOL questionnaire addressed eight RAND-36 (SF-36) measures, with each measure having a possible score of 0 to 100 (maximum possible total score, 800); the higher the number, the better the QOL. The researchers considered a difference of 15 points between the two surgical approaches on any single parameter to be statistically significant.

Findings. The mean total RAND-36 (SF-36) score was 50.4 points (95% confidence interval, 1.0–99.7) higher in the laparoscopic hysterectomy group at each point of measurement in the weeks postoperatively, up to 4 years of follow-up. Higher scores at 4 years were also seen in the laparoscopy group for vitality, physical functioning, and social functioning.

From these findings, the authors surmise that QOL remains better 4 years after laparoscopic hysterectomy than it does after abdominal hysterectomy.

Why these findings? The Nieboer team offers several explanations for ongoing improvement in QOL scores among laparoscopic hysterectomy patients.

First, it is conceivable that laparoscopic patients scored higher on the Body Image Scale, benefiting from the knowledge that they underwent what, even in layman’s terms, would be called the “minimally invasive approach.”

Second, chronic abdominal or pelvic pain could affect QOL scores. It has been shown that, for other laparotomy procedures, the incidence of postop chronic pain ranges from 3% to 56%. Risk factors for postop chronic pain are female gender, younger age, and surgery for benign disease—similar to those that characterized the patient population in this study.

Some weaknesses. The authors acknowledge that the study has shortcomings, including 1) a small sample and 2) their inability to discriminate QOL that reflects subjects’ surgical outcome from QOL related to typical life events—the death of a spouse, for example.

Nieboer and colleagues conclude by saying that, given the apparent improved QOL after laparoscopic hysterectomy compared with abdominal hysterectomy, all patients in whom vaginal hysterectomy is not feasible should be able to opt for laparoscopic hysterectomy.

WHAT THIS EVIDENCE MEANS FOR PRACTICE

Vaginal and laparoscopic approaches to hysterectomy have significant short-term advantages over abdominal hysterectomy by traditionally compared measures of surgical outcome. Taking the less-invasive approach allows you to offer greater long-lasting improvement in your surgical patients’ quality of life.

Quality of life improves after laparoscopic supracervical hysterectomy—more than after a total lap procedure

Einarsson J, Suzuki Y, Vellinga T, et al. Prospective evaluation of quality of life in total versus supracervical laparoscopic hysterectomy. J Minim Invasive Gynecol. 2011;18(5):617–621.

Einarsson and colleagues sought to prospectively evaluate a cohort of patients undergoing total laparoscopic hysterectomy (TLH) or laparoscopic supracervical hysterectomy (LSH) for 1) time to recovery and 2) short-term QOL after surgery. In all, 122 women underwent surgery (TLH: N=71; LSH: N=51) for benign indications. A QOL questionnaire (again, the SF-36) was administered immediately preoperatively, as a baseline, and at 3 to 4 weeks postoperatively.

Preoperatively, patients were presented with the two surgical options, without being influenced with information about any benefit to removing or retaining the cervix at laparoscopic hysterectomy. Patients then chose which surgery they wanted, and were neither randomized nor blinded to the procedure that was performed.

Findings. The data show greater patient self-selection and more patients with endometriosis in the TLH group; other preoperative baseline characteristics were similar across groups. More operative and postoperative complications were seen in the TLH group (vaginal cuff bleeding requiring return to the operating room, 2 patients; cuff cellulitis, 1; intraoperative vaginal laceration, 1; urinary tract infection, 1), although the difference did not reach statistical significance. There were no significant differences group to group in postop nausea, pain, narcotic use, or return to daily activities.

Regarding the eight QOL parameters, however, a statistically significant difference was observed in six of them to favor laparoscopic supracervical hysterectomy: physical functioning, physical role, bodily pain, vitality, social functioning, and physical component summary.

Study has shortcomings. The authors address two limitations of their study: namely, that the participants were neither blinded nor randomized. They acknowledge that these limitations might have biased QOL measurements in a way that showed improved QOL among the supracervical hysterectomy group. They raise the possibility that not being blinded to whether the cervix was removed may have affected subjects’ bodily perception. (Patients also returned to their daily activities 5 days earlier in the supracervical group, but this finding was found to be statistically insignificant.)

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