Determining the best route for hysterectomy

While hysterectomy is one of the most frequently performed operations in gynecology, how to perform it—abdominally, vaginally, or laparoscopically—is less evident. Numerous studies have been published in an attempt to shed some light on this controversy.

Individualize the approach for each patient rather than rely on a dogmatic assignment of technique.

Prior to the introduction of the laparoscopic-assisted vaginal hysterectomy (LAVH) by Reich et al in 1989,¹ several large studies were published that compared the abdominal and vaginal routes for hysterectomy. The largest was the Collaborative Review of Sterilization (CREST) study conducted by the Centers for Disease Control (CDC).² This report included 1,856 women aged 15 to 44 who underwent non-emergency, non-radical hysterectomies at 9 institutions between 1978 and 1981. Fewer complications were associated with vaginal hysterectomy (VH) than abdominal hysterectomy (AH) (Table 1).

Now, several trials have included LAVH in the comparison of hysterectomy routes. In the most comprehensive study to date, Johns et al reviewed 2,563 hysterectomies performed for nonmalignant indications by 37 private gynecologists from a single institution.³ The researchers found that bowel, bladder, and ureteral injuries were uncommon, and the rates of each were similar among LAVH, abdominal hysterectomy, and vaginal hysterectomy (Table 2). In addition, a review of the literature between 1989 and 1995 revealed that LAVH is associated with a shorter hospital stay, decreased recovery time, and less analgesia compared with AH.⁴

However, since most of the data on route for hysterectomy are from retrospective and uncontrolled trials, one must interpret the findings carefully. For example, many studies do not control for additional procedures performed at the time of hysterectomy (e.g., enterocele, rectocele, and cystocele repairs). In addition, information on how researchers categorized unsuccessful attempts at VH or LAVH—which then had to be converted to AH—often is excluded. Also, physicians usually select the technique based on personal preference, practice style, and traditional dogma such as uterine size rather than a standard protocol.^5,6 Therefore, the increased incidence of postoperative morbidity associated with AH is difficult to decipher. Is it due to the increased number of obese and nulliparous women undergoing AH, the surgeon’s experience, pelvic pathology or operative indication, or is it related to the actual opening of the abdomen and intraperitoneal manipulation? Most likely, it is a combination of these factors.

Overall, hysterectomy is a relatively safe procedure with a mortality rate of 1 to 2 per 1,000.⁷ Morbidity, however, remains high. Fortunately, most complications are minor and easily remedied with little clinical consequence. Since certain aspects of postoperative morbidity are related to the route for hysterectomy, the surgeon must individualize the approach for each patient and not rely on a dogmatic assignment of technique. Here, we will review the patient selection for and provide pearls on abdominal, vaginal, and laparoscopic-assisted vaginal hysterectomy, as well as look at the advantages and disadvantages of each method.

TABLE 1

CREST^*study results

TABLE 2

Complications at hysterectomy

Abdominal hysterectomy

Patient selection. Choose the abdominal route when extensive intraperitoneal surgery and/or exploration are required in addition to the hysterectomy, i.e., in cases of pelvic organ carcinoma. Severe pelvic adhesive disease from documented severe endometriosis, salpingitis, or significant adnexal pathology and a considerably enlarged uterus also are best approached abdominally (Figure 1). In addition, use the abdominal route for obstetric emergencies such as postpartum hemorrhage.

Technique. First, determine the type of incision based on the following factors: Which one will allow completion of the procedure in a safe and efficient manner, minimize complications, expedite recovery, and offer a favorable cosmetic result? A vertical midline incision is the most adaptable to unsuspected pathology, especially if found in the upper abdomen. It is the quickest to perform and is associated with the least blood loss, an important advantage when operating emergently on an anemic or hemorrhaging patient. However, bear in mind that vertical incisions that have been extended into the upper abdomen are accompanied by increased postoperative pulmonary morbidity, pain, and risk of hernia formation.^8,9