Choosing The Route of Hysterectomy

/

Here’s the RoshReview Question of the Week!

​​A 49-year-old P3003 woman presents to the clinic with a complaint of heavy menses for several years and asks for definitive management. She has a history of type 4 fibroids, all < 3 cm, and hypercholesterolemia. Her obstetrical history is significant for two vaginal deliveries and one cesarean section. On physical examination, her BMI is 31 kg/m2. Her uterus is anteverted, and the fundus reaches 3 fingerbreadths below the umbilicus. What surgical intervention would be most cost- and clinically effective for this patient?

Check if you got the right answer at the links above!

Reading: Committee Opinion 701 - Choosing the Route of Hysterectomy for Benign Disease 

Why do we do a hysterectomy?  

  • Hysts are one of the most common surgeries in the United States (per the CDC, over 600,000 are performed annually) 

  • Many of them are elective - ie. patients are choosing surgical option over medical for example  

What exactly are the ways to do a hyst anyway and why does route matter?

Note: We won’t go into exact techniques here since we are a podcast. However, some great resources include the Atlas of Pelvic Surgery online: http://www.atlasofpelvicsurgery.com/home.html

Also the textbook by Baggish and Karam: Atlas of Pelvic Anatomy and Gynecologic Surgery 

Vaginal hysterectomy 

  • First type of minimally invasive hysterectomy 

  • Advantages 

    • Preferred type of hysterectomy when possible due to no incisions on the abdomen and minimally invasive route 

    • High safety and low cost

      • Meta-analysis of seven trials report similar rates of visceral injury and long-term complication among vaginal and laparoscopic procedures 

    • Minimally invasive approach associated with faster recovery compared to laparotomy 

  • Disadvantages

    • Unfortunately, despite advantages, there are fewer vaginal hysts performed compared to others due to limited training, fewer numbers of hysts overall being performed and greater diversity of operative approaches 

    • Must remove cervix with this type of procedure - no option for supracervical hyst 

    • Small chance of converting to laparotomy 

Laparoscopic hysterectomy 

  • Usually performed with laparoscopic instruments via 3-4 small ports in the abdomen. Uterus can be morcellated and removed through a bag (morcellate in bag) or via the vagina 

  • Increasing in popularity 

  • Advantages 

    • Better visualization with minimally invasive surgery 

    • Can perform supracervical hyst if needed 

    • Can also perform last part vaginally for ease if needed 

    • May be easier in some obese patients 

  • Disadvantages 

    • Requires surgeon skilled in use of laparoscopy 

    • Certain patient populations with certain medical illnesses may not tolerate Trendelenburg position or pneumoperitoneum 

    • Possibility of conversion to laparotomy 

    • Slightly higher rate of vaginal cuff dehiscence compared to other routes of hyst (still low, like 0.64-1.1%) 

Robotic hysterectomy 

  • Very similar overall in terms of advantages and disadvantages to laparoscopic hysterectomy due requiring Trendelenburg and pneumoperitoneum, as well as minimally invasive course 

  • Advantages 

    • Superior visualization compared to traditional laparoscopy due to ability to move camera and 3D vision 

    • Mechanical improvement - wrists with robots 

    • Better stabilization of instruments 

    • Improved ergonomics for surgeons - you can sit down (as someone who has definitely passed out during a long case) 

    • Even more options for minimally invasive routes (ie. single port hyst) 

  • Disadvantages 

    • Additional surgical training 

    • Does not necessarily decrease time (in fact can increase cost and operating room times) 

      • Cost of instruments overall + cost of robot 

    • Lack of haptics (no tactile feedback) 

Abdominal hysterectomy  

  • Only non minimally-invasive technique 

  • Advantages

    • Visualization 

    • Ability to remove large masses and large uteruses 

    • Tactile feedback  

    • Lowest risk of vaginal cuff dehiscence compared to other methods 

    • Studies like the VALUE study and the eVALuate trial showed decreased rates of complications of abdominal hyst compared to laparoscopic hyst, but these studies are also old (1990s) 

  • Disadvantages 

    • Increased postoperative pain and length of stay (average LOS is 3 days after abdominal hyst) 

    • Increased risk of bleeding and infection 

    • Increased risk of VTE (also may be due to increased stasis) 

    • Increased risk of colonic stasis 

How do we pick the route of hysterectomy? 

Consideration of minimally invasive routes 

  • MIS should be considered whenever possible because of well-documented advantages over abdominal hysterectomy 

  • Vaginal hyst is preferred over other types due to cost, effectiveness, and overall outcomes 

  • Even if opportunistic salpingectomy is desired, these can be performed with vaginal hysterectomy 

Anatomy 

  • Size and shape of vagina and uterus + descent of uterus 

  • More difficult to perform a vaginal hysterectomy if there is no descent, if there is large uterus (bulky fibroids) and small introitus 

    • However, nulliparity is not a contraindication to vaginal hysterectomy 

    • Study showed that 92% of vaginal hysterectomies planned for women with no prior vaginal deliveries could be successfully completed 

  • Accessibility of the uterus also important - is there likely to be a lot of pelvic adhesive disease? (endometriosis) 

    • Large uterine size - morcellation has come under scrutiny previously 

    • However, still can morcellate in a bag 

    • Even if large, bulky uterus, can refer to skilled MIS surgeon

  • Need of concurrent procedures (ie. will the patient need their appendix removed as well?) 

  • Work up: 

    • Physical exam with evaluation of mobility of uterus on bimanual 

    • Evaluation for adnexal masses on bimanual 

    • Feel for fundal height 

    • Pelvic ultrasound may be helpful 

Surgeon comfort/preference 

  • Surgeon preference for other operative routes - no longer considered an appropriate reason to avoid vaginal approach 

  • Surgeon experience 

    • Average case volume

    • Available hospital technology, devices, and support 

Patient preference 

  • If patient desires supracervical hysterectomy, will need laparoscopic or abdominal approach 

  • However, no clinically significant difference in complication and uncertain benefit in terms of patient outcomes (ie. sexual function, urinary function, bowel function)

ACOG CO 701