Choosing route of hysterectomy - When is laparoscopy superior?

Feb 22, 2018

Hysterectomy can be performed vaginally, abdominally, laparoscopically, or with robot-assisted laparoscopy. Hysterectomy can also be performed by combining two of these four routes. Hysterectomy has been associated with improvements in physical and mental quality-of-life measures, body image, and aspects of sexual activity, with few differences among surgical routes.

Broadly, hysterectomies are done for five major indications:

• Uterine fibroids
• Abnormal uterine bleeding
• Pelvic organ prolapse
• Pelvic pain or infection (e.g. endometriosis, acute/chronic pelvic inflammatory diseases)
• Malignant and premalignant disease

Choosing route of hysterectomy

Most major national and international organizations agree that vaginal hysterectomy is the preferred approach for most patients because of its documented advantages and relatively lower complication rates. If a vaginal hysterectomy is not feasible because of limited vaginal access, the size of the uterus, or major adhesive disease, then laparoscopic hysterectomy is performed. Hysterectomy by laparotomy is reserved for all other cases.

Factors influencing the decision include:

• Extent of gynaecologic pathology – What is the best access to appropriately treat the disease?
• Relative risks and benefits of hysterectomy route – Which technique is associated with the lowest risk of complication for this patient?
• Need to perform additional procedures – What is the best access for management of concomitant pathology?
• Patient preferences – Does the informed patient have a preference for hysterectomy approach?
• And, surgeon’s competence, preference, and available support facilities

Laparoscopic hysterectomy

When vaginal hysterectomy is not possible, laparoscopic hysterectomy has several advantages over the abdominal route. A meta-analysis of 21 randomized trials that comprised a variety of laparoscopic hysterectomy techniques, including laparoscopic-assisted vaginal hysterectomy, laparoscopic hysterectomy with a vaginal cuff closure, total laparoscopic hysterectomy and single-port laparoscopic hysterectomy reported the following.

• Outcomes favouring laparoscopic hysterectomy compared with abdominal hysterectomy:
• Quicker return to normal activities by over 15 days
• Shorter hospital admission by one to three days, depending on type of laparoscopic hysterectomy
• Reduction in wound or abdominal wall infection by approximately 70 percent

Laparoscopic approach can be very helpful and provide more information in certain conditions like,

• Hysterectomy in a patient with documented endometriosis
• Chronic pelvic pain, known pelvic adhesive disease
• Concurrent benign adnexal mass that requires removal
• Limited vaginal access, a fixed immobile uterus
• Multiple previous Caesarean sections
• And in those women who desire supracervical hysterectomy

While the current research suggests twofold increased risk of urinary tract (bladder or ureter) injuries and approximately 30 minute longer operative time for laparoscopic hysterectomy compared with abdominal hysterectomy, most trained laparoscopic surgeons who have crossed learning curve would agree that the operating time may even be shorter than abdominal hysterectomy if not the same.

Single-port laparoscopic hysterectomy

Single-port laparoscopic hysterectomy is a modification where the hysterectomy is performed through single incision at the umbilicus with the aid of a multiport system. A randomized trial showed that pain scores at 24 and 48 hours and the amount of narcotic use were statistically lower but not clinically important. A study that surveyed women’s preferences for minimally invasive incisions demonstrated that women prefer both single-site and traditional laparoscopic incisions over robotic incision.

Conclusion:

While vaginal hysterectomy still remains gold standard and first choice of route in benign gynaecological diseases, laparoscopic hysterectomy can replace most of abdominal hysterectomies and provides greater understanding and opportunity to treat various pelvic pathologies including chronic pain, endometriosis, adhesions from previous laparotomies.

Dr Dharmesh Kothari
Obstetrics & Gynaecology
The Private
Suite 503, Level 5
Wollongong Private Hospital
360-364 Crown Street
Wollongong NSW 2500
P: 02 4288 8080
F: 02 4288 8080