Overview of Current Trends in Hysterectomy

Santiago Domingo; Antonio Pellicer


Expert Rev of Obstet Gynecol. 2009;4(6):673-685. 

In This Article

Abstract and Introduction


Hysterectomy is one of the most prevalent surgeries worldwide. Nine out of every ten hysterectomies are performed for noncancerous conditions that are not life threatening but have a negative impact on quality of life. Indication policy must be revised as new treatments become available. Menorrhagia is the primary indication and is not always a response to an anatomical disease. New and improved alternatives are increasingly employed for this indication and are responsible for the fall in the rate of hysterectomies performed in the last decade. Up-to-date knowledge of the procedure and its possible routes and their outcomes should form part of all clinical decision-making processes if optimum short- and long-term results, an improvement in the patient's quality of life, and cost–effectiveness are to be achieved. Vaginal hysterectomy fulfils all these requirements and, when combined with the laparoscopic approach, represents the best option among possible routes.


Hysterectomy is, after Caesarean delivery, one of the most common surgical techniques performed in women and, together with cholecystectomy and appendicectomy, is the most frequently performed intra-abdominal surgery. The majority of gynecologic surgeons continue to perform hysterectomies by means of a laparotomy, while cholecystectomy is almost always performed through laparoscopic surgery.[1] Many women's health institutions recommend avoiding laparotomy, and advise abdominal hysterectomy (AH) only when the vaginal or laparoscopic route is ruled out.[2] We may ask ourselves why practice tends to go against this consensus. Vaginal surgery offers great potential in terms of access to the uterus, and fulfils all the criteria for minimally invasive surgery, as it employs a natural orifice, thereby avoiding an abdominal scar. The vagina becomes a new trocar port-site, permitting uterine manipulation, pelvis dissection and easy removal of the specimen. Vaginal hysterectomy (VH) is the safest route and has the best cost–effectiveness ratio, making it the first-choice option in clinical practice. When contraindications or difficulties are expected, vaginal surgery should be performed with the aid of laparoscopy when necessary or throughout the entire intervention, according to the professional opinion of the surgeon. Although AH is not currently contraindicated, there are now sufficient surgical resources for it to be relegated to the end of the list of options. Scientific evidence favors VH and laparoscopic hysterectomy (LH), which have lower complication rates, produce less postoperative pain and shorter hospital stays, and allow a more rapid return to normal activity, thereby resulting in a better quality of life (QoL).[3–5]

Laparotomy continues to be the preferred method for hysterectomy in approximately 60–70% of benign uterine processes.[1] Is this a sign of a deficit in surgical skill that is transmitted from generation to generation of specialists? The hysterectomy rate is showing a slight change in favor of VH rather than LH, although it is no way near the estimated 80–90% of hysterectomies that could potentially be managed with a minimally invasive approach. Unfortunately, the decision to adopt the surgical route evidently depends more on the skill of the surgeon than the advantages this technique may have for the patient.

In this review, we intend to assess the options available when considering a hysterectomy and to establish the most appropriate indications for its recommendation, to consider the alternatives to hysterectomy and to analyze the different surgical techniques and their routes and complications.


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