Surgical Approaches to Hysterectomy: Relevant Factors in Decision Making
The American College of Obstetricians and Gynecologist's (ACOG) guidelines for hysterectomy are probably the most widely accepted and most employed of those found in the literature. The most determinant factors for choosing one or another approach are surgeon skill, uterus size, uterine mobility, nulliparity and previous pathological conditions (Box 1).
Age, parity, uterine size, vaginal anatomy, pelvic mobility and any pelvic disease or previous pelvic surgery are among the most important factors to take into account when considering a hysterectomy. Yet, an even more important aspect is the quality of the surgeon's training with respect to the different possible approaches. This is why continuous training programs must be offered to residents and gynecologic surgeons with the intention of developing effective guidelines for the determination of the route of hysterectomy in every medical center. Many publications confirm that route indication may change when guidelines are consulted; up to 90% of hysterectomies are performed vaginally when a consensuated guideline is applied, reversing the abdominal/vaginal procedures to a ratio of 1:11. Each hospital should examine its own AH:VH ratios as a quality-assistant index. This dramatic change requires a learning curve, and that of the laparoscopic technique is more difficult and longer than that of the vaginal technique. In 5 years, a VH rate of 95% could be achieved in some centers in the UK, where only 32% of hysterectomies have, until now, been performed via the vagina. This highlights the strong economic argument for VH in medical centers and confirms that the major determinant of hysterectomy route is not clinical circumstances but, rather, the professional preparation of the surgeon. Appropriate practice guidelines are needed to reduce inconsistencies in the indications for AH and VH. Unfortunately, almost all teaching programs focus more on AH rather than VH or LH.
The ACOG and other researchers assert that VH should be indicated in women with mobile uteri of less than 12-week gestational size (~280 g), maintaining that the contrary can represent a handicap for surgeons. Randomized studies that compare the advantages, disadvantages and outcomes of AH and VH for enlarged symptomatic uteri between 200 and 1300 g have clearly demonstrated the advantages of the vaginal route in terms of operative times, febrile morbidity, less demand for narcotics and reduction of hospital stay. Uterine size reduction is usually the principal problem confronting surgeons, and morcellation technique skills are a limiting factor. The mechanical difficulties and the higher risk of complications during morcellation are common contraindications of VH and an indication for abdominal hysterectomy for many gynecologic surgeons not trained in the technique. Uterine morcellation techniques (e.g., coring, corporeal bisection and wedge morcellation) are safe and facilitate the vaginal removal of a moderately enlarged uterus without increasing perioperative morbidity.[31–33]
Uterine mobility is another of the relevant factors in determining the route of a hysterectomy. A vaginal route is usually indicated in cases of vaginal prolapse (stage ≥ 1), a wide vaginal apex and a bimanual pelvic palpation presenting a nonadhered uterus. Occasionally, a pelvic examination under anesthesia is required prior to determining if vaginal access is possible.
Uterine prolapse is one of the most usual indications for hysterectomy. Although a laparoscopic approach is feasible in such circumstances, VH with a McCall culdoplasty is the standard treatment. Other situations should be attemped vaginally once malignancy has been ruled out, such as cervical carcinoma in situ or abnormal uterine bleeding. Even if an endometrial carcinoma is detected, the vaginal route may be possible, with a vaginal adnexectomy being performed if lymph node dissection is not indicated (low risk of endometrial carcinoma). Moreover, in cases of malignancy and poor patient clinical outlook, a VH should be the first option, as it allows a locoregional anesthesia to be administered. A myomatous uterus is one of the most controversal indications for VH. Uterus shape is probably more relevant than uterus size, as multiple myoma can be easier to remove than a single myoma located above the round ligament. An ultrasound scan should assess the exact location of the fibroids and their size.
If the clinical history or pelvic examination indicates possible extrauterine disease or adhesions (e.g., endometrosis, pelvic inflammatory disease, ovarian disease, previous pelvic surgery or Caesarean delivery), a laparoscopy should be performed. This allows the pelvic pathology to be treated correctly and can be of assistance in performing or finalizing the hysterectomy. Laparoscopic scoring systems have been designed to document the severity of extrauterine pathologic conditions.
Nulliparity usually leads to VH being ruled out, as a general consensus among health professionals. On the other hand, there are no differences between the complication rates of AH and LH in nulliparous women.[35,36] The lack of cervical descent represents a problem when performing VH. The main supports of the uterus are the uterosacral and cardinal ligaments. When the vaginal route is chosen, these ligaments are easy to identify and hold on to, and are the first structures to be dissected, even in nulliparous women. When they are sectioned, the uterus gains mobility, thus making the procedure easier.
Expert Rev of Obstet Gynecol. 2009;4(6):673-685. © 2009 Expert Reviews Ltd.
Cite this: Overview of Current Trends in Hysterectomy - Medscape - Nov 01, 2009.