ACOG updates it recommendations for selecting the best route of hysterectomy for benign diseases

ACOG updates its committee opinion for choosing the best route for Hysterectomy in Benign Disease. It replaces the Committee Opinion Number 444, issued November 2009.

In the United States, approximately 600,000 hysterectomies are performed each year, and the procedure is the second most frequently performed major surgical procedure among reproductive-aged women.

More than 50% of benign hysterectomies are performed for uterine fibroids followed by Abnormal uterine bleeding (42%), endometriosis (30%) and prolapse (18%), although some indications are overlapping.

Hysterectomies are performed vaginally, abdominally or laparoscopically (total laparoscopic hysterectomy [with or without robotic assistance] or laparoscopically assisted vaginal hysterectomy).

An analysis of data in between 1998 – 2010 shows a decreasing trend of abdominal route (65% to 54%) in favor of Minimal Invasive Surgery. But, the vaginal approach has shown a consistent decline in use from 1998-2010 (25% to 17%).

The recommendations and conclusions are as follows:

Vaginal Hysterectomy should be the route of choice when feasible. Evidence supports that it is associated with shorter operation time, better outcome and it is also the most cost effective of all procedures. Society of Pelvic Reconstructive Surgeons has issued its own guidelines incorporating the uterine size, mobility, and accessibility of uterus to determine the best route of hysterectomy for a patient.

In patient with adnexal pathology, adhesions or endometriosis vaginal hysterectomy is not feasible, in such patient’s laparoscopic hysterectomy is the alternative of choice over open surgery.

Each patient should be evaluated for the route of hysterectomy based on clinical factors, anatomical characteristics and patient’s individual choice combined with surgeon’s training and experience.

The healthcare provider should discuss with each patient the best possible route for her, and she should be informed the pros and cons of each route based on her clinical situation.

Opportunistic salpingectomy can safely be performed at the time of vaginal hysterectomy.  A 2015 study showed that the procedure can be accomplished in 88% of planned cases by vaginal route.

Prophylactic bilateral salpingo-oophorectomy in cases of genetic mutation represents a total different clinical scenario. The procedure should be performed by laparoscopic or open abdominal approach to get proper tissue margins and inspect the peritoneal surface.

If patient choose to have a supracervical hysterectomy, laparoscopic or abdominal approach is best suited.

In case a laparoscopic approach is decided upon, the uterus can be removed intact or scalpel morcellation. Power morcellation is under scrutiny after Dr Amy Reed and her husband lobbied against its use in Minimal Invasive Surgery. The dangers of power morcellation, contained power morcellation should be discussed with patient and she should be explained about presence of an occult malignancy that may worsen the cancer prognosis.

The committee opinion can be accessed here. 

ACOG statement on power morcellator use in gynecological surgery can be accessed here.