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.
