In the News


by | October 25th, 2009


Hysterectomy is the most common nonobstetric major surgical procedure performed in the U.S. with over 670,000 performed annually. Today, in the U.S. over 75% of these surgeries are performed by an open abdominal approach. It has been well documented and is the American College of Obstetrics and Gynecology opinion that the majority of hysterectomies performed in the U.S. should be done by the vaginal approach.

Studies have show that the decision to perform a hysterectomy abdominally or vaginally has more to do with the training and experience of the surgeon than the condition for which the procedure is being performed. Many doctors state that having had a prior Cesarean Section, or an enlarged uterus with Fibroids make vaginal hysterectomy not possible. The most recent studies suggest that physicians can perform vaginal hysterectomy in approximately 77 to 89% of patients and Cesarean Section and Fibroids are not contraindications for vaginal hysterectomy.

So why are most hysterectomies done abdominally? The answer has to do with the training programs in the U.S. The overwhelming majority of these programs are heavily weighted with Obstetrical care and provide minimal gynecological surgical training. Many of todays graduates have less than 10 vaginal hysterectomies on their case list. The deficiency in training and experience in vaginal surgery is a considerable concern for our College and organizations such as The Society of Pelvic Reconstructive Surgeons. The recent development of a sub specialty in Pelvic Medicine and Reconstructive Surgery is one way this problem is being addressed.

Over the past several years, laparoscopic hysterectomies have become popular. The Laparoscopic Supracervical Hysterectomy or LASH procedure has gotten considerable attention in the lay press and on the Internet. The proponents of this approach state there is better sexual function, less vaginal prolapse, and faster recovery. Numerous well designed studies have shown that there is no benefit regarding sexual function and no deference in the incidence of vaginal prolapse. Furthermore, the benefits of a decreased recovery time are only present when Laparoscopic Hysterectomy is compared to an Open Abdominal approach and not a vaginal hysterectomy. “There has been renewed interest in supracervical hysterectomy as a way to reduce operative complications and reduce the effects of hysterectomy on urinary and sexual function. Unfortunately, these possible benefits are not supported by recent evidence,” says Denise J. Jamieson, MD, chair of ACOG’s Committee on Gynecologic Practice. Studies go on to say that Laparoscopic Supracervical Hysterectomy is associated with increased operative time, increased operating room expense, increased complication with injury to the bladder being the most common, and up to a 20% rate of cyclic bleeding from the cervical stump when the cervix is left behind. While there are indications for this procedure, they are limited.

Robotic Surgery has now become the next marketing campaign to be presented to patients. The da Vinci is stated to be “one of the most effective, least invasive treatment options for a range of uterine conditions. da Vinci Hysterectomy is performed using the da Vinci™ Surgical System, which enables surgeons to perform with unmatched precision and control – using only a few small incisions.”

This technology, while impressive, essentially takes the Laparoscopic Hysterectomy to a new level of complexity and cost. The proposed benefit of improved precision, less complications, less blood loss, shorter hospital stays, less scaring, less pain, and faster return to normal daily activity have not been proven by well controlled studies.What is known is that the average operative time is nearly doubled and the complication rate is significantly increased during the initial learning phase.

This technique is technically difficult and has a long learning period. If your doctor suggest this technique, you should ask how many he or she has done. Recognized experts in the field of Robotic Surgery suggest a minimum of 20 and up to 100 cases be done before one can be considered well trained. This technology takes a fairly straightforward case and creates unnecessary complexity and risk in my opinion.

So which approach is right? There may be instances in which any of the above mentioned approaches for hysterectomy would be appropriate. That said, the literature is clear in its findings that vaginal hysterectomy should be the preferred approach whenever feasible.

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Dr. J. Kyle Mathews is an expert in the field of Urogynecology, minimally invasive laparoscopic and robotic surgery, and reconstructive gynecologic surgery. Dr. Mathews is board certified and a Fellow of the American College of Obstetrics and Gynecology as well as the American College of Surgeons. With over two decades of experience, Dr. Mathews is one of the most experienced surgeons in north Texas.

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