A hysterectomy is the removal of the uterus, cervix, and possibly the fallopian tubes and ovaries through an incision or incisions in the abdomen or vagina. This surgical procedure is the second-most common surgery among women in the United States, topped only by Cesarean section (C-section) surgery to deliver babies.
What type of hysterectomy is best?
Sometimes other reproductive organs are removed at the same time as the hysterectomy. When the cervix is removed along with the uterus, the procedure is called a “complete” or “total” hysterectomy. If the ovaries and fallopian tubes are removed it is stated separately. “Complete or Total Hysterectomy with removal of Fallopian Tubes and Ovaries,” or “Bilateral Salpingo-oophorectomy.”If only the upper part of the uterus is removed, leaving the cervix in place, the procedure is called a “partial,” “subtotal” or “supra cervical” (pronounced “soop-ruh-SER-vuh-kul”) hysterectomy.
Hysterectomy is the most common non-obstetric 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 today’s 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 Female Pelvic Medicine and Reconstructive Surgery or Urogynecology 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 these approaches, they should be based on medical indications and not marketing. I do perform these approached in those patients where this approach is indicated.
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 shown to be true when compared to open abdominal hysterectomy. When compared to Laparoscopic Hysterectomy these benefits are less obvious and when compared to Vaginal Hysterectomy, they are non existent. Studies have shown that the average operative time is nearly doubled and the complication rate is significantly increased during the initial learning phase. The Robot does not make a surgeon a better surgeon.
The Robots true benefit is in cases where the patient would have to undergo an Open Incision such at treating Endometrial (Uterine) Cancer or where hysterectomy would have to be done open, abdominal approach, because of some condition present. In the case of Endometrial Cancer, patients traditionally have an Open Abdominal Hysterectomy and Biopsy of Lymph Nodes. With Robotic Surgery, the patient can undergo a Laparoscopic or Vaginal Hysterectomy and then the Robot is used to do the Lymph Node Biopsies. The Robot also is of benifit in cases where a large amount of suturing is required such as Myomectomy. Suturing with the Robot is easier than with a laparoscopy. This technology is remarkable and should be used. It should however not be marketed as having benefits over vaginal hysterectomy. NO STUDY to date has shown that to be the case. When vaginal hysterectomy is not possible, Robotic Surgery may be a viable option.
Dr. Mathews offers the da Vinci Surgical System for patients with complex gynecological problems as part of his ongoing effort to bring the most advanced minimally invasive tools and technology to his patients.
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. See the references below.
Reference web links on hysterectomy
American College Of Obstetrics & Gynecology