Hysterectomy Disconnect

At least two-thirds of hysterectomies in the United States are still performed through an abdominal incision, despite the availability of minimally invasive approaches that are associated with less pain, shorter hospital stay, more rapid recovery, and better cosmesis. In an attempt to change that, the AAGL  Advancing Minimally Invasive Gynecology Worldwide has just issued a position statement calling for nearly all hysterectomies that are done for benign uterine disease to be performed vaginally or laparoscopically, rather than abdominally.

"TAH" stands for Total Abdominal Hysterectomy. Image courtesy of Intuitive Surgical Inc.

According to the AAGL, the few contraindications to laparoscopic hysterectomy (LH) include conditions in which the risks of general anesthesia or intraperitoneal pressure are deemed unacceptable or where uterine malignancy is suspected. For both LH and vaginal hysterectomy (VH), exceptions include situations where trained surgeons or required facilities are unavailable, or in certain cases of distorted anatomy.

Otherwise, AAGL said, “When hysterectomy is necessary, the demonstrated safety, efficacy, and cost-effectiveness of VH and LH mandate that they be the procedures of choice.” 

So why aren’t they?  After all, in some European countries the rate of abdominal hysterectomy (AH) is less than 25%.  Interesting insight can be found in the results of a recently published online/paper survey sent to a random sample of 1,500 practicing U.S. obstetrician-gynecologists.

Among the 376 who responded, the most commonly performed hysterectomy procedure in the previous year was AH (by 84% of respondents), followed by VH (76%).  But when asked to rank which hysterectomy approach they would prefer for themselves or their partner, 56% ranked VH as their first choice and 41% ranked LH as their first choice, with only 8% opting for AH. 

When asked about barriers to performing minimally invasive procedures, the most common ones reported for VH included technical difficulty, potential for complications, and personal caseload. For LH, respondents cited lack of training during residency, technical difficulty, personal surgical experience, and operating time as barriers. 

Nonetheless, when asked about their ideal goal for mode of access, the respondents felt on average that minimally invasive techniques should comprise 79% of all hysterectomy procedures. 

According to the AAGL’s position statement, “Surgeons without the requisite training and skills required for the safe performance of VH or LH should enlist the aid of colleagues who do, or should refer patients requiring hysterectomy to such individuals for their surgical care.”

-Miriam E. Tucker (@MiriamETucker on Twitter)

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Filed under Anesthesia and Analgesia, Family Medicine, Geriatric Medicine, Hospital and Critical Care Medicine, IMNG, Internal Medicine, Obstetrics and Gynecology, Plastic Surgery, Practice Trends, Surgery, Uncategorized

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