WOMEN'S HEALTH
CURRENT Hysterectomy Trends
Lori Warren, MD, FACOG, FPMRS
H
ysterectomy is one of the most
frequently performed surgical
procedures in the United States.
It is only second to cesarean sec-
tion for female surgeries. The
majority of these procedures (90 percent) are
done for benign indications, such as fibroids,
abnormal uterine bleeding, endometriosis and
pelvic organ prolapse. Fibroids are the most common condition
necessitating a hysterectomy. Symptomatic fibroids often cause
bleeding and pelvic pain.
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In 2011, The American Association of Gynecologic Laparos-
copists (AAGL) recommended in a position statement that most
hysterectomies for benign disease should be done vaginally or
laparoscopically, and continued efforts should be taken to facilitate
these approaches.
It has been clearly shown that abdominal hysterectomy is asso-
ciated with longer hospital stays, more pain, more blood loss, and
longer recovery time for the patient. Contrast that to minimally
invasive surgery, which can be accomplished in an outpatient setting
with a much quicker return to work and normal activities.
Laparoscopic and vaginal hysterectomies are considered “min-
imally invasive” compared to abdominal hysterectomies because
they do not require a large incision (laparotomy). Over the last 10
years, robot-assisted hysterectomy has become one of the leading
ways to accomplish a minimally invasive hysterectomy. With minimal discomfort immediately post-op, many women
decide to go home on the day of surgery or stay in the hospital just
one night. Laparoscopy also has other advantages for the surgeon,
the surgical team and the patient. Two major advantages include
enhanced visualization and finer dissection of tissue leading to
improved outcomes and less risk of adhesion formation.
It is the opinion of the American College of Obstetrics and Gyne-
cology (ACOG) that a minimally invasive approach to hysterectomy
should be performed whenever possible given the well-documented
benefits over abdominal surgery. A vaginal hysterectomy may be
the route of choice when feasible, but many surgeons find that with
pelvic pathologies and the recommendation to remove tubes at the
time of hysterectomy, that a total laparoscopic, laparoscopic assisted,
or a robotic assisted approach for hysterectomy to be superior and
still allow for a minimally invasive option. Surprisingly, at least 40 percent of the hysterectomies in the
US are still being done with a large abdominal incision. The rates
of minimally invasive hysterectomies are slowly increasing with
improved instrumentation and surgical training. Every year there
are OB/GYN residents who go on to do a fellowship in minimally
invasive gynecologic surgery. They learn robot-assisted, laparoscopic
and vaginal surgery during their fellowship and acquire the volume
of surgeries needed to become an expert with the various techniques.
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