Each year approximately 600,000 hysterectomies are performed in the United States, i.e. a little more than one uterus for every minute of the year. The vast majority (90%) is performed for non-cancerous conditions, such as fibroids, abnormal uterine bleeding and prolapse of the pelvic organs, with fibroids being the most common indication (30-35%). This incredible number of surgeries means that approximately one third of American women will have had a hysterectomy by the age of 60.
Surprisingly, 60% of hysterectomies in the United States are still being performed through a large abdominal incision (laparotomy). This is despite convincing scientific evidence that clearly shows that an abdominal hysterectomy is associated with more pain, more blood loss, longer hospital stay and longer recovery period than the minimally invasive alternatives, laparoscopic hysterectomy and vaginal hysterectomy. There are also numerous reports from several national and international institutions, where abdominal hysterectomy rates are 10-20% of all hysterectomies performed and in some cases less than 5%.
Why is it that most women who need a hysterectomy are still having an abdominal hysterectomy in the United States?
One explanation is lack of training. Many gynecologists in practice today do not have adequate training in laparoscopic or vaginal surgery. Laparoscopic surgery is a relatively new surgical modality with the first laparoscopic hysterectomy performed in 1988. Therefore, many gynecologists were not exposed to advanced laparoscopic surgery during their training. In addition the number of surgical cases that a gynecologist performs each year is in many cases rather low. It has been estimated that the average gynecologist performs 12-15 hysterectomies each year.
With so few cases per year it is difficult to learn new techniques that often take 30-50 cases or more to master. Even today, many gynecologists who are graduating from residency programs do not feel comfortable performing advanced laparoscopic procedures upon graduation. This has led to the development of special fellowship programs in advanced laparoscopic surgery, where gynecologists spend additional one or two years performing a large number of advanced procedures (perhaps 400-600) at a center that specializes in minimally invasive surgery.
Another problem is lack of patient awareness. Unfortunately, many patients are not aware that there are other options available to treat their condition and so they do not question their gynecologist when they suggest that the best plan of action is an abdominal hysterectomy. An abdominal hysterectomy is of course warranted in certain cases and patients usually do not have enough knowledge to know when there is a clear indication for an abdominal hysterectomy and when there is not. Also, they may know that their mother or grandmother had an abdominal hysterectomy and consider this to be the normal way of performing the procedure.
Yet anther problem is reimbursement. Gynecologists get paid about the same amount of money to perform a hysterectomy regardless of the technique used. Since the abdominal approach is the easiest for most gynecologists and requires the least amount of training, there is not much impetus for gynecologists to learn to perform other procedures that initially will take them much longer to do and therefore slow down their practice.
There are several ways to change these statistics.
Increased patient awareness will prompt patients to seek alternative surgical options for their problem. This will put pressure on gynecologists to seek additional training or refer their patients to high volume minimally invasive surgeons.
A three level tier system should be in place. First, gynecologists should perform simple vaginal hysterectomies or laparoscopic hysterectomies as long as they have sufficient experience and training to do so. Second, when the average gynecologist feels uncomfortable performing a minimally invasive hysterectomy and would like to seek additional training, he or she should enlist the help of a high volume minimally invasive gynecologic surgeon who will help with the case, sharing his expertise and thereby potentially enabling the gynecologist to feel more comfortable with these cases in the future. More challenging cases should be referred to a high volume minimally invasive surgeon, since it has been relatively well established that high volume surgeons have fewer complications and better patient outcomes than low volume surgeons, especially in complicated surgical cases.
Finally, national physician organizations should lobby policy makers and lawmakers to make them aware of this disparity so that reimbursement is increased for minimally invasive procedures that result in decreased pain and shorter time away from work and daily activities.
There are several alternatives that can be tried before performing a hysterectomy. Simply placing a hormonal IUD can significantly reduce menstrual bleeding and allow some women to avoid major surgery. Uterine fibroid embolization or laparoscopic myomectomy can be minimally invasive options to a hysterectomy in women with uterine fibroids. However, there are cases where other options are not appropriate or a woman might have had enough of her excessive bleeding and is not willing to accept a 10-15% chance that her initial procedure will not be successful.
A hysterectomy is a permanent solution for uterine fibroids, abnormal uterine bleeding and adenomyosis. It is also often helpful for women with endometriosis, although this is not always the case. Hysterectomies have traditionally been performed in many women with pelvic organ prolapse, but physicians have recently come to understand that the uterus is really just an "innocent bystander" and has nothing to do with the prolapse itself, since this is due to torn ligaments and weak connective tissue.
Hysterectomies are also commonly performed for cancer of the uterus and cervix. When these cases are very advanced however, it is better to leave the uterus in place, since these women will need radiotherapy and the uterus helps to shield other pelvic organs, such as the urinary bladder and the rectum.
The minimally invasive approaches to hysterectomy are vaginal hysterectomy and laparoscopic hysterectomy. Before discussing these techniques we will briefly describe the abdominal hysterectomy technique.
In abdominal hysterectomy, the physician will make an approximately 15 cm incision on the belly. Most often these incisions are made above the hairline (bikini cut), but sometimes the cut is running up and down, starting at the pubic hairline and sometimes going above the belly button (vertical incision). When dealing with a very large mass, the physician may elect to perform a vertical incision since this allows for better visibility and it gives more room to remove the mass through. The problem with the vertical incision is that it is less cosmetically appealing to most women and it is more painful.
Following the skin incision, there are several layers of the abdominal wall that the surgeons needs to cut through. These are fat, fascia (strong tissue that holds the abdominal organs in place), muscles and peritoneum (thin lining of the inside of the abdominal cavity). Sometimes it is necessary to cut the muscles to get more room, but most often they are split in the middle and pushed to the sides.
Once inside the abdomen, the bowel is usually pushed away using large sponges and a retractor is put into the incision to keep it maximally open so that the doctor can see better what he or she is doing. Retractors come in many shapes and sizes, but usually have a locking system in place, so that once they have been set in a certain way they stay put. The uterus is identified and the physician clamps the attachments and blood vessels of the uterus, cuts the attachments and places sutures to prevent any bleeding.
The uterus needs to be freed from its attachment to the ovaries, ligaments, urinary bladder and vagina. This can be difficult at times, especially if there are adhesions (scar tissue) from previous surgeries, in the case of endometriosis or a very large uterus. Once the uterus is completely freed it is removed through the abdominal incision. The top of the vagina is sutured with suture that will go away on its own over a period of 4-6 weeks. Once the surgeon is happy that there is no bleeding, all instruments and sponges are removed from the abdomen and the abdominal incision is closed in a few layers.
Most abdominal hysterectomies are so called total abdominal hysterectomies (TAH). This is in contrast with a supracervical hysterectomy (SCH). In a total abdominal hysterectomy, the cervix is removed whereas in a supracervical hysterectomy the cervix is left in place. There has been some controversy about which procedure is better. Those who like TAH argue that this is a complete procedure since the cervix is really just an extension of the uterus. In addition, by leaving the cervix in place there might be a higher risk of cervical cancer down the road. Women who have a hysterectomy and keep their cervix also have a 5-20% risk of having continued vaginal spotting. This is usually not a large amount of bleeding, but can be bothersome, especially if a woman was expecting no periods following her surgery.
Gynecologists who like to leave the cervix argue that you should not remove tissue that is healthy (because the problem you are fixing is really in the uterus). In addition, many have argued the cervix is important for sexual function and by keeping it in place there might be less risk of damage to the bladder, rectum or ureter since there is less dissection involved. They also argue that as long as women have regular pap smears, the risk for developing cervical cancer is very small.
Recently, there have been three well- designed studies that have looked at this by carefully comparing the outcome of the two methods. What they all found was that there was no difference in sexual function or complication associated with urinary bladder, rectum or bowel. Also, there was no significant difference in other outcomes, such as pain and time to recovery. The only difference was that there were more women in the SCH group that continued to have some vaginal spotting after the hysterectomy. Based on this, it seems that there does not seem to be much benefit to keeping the cervix, however if a woman would like to keep her cervix she can safely do so, as long as she realizes that she may have some continued vaginal spotting afterwards.
Women who have a history of abnormal pap smears in the past, and especially women who have had significant abnormalities should probably have a total hysterectomy, since they have a higher risk of developing abnormal cells in the cervix in the future. Also, one study that followed 70 women for 5 years after a supracervical hysterectomy found that 23% of them needed have the cervix removed during this time period because of symptoms of either pain or bleeding. Most of the patients that had problems had their operation for endometriosis. Based on this, women who are having a hysterectomy because of endometriosis or pelvic pain should strongly consider having the cervix removed during their surgery. It is possible that some of the endometriosis was also present in the cervix, leading to continued problems with pain and bleeding.
Conrad Langebeck performed the first vaginal hysterectomy in Germany in 1813. He did the procedure without any anesthesia and used no gloves or other means of sterilization, since at this time germs were not known to exist. He was supposed to have an assistant, but since he was in significant pain because of gout he could not help Dr. Langebeck with the procedure. This meant that he had to hold suture with his teeth at one point during the surgery! Amazingly, the patient survived "despite considerable hemorrhage" and did well after her surgery.
Vaginal hysterectomies performed today are a little more sophisticated, but the basic principles are the same. The patient lies on her back with the feet held up in the air by specially designed stirrups. The surgeon grasps the cervix and makes a circular cut around it. The surgeon then gently separates the bladder from the cervix and uterus in the front and from the rectum in the back. Following this clamps are placed on the ligaments and blood vessels, they are cut and sutured to prevent bleeding. Once the uterus is completely freed it is removed through the vagina and the top of the vagina is sutured with sutures that will go away on their own in a period of 4-6 weeks.
Vaginal hysterectomy has several advantages. There are no scars on the belly, which means that it is less painful than abdominal hysterectomy for the patient. It requires only a few simple instruments, which means that it is cheaper to perform than a laparoscopic hysterectomy where more specialized instruments are needed. Women with sagging (prolapse) of the bladder or rectum are especially good candidates for this procedure, since there is easy access to correct these problems as well during the vaginal approach.
The main disadvantages of the vaginal approach is that you cannot see the pelvic organs as well as during a laparotomy or laparoscopy. It is also more technically difficult to do when there is scar tissue inside the abdomen or in patients who have had endometriosis. Also, it is not well suited when there are ovarian masses that need to be removed as well, and overall it is not possible to remove the ovaries through the vagina in 10% of cases. Some women also have narrow pelvic bones, which makes it even more difficult for the surgeons to see during surgery.
Because vaginal hysterectomy is the least expensive method and a minimally invasive method with similar recovery times as a laparoscopic hysterectomy, it should be the first option in women with a relatively small uterus who have delivered their children vaginally, have no history of previous surgery in the pelvis or of endometriosis, and who do not have any ovarian masses or cysts present.
Laparoscopic hysterectomy is intended to replace abdominal hysterectomy. It has several advantages over abdominal hysterectomy. It has been well established that patients who have a laparoscopic hysterectomy have less pain, less bleeding, less risk of infection and are quicker to return to work and normal activities than women who have an abdominal hysterectomy. Therefore it should be the first option in women who are not good candidates for a vaginal hysterectomy as outlined above.
The laparoscopic approach gives the surgeon superior visibility inside the pelvis than during vaginal surgery and even better visibility than during abdominal surgery. This is in part because of the possibility to magnify the image on the screen and because the lighting is much better during laparoscopy.
Following insertion of laparoscopic trocars or sleeves the procedure is carried out in a similar manner as the abdominal hysterectomy, i.e. the attachments and blood vessels of the uterus are released from the uterus. Instead of using a clamp and sutures, most surgeons now use thermal energy to seal and cut the blood vessels, since this saves significant time over the traditional suturing technique. This adaptation was necessary since the clamps used during open surgery are not as well suited for laparoscopic surgery.
Once the uterus is completely freed it is either delivered through the vagina or through the abdominal wall through a small incision (see section on uterine fibroids). The top of the vagina is sutured either laparoscopically or through the vagina with sutures that go away on their own over a period of 4-6 weeks.
The average time that it takes for a woman to get completely back to normal after a laparoscopic or vaginal hysterectomy is approximately 3 weeks. Some women are up and running in less than a week, but most women take a little longer than that. This is a big difference compared to the 6-8 weeks it takes to get back to normal after an abdominal hysterectomy.
With advancements in anesthesia and surgical techniques, many patients are able to go home the same day after a laparoscopic or a vaginal hysterectomy, which is an added benefit to those patients that do not want to spend the night in a hospital. Many patients elect to stay overnight and a few require a longer hospital stay, especially if there are any complications.
It is important to remember that regardless of the method used, a hysterectomy is a major surgical procedure and can lead to serious complications. Fortunately these complications are rare, especially in the hands of an experienced surgeon. The most common complications following a hysterectomy are infection and bleeding. Infection usually happens either in the skin incision or in the vaginal cuff (top of the vagina). Most often these infections respond to antibiotic therapy, but occasionally additional surgery is needed.
The average blood loss during a vaginal and a laparoscopic hysterectomy is probably about 50-100 ml, which is equal to the amount of blood lost during three normal menstrual cycles. The average blood loss during abdominal hysterectomy is usually a little more than that (200ml). Occasionally, there can be significantly more bleeding and therefore women are always asked whether they would be willing to accept a blood transfusion in the event of an emergency. This is especially important in women who are already low on blood because of long-standing heavy menstrual periods.
Damage to other pelvic organs is also a potential risk, such as injury to the urinary bladder, bowel or the ureters. Fortunately the risk of these complications is less than 1%. However, they can be very serious and in some cases fatal. They become especially dangerous when they are not seen during surgery. This is especially dangerous with injuries to the bowel, since severe infection can develop rapidly following a bowel injury that is not corrected during surgery. Every attempt is therefore made to recognize these injuries during surgery. Occasionally, surgeons will cut into these organs on purpose, such as in the case of endometriosis or cancer, so experienced gynecologic surgeons are used to dealing with these complications.
Finally, women should always be aware that any time a hysterectomy is attempted laparoscopically or vaginally, there is a small risk that it will be necessary to make a larger incision to safely complete the procedure. How often this happens depends on the experience of the surgeon and the difficulty of the surgery, but over all this should not happen more than 5% of the time. Patients operated on by physicians of the Brigham and Women's MIGS Division have a conversion rate that is less than one percent.
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