November 16, 2010 — The American Academy of Gynecologic Laparoscopists (AAGL) recommends minimally invasive surgical approaches such as vaginal hysterectomy (VH) and laparoscopic hysterectomy (LH) for benign uterine disease, according to a position statement published online November 7 in the Journal of Minimally Invasive Gynecology.
"When procedures are required to treat gynecologic disorders, the AAGL is committed to the principles of informed patient choice and provision of minimally invasive options," said Franklin D. Loffer, MD, executive vice president/medical director of the AAGL, in a news release. "When hysterectomy is necessary, the demonstrated safety, efficacy, and cost-effectiveness of VH and LH mandate that they be the procedures of choice. When hysterectomy is performed without a laparotomy, early institutional discharge is feasible and safe, in many cases within the first 24 hours."
In the United States, approximately 600,000 hysterectomies are performed every year for benign disorders of the pelvis, and more than two thirds are performed via an abdominal approach. In some countries, however, as few as 24% of hysterectomies are performed abdominally.
To lower morbidity risk and speed recovery, the AAGL recommends a vaginal or laparoscopic approach to hysterectomy for benign disease. Surgical risks are low for these minimally invasive procedures, which can often be done as an outpatient procedure or with a short hospital stay.
In contrast, the relatively large abdominal incision needed for abdominal hysterectomy (AH) may result in more complications, particularly associated with abdominal wound infections, leading to longer hospitalization and disability before normal activities can be resumed.
Obesity and a previous cesarean delivery were once thought to be contraindications to LH. However, the safety and efficacy of LH are similar in obese and nonobese patients, although operative times are longer in obese patients. Compared with other techniques, LH may be associated with an increased risk for cystotomy, but overall risk is low. The AAGL recommends that previous cesarean delivery should no longer be considered a contraindication to either VH or LH.
Even when the uterus is large, a number of surgeons can feasibly and safely perform VH. LH appears to be a safe alternative preserving most of the advantages of VH vs AH, and it can be performed when uterine size or other coexisting disease or surgical considerations preclude performance of VH.
Direct costs of either VH or LH are less than those of AH, but institutional costs of LH may be higher vs VH depending on what instrumentation is used. Compared with AH, LH appears to reduce indirect costs of hysterectomy by 50%, based on high-quality evidence from several randomized controlled trials.
In several oncologic studies, LH vs AH has been shown to lower morbidity risk without compromising clinical efficacy in women with cervical or endometrial carcinoma.
"Given the advantages that VH and LH offer to women, their families, their employers, and the health care system in general, it seems desirable to optimize their application in women requiring hysterectomy because of benign uterine conditions," the authors of the position statement write. "Abdominal hysterectomy should be reserved for the minority of women for whom a laparoscopic or vaginal approach is not appropriate. These situations are not common."
Women in whom LH is not appropriate may include the following:
- Those with cardiopulmonary disease or other medical conditions in which the risks are unacceptable, either for general anesthesia or for increased intraperitoneal pressure associated with laparoscopy.
- Those in whom morcellation, or cutting the tumor into pieces before removal, is known or likely to be required and uterine malignancy is either known or suspected.
Situations in which LH and VH are not appropriate may include the following:
- Although hysterectomy is indicated, there is no access to the surgeons or facilities needed for VH or LH, and referral is not feasible.
- Surgeons expert in either VH or LH techniques consider the vaginal or laparoscopic approach to be unsafe or unreasonable because of uterine disease or adhesions significantly distorting the anatomy.
"It is the position of the AAGL that most hysterectomies for benign disease should be performed either vaginally or laparoscopically and that continued efforts should be taken to facilitate these approaches," the authors of the position statement write. "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."
J Minim Invasive Gynecol. Published online November 7, 2010.
Clinical Context
For surgical treatment of benign disorders of the pelvis, approximately 600,000 hysterectomies are performed in the United States each year. Although an abdominal incision is used in more than two thirds of these procedures, as few as 24% of hysterectomies are performed abdominally in some countries.
The AAGL therefore issued a position statement committed to the principles of informed patient choice and provision of minimally invasive options, and recommending VH or LH to reduce morbidity risk and recovery time. Because surgical risks are low, VH or LH can often be performed in an outpatient setting or with a short hospital stay.
- Study Highlights
- VH and LH are safe, effective, and cost-effective approaches to hysterectomy.
- Avoiding laparotomy allows early, safe institutional discharge, often within the first 24 hours and/or as an outpatient procedure.
- Surgical risks of VH and LH are low, whereas AH requires a relatively large abdominal incision.
- Abdominal wound infections and other complications of AH may result in longer hospital stay and delayed return to usual activities.
- Although obesity was once thought to be a contraindication to LH, the safety and efficacy of LH are similar in obese and nonobese patients.
- Operative times for LH are longer in obese patients vs nonobese patients.
- LH vs other techniques may be associated with an increased risk for cystotomy, but overall risk is low.
- Previous cesarean delivery should no longer be considered a contraindication to either VH or LH.
- VH may be feasible and safe in the hands of expert surgeons, even when the uterus is large.
- When uterine size or other coexisting disease or surgical considerations render VH not feasible, LH appears to be a safe alternative, with most of the advantages of VH over AH.
- Direct costs of either VH or LH are less than those of AH.
- Institutional costs of LH may be higher than for VH, depending on instrumentation.
- LH has approximately half the indirect costs of AH.
- In women with cervical or endometrial carcinoma, LH vs AH has a lower morbidity risk but a comparable efficacy.
- LH may not be appropriate for women with cardiopulmonary disease or other medical conditions posing unacceptable risks for general anesthesia or for increased intraperitoneal pressure because of laparoscopy.
- LH may be inappropriate in women needing morcellation for uterine malignancy.
- Neither LH nor VH may be appropriate if access is lacking to the surgeons or facilities needed, or if these approaches are unsafe or unreasonable because of uterine disease or adhesions significantly distorting the anatomy.
- Surgeons lacking the needed training and skills to safely perform VH or LH should collaborate with or refer patients to surgeons with these qualifications.
Clinical Implications
- The AAGL has issued a position statement recommending minimally invasive surgical approaches such as VH and LH for benign uterine disease because these procedures offer advantages vs AH to women, their families, their employers, and the healthcare system in general.
- AH should be reserved for those few women in whom a LH or VH is not appropriate. These situations are not common.
