FARR NEZHAT, MD, JYOTI YADAV, MD
Hysterectomy is the most frequently performed major gynecologic procedure with approximately 600,000 cases in the United States each year. In this era of advanced operative laparoscopy and minimally invasive surgery, where almost all types of procedures have been performed endoscopically, a considerable number of hysterectomies are still being performed through large abdominal incisions. However, a slow but gradually increasing trend has occurred towards laparoscopic or laparoscopic-assisted vaginal hysterectomies, 0.3% in 1990 to 9.9% in 1997 . The extent of laparoscopic involvement has ranged from simply before vaginal hysterectomy to evaluate the peritoneal and pelvic cavity and to assess the feasibility of vaginal hysterectomy , to performing the most advanced and complicated procedures, such as total laparoscopic radical hysterectomy with pelvic and paraaortic lymphadenectomy .
As per data from the nationwide Inpatient Sample of the Healthcare Cost and Utilization Project, the indications for laparoscopic hysterectomies have been leiomyomas (28%), endometriosis (19%), menstrual irregularities (15%), prolapse (13%), malignancy (5%), and pelvic inflammatory disease (3%). The advantage of a laparoscopic approach over the open abdominal route in terms of intraoperative blood loss, short- and long-term postoperative morbidity, and recovery has been demonstrated repeatedly [4-7]. However, little benefit over the vaginal approach has been seen .
The indications for laparoscopic and laparoscopic-assisted vaginal hysterectomy are generally those that would preclude a vaginal approach, ie, similar to those for abdominal hysterectomy. Notably, the 9% increase in laparoscopic hysterectomies from 1990 to 1997 corresponds to the decline in the rate of abdominal hysterectomies during the same period. Broadly, the considerations are prior surgery or pelvic inflammatory disease necessitating lysis of adhesions, endometriosis and a coexistent pelvic mass requiring evaluation. Considerations like large uteri, adnexectomy, surgery in an obese patient and the role of laparoscopy in gynecologic malignancies are a matter of debate and are dependent on the surgeon's experience. Moreover, as experience in vaginal surgery continues to decline with each consecutive batch of graduating residents, with rapid technological developments in the field of laparoscopy, and as data regarding various outcomes mature, increasing numbers of indications for the laparoscopic approach to hysterectomy will continually be defined.
Some of the factors that have limited the widespread adoption of the laparoscopic approach have been concerns regarding cost, complications, learning curve, operative time and the lack of well-defined indications. In terms of cost, several studies over the last decade have demonstrated that with the use of reusable instruments, shorter length of stay with laparoscopic procedures, and decreasing operative times with experience, the cost of a laparoscopic hysterectomy is comparable to the cost of a vaginal or an abdominal hysterectomy [9-11]. The incremental savings from quicker recovery and return to work and fewer postoperative visits certainly reduce the overall cost following laparoscopic hysterectomy .
As for the complication rate and length of the procedure, these are dependent on surgeon experience and expertise in laparoscopic procedures. Nezhat et al  in their series of 361 laparoscopic hysterectomies had no mortality, major vessel, or urinary tract injury, and one case of small bowel perforation. Wattiez et al  in their series of over 1600 laparoscopic hysterectomies over 10 years demonstrated a significant decline in major complication rates, conversion rates to laparotomy, and operative time from 5.6% to 1.3%, 4.7% to 1.4%, and 115 minutes to 90 minutes, respectively, with increasing surgical experience. A large Finnish study  attempted to define the learning curve for laparoscopic hysterectomies by demonstrating a significant drop in all major complications beyond 30 procedures. The rate of conversion to laparotomy has been described as ranging from 4% to 11%, for reasons like large uteri, diminished uterine mobility, excessive dense abdominal adhesions, and uncontrolled hemorrhage .
Recently, there has been a resurgence of interest in the supracervical hysterectomy for benign conditions. Proponents of this approach tout the preservation of neurovascular integrity, and as a result less bowel, bladder, and sexual dysfunction, as well as complications, as reasons for offering supracervical hysterectomy, although none of the retrospective and prospective randomized studies so far has substantiated this contention.17,18 Limited data are available on the outcome of this procedure via laparoscopy and how it compares with total laparoscopic or assisted vaginal hysterectomy.
In conclusion, the vaginal approach should be preferred for hysterectomy, whenever feasible. Laparoscopic, or laparoscopic-assisted vaginal hysterectomy can diminish the need for laparotomy in more than 90% of cases. Defining guidelines for training, credentialing, and improvement in instrumentation will help in minimizing complications, decreasing operative time, and improving patient satisfaction.
Address reprint requests to: Farr Nezhat, MD,
25 Columbus Cir, Apt 60B, New York, NY 10023, USA. Tel: 212 241 9434, Fax: 212 987 6386,
Farr Nezhat, MD, is a Past President of the Society of Laparoendoscopic Surgeons. He is the Director and Fellowship Director of the Gynecologic Minimally Invasive Surgery Division, and a Professor of Obstetrics and Gynecology at the Mount Sinai School of Medicine in New York. A pioneering leader in the application of minimal access surgery to pelvic malignant and benign gynecologic pathologies, he is nationally and internationally known for his research, teaching and clinical contributions to the field of gynecologic and pelvic surgery.
Jyoti Yadav, MD, is an Instructor at New York Medical College and an Attending Physician in Obstetrics, Gynecology and Gynecologic Minimally Invasive Surgery at Our Lady of Mercy Medical Center in Bronx, New York. In 2004, Dr. Yadav completed a fellowship in Gynecologic Minimally Invasive Surgery at Mount Sinai Hospital in New York, New York. She has expertise in advanced hysteroscopic and laparoscopic procedures for challenging conditions like fibroids and severe endometriosis.
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