RCT-Laparotomy Vs. Laparoscopic Hysterectomy

June 30, 2011

In spite of readily available alternatives to hysterectomy such as endometrial ablation, hysterectomy rates have not fallen. Several comparative trials of hysterectomy have shown shorter hospital stay and convalescence after laparoscopic approach compared to an abdominal approach.

Summary
In spite of readily available alternatives to hysterectomy such as endometrial ablation, hysterectomy rates have not fallen. Several comparative trials of hysterectomy have shown shorter hospital stay and convalescence after laparoscopic approach compared to an abdominal approach.

Introduction
Hysterectomy is the second most commonly performed surgical procedure in the United States1. Approximately 600,000 hysterectomies are performed annually in the United States 2 of which 70% are performed by the abdominal route 3. In some countries, this rate is as high as 95% 4. However, the vaginal approach is clearly superior to laparotomy3, 5. Patients undergoing vaginal hysterectomy have fewer overall complications, shorter hospital stays, and shorter convalescence periods than abdominal hysterectomy3. 

Laparoscopic- assisted vaginal hysterectomy was introduced in the past 10 years6-13 as an alternative to abdominal hysterectomy. In a large hospital survey in the state of Ohio, USA only 8% of all hysterectomies were performed with laparoscopic assistance14. Rates of laparoscopic hysterectomy in the United Kingdom are similar to those in the USA. Laparoscopic- assisted vaginal hysterectomy is a safe alternative to abdominal hysterectomy when a vaginal hysterectomy is contraindicated 6-13. 

Materials and Methods
There are several published comparative trials of laparoscopic versus abdominal hysterectomy. The main bias of surgical studies is attributed to the non-masked nature of the study. Even with standard protocols, it is difficult to eliminate the traditions that are part of a surgical practice, as well as the expectations of patients. The major criticisms of previous trials are that most of the hysterectomies could be managed by the more cost-effective vaginal route and that postoperative recovery variables, such as hospital length of stay, are more a comparison of traditional surgical practice than precise outcomes. In our institution most hysterectomies (66.5 %) for non-malignant disease are performed vaginally.

Results
In a prospective randomized clinical of laparoscopic assisted vaginal hysterectomy versus total abdominal hysterectomy at the Cleveland Clinic Foundation laparoscopic - assisted vaginal hysterectomy was shown to be associated with less postoperative pain, shorter hospital stays, and more rapid return to normal activities and work than abdominal hysterectomy15. In our study, the costs of a laparoscopic assisted vaginal hysterectomy were similar to the costs of a total abdominal hysterectomy. 

The median length of stay for abdominal hysterectomies in our center is 2.5 days. The median length of stay for laparoscopic assisted vaginal hysterectomy is 1.5 days.

Conclusions
In spite of readily available alternatives to hysterectomy such as endometrial ablation, hysterectomy rates have not fallen16. Our own experience has shown that most hysterectomies can be performed vaginally and it can be expected that many hysterectomies that are performed by laparotomy can be converted to a laparoscopic-assisted vaginal approach. These patients will probably have a large uterus and the surgeon will require experience with vaginal morcellation techniques. These procedures can be associated with longer operating times (approximately 51 minutes in our study). There is no difference in postoperative morbidity or blood transfusion rates between laparoscopic assisted vaginal hysterectomy and abdominal hysterectomy.

References:

References

1. POKRAS R. Hysterectomy: past, present and future. Stat Bull Metrop Insur Co. 70:12. 1989.

2. GRAVES EJ National hospital discharge survey: annual summary, 1990. National Center for Health Statistics, Vital Health Stat Series, 13:112. 1992.

3. DICKER RC, GREENSPAN JR, STRAUSS LT, et al. Complications of abdominal and vaginal hysterectomy among women of reproductive age in the United States. Am J Obstet Gynecol 144:841-8. 1982.

4. ELLSTROM M, FERRAZ-NUNES J, HAHLIN M, OLSSON J H. A randomized trial with a cost consequence analysis after laparoscopic and abdominal hysterectomy. Obstet Gynecol 91:30-4. 1998.

5. VA DEN EEDEN SK, GLASSER M, MATHIAS SD, COLWELL HH, PASTA DJ, KUNZ K. Quality of life, health care utilization, and costs among women undergoing hysterectomy in a managed-care setting. Am J Obstet Gynecol 178:91-100.1998.

6. SUMMITT RL, STOVALL TG, LIPSCOMB GH, LING F W. Randomized comparison of laparoscopy- assisted vaginal hysterectomy with standard vaginal hysterectomy in an outpatient setting. Obstet Gynecol 80:895-901. 1992.

7. REICH H, DECAPRIO J, MCGLYNN F. Laparoscopic hysterectomy. J Gynecol Surg 5:213-6.1989.

8. NEZHAT C, NEZHAT F, GORDON S, WILKINS E. Laparoscopic versus abdominal hysterectomy. J Reprod Med 37: 247-50.1992.

9. BOIKE GM, ELFSTRAND EP, DEL PRIORE G, et al Laparoscopically-assisted vaginal hysterectomy in a university hospital: report of 82 cases in comparison with abdominal and vaginal hysterectomy. Am J Obstet Gynecol 168:1690-701.1993

10. RICHARDSON R E, BOURNAS N, MAGOS AL. Is laparoscopic hysterectomy a waste of time ? Lancet 345:36-41.1995.

11. RAJU K S, BARRY JA. A randomized prospective study of laparoscopic vaginal hysterectomy versus abdominal hysterectomy each with bilateral salpingo-oophorectomy. Br J Obstet Gynecol 101:1068-71.1994

12. OLSSON JH, ELLSTROM J, HAHLIN M. A randomized prospective trial comparing laparoscopic and abdominal hysterectomy. Br J Obstet Gynecol 103:345-50.1996

13. PHIPPS JH, JOHN M, NAYAK S. Comparison of laparoscopically assisted vaginal hysterectomy and bilateral salpingo-ophorectomy with conventional abdominal hysterectomy and bilateral salpingo-ophorectomy. Br J Obstet Gynaecol 100:698-700.1993

14. WEBER AM, LEE JC. Use of alternative techniques of hysterectomy in Ohio. N Engl J Med 335:483-9.1996

15. FALCONE T, PARAISO MF, MASCHA E. Prospective Randomized Clinical Trial of Laparoscopic Assisted vaginal hysterectomy versus Abdominal Hysterectomy. Am J Obstet Gynecol 180:955-62.1999

16. BRIDGEMAN SA, DUNN KM Has endometrial ablation replaced hysterectomy for the treatment of dysfunctional uterine bleeding?National figures. Br J Obstet Gynaecol 107:531-34.2000