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CONTROVERSIES IN OB/GYN
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Seven years, another 700 hysterectomies, a few complications, innumerable postgraduate courses, and continually advancing age and maturity(?) have convinced me that the opinions I voiced in the symposium on LAVH (laparoscopic-assisted vaginal hysterectomy) that was published in Contemporary OB/GYN remain accurate and factual. Specifically, vaginal hysterectomy is the safest, most cost-effective alternative and should be our first choice. If the procedure is not feasible for any reason (other than malignancy), in the vast majority of cases, hysterectomy can be completed with operative laparoscopy and without laparotomy. Having revealed my slight bias, I will revisit the issue of laparoscopy and hysterectomy in the new millennium. My arguments are solely directed toward hysterectomy for benign disease, including cervical intraepithelial neoplasia.
Although several authors have proposed definitions and staging systems for LAVH, none has been widely accepted. Thousands of gynecologic surgeons scattered across the country all possess varying degrees of skill in operative laparoscopy and vaginal surgery. Each of these surgeons may or may not require a laparoscope to complete the majority of their hysterectomies without laparotomy. Of those who do utilize laparoscopy, there is no agreement on how much laparoscopic surgery is necessary to avoid total abdominal hysterectomy (TAH). Supracervical hysterectomy now is making a comeback, particularly in the Northeast and West coast regions. Given these variables, it is unlikely that any staging system will be universally applicable. The "Powers That Be" in our specialty can't even agree on indications and contraindications for vaginal hysterectomy that reflect even moderate skill in vaginal surgery.
With this in mind and for the sake of this discussion, I will consider LAVH to encompass any hysterectomy performed with the use of a laparoscope and completed without an abdominal incision (laparotomy or "mini" laparotomy). This includes total laparoscopic hysterectomy, LAVH, and laparoscopic supracervical hysterectomy.
Despite a renewed emphasis on training in operative laparoscopy and vaginal surgery, the abdominal hysterectomy rate in the US remains in the 60% to 70% range. This is truly a sad commentary on the surgical skill level of practicing gynecologists. Although many reports in our literature suggest that a minimum of 80% to 90% of hysterectomies for benign disease can be performed vaginally (with or without laparoscopic assistance), the abdominal hysterectomy rate has not significantly changed over the past decade. Unfortunately, the route of hysterectomy does not depend on what is most advantageous for the patient, but rather on the skill and preference of the surgeon. Unlike laparoscopic cholecystectomy, which has become the "standard of care" in general surgery, LAVH and vaginal hysterectomy have not been recognized by the majority of gynecologists as the preferable route for hysterectomy. It seems many have the "if I can't do it, it can't be done" mentality.
Since 1993, numerous studies have shown LAVH to be comparable in hospital cost to abdominal hysterectomy. Rates of complication related to vaginal hysterectomy and LAVH are consistently lower than for TAH. Postoperative pain, recovery time, general patient comfort, and return to normal activity strongly favor vaginal hysterectomy and LAVH over TAH. Even my honorable opponent in this discussionand the one 7 years agopublished an article in 1998 substantiating these opinions. There can no longer be any doubt that the vaginal route (with or without laparoscopic assistance) offers numerous advantages over TAH. In fact, based on available data on these alternatives, it could be argued that TAH is rarely in the patient's best interest. The only doctors arguing against this fact are those without the skills to perform VH or LAVH. Ironically, it is unlikely that these same gynecologists would easily accept the need for their own cholecystectomy to be performed via conventional incision rather than laparoscopic techniques.
The most common "indications" for TAH are endometriosis and large myoma. Given our current understanding of endometriosis, it is clear that implants of endometriosis must be removed (excised, coagulated, or vaporized) to best alleviate pain. To be removed, they must first be seen. Laparoscopy offers the surgeon a magnified, close-up view of the deep cul-de-sac, ovarian fossa, and abdominal wall that would be very difficult to attain at laparotomy (unless the surgeon performs TAH with an operating microscope). Obviously, if the patient is undergoing hysterectomy for endometriosis, the proper operation (including treatment of all endometriotic lesions and nodules) can best be performed laparoscopically. During TAH, such implants and nodules are usually overlooked, ignored, or both.
"Fibroids" are a common "excuse" for abdominal hysterectomy. Vaginal morcellation of large uteri has been taught for decades. New laparoscopic morcellators are fast, safe, efficient, and unfortunately expensive. Between these two, there is little reason to subject a patient with large myoma to TAH. Numerous articles have established the safety and efficacy of vaginal and supracervical hysterectomy and LAVH in such patients. In reality, TAH is rarely necessary in patients with fibroid uteri as large as 20-week size, yet the American College of Obstetricians and Gynecologists suggests TAH in patients with 12-week-size fibroids!
Given these facts, why are the majority of hysterectomies in the US for benign disease still performed abdominally? I fear the answer is clear. The surgical arm of our specialty has become mired in mediocrity. The majority of practicing gynecologists perform fewer than one hysterectomy every 2 to 3 weeks. This is obviously not enough volume to maintain, much less improve, surgical skill. When patients are scheduled for abdominal hysterectomy, how often are they given the alternative of referral to a gynecologist who could perform the procedure vaginally (with or without a laparoscope)? I don't pretend to know the answer, but I'm certain it is less than 1%. Unfortunately, economic pressures, diminished reimbursement, and decreasing surgical volume have prevailed over the best interests of patients. Contrast this with general surgery. Since laparoscopic cholecystectomy is now recognized as the "standard," our colleagues in general surgery don't have this luxury. If they can't perform a laparoscopic cholecystectomy in the majority of their patients, they won't be operating on gallbladders for long. Good for their patients, bad for ours.
In summary, there is no doubt that (in surgically competent hands) vaginal hysterectomy or any of the laparoscopic variants thereof offer unquestioned advantages to our patients over TAH. Operative laparoscopy has allowed most patients to take advantage of these benefits who would otherwise have undergone laparotomy. The environment in which we practice obviously prevents many patients from benefiting from these advances. It's a shame.
Garry R. Towards evidence-based hysterectomy. Gynaecological Endoscopy. 1998;7;225-223.
Johns DA. Laparoscopically assisted vaginal hysterectomy (LAVH). In: Soderstrom RM, ed. The Masters' Techniques In Gynecologic Surgery. Operative Laparoscopy. 2nd ed. Lippincott-Raven; 1998:221-227.
Kovac SR. Guidelines to determine the route of hysterectomy. Obstet Gynecol. 1995;85:18-23.
Kovac SR, Ameo RA. Choosing the approach to hysterectomy. Contemporary OB/GYN. 1999;12:35-49.
Marana R, Busacca M, Zupi E, et al. Laparoscopically assisted vaginal hysterectomy versus total abdominal hysterectomy: a prospective, randomized, multicenter study. Am J Obstet Gynecol. 1999;180:270-275.
Summitt RL Jr, Stovall TG, Steege JF, et al. A multicenter randomized comparison of laparoscopically assisted vaginal hysterectomy and abdominal hysterectomy in abdominal hysterectomy candidates. Obstet Gynecol. 1998;92:321-326.
Controversies in OB/GYN focuses on controversial issues pertaining to the clinical practice of obstetrics and gynecology. The authors have been selected for their ability to articulate a particular point of view, regardless of their own personal convictions.
We hope that these short essays will provoke discussion and help Contemporary OB/GYN's readers clarify and refine their own practice management. You can join in the dialogue by completing and faxing in the response form at the end of this article or sending us your opinion (pro or con) via e-mail to firstname.lastname@example.org. A summary of the correspondence we receive will be published in a future issue.
David B. Seifer, MD, Series Editor Department of Obstetrics, Gynecology, and Reproductive Sciences UMDNJ-Robert Wood Johnson Medical School New Brunswick, N.J.
Alan John. Should we use laparoscopic-assisted vaginal hysterectomy?. Contemporary Ob/Gyn 2000;4:11-14.