Surgical approach to hysterectomy for benign gynaecological diseases

Abdominal hysterectomy involves removal of the uterus through an incision on the lower abdomen. Vaginal hysterectomy involves removal of the uterus via the vagina, with no abdominal incision. Laparoscopic hysterectomy involves 'keyhole surgery' with small incisions on the abdomen. In laparoscopic hysterectomy, the uterus is removed with the aid of a surgical telescope (laparoscope) inserted through the umbilicus (belly button) and instruments inserted through two or three further keyholes. Laparoscopic hysterectomy may be further subdivided depending on the extent of the surgery performed laparoscopically compared to that performed vaginally. More recently, laparoscopic hysterectomy can be performed with the use of a so-called robot which is operated from a distance by the surgeon.

Vaginal hysterectomy should be performed in preference to abdominal hysterectomy, where possible. This review found that vaginal hysterectomy meant quicker return to normal activities, fewer infections and episodes of raised temperature after surgery, and a shorter stay in hospital compared to abdominal hysterectomy.

Laparoscopic hysterectomy meant quicker return to normal activities, less blood loss and a smaller drop in blood count, a shorter stay in hospital, and fewer wound infections and episodes of raised temperature after surgery compared to abdominal hysterectomy, but laparoscopic hysterectomies have a greater risk of damaging the bladder or ureter (the tube leading to the bladder from the kidney) and are longer operations.

No benefits were found for laparoscopic versus vaginal hysterectomy. Laparoscopic hysterectomies are longer operations associated with a higher rate of substantial bleeding.

The authors concluded that vaginal hysterectomy should be performed in preference to abdominal hysterectomy, where possible. Where vaginal hysterectomy is not possible, a laparoscopic approach may avoid the need for an abdominal hysterectomy. Risks and benefits of different approaches may however be influenced by the surgeon's experience. More research is needed, particularly to examine the long-term effects of the different types of surgery.

Authors' conclusions: 

Because of equal or significantly better outcomes on all parameters, VH should be performed in preference to AH where possible. Where VH is not possible, LH may avoid the need for AH however the length of the surgery increases as the extent of the surgery performed laparoscopically increases. The surgical approach to hysterectomy should be decided by the woman in discussion with her surgeon in light of the relative benefits and hazards.

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Background: 

The three approaches to hysterectomy for benign disease are abdominal hysterectomy (AH), vaginal hysterectomy (VH), and laparoscopic hysterectomy (LH). Laparoscopic hysterectomy has three further subdivisions depending on the part of the procedure performed laparoscopically.

Objectives: 

To assess the most beneficial and least harmful surgical approach to hysterectomy for women with benign gynaecological conditions.

Search strategy: 

We searched the Cochrane Menstrual Disorders and Subfertility Group Specialised Register of controlled trials (15 August 2008), CENTRAL (The Cochrane Library 2008, Issue 3), MEDLINE (1950 to August 2008), EMBASE (1980 to August 2008), Biological Abstracts (1969 to August 2008), the National Research Register, and relevant citation lists.

Selection criteria: 

Only randomised controlled trials comparing one surgical approach to hysterectomy with another were included.

Data collection and analysis: 

Independent selection of trials and data extraction were employed following Cochrane guidelines.

Main results: 

There were 34 included studies with 4495 women. The benefits of VH versus AH were speedier return to normal activities (mean difference (MD) 9.5 days), fewer febrile episodes or unspecified infections (odds ratio (OR) 0.42), and shorter duration of hospital stay (MD 1.1 days). The benefits of LH versus AH were speedier return to normal activities (MD 13.6 days), lower intraoperative blood loss (MD 45 cc), a smaller drop in haemoglobin (MD 0.55 g/dl), shorter hospital stay (MD 2.0 days), and fewer wound or abdominal wall infections (OR 0.31) at the cost of more urinary tract (bladder or ureter) injuries (OR 2.41) and longer operation time (MD 20.3 minutes). The benefits of LAVH versus TLH were fewer febrile episodes or unspecified infection (OR 3.77) and shorter operation time (MD 25.3 minutes). There was no evidence of benefits of LH versus VH and the operation time (MD 39.3 minutes) as well as substantial bleeding (OR 2.76) were increased in LH. For some important outcomes, the analyses were underpowered to detect important differences or they were simply not reported in trials. Data were absent for many important long-term outcome measures.

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