A Cochrane review validated the perception that vaginal hysterectomy is the surgical route of choice for hysterectomy (42). This review included 3,643 patients from 27 randomized trials. It compared abdominal hysterectomy with vaginal hysterectomy and three types of laparoscopic hysterectomies. The main observations were the shorter length of hospital stay, faster postoperative recovery, and decreased febrile morbidity of vaginal and laparoscopic hysterectomy compared with abdominal hysterectomy. The report concludes that there are improved outcomes with vaginal hysterectomy, and, when vaginal access is not possible, laparoscopic hysterectomy appears to have advantages over abdominal hysterectomy. Cost-analysis trials demonstrate that laparoscopic hysterectomy can be cost-effective relative to abdominal procedure but not compared with vaginal hysterectomy (43,44). The main cost determinants are the length of hospital stay and the use of disposable surgical devices.
Risk of complication from each type of procedure provides insight into the proper options for the patient. The eVALuate study comprised two parallel randomized multicenter trials, with one comparing laparoscopic with abdominal hysterectomy and the other comparing laparoscopic with vaginal hysterectomy for nonmalignant disease (45). Patients with a uterine mass less than 12-week pregnancy were included. The primary end points were assessment of complications. A total of 1,380 patients were recruited. The trial included conversion to laparotomy for the laparoscopic and vaginal groups as a major complication. If you include conversion to laparotomy as a major complication, the number needed to treat to harm would be 20 for the laparoscopic group. If you exclude conversion to laparotomy as a complication, then the complication rates are similar between all groups. All six ureter injuries reported in this series occurred in the laparoscopic group. The overall lower urinary tract complication rate is three times higher with the laparoscopic group compared with vaginal or abdominal procedures. A minor complication, mostly postoperative fever or infection, occurred in approximately 25% of each group.
It is important to systematically go through a checklist of perioperative measures to effectively reduce potential complications (Table 24.2). If excessive blood loss is expected, intra-operative blood salvage techniques should be considered. All patients undergoing hysterectomy for benign disorders are at moderate risk for venous thromboembolism and require prophylaxis (18). Unfractionated heparin (5,000 U every 12 hours) or low molecular weight heparin (e.g.,
Table 24.2 Perioperative Checklist 1.
Is the informed consent signed?
2.
Is there a recent Pap test documented in the chart?
3.
Has pregnancy been ruled out?
4.
Are blood products available if needed?
5.
Will prophylactic antibiotics be initiated within 1 hour of incision?
6.
Was the appropriate antibiotic selected according to American College of Obstetricians and Gynecologists guidelines?
7.
Was the appropriate prophylaxis for venous thromboembolic events chosen?
8.
Document that prophylactic antibiotics will be discontinued within 24 hours after surgery.
Enoxaparin, 40 mg) or intermittent pneumatic compression device is recommended. Patients on oral contraceptives up to the time of hysterectomy should be considered for pharmacologic treatment. Mechanical bowel preparation for prevention of infection complications from bowel injury is no longer recommended (46).
Incision The choice of incision should be determined by the following considerations: 1.
Simplicity of the incision 2.
3.
Potential need for enlarging the incision 4.
Strength of the healed wound 5.
Cosmesis of the healed incision 6.
Location of previous surgical scars