Which is better - Abdominal, Vaginal or Laparoscopic hysterectomy?

Hysterectomy or removal of the uterus can be done by one of several routes and are one of several types.

  

  

Routes –

1.     Abdominal.

2.     Vaginal.

3.     Laparoscopic.

Types –

1.     Supracervical hysterectomy.

2.     Total Hysterectomy only.

3.     Hysterectomy with bilateral salpingectomy (removal of both fallopian tubes).

4.     Hysterectomy with bilateral salpingo-oophorectomy (removal of both f. tubes and ovaries).

5.     Wertheim’s hysterectomy.

·        First successful vaginal hysterectomy - Performed by a patient on herself in 1670. A 46-year old peasant named Faith Haworth was carrying a heavy load of coal when her uterus collapsed completely. Frustrated by this frequent occurrence, she grabbed her uterus, pulled as hard as possible, and cut the whole lot off with a short knife. The bleeding stopped and she lived on for many years, "water passing from her insensibly day and night".

·         First planned vaginal hysterectomy – Conrad Langenbeck. 1813.

·    First successful abdominal hysterectomy – Walter Burnham. 1853 (by accident). Upon opening the patient to remove a large ovarian cyst, she vomited expelling a large fibroid uterus. As the surgeon was unable to put it back into the peritoneal cavity, he removed it supracervically.

·         First planned abdominal hysterectomy -  Clay and Koeberle. 1863.

·         First total laparoscopic hysterectomy. - Harry Reich. 1985.

Vaginal hysterectomy and abdominal hysterectomy techniques were progressively refined over the remainder of the nineteenth century, and by the early twentieth century had become established as the “classic” techniques, to be passed down essentially unaltered to successive generations of gynecologists.

Laparoscopic hysterectomy remains a reasonable substitute for abdominal hysterectomy. Most hysterectomies currently requiring an abdominal approach may be performed with laparoscopic dissection of part, or all, of the abdominal portion followed by vaginal removal of the specimen.

Surgical Advantages

There are many surgical advantages to laparoscopy, particularly magnification of anatomy and pathology, easy access to the vagina and rectum, and the ability to achieve complete hemostasis. Patient advantages are multiple and are related to avoidance of a painful abdominal incision. They include reduced duration of hospitalization and recuperation and an extremely low rate of infection and ileus. The goal of vaginal hysterectomy, LAVH, or LH is to safely avoid an abdominal wall incision, with resultant benefits just described. The surgeon must remember that if he/she is more comfortable with vaginal hysterectomy after ligating the ovarian ligaments, this should be done. I emphasize, a laparoscopic hysterectomy is not indicated when vaginal hysterectomy can be easily and safely done.

Abdominal hysterectomy	Vaginal hysterectomy	Laparoscopic hysterectomy
Involves comparatively large abdominal incision.	No abdominal incision. Uterus is taken out entirely by vaginal route.	Multiple small abdominal incisions (typically 4-5) which is closed easily by 1-2 stitches.
Longest hospitalization 4-5 days.	2-3 days.	1-2 days.
Longer operative time (127 mins). J Reprod Med. 2006 Dec; 51(12):945-5.	Shortest operative time (103 mins). J Reprod Med. 2006 Dec; 51(12):945-5.	Longest operative time (157 mins). J Reprod Med. 2006 Dec; 51(12):945-5.
Post-op pain and wound complications.	Less or no post op pain.	Less post operative pain and quick recovery.
All patients can be subjected to this procedure.	Patients with very large uterus and no vaginal descent (high up and fixed uterus) are difficult to manage by this procedure.	Multiple previous abdominal operations, severe endometriosis, co-existing moderate to severe cardiac/ respiratory disease are difficult to manage by this procedure.

J Reprod Med. 2006 Dec;51(12):945-5. - Operative time was shortest for TVH (103 minutes), followed by TAH (127 minutes), and longest for LH (157 minutes) (p = 0.000). Blood loss was significantly higher in the TAH groups as compared to the TVH and LH groups. Pain estimates and analgesia requirements were significantly lower for the LH and TVH groups as compared to the TAH group. Recovery milestones were met significantly earlier in the TVH and LH groups. Complication rates did not differ significantly between the groups. Hospital stay was significantly longer for the TAH group (3.7 days) than for the TVH (1.9 days) and LH (1.5 days) groups. Hospital costs were significantly lower for the TVH groups as compared to TAH and LH groups. No significant cost difference was seen between TAH and LH. Satisfaction rates did not differ significantly between the groups though a greater percentage of patients in the LH group reported high satisfaction as compared to the other groups.

CONCLUSION:

Vaginal hysterectomy remains the most cost-effective approach; laparoscopy's role may be best suited to allowing conversion of laparotomy cases to a vaginal approach with assistance of a laparoscope.