RCT-Laparotomy Vs. Laparoscopic Hysterectomy

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

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