Scholarly Debate

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During the 20th century, surgery has evolved from a high-risk intervention used in extreme cases to a safe intervention used routinely to treat a myriad of problems. The 21st century will see further fine-tuning of procedures and advances in technology, along with ongoing critical evaluation of outcomes.

A DECADE OF CHANGE
Hysterectomy is the third most commonly performed major operation in the United States. The "exit strategy" for removing the uterus--through the abdomen or the vagina--had remained essentially unchanged until 10 years ago, when Reich reported the first experiences with laparoscopic hysterectomy.¹ This report and others that have followed proved that the laparoscopic procedure could be performed successfully. Training courses subsequently proliferated in this country and abroad. During the early 1990s, however, the literature on laparoscopic hysterectomy remained primarily anecdotal, consisting mostly of descriptions of the technique without meaningful statistics.² It was not until 4 years ago that preliminary statistics started appearing in the literature, making it possible to begin evaluating the clinical significance of this operation.

It is worth mentioning that the first papers on laparoscopic cholecystectomy were published at about the same time as those on laparoscopic hysterectomy. Although the laparoscopic approach to cholecystectomy has become the standard of care for this operation, the laparoscopic technique is used in fewer than 5% of hysterectomies. Even when laparoscopy is used, it serves primarily as a diagnostic modality combined with vaginal hysterectomy. Finally, whereas almost every surgeon who performs cholecystectomy has mastered the laparoscopic technique, fewer than one-half of the gynecologists who perform hysterectomy have learned the laparoscopic procedure. What accounts for this significant difference? The answer begins with a look at the outcome data.

THE DATA
The current data are scanty; preliminary conclusions may change as more results are reported. Most papers compare the outcomes of laparoscopic hysterectomy with those of abdominal hysterectomy; the consensus is that the laparoscopic approach may be used as a substitute for the abdominal approach but not for the vaginal approach. Again, however, there are not enough data to support or refute this position.

Any new procedure proposed as a substitute for an established technique must represent some type of improvement. The purported benefits of laparoscopic hysterectomy include decreased operative time, shortened hospital stay, diminished postoperative pain and disability, improved cosmesis, lower cost, and a reduced incidence of complications. Therefore, it seems reasonable to evaluate this 10-year-old procedure on each of these points.

Operative Time
Over the past 4 years, several studies comparing the duration of the laparoscopic hysterectomy procedure with that of abdominal hysterectomy have been published. In nearly all cases, the laparoscopic procedure took longer, by an average of 30 to 81 minutes.^2-4 Results of my own study confirmed that laparoscopic hysterectomy took longer to perform, even in experienced hands.⁵

Hospital Stay
Length of hospital stay has become the focus of both medical insurers and hospital administrators, but it is rarely a major concern for patients. Research has shown that laparoscopic hysterectomy entails an average postoperative stay that is approximately 2 days shorter than that for the abdominal approach. ^2,3,6 However, the length of stay following abdominal hysterectomy has declined significantly over the past few years, making the difference in length of stay less consequential.
Postoperative Pain

Of all the parameters in the comparison between abdominal and laparoscopic hysterectomy, the degree of immediate postoperative pain is the least debatable: The small incisions required for the laparoscopic approach are indisputably less painful than a major abdominal incision. Nevertheless, published data on this topic are scanty--perhaps because this point is considered self-evident. Findings have shown that women recovering from laparoscopic hysterectomy use less postoperative pain medication than do those recovering from abdominal hysterectomy.^2,6

Studies have also shown that postoperative disability--as measured by intensity and duration of pain and length of time until resumption of normal activity--was of a lesser magnitude in patients who underwent laparoscopic hysterectomy than in those who underwent abdominal hysterectomy.^2,3,6,7 Correspondingly, quality-of-life scores were higher in patients whose surgeons operated laparoscopically than in those whose surgeons operated abdominally.⁸

Cosmesis
Many gynecologists believe that laparoscopic incisions are cosmetically superior to a low transverse abdominal incision, but no comparative studies have been conducted to support or refute that belief. In my experience with participants in courses and with patients, the lower abdominal incision is preferred over multiple smaller ones in the umbilicus and the lateral abdomen when only the cosmetic outcome is considered.

Cost
The cost of medical care plays a major role in treatment decisions. To date, 11 studies have found the cost of laparoscopic hysterectomy to be no lower than that of abdominal hysterectomy: Indeed, 8 studies found the laparoscopic approach to be more expensive than the abdominal approach,^2,4,5,9-13 and three studies found the costs for the two procedures to be equal.^14-16

Complications
Although many physicians assume that laparoscopic hysterectomy is safer than traditional abdominal hysterectomy, most studies show that the complication rate is significantly higher with the former than the latter. It should be noted that most of these studies have been reviews or case-control studies. Nonetheless, the lack of prospective, randomized research does not invalidate the consistency of the data.

In general, the complication rate in operative laparoscopic procedures has been found to rise as the complexity of the operation increases.¹⁷ Saidi and colleagues found a urinary tract complication rate of 1.6%, a major complication rate of 5.3%, and a total complication rate of 10.4%.^17,18 Jansen and coworkers reported a complication rate of 1.8% for all operative laparoscopies, with a "higher" rate for laparoscopic hysterectomy.¹⁹ A Finnish analysis, which noted a 1% complication rate for operative laparoscopy, concluded that more complex laparoscopies were associated with an unacceptably high number of serious complications.²⁰

A study dealing specifically with the sequelae of laparoscopic hysterectomy found a complication rate of 11%.²¹ Another study demonstrated that the overall complication rate was higher after laparoscopic hysterectomy than after abdominal hysterectomy but that these complications were predominantly mild to moderate in severity.²² A Chinese study found no benefits of the laparoscopic approach in terms of reduced postoperative complications.²³ Finally, a study that reported a major complication rate of 11% with laparoscopic hysterectomy concluded that the actual complication rate of this procedure appeared to exceed the expected risks of open hysterectomy.²⁴

A literature review found that bladder injuries occurred in 0.4% of patients following abdominal hysterectomy and in 1.8% of patients following laparoscopic hysterectomy.²⁵ In a Finnish study, the incidence of vesicovaginal fistula was 2.2/1000 following laparoscopic hysterectomy versus 1/1000 for abdominal hysterectomy and that of ureteral injury was 13.9/1000 versus 0.4/1000, respectively.⁷

THE FUTURE
Enumeration of these drawbacks is not meant to imply that laparoscopic hysterectomy should be eliminated from our surgical repertoire.

On the contrary, the laparoscopic approach will undoubtedly represent a great improvement over traditional hysterectomy one day. For now, however, it is still a "rough draft" that needs significant modification. The initial reports documenting lengthened operating time, increased costs, and relatively high rates of complications all indicate that this procedure is not yet ready for use by the general gynecologist.

There are many reasons for the delay. First of all, the instrumentation and surgical techniques are not sufficiently refined to ensure that the surgery can be performed consistently and safely.

Second, although most gynecologists could learn the techniques with enough time and practice, few busy ones can devote more than a week to mastering the approach. Third, even if these practitioners had adequate time for learning, they might not have practices large enough to generate the number of patients necessary to maintain their skills. Thus, although the specialist gynecologist with a large referral practice can acquire sufficient experience to perform this surgery effectively and safely, laparoscopic hysterectomy in its present form remains beyond the reach of most generalists--accounting for the unacceptably high complication rate.

Skilled gynecologists need to work with the technology companies to refine the laparoscopic hysterectomy technique. That is, they need to develop a better method for morcellation so as to make removal of the enlarged uterus both safer and quicker. New devices to help secure the vascular pedicles and safer techniques of ligation such as clips or advanced energy sources need to be invented. Laparoscopic suturing can be very difficult for the generalist gynecologist, thereby limiting its application.

More specific indications and relative contraindications for laparoscopic hysterectomy must be established based on prospective outcome data rather than on anecdotal reports. This information is essential if the surgeon is to determine which patients would benefit from this new procedure and which patients would not.

The ultimate goal is still to eliminate the need for hysterectomy. Toward this end, we must seek to substitute medical therapies and minor surgical procedures whenever possible and pursue evolving techniques such as endometrial ablation and fibroid embolization. This goal remains elusive despite the significant progress that has been made.

CONCLUSION
I am an ardent proponent of laparoscopic hysterectomy, but not in its current form. With 10 years of experience behind us, it is time to undertake the necessary modifications to bring the procedure into the mainstream--to make it safe, practical, cost-effective, and widely available.

References:

REFERENCES

1. Reich H, DeCaprio J, McGlynn F. Laparoscopic hysterectomy. J Gynecol Surg. 1989;5:213-216.

2. Meikle SF, Nugent EW, Orleans M. Complications and recovery from laparoscopy-assisted vaginal hysterectomy compared with abdominal and vaginal hysterectomy. Obstet Gynecol. 1997;89 (2):304-311.

3. Olsson JH, Ellstrom M, Hahlin M. A randomized prospective trial comparing laparoscopic and abdominal hysterectomy. Br J Obstet Gynaecol. 1996;103(4): 345-350.

4. Laveran RL, Simon NV, Gerlach DH, Jackson JR. Cost analysis of laparoscopic hysterectomy and abdominal hysterectomy. J Am Assoc Gynecol Laparoscopists. 1996;103(4):345-350.

5. Angle HS, Cohen SM, Hidlebaugh D. The initial Worcester experience with laparoscopic hysterectomy. J Am Assoc Gynecol Laparoscopists. 1995;2(2): 155-161.

6. Kadar N. Implementation of laparoscopic hysterectomy in community hospitals. J Am Assoc Gynecol Laparoscopists. 1995;2(4, suppl):S21.

7. Harkki-Siren P, Sjoberg J, Tiitinen A. Urinary tract injuries after hysterectomy. Obstet Gynecol. 1998;92(1):113-118.

8. Van den Eeden SK, Glasser M, Mathias SD, et al. Quality of life, health care utilization, and costs among women undergoing hysterectomy in a managed-care setting. Am J Obstet Gynecol. 1998;178(1, pt 1):91-100.

9. Boike GM, Elfstrand EP, DelPriore G, et al. Laparoscopically assisted vaginal hysterectomy in a university hospital: report of 82 cases and comparison with abdominal and vaginal hysterectomy. Am J Obstet Gynecol. 1993;168(6, pt 1): 1690-1701. Discussion.

10. Laveran RL, Simon NV, Gerlach DH, Jackson JR. Cost analysis of laparoscopic hysterectomy and abdominal hysterectomy. J Am Assoc Gynecol Laparoscopists. 1996;3(4, suppl):S24.

11. Kjerulff KH, Guzinski G, Langenberg P, Pegues R. Cost-effectiveness of laparoscopic-assisted vaginal hysterectomy. J Am Assoc Gynecol Laparoscopists. 1996;3(4, suppl):S22.

12. Ellstrom M, Ferraz-Nunes J, Hahlin M, Olsson JH. A randomized trial with a cost-consequence analysis after laparoscopic and abdominal hysterectomy. Obstet Gynecol. 1998;91(1):30-34.

13. Garry R. Comparison of hysterectomy techniques and cost-benefit analysis. Baillieres Clin Obstet Gynaecol. 1997;11(1): 137-148.

14. Mehra S, Bokaria R, Gujral A, et al. Experience in laparoscopic hysterectomy: analysis of three hundred cases. Ann Acad Med Singapore. 1996;25(5):660-664.

15. Tsaltas J, Magnus A, Mamers PM, et al. Laparoscopic and abdominal hysterectomy: a cost comparison. Med J Aust. 1997;166(4):205-207.

16. Johns DA, Carrera B, Jones J, et al. The medical and economic impact of laparoscopically assisted vaginal hysterectomy in a large, metropolitan, not-for-profit hospital. Am J Obstet Gynecol. 1995;172(6):1709-1719. Discussion.

17. Saidi MH, Sadler RK, Vancaillie TG, et al. Diagnosis and management of serious urinary complications after major operative laparoscopy. Obstet Gynecol. 1996;87(2):272-276.

18. Saidi MH, Vancaillie TG, White AJ, et al. Complications of major operative laparoscopy. J Reprod Med. 1996;41(7): 471-476.

19. Jansen FW, Kapiteyn K, Trimbos-Kemper T, et al. Complications of laparoscopy: a prospective multicentre observational study. Br J Obstet Gynaecol. 1997;104(5):595-600.

20. Harkki-Siren P, Kurki T. A nationwide analysis of laparoscopic complications. Obstet Gynecol. 1997;89(1):108-112.

21. Nezhat F, Nezhat CH, Admon D, et al. Complications and results of 361 hysterectomies performed at laparoscopy. J Am Coll Surg. 1995;180(3):307-316.

22. Schwartz RO. Complications of laparoscopic hysterectomy. Obstet Gynecol. 1993;81(6):1022-1024.

23. Yuen PM, Rogers MS. Is laparoscopically-assisted vaginal hysterectomy associated with low operative morbidity? Aust N Z J Obstet Gynaecol. 1996;36(1):39-43.

24. O'Shea RT, Petrucco O. Complications of laparoscopic-assisted vaginal hysterectomy. J Am Assoc Gynecol Laparoscopists. 1995;2(4, suppl):S38.

25. Meikle SF, Nugent EW, Orleans M. Complications and recovery from laparoscopy-assisted vaginal hysterectomy compared with abdominal and vaginal hysterectomy. Obstet Gynecol. 1997;89(2):304-311.

Stephen M. Cohen, MD, FACOG, is the Director of the Center for Women's Minimal Access Surgery and an Associate Clinical Professor of Obstetrics and Gynecology, Columbia University, New York, NY.

Originally published in The Female Patient -- May, 1999

© Copyright, 1999 Quadrant Publishing, All Rights Reserved. Reprints are not allowed without the expressed written consent of Quadrant Publishing.