Selecting the route for hysterectomy: A structured approach

More than 600,000 hysterectomies are performed in the United States each year.¹ Although recent data have shown an increase in rates of minimally invasive hysterectomy, the majority of hysterectomies continue to be performed through abdominal routes.^1-3 This is in spite of a large body of evidence supporting that vaginal and laparoscopic hysterectomy are associated with less infectious morbidity, shorter hospital stay, and faster return to normal activity than abdominal hysterectomy.^4-13 Vaginal hysterectomy is also the most cost-effective type of hysterectomy.¹⁴ Based on these findings, vaginal and laparoscopic hysterectomy should be recommended over the abdominal route when possible.^15,16

Determining surgical candidacy and selecting the appropriate route of hysterectomy are decisions made at the time of patient evaluation in the office, and can be limiting factors to offering a minimally invasive approach. The algorithm in Figure 1 is provided to help guide the surgeon through this decision-making process.¹⁷ The structured approach presented here presumes that the patient has been counseled regarding alternatives to hysterectomy and that gynecologic malignancy has been ruled out to the best of the surgeon’s ability using endometrial biopsy, imaging studies, and tumor markers as indicated based on the patient’s risk factors and the surgeon’s index of suspicion.

In addition, robotic surgery is not considered separately, but rather is grouped as a subset of the laparoscopic approach. Several case studies are presented to highlight important factors in choosing the best route of hysterectomy.

Case 1: Above or below

A 42-year-old obese G2P2 presents with heavy menses failing medical management. She has no significant past medical or surgical history and has had 2 spontaneous vaginal deliveries of 7-lb infants. Ultrasound showed a 12.5-cm uterus with evidence of adenomyosis and normal ovaries. On exam she has a 12-week size mobile uterus located high in the pelvis with descent to 5 cm above the hymen on valsalva, and her pubic arch is wide. She desires hysterectomy.

Q. How would you counsel this patient regarding route of hysterectomy?

A. An orderly approach is necessary to determine the least invasive route of hysterectomy, including detailed history and physical exam to assess this woman's candidacy for surgery. Consider asking yourself the following questions while performing the exam:

Does the patient have adequate vaginal access?

In our experience vaginal access is determined by assessing 3 key components: angle of the pubic arch, breadth of the vaginal apex, and uterine descent.

A narrow pubic arch significantly limits access to the uterus and its vasculature, and if present, may be prohibitive. A pubic arch that is wide, or more than 90 degrees, allows for easier access to the uterus and placement of instruments, facilitating the vaginal approach. Therefore this is the first anatomic factor to evaluate on exam in the office.

The breadth of the vaginal apex is best assessed at the time of bimanual exam by placing 2 fingers in the posterior fornix and opening them laterally. If the apex is greater than 3 cm in width there is generally adequate access for vaginal hysterectomy. A wider vaginal apex facilitates a vaginal approach because it provides ample space for anterior and posterior entry and improves lateral visualization of the vasculature. A narrow introitus noted on exam that limits access to an otherwise adequate vaginal apex can be overcome with a 1- to 2-cm posterior midline first-degree episiotomy.^18,19 This short incision can increase the width of the introitus and can be easily repaired with delayed absorbable suture at the conclusion of the procedure.

Uterine descent is the final component of vaginal access and can be evaluated by asking the patient to perform a valsalva maneuver and observing the movement of the uterus. Descent is measured relative to the ischial spines on an obstetric exam. In general, descent to at least 1 cm below the level of the ischial spines is adequate. Although this is often given heavy weight in determining a patient's candidacy for vaginal hysterectomy, lack of descent need not rule out the option of a vaginal approach.^20-22 If the patient otherwise has good vaginal access but lacks descent, that factor can be reassessed preoperatively under anesthesia with paralysis.

What is the size and shape of the uterus?

Uterine size is assessed on bimanual exam or by ultrasound imaging if exam is limited by body habitus. A measurement of approximately 12 cm or less usually allows for a vaginal approach, but that cutoff is loose and can increase with time and experience.^22,23 Equally important is the evaluation of uterine shape and mobility. The presence of bulky fibroids in the cervix or lower uterine segment can make colpotomy difficult. Large lateral fibroids can limit the ability to safely secure the uterine vasculature and reach the cornua to complete vaginal hysterectomy. In addition, presence of a fibroid that obstructs uterine descent is unlikely to improve under anesthesia and can preclude a vaginal approach. Limited mobility can also be an indication of extrauterine pathology, as discussed herein.

Is uterine size reduction possible?

Uterine size can be preoperatively reduced with gonadotropin-releasing hormone (GnRH) agonists. Administration for 3 months results in an average uterine size reduction of 25% to 50%. If the patient complains of abnormal uterine bleeding and is found to be anemic, this pharmacologic cycle suppression allows for improvement in hemoglobin before surgery.^24,25 Patients should be counseled regarding the menopausal side effects of this medication. They should also be warned of the flare associated with initiation of GnRH agonist therapy, which can result in a short period of increased bleeding.

Uterine size can be intraoperatively reduced by performing transvaginal uterine morcellation (Figure 2). Many morcellation techniques have been described, and all can only be performed after the uterine vessels are secured.^23,26 It is useful to begin with uterine bivalving, wherein the cervix and lower uterine segment are sharply divided into right and left halves using a scalpel (Figure 2, A and B). Once this step is complete the central portion of the uterine body is accessible, including submucosal and/or intramural fibroids that may be present. This centrally located tissue can then be grasped with a toothed clamp, and serial wedges of tissue can be sharply resected from the uterus (Figure 2, C and D). Alternatively, coring can be performed by making a circumferential incision at the level of the internal cervical os, and then sharply removing cores of myometrium from the uterus. With either method the uterine body is decompressed, which permits further uterine descent, lateral mobility, and eventual access to the uterine cornua.

Is extrauterine pathology present?

A final consideration in determining a patient’s candidacy for vaginal hysterectomy is the possible presence of extrauterine pathology, such as pelvic adhesive disease, endometriosis, or large adnexal cysts. If extrauterine pathology is suspected based on history, exam, or ultrasound findings, but the patient is otherwise a good candidate for a vaginal approach, diagnostic laparoscopy can be performed immediately prior to hysterectomy to quickly visualize pelvic anatomy and determine if vaginal hysterectomy is feasible. Additional laparoscopic procedures can also be performed if needed to allow for vaginal hysterectomy.

Case 2: Open or laparoscopic

A 46-year-old G3P3 presents with symptomatic uterine fibroids and heavy menstrual bleeding. She previously controlled her bleeding with oral contraceptive pills, but now her bleeding is increasing and she has become mildly anemic. She is also bothered by increasing pelvic pressure and is interested in definitive surgical management. She has no other past medical history, and her past surgical history is significant for 3 prior cesarean sections. Ultrasound showed a dominant fundal fibroid with likely submucosal component measuring 8 cm and normal ovaries. On exam she has a 16-week size mobile uterus with a narrow lower uterine segment. Her pubic arch is narrow and there is no descent on valsalva.

Q. How would you counsel her regarding route of hysterectomy?

A. The combination of large uterine size, prior uterine surgeries, narrow pubic arch, and lack of uterine descent in this patient makes vaginal hysterectomy difficult for all but the most experienced vaginal surgeons. Thus the decision lies between laparoscopic and open hysterectomy. In contrast, consider Case 3.

Case 3: Open or laparoscopic

A 48-year-old G3P2012 presents with increasing pelvic pressure and a visible abdominal mass. She requests surgical management. She has no other past medical or surgical history, and she has had 2 vaginal deliveries of 8- to 9-lb infants. Ultrasound showed a 25-cm multifibroid uterus. On exam the uterus has limited mobility, fills the pelvis laterally, and projects to 5 cm above the umbilicus.

Q. What are the key factors you would use to determine route of hysterectomy in Cases 2 and 3? Uterine size is certainly larger inCase 3, but what is it about the size and shape of each uterus that makes one patient a good candidate for laparoscopic hysterectomy and the other a poor candidate?

A. In Case 3, the decision also lies between laparoscopic and open hysterectomy, because vaginal hysterectomy is not feasible for most surgeons. As with the evaluation for vaginal hysterectomy, it is useful to take a stepwise approach to determine if laparoscopic or abdominal hysterectomy is most appropriate. Asking the following questions may be helpful:

Is laparoscopy contraindicated?

There are very few contraindications to laparoscopic surgery, which usually arise from inability to tolerate pneumoperitoneum and/or Trendelenburg positioning, such as in patients with severe cardiopulmonary disease. For women with these conditions who need hysterectomy, an open approach may be indicated for patient safety. Obesity may make a laparoscopic approach to hysterectomy more challenging due to comorbid diseases, the impact of obesity on respiratory mechanics, and the impact of abdominal body fat distribution on patient positioning, trocar placement, and intraoperative visualization.²⁷ Obesity, particularly morbid obesity, is associated with increased operative time, estimated blood loss, and perioperative morbidity when compared with patients of normal weight.^28,29  However, when compared to obese women having abdominal hysterectomy, those undergoing minimally invasive routes of hysterectomy benefit from lower estimated blood loss and shorter hospital stay.^6,30 Obesity alone should not be considered a contraindication to vaginal or laparoscopic approaches.

Are the uterine vessels accessible laparoscopically?

The next important factor in determining if laparoscopic hysterectomy is possible is access to the uterine vasculature. The upper pedicles can typically be secured regardless of uterine size. Access to the uterine vessels deeper in the pelvis can be limited, however, by the confines of the bony pelvis, particularly if the lower uterine segment is wide.

Compare the narrow lower uterine segment in Figure 3A to the bulky lower uterine segment seen in Figure 3B. Despite the fact that the first uterus projects higher above the sacral promontory and may be palpably larger on exam, the uterine vessels are likely more accessible, because there is more space between the uterus and pelvic side wall. Uterine manipulation can also be impaired in cases in which significant uterine bulk is present. Access to the vasculature can be evaluated on bimanual exam by palpating the width of the lower uterine segment at its junction with the cervix, and by moving this segment of the uterus toward the contralateral pelvic side wall. Lateral mobility of more than 2 cm on each side usually provides adequate access to the uterine vessels.

Obstructing fibroids or pelvic adhesive disease limiting uterine mobility should also be considered. Placing cephalad pressure on the lower uterus and evaluating if it can be elevated out of the pelvis is also helpful, as lateral space and therefore access to uterine vessels increases higher in the pelvis. In Case 2 there is adequate access to the uterine vasculature, but access is inadequate in Case 3.

Can extrauterine pathology be addressed laparoscopically?

The presence of pelvic adhesive disease, endometriosis, adnexal cysts, or other benign pelvic pathology can impact successful completion of laparoscopic hysterectomy. The ability to address these issues laparoscopically is dependent on the experience, skill, and comfort of the surgeon. Diagnostic laparoscopy can also be useful in these cases, adding minimal time and risk in the event that abdominal hysterectomy is ultimately required. Consultation with surgeons who have additional training and/or expertise in minimally invasive gynecologic surgery can also be of benefit to the patient.

Other considerations

When adding new surgical skills or increasing the difficulty of procedures performed using a less invasive approach, it is best to select patients with presentations that optimize the likelihood of successful completion of the planned surgery and then gradually move toward more challenging cases. One way to safely achieve this gradual acquisition of skill is to think of factors that may inhibit your ability to safely complete the surgery as “strikes.” For example, strikes against successful vaginal hysterectomy may include a narrow vaginal apex, limited uterine descent, uterine size greater than 12 weeks, or history of cesarean section. Beginning with cases that have no strikes and then gradually adding cases that have 1, 2, or 3 strikes will allow you to progress along your learning curve and perform less invasive surgeries in more complex patients over time.

It is also helpful to view conversion (from vaginal to laparoscopic surgery or from laparoscopic to open surgery) as a decision made to safely complete hysterectomy rather than as a failure to perform the intended approach.

Practical considerations such as the hospital environment, availability of surgical mentorship from senior partners, and availability of skilled surgical assistants can impact a surgeon's ability to acquire or improve on existing minimally invasive surgical skills. It is helpful to reflect on which portion of the procedure is the most challenging. Is it entering anteriorly or securing the upper pedicles during vaginal hysterectomy, or creating the colpotomy or closing the vaginal cuff during laparoscopic hysterectomy? Are you comfortable with vaginal or laparoscopic morcellation techniques needed for removal of large uterine specimens? Thinking about the steps that are difficult for you can help you to define your strikes and allow you to seek additional training or assistance with those portions of the procedure. National courses and simulation training are available to those who want to add new surgical skills or refine existing techniques.

It is notable that surgical volume has been found to affect route of hysterectomy and postoperative morbidity and mortality, with high-volume surgeons (those who perform more than 10 hysterectomies per year) performing significantly fewer abdominal hysterectomies and having significantly lower rates of postoperative complications and death.³¹ Surgical complications and procedure costs associated with laparoscopic hysterectomy have also been found to be lower for high-volume surgeons (those who perform more than 14 hysterectomies per year) at high-volume centers.³² In light of these findings, lower-volume surgeons early in their learning curves should consider consulting more experienced surgeons or referring patients with multiple strikes to surgeons with advanced training in minimally invasive gynecologic surgery.

Summary

Given the considerable data supporting an association between less-invasive routes of hysterectomy and lower morbidity and faster recovery, vaginal and laparoscopic routes should be considered for every patient in need of hysterectomy. Structured evaluation in clinic and the operating room can help the surgeon chose the appropriate type of hysterectomy by clarifying factors that hinder or facilitate a given route.

Choosing cases with no strikes against success and gradually adding more difficult cases allows gynecologic surgeons to move along the learning curve and improve surgical skill while maintaining patient safety. Most women are candidates for vaginal or laparoscopic hysterectomy, and minimally invasive routes should be considered the standard of care.

Use of the structured approach described here to determine route of hysterectomy will help a surgeon maximize minimally invasive routes in women undergoing hysterectomy.

References

1. Wu JM, Wechter ME, Geller EJ, et al. Hysterectomy rates in the United States, 2003. Obstet Gynecol. 2007;110:1091–1095.

2. Wright JD, Ananth CV, Lewin SN, et al. Robotically assisted vs laparoscopic hysterectomy among women with benign gynecologic disease. JAMA. 2013;309:689–698.

3. Whiteman MK, Hillis SD, Jamieson DJ, et al. Inpatient hysterectomy surveillance in the United States, 2000-2004. Am J Obstet Gynecol. 2008;198:34.e1–e7.

4. Nieboer TE, Johnson N, Lethaby A, et al. Surgical approach to hysterectomy for benign gynaecological disease. Cochrane Database Syst Rev. 2009;(3):CD003677.

5. Walsh CA, Walsh SR, Tang TY, Slack M. Total abdominal hysterectomy versus total laparoscopic hysterectomy for benign disease: a meta-analysis. Eur J Obstet Gynecol Reprod Biol. 2009;144:3–7.

6. Brezina PR, Beste TM, Nelson KH. Does route of hysterectomy affect outcome in obese and nonobese women? JSLS. 2009;13:358–363.

7. Garry R, Fountain J, Mason S, et al. The eVALuate study: two parallel randomised trials, one comparing laparoscopic with abdominal hysterectomy, the other comparing laparoscopic with vaginal hysterectomy. BMJ. 2004;328:129.

8. Miskry T, Magos A. Randomized, prospective, double-blind comparison of abdominal and vaginal hysterectomy in women without uterovaginal prolapse. Acta Obstet Gynecol Scand. 2003;82:351–358.

9. Seracchioli R, Venturoli S, Vianello F, et al. Total laparoscopic hysterectomy compared with abdominal hysterectomy in the presence of a large uterus. J Am Assoc Gynecol Laparosc. 2002;9:333–338.

10. Hwang JL, Seow KM, Tsai YL, et al. Comparative study of vaginal, laparoscopically assisted vaginal and abdominal hysterectomies for uterine myoma larger than 6 cm in diameter or uterus weighing at least 450 g: a prospective randomized study. Acta Obstet Gynecol Scand. 2002;81:1132–1138.

11. Ottosen C, Lingman G, Ottosen L. Three methods for hysterectomy: a randomised, prospective study of short term outcome. BJOG. 2000;107:1380–1385.

12. Falcone T, Paraiso MF, Mascha E. Prospective randomized clinical trial of laparoscopically assisted vaginal hysterectomy versus total abdominal hysterectomy. Am J Obstet Gynecol. 1999;180:955–962.

13. Marana R, Busacca M, Zupi E, et al. Laparoscopically assisted vaginal hysterectomy versus total abdominal hysterectomy: a prospective, randomized, multicenter study. Am J Obstet Gynecol. 1999;180(2 Pt 1):270–275.

14. Warren L, Ladapo JA, Borah BJ, Gunnarsson CL. Open abdominal versus laparoscopic and vaginal hysterectomy: analysis of a large United States payer measuring quality and cost of care. J Minim Invasive Gynecol. 2009;16:581–588.

15. ACOG Committee Opinion No. 444: Choosing the route of hysterectomy for benign disease. Obstet Gynecol. 2009;114:1156–1158.

16. AAGL position statement: route of hysterectomy to treat benign uterine disease. J Minim Invasive Gynecol. 2011;18:1–3.

17. Kovac SR, Barhan S, Lister M, et al. Guidelines for the selection of the route of hysterectomy: application in a resident clinic population. Am J Obstet Gynecol. 2002;187:1521–1527.

18. Heaney NS. Vaginal hysterectomy – its indications and technique. Am J Surg. 1940;48:284–288.

19. Occhino JA, Gebhart JB. Difficult vaginal hysterectomy. Clin Obstet Gynecol. 2010;53:40–50.

20. Paparella P, Sizzi O, Rossetti A, et al. Vaginal hysterectomy in generally considered contraindications to vaginal surgery. Arch Gynecol Obstet. 2004;270:104–109.

21. Doucette RC, Sharp HT, Alder SC. Challenging generally accepted contraindications to vaginal hysterectomy. Am J Obstet Gynecol. 2001;184:1386–1389.

22. Varma R, Tahseen S, Lokugamage AU, Kunde D. Vaginal route as the norm when planning hysterectomy for benign conditions: change in practice. Obstet Gynecol. 2001;97:613–616.

23. Magos A, Bournas N, Sinha R, et al. Vaginal hysterectomy for the large uterus. Br J Obstet Gynaecol. 1996;103:246–251.

24. Lumsden MA, West CP, Thomas E, et al. Treatment with the gonadotrophin releasing hormone-agonist goserelin before hysterectomy for uterine fibroids. Br J Obstet Gynaecol. 1994;101:438–442.

25. Stovall TG, Summit RL Jr, Washburn SA, Ling FW. Gonadotropin-releasing hormone agonist use before hysterectomy. Am J Obstet Gynecol. 1994;170:1744–1748.

26. Kovac SR. Intramyometrial coring as an adjunct to vaginal hysterectomy. Obstet Gynecol. 1986;67:131–136.

27. Lamvu G, Zolnoun D, Boggess J, Steege JF. Obesity: physiologic changes and challenges during laparoscopy. Am J Obstet Gynecol. 2004;191:669–674.

28. Siedhoff MT, Carey ET, Findley AD, et al. Effect of extreme obesity on outcomes in laparoscopic hysterectomy. J Minim Invasive Gynecol. 2012;19:701–707.

29. Morgan-Ortiz F, Soto-Pineda JM, López-Zepeda MA, Peraza-Garay Fde J. Effect of body mass index on clinical outcomes of patients undergoing total laparoscopic hysterectomy. Int J Gynaecol Obstet. 2013;120:61–64.

30. Sheth SS. Vaginal hysterectomy as a primary route for morbidly obese women. Acta Obstet Gynecol Scand. 2010;89:971–974.

31. Boyd LR, Novetsky AP, Curtin JP. Effect of surgical volume on route of hysterectomy and short-term morbidity. Obstet Gynecol. 2010;116:909–915.

32. Wallenstein MR, Ananth CV, Kim JH, et al. Effect of surgical volume on outcomes for laparoscopic hysterectomy for benign indications. Obstet Gynecol. 2012;119:709–716.