Minimally invasive approaches should be the "procedures of choice" for nearly all women undergoing hysterectomy to treat benign uterine disease, according to a new position statement from AAGL.
Courtesy of Dr. Jon I. Einarsson
The AAGL says laparoscopic hysterectomy (shown here) is a highly underutilized procedure that is less invasive, less costly and involves a faster recovery time in comparison to abdominal incision hysterectomy.
Currently, more than two-thirds of the 600,000 hysterectomies performed annually in the United States are done through an abdominal incision, despite the availability of less-invasive vaginal and laparoscopic approaches, which are associated with reduced morbidity, faster recovery, and lower cost. The AAGL Advancing Minimally Invasive Gynecology Worldwide (formerly known as the American Association of Gynecologic Laparoscopists) has now issued a strongly worded statement advising that abdominal hysterectomies be limited to only a few specific, defined circumstances.
"When hysterectomy is necessary, the demonstrated safety, efficacy, and cost-effectiveness of vaginal hysterectomy (VH) and laparoscopic hysterectomy (LH) mandate that they be the procedures of choice. When hysterectomy is performed without laparotomy, early institutional discharge is feasible and safe, in many cases within the first 24 hours," the AAGL said in the statement, posted online in November and due to be published in the January issue of the Journal of Minimally Invasive Gynecology.
The statement went on to advise that, "Surgeons without the requisite training and skills required for the safe performance of VH or LH should enlist the aid of colleagues who do or should refer patients requiring hysterectomy to such individuals for their surgical care."
The short list of contraindications given for LH include medical conditions in which the risk of either general anesthesia or increased peritoneal pressure are deemed unacceptable, or where morcellation may be required or uterine malignancy is known or suspected. For both VH and LH, the only contraindications are when there is no access to an experienced surgeon or the necessary facilities, or where the anatomy is so distorted that neither a laparoscopic nor vaginal approach is deemed safe.
Other clinical situations such as obesity or previous cesarean section should not be considered contraindications to minimally invasive procedures, AAGL said. Obesity may be associated with longer operative times but otherwise does not impair safety or efficacy of minimally invasive procedures, and the risks of inadvertent cystotomy and other complications with LH in women with previous Cesarean section is low (J. Minim. Invasive Gynecol. 2010;17:186-91).
The statement is aimed at several constituencies, AAGL executive vice president and medical director Dr. Franklin Loffer said in an interview. "We want patients to know, insurance companies to pay attention, and we want doctors to either learn how to do the procedures, get someone to help them, or just refer. I don’t think it’s justified doing an abdominal hysterectomy simply because you can’t do anything else. That’s not in the patient’s benefit."
He added, "We wish to point out that our specialty needs to do a better job of educating people to do these procedures."
In calling for a dramatic reduction in the number of abdominal hysterectomies, the AAGL position is in line with that of the American College of Obstetricians and Gynecologists, issued in a committee opinion paper "Choosing the Route of Hysterectomy for Benign Disease" in November 2009 (#444). But ACOG differed from AAGL in that it deemed the vaginal approach as the procedure of choice, with the laparoscopic approach second and abdominal approach as a last resort. Also, ACOG did not recommend referring patients to specialists as AAGL did.
According to Dr. Cheryl B. Iglesia, chair of the ACOG Committee on Gynecologic Practice, which wrote the opinion paper, "We do agree that for the most part hysterectomy should be done minimally invasively, and the least invasive [approach] is vaginal over laparoscopic. It’s associated with less operator time, less pain, less cost, and less potential injury. But, there are some technical skills to be developed," she said in an interview.
As for the referral issue, "We have lots of constituents, and we have to look at what’s practical. If you’re the only doctor in a big rural setting for 300 miles, you’re going to do whatever is safest in your hands. We try to be very practical at ACOG," said Dr. Iglesia, who is section director for female pelvic medicine and reconstructive surgery at Washington Hospital Center and is also in the ob.gyn. department at Georgetown University, Washington.
Dr. Loffer noted that the ACOG evidence base included a Cochrane review (Cochrane Database Syst. Rev. 2009 [doi:10.1002/14651858.CD003677.pub4]) containing data from the earliest laparoscopic procedures when there were more complications as surgeons acquired the skills, and that now the complication rates are approximately equal to that of vaginal hysterectomy. But, he said with regard to the two organizations’ positions in general, "I don’t think we’re that far apart."