Frequently Asked Questions About Hysterectomy for Physicians

Hysterectomy is one of the most common non-obstetric procedures performed in the United States, with more than 430,000 of them performed in 2010.^(1,2)

In 1999, 11 % of women between 35-45 years of age had a hysterectomy, with an estimated annual cost of $5 billion.⁽³⁾

Minimally invasive hysterectomy (MIH) includes vaginal, laparoscopic, and robotic routes. Costs differ by surgical approaches^(4-6), with total abdominal hysterectomy being the costliest approach due to a higher risk of complications and longer duration of hospital stay.

The American College of Obstetricians and Gynecologists (ACOG) and the American Association of Gynecologic Laparoscopists (AAGL) recommended the use of either vaginal or laparoscopic routes for benign indications in 2009 and 2011.^(7,8)

Patients undergoing minimally invasive hysterectomy (MIV) often have a more favorable experience compared to those undergoing a conventional abdominal procedure.

MIH has proven to be as effective as abdominal surgery for many pathologies, and benefits the patient and employer with:

• A speedy recovery time
• Shorter length of stay (LOS) in the hospital
• Less pain
• Lower infection rate
• Fewer complications
• Quicker return to normal activities^(7,9,10)

Complications, especially those associated with abdominal surgical procedures, impact LOS, treatment costs, recovery time, and patient satisfaction. For example, it has been shown that hospital acquired infections adds $4,528 to the cost of stay and 2.52 days to the length of stay.⁽¹¹⁾ Shorter LOS reflects effectiveness of symptom management, patient mobilization, and fewer if any complications.

Individuals undergoing MIH are more likely to go back to work activities faster than those having an abdominal procedure for the same condition. It has been shown that the time to return to normal activities was 18 days shorter for laparoscopic hysterectomy and 3.15 days shorter for vaginal hysterectomy when compared to an abdominal procedure.⁽¹²⁾

From an employer point of view, increased disability duration means higher rate of sick leave, disability payments, or even replacement employees; therefore, shorter disability duration will result in decreased costs. In many cases, both vaginal and laparoscopic can be performed in an outpatient setting.^(13,14)

AAGL, the professional society for laparoscopic gynecologic surgery, believes that “a number of clinical situations considered as contraindications to laparoscopic hysterectomy seem not to have merit when subjected to critical analysis”⁽⁸⁾ including obesity and previous cesarean section.

A study by Chopin et al. showed that the safety and efficacy of laparoscopic hysterectomy are similar for obese and non-obese patients.⁽¹⁵⁾ Other studies showed that previous cesarean section should not be considered as a contraindication to either a vaginal hysterectomy or laparoscopic hysterectomy.^(16,17)

However, when a vaginal hysterectomy is not feasible due to a large uterus or adhesions, laparoscopic hysterectomy seems to be a safer alternative rather than abdominal hysterectomy.^(18,19)

It has been shown that the direct cost of both vaginal hysterectomy and laparoscopic hysterectomy are less than those for abdominal hysterectomy.^(20,21)

AAGL believes that “abdominal hysterectomy should be reserved for the minority of women for whom a laparoscopic or vaginal approach is not appropriate. These circumstances are not common, and may include the following situations:”⁽⁸⁾

• Patients with other comorbidities, who are not good candidates for general anesthesia or the increased intraperitoneal pressure associated with laparoscopy which puts them at unacceptable higher risk.
• Where morcellation is known or likely to be needed and uterine malignancy is either confirmed or suspected.

AAGL recommends that “surgeons without the requisite training and skills required for the safe performance of vaginal hysterectomy or laparoscopic hysterectomy should enlist the aid of colleagues who do or should refer patients requiring hysterectomy to such individuals for their surgical care.”⁽⁸⁾

• Fellowship programs
• Surgeons who are fellowship trained and specialize in the latest minimally invasive surgical techniques
• Rich expertise in minimally invasive management of complex pathologies including but not limited to:
• Large uterus > 20 week
• Stage 4 endometriosis involving bladder and bowel
• Significant adhesions (which used to be a contraindication for laparoscopic hysterectomy)

References:

1. Inpatient Surgery: CDC/National Center for Health Statistics; [updated 5/14/2014; cited 2015 February, 12]. Available here.
2. Wright JD, Herzog TJ, Tsui J, Ananth CV, Lewin SN, Lu YS, et al. Nationwide Trends in the Performance of Inpatient Hysterectomy in the. Obstetrics and gynecology. 2013;122(2 0 1):233-41.
3. Matteson KA, Peipert JF, Hirway P, Cotter K, DiLuigi AJ, Jamshidi RM. Factors associated with increased charges for hysterectomy. Obstetrics and gynecology. 2006;107(5):1057-63.
4. Dorsey JH, Holtz PM, Griffiths RI, McGrath MM, Steinberg EP. Costs and Charges Associated with Three Alternative Techniques of Hysterectomy. New England Journal of Medicine. 1996;335(7):476-82.
5. Lenihan JP, Jr., Kovanda C, Cammarano C. Comparison of laparoscopic-assisted vaginal hysterectomy with traditional hysterectomy for cost-effectiveness to employers. American journal of obstetrics and gynecology. 2004;190(6):1714-20; discussion 20-2.
6. Raju KS, Auld BJ. A randomised prospective study of laparoscopic vaginal hysterectomy versus abdominal hysterectomy each with bilateral salpingo-oophorectomy. British journal of obstetrics and gynaecology. 1994;101(12):1068-71.
7. ACOG Committee Opinion No. 444: choosing the route of hysterectomy for benign disease. Obstetrics and gynecology. 2009;114(5):1156-8.
8. AAGL position statement: route of hysterectomy to treat benign uterine disease. J Minim Invasive Gynecol. 2011;18(1):1-3.
9. Walsh CA, Walsh SR, Tang TY, Slack M. Total abdominal hysterectomy versus total laparoscopic hysterectomy for benign disease: a meta-analysis. European journal of obstetrics, gynecology, and reproductive biology. 2009;144(1):3-7.
10. Nieboer TE, Johnson N, Lethaby A, Tavender E, Curr E, Garry R, et al. Surgical approach to hysterectomy for benign gynaecological disease. The Cochrane database of systematic reviews. 2009(3):Cd003677.
11. Gunnarsson C, Rizzo JA, Hochheiser L. The Effects of Laparoscopic Surgery and Nosocomial Infections on the Cost of Care: Evidence from Three Common Surgical Procedures. Value in Health. 2009;12(1):47-54.
12. Roumm AR, Pizzi L, Goldfarb NI, Cohn H. Minimally invasive: minimally reimbursed? An examination of six laparoscopic surgical procedures. Surgical innovation. 2005;12(3):261-87.
13. Stovall TG, Summitt RL, Jr., Bran DF, Ling FW. Outpatient vaginal hysterectomy: a pilot study. Obstetrics and gynecology. 1992;80(1):145-9.
14. Levy BS, Luciano DE, Emery LL. Outpatient vaginal hysterectomy is safe for patients and reduces institutional cost. J Minim Invasive Gynecol. 2005;12(6):494-501.
15. Chopin N, Malaret JM, Lafay-Pillet MC, Fotso A, Foulot H, Chapron C. Total laparoscopic hysterectomy for benign uterine pathologies: obesity does not increase the risk of complications. Human reproduction (Oxford, England). 2009;24(12):3057-62.
16. Sinha R, Sundaram M, Lakhotia S, Hedge A, Kadam P. Total laparoscopic hysterectomy in women with previous cesarean sections. J Minim Invasive Gynecol. 2010;17(4):513-7.
17. Wang L, Merkur H, Hardas G, Soo S, Lujic S. Laparoscopic hysterectomy in the presence of previous caesarean section: a review of one hundred forty-one cases in the Sydney West Advanced Pelvic Surgery Unit. J Minim Invasive Gynecol. 2010;17(2):186-91.
18. Garry R, Fountain J, Mason S, Hawe J, Napp V, Abbott J, et al. The eVALuate study: two parallel randomised trials, one comparing laparoscopic with abdominal hysterectomy, the other comparing laparoscopic with vaginal hysterectomy. BMJ (Clinical research ed). 2004;328(7432):129.
19. Seracchioli R, Venturoli S, Vianello F, Govoni F, Cantarelli M, Gualerzi B, et al. Total Laparoscopic Hysterectomy Compared with Abdominal Hysterectomy in the Presence of a Large Uterus. The Journal of the American Association of Gynecologic Laparoscopists. 2002;9(3):333-8.
20. 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(5):581-8.
21. Sculpher M, Manca A, Abbott J, Fountain J, Mason S, Garry R. Cost effectiveness analysis of laparoscopic hysterectomy compared with standard hysterectomy: results from a randomised trial. BMJ (Clinical research ed). 2004;328(7432):134.