Advocating Vaginal Hysterectomy
Advocating Vaginal Hysterectomy
Abstract & Commentary
By Frank W. Ling, MD, Clinical Professor, Department of Obstetrics and Gynecology, Vanderbilt University School of Medicine, Nashville, is Associate Editor for OB/GYN Clinical Alert.
Dr. Ling reports no financial relationship to this field of study.
Synopsis: The stated goal of describing "… some of the advantages of the vaginal route in order to help vaginal surgery schools to re-establish the leading role of this approach as part of the minimally invasive gynecological surgery trend" is addressed in a systemic review of key findings in the literature.
Source: Salcedo F. Vaginal hysterectomy in non-prolapsed uteruses: "No scar hysterectomy." Int Urogynecol J Pelvic Floor Dysfunct 2009;20:1009-1012.
This is an almost blatant advertisement for vaginal hysterectomy. So the astute reader would logically ask, "Why is this being reviewed in this newsletter? Aren't we supposed to be getting the cutting edge literature to help us advance our practice?" Fair questions, and there is actually a logical answer. Since the newest literature is being generated on the most recent advances in gynecologic surgery, the old standbys don't often get attention in a fashion that encourages the physician or patient to view the entire surgical landscape. It's a bit like the nightly news in that rarely does one hear a story about how things are going well.
As more clinical emphasis and research endeavors point toward minimally invasive surgery, the author points out in this "Current Opinion/Update" piece that vaginal hysterectomy is, in fact, also minimally invasive. It just doesn't happen to be "new." The author also correctly points out that since the advent of laparoscopic hysterectomy (be it laparoscopic-assisted or total laparoscopic), the commercial interests behind the laparoscopic approach should not be ignored. Of note, he refers to the recent reports of use of the vaginal route for laparoscopic cholecystectomies and nephrectomies as an indication that the gynecologist as vaginal surgeon can be in charge of the destiny of this surgical technique.
The primary reasons for not performing vaginal hysterectomy are listed and literature is cited for each one that refutes these common misconceptions. He describes these as "myths" and focuses on the key point, "In the end, it is actually the surgeon's experience and skills that will play the decisive role … ." How many of the 5 contraindications to vaginal hysterectomy (see Table, below) have you heard used to justify an alternative approach?
Just as he is able to refute the contraindications, he points out the advantages of the vaginal approach over both the abdominal and laparoscopic approaches. As compared with the abdominal approach, the literature shows that there is less surgical time, less post-operative ileus, less pain, fewer hospital days, less time to return to full function, fewer scar complications, and less risk for those with medical problems.
Comparing the vaginal approach with the laparoscopic approach, he notes that the recovery time is similar, the vaginal approach can be learned faster, there are no trocar/pneumoperitoneum risks, general anesthesia is not mandatory, and the cost for instrumentation is less.
Commentary
The author recommends that the vaginal hysterectomy be advocated for in medical schools and training programs. Those are indeed places where the basics are taught and the role of various surgical approaches are learned. I would add, however, that the readers of this publication are the real keys to success in that how an individual practices is a reflection of the environment that he/she finds himself/herself in. I refer to my own practice in which we have both senior gynecologists who use vaginal surgery extensively, as well as younger, less experienced surgeons who have trained relatively recently and whose numbers of cases are limited.
You are, by definition, in one of those two groups, i.e., either you are comfortable performing vaginal hysterectomy, often in the face of the "contraindications" listed in the Table or you tend to accept those contraindications and lean toward either abdominal or laparoscopic approaches. May I suggest that if you are in the first group, that you make yourself available to junior partners or colleagues at your hospital to assist in surgery to show them the "tricks of the trade." Alternatively, you can be part of the local teaching program in which you can teach those still in training. As fewer faculty are extensively experienced in vaginal surgery (similar to the problem of operative vaginal delivery), having input from part-time or volunteer clinicians will be increasingly important.
Alternatively, if you are in the second group, I encourage you to link up with a surgical mentor who can enhance your surgical training from residency with different approaches or thought processes. Attending meetings that focus on surgical technique (even without hands-on opportunities) can often aid in addressing your surgical questions.
I totally agree with the author of this review. The future of vaginal surgery is in the hands of those who are able to both perform as well as advocate it. Newer is not always better, it's just newer. Therein lies the challenge for all of us: How do we best serve our patients who need a hysterectomy? You can be the best judge, one patient at a time.
This is an almost blatant advertisement for vaginal hysterectomy. So the astute reader would logically ask, "Why is this being reviewed in this newsletter? Aren't we supposed to be getting the cutting edge literature to help us advance our practice?"Subscribe Now for Access
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