The history

In the history of medicine, the uterus holds a prominent place – often of ill-repute. From its designation in ancient Greece as the source of hysteria as well as many unrelated ailments in women, one would imagine its removal as being the pinnacle of medical achievements. The first descriptions of vaginal hysterectomy (VH) were by Themison of Athens in 50BCE, followed by VH for a gangrenous prolapsed uterus (unfortunately with en bloc resection of the bladder and ureters) described in ‘Gynaecology’ by Soranus of Ephesus in 120CE. These early cases were almost invariably fatal. Then, in the 17th century, midwife Percival Willoughby reported a remarkable case of autosurgery, when Faith Haworth is said to have become so frustrated with her procidentia that she one day cut her uterus free. After a brief period of unconsciousness, her bleeding settled and despite a vesicovaginal fistula, she survived for many years.²

The first planned and successful VH was performed by Langenbeck in 1813 for a case of suspected cervical cancer; his claimed success was ridiculed until the patient’s death 26 years later, when post-mortem confirmed surgical absence of the uterus.³

In 1809, the world’s first planned laparotomy was performed for an ovarian cyst, paving the way for the first successful transabdominal hysterectomy (TAH) by Burnham in 1853.⁴ Hysterectomy grew in popularity and with improved asepsis, anaesthesia and surgical technique, mortality rates fell from more than 80 per cent in the 19th century to less than 3 per cent in the 1920s. The majority of procedures during the 20th century were performed abdominally, although there were many notable advocates of vaginal hysterectomy (including Heaney, Green-Armytage and Navratil).

In 1988, the first total laparoscopic hysterectomy (TLH) was performed by Harry Reich,⁵ leading to rapid development of laparoscopic skills among gynaecologists and an additional surgery in the armamentarium against uterine pathology.

The landmark 2004 eVALuate trial compared TLH with VH and TAH in parallel randomised controlled trials (RCTs). While there were no differences in the (underpowered) vaginal versus laparoscopic arm, compared to the abdominal approach laparoscopic hysterectomy took longer and had more complications but resulted in quicker recovery, shorter hospital stay and better medium-term quality of life.⁶ However, technical abilities, training and experience, equipment and surgical techniques have all advanced in the last 15 years, making the application of that data to modern practice debatable. Furthermore, yet another approach has been added to the canon of hysterectomy techniques in the form of robotic hysterectomy, increasingly available at centres across Australia and requiring new skills and expertise.

Although rates are falling with the advent of non-surgical management options for fibroids and heavy menstrual bleeding, hysterectomy remains one of the commonest major surgeries in Australia, with one-in-five women undergoing hysterectomy by age 50. Each year, 30 000 hysterectomies are performed in Australian hospitals, making experience and confidence essential for the trainee gynaecologist.⁷

But, how is a trainee to choose the optimal approach? We have asked four consultants to advocate for each of the abdominal, vaginal, laparoscopic and robotic approaches.

Abdominal hysterectomy – Dr Eman Al Naggar

When I was given a very old edition of Bonney’s Gynaecological Surgery as a young registrar, I studied it from beginning to end. It fascinated me how much surgical preparation and comorbidities had changed with medical advances and enlightened me to the significance of different hysterectomy approaches.

For many years, abdominal hysterectomies have been performed by most gynaecologists, possibly due to the fact that acquiring open surgical skills is easier due to the practise of caesarean section, and that the hand-eye coordination isn’t as challenging as in laparoscopic surgery.

It offers visual and tactile examination of the abdominopelvic structures, which can be beneficial in diagnosing diseases that aren’t yet visible, and allows easy manipulation of the uterus. Abdominal incisions offer easier adhesiolysis and allow for easier packing of the bowel with wet packs, which are superior to laparoscopic retractors in helping to reduce bowel injury.

Furthermore, some patients will ask to retain their cervix, which is easily performed abdominally. This may preserve urinary function, and sexual function in women with cervical orgasms, thanks to preservation of the uterovaginal nerve plexus and the maintenance of cervical position. RCTs have failed to prove these claims.

For large uteri, laparoscopic morcellation has been advised against by the TGA, leaving laparotomy as the only option in some cases. Finally, the space of Retzius has historically been entered via laparotomy for concurrent urogynaecological procedures; however, with laparoscopic advances that is no longer the case.

Although recovery and morbidity are generally higher with an open approach, in selected patients, the advantages may outweigh the risks.

Vaginal hysterectomy – Dr Todd Ladanchuk

In an era where minimally invasive surgery is promoted, vaginal hysterectomy for benign gynaecological disease should be the evidence-based minimally invasive approach of choice. The 2015 Cochrane Review recommends that vaginal hysterectomy should be performed whenever possible.9 ‘No advantages of LH over VH could be found; LH had a longer operation time, and TLH had more urinary tract injuries.’ ACOG states that the evidence supports vaginal hysterectomy as being associated with better outcomes than laparoscopic or abdominal routes, being safer and more cost effective.13

The rate of vaginal hysterectomy in Australia is falling as the rate of laparoscopic hysterectomy rises. From 2000–2014, Wilson et al found a fall in the rate of vaginal and abdominal hysterectomy and an increase in laparoscopic hysterectomy,7 suggesting that gynaecologists are moving away from the vaginal approach in favour of the laparoscope.

There are a variety of reasons for this trend. There may be a perception that laparoscopic and robotic hysterectomy is better and more advanced. The commercial interests of industry in laparoscopic and robotic surgery precludes promotion of vaginal hysterectomy. World records have been awarded for laparoscopic hysterectomy further increasing its ‘coolness.’ As the number of vaginal hysterectomies declines, so does trainees’ exposure to this technique, and the skill set may one day become lost.

Vaginal hysterectomy is the evidence-based choice for what is in the best interest of women. Colleges and gynaecologists must strive to continue to perform vaginal hysterectomy, include it in curricula and encourage trainees’ interest in vaginal hysterectomy. Then we can ensure we are providing ‘Excellence in Women’s Health’ for the next generation.

Laparoscopic hysterectomy – Prof Yee Leung

The laparoscopic approach to hysterectomy can vary widely, from laparoscopically assisted vaginal hysterectomy to total laparoscopic radical hysterectomy. Variations include single incision and natural orifice translumenal approaches,⁸ with ongoing refinements using new technologies.

Compared to abdominal hysterectomy, laparoscopic hysterectomy offers faster return to normal activity, shorter hospital stay, less wound infection, non-inferior outcomes in endometrial cancer and better quality of life.^{9 10 11} Possible disadvantages include longer operating time and increased urinary tract injuries,¹² while vault dehiscence rates are comparable.¹³

For trainees, decisions regarding the approach for a hysterectomy can be confusing. Where possible, a minimally invasive approach for a hysterectomy is preferred.9 Factors to consider include:

• Patient factors
• Pathology present
• Proceduralist’s skills
• Place where surgery is being performed

The chosen modality is often dictated by the surgeon’s preference and skills. The overarching principle is to adopt the approach that ‘will most safely facilitate removal of the uterus and optimise patient outcomes.’¹⁴ Where there is anticipated extrauterine pathology, a high index of suspicion for cancer in an enlarged uterus, or the need to perform sentinel node biopsies, vaginal hysterectomy would not be the favoured approach. The choice of a laparoscopy or laparotomy would then depend on the surgeon’s skillset.

Training for the different approaches is dependent upon the preceptors at a training site. Each site may have a preference for one particular approach or have sufficient caseload and expertise to offer training in all approaches. With current caseloads at many training sites, it is becoming difficult for trainees to become competent with all approaches to a hysterectomy at the completion of their training time. Where possible, it would be ideal to gain as much experience with the laparoscopic approach for the above reasons.

Robot-assisted hysterectomy – Prof Maneesh Singh

Despite rapid adoption in the US, Australia has been slow to embrace robotic-assisted hysterectomy (RAH) perhaps due to cost without demonstrable improvement in outcomes. Surgical expertise in laparoscopy and lack of robotic surgical training have also led to the sluggish uptake. RCTs comparing laparoscopic and robotic hysterectomy should be interpreted with caution given substantial variation in skills and surgical proficiency of surgeons and their teams. Individual surgeon bias and patient selection make transference into practice complex.¹⁵

RAH may have prolonged surgical time and lack tactile response; however, with experience and improved technology this can be overcome. Furthermore, RAH may achieve a shorter length of stay, with no difference in blood loss or postoperative complications.¹⁶

RAH is associated with a higher incidence of cuff dehiscence versus TLH (1.64 versus 0.64 per cent); however, judicious use of electrocautery at the vaginal cuff by blended cutting rather than coagulation current and the use of a two-layer cuff closure or barbed suture may decrease the risk.¹⁷

A Cochrane review concluded, despite moderate–high overall risk of bias, that complication rates of RAH and TLH might be comparable, but that RAH was an operator-dependent and expensive technology.¹⁸ More recently, a Danish study concluded that the national introduction of robotic surgery was associated with improved survival irrespective of age and body mass index for women with early endometrial cancer.¹⁹

Initially, the robot was seen as an expensive tool in gynaecology, but advantages have been shown with increasing use in a variety of patients, including less blood loss and analgesia requirements for women with large uteri, and higher rates of same-day discharge for women over 65.^{20 21}

As RAH becomes more available and cheaper, uptake and training will increase. Ultimately, the mode of hysterectomy resides with the surgeon’s expertise; correct patient selection and robotics can only be enhanced by the availability of dedicated surgical teams proficient in its use.

Conclusion

There are several options for hysterectomy, each with benefits and shortcomings, and none with suitability for every patient and pathology. The most recent evidence suggests a faster return to normal activity following vaginal, rather than abdominal, hysterectomy. This is also the case for laparoscopic hysterectomy when compared to abdominal, although urinary tract injuries are more common. In randomised trials, laparoscopic hysterectomy has not been shown to offer a benefit over vaginal, while there is no robust evidence of robotic offering a benefit over laparoscopic. Importantly, the benefits and risks of each approach appear to be related to surgical expertise.²²

In summary, the approach to hysterectomy should be selected based on patient factors, the pathology being treated, surgical experience and patient preference. The options and their potential benefits and risks should be discussed with the woman and a shared plan for management agreed upon. Where appropriate, minimally invasive approaches offer improved recovery over a laparotomy; however, there remains a role for each method in modern gynaecological practice. Trainee surgeons should endeavour to accrue experience in each approach to allow them to offer the best possible care to their patients.

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17. S Uccella, F Ghezzi, A Mariani, et al. Vaginal cuff closure after minimally invasive hysterectomy: our experience and systematic review of the literature. Am J Obstet Gynecol. 2011;205(2):119.e1-12.
18. TA Lawrie, H Liu, D Lu , et al. Robot-assisted surgery in gynaecology. Cochrane Datatbase Syst Rev. 2019;4:CD011422.
19. SL Jørgensen, O Mogensen, CS Wu, et al. Survival after a nationwide introduction of robotic surgery in women with early-stage endometrial cancer: a population-based prospective cohort study. Eur J Cancer. 2019;109:1-11.
20. R Sinha, R Bana, M Sanjay. Comparison of Robotic and Laparoscopic Hysterectomy for the Large Uterus. JSLS. 2019;23(1):Pii e2018.00068.
21. N Madden, MK Frey, L Joo, et al. Safety of robotic-assisted gynecologic surgery and early hospital discharge in elderly patients. Am J Obstet Gynecol. 2019;220(3):253.
22. JWM Aarts, TE Nieboer, N Johnson, et al. Surgical approach to hysterectomy for benign gynaecological disease. Cochrane Database Syst Rev. 2015;(8):CD003677.