Editorials
Volume 166 - Issue 4

Laparoscopic hysterectomy

Author:  Barbara A Hall

Med J Aust 1997; 166 (4): 172.
Published online: 17 February 1997
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Laparoscopic hysterectomy

Perhaps the most important role of laparoscopic hysterectomy has been to show that many more women are suitable candidates for vaginal hysterectomy than was once thought

MJA 1997; 166: 172

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If LAVH is more acceptable to patients, not more dangerous and no more expensive than TAH, why is it not performed more commonly? Laparoscopically assisted vaginal hysterectomy (LAVH) was pioneered by Reich in the United States in 1989 and introduced to Australia the same year. Like all new techniques in medical practice, it has its share of ardent supporters and cynical detractors. The supporters quote advantages for the patient -- lower postoperative analgesia requirements, shorter hospital stay, and more rapid return to work and normal activities1,2 -- when compared with total abdominal hysterectomy (TAH). The detractors don't dispute this, but are mainly concerned with complications of LAVH and the cost of the procedure.

Unfortunately, most of the data on complication rates of LAVH have come from small retrospective studies. A recent meta-analysis of 29 such studies3 showed an overall complication rate of 15.6% for LAVH, compared with 24.5% for vaginal hysterectomy (VH) and 42.8% for TAH.4 These figures for VH and TAH are from a large prospective multicentre study in 1982, but this study has provided the benchmark for comparison for most of the published series of LAVH complications. Many small, uncontrolled retrospective studies have been published within the last three years and have consistently found no evidence that LAVH has an unacceptably high complication rate. Of three recent studies comparing complication rates between LAVH, TAH and VH, one found very little difference between the groups,5 while the other two6,7 found the complication rate for LAVH to be intermediate between that for the vaginal and abdominal procedures.

The greatest concern would appear to be a suggestion of a higher proportion of more serious complications with LAVH. The study of Dicker et al. showed a urinary tract injury rate of 1.6% for VH and 0.5% for TAH.4 A retrospective audit of all cases of LAVH in South Australia from 1991 to 1994 showed that urinary tract injury occurred in 2.4%,8 while rates of up to 4.8% have been reported elsewhere.9 Both of these studies may reflect an earlier stage in the learning curve of the procedure. The meta-analysis study by Garry and Phillips included only "skilled gynaecological laparoscopists" and they reported urinary tract damage in 1.38% of cases.3 Trochar injuries occurred in 2.57% of cases.

If we accept that, in skilled hands, LAVH is not more dangerous for the patient than VH or TAH, the detractors are then left with the argument that LAVH is much more expensive than the traditional options, and several American studies have certainly shown this.2,5,6,10 However, the cost of LAVH can be reduced substantially by the use of non-disposable instruments. In this issue of the Journal, Tsaltas and colleagues present the first cost analysis of LAVH compared with TAH in an Australian hospital casemix setting. They found that, at least in this context, LAVH is no more expensive than traditional abdominal hysterectomy -- even with the use of disposable trochars and stapling devices. The shorter hospital stay is the main factor offsetting the increased cost of disposable instruments and longer theatre time, as was also found in a British study where LAVH was shown to be cheaper than TAH.1

If LAVH is more acceptable to patients, not more dangerous and no more expensive than TAH, why is it not performed more commonly? An analysis of the Health Insurance Commission Medicare computer data11 has shown that in Australian private hospitals in 1994-1995 7.4% of hysterectomies were performed with laparoscopic assistance, while 57.5% were performed abdominally and 34.9% vaginally. In 1991-1992 the incidence of TAH was 70.5%, with 29.5% of hysterectomies being performed vaginally. Thus, since the advent of LAVH there has not only been a decrease in the rate of TAH, but also an increase in the number of vaginal hysterectomies. At least two prospective randomised controlled trials12,13 have failed to show that LAVH has any advantage over VH, and that, without gross pelvic disease, VH can be successfully completed in most women who would have previously been considered to have relative contraindications to vaginal surgery. This includes the need for oophorectomy, which can be accomplished vaginally in the vast majority of patients.

The obvious conclusion is that too many hysterectomies are still being performed by the abdominal route, and that the vaginal route should be chosen where possible. LAVH has given gynaecologists the opportunity to re-evaluate vaginal surgery and has facilitated the removal of many of the traditional contraindications to this approach.

So, is there still a place for LAVH or has it been overtaken by the rediscovery of vaginal hysterectomy? The major technical advantage of LAVH is that it allows a panoramic view of the pelvis not afforded by VH. Thus, there will still be cases of pelvic adhesions and adnexal disease where LAVH will allow the patient to avoid a laparotomy and the associated increased postoperative pain and longer recovery period. It is reassuring for the health economists among us to see that, in an Australian hospital casemix setting, LAVH does not overburden the system with unnecessarily increased cost.

Barbara A Hall
Visiting Gynaecologist, Mater Hospital, Brisbane, QLD

  1. Raju KS, Auld BJ. A randomised prospective study of laparoscopic vaginal hysterectomy versus abdominal hysterectomy each with bilateral salpingo-oophorectomy. Br J Obstet Gynaecol 1994; 101: 1068-1071.
  2. Phipps JH, Nayak JS. Comparison of laparoscopically assisted vaginal hysterectomy and bilateral salpingo-oophorectomy with conventional abdominal hysterectomy and bilateral salpingo-oophorectomy. Br J Obstet Gynaecol 1993; 100: 698-700.
  3. Garry R, Phillips G. How safe is the laparoscopic approach to hysterectomy? Gynecol Endosc 1995; 4: 77-79.
  4. Dicker RC, Greenspan JR, Strauss LT, et al. Complications of abdominal and vaginal hysterectomy among women of reproductive age in the United States. Am J Obstet Gynecol 1982; 144: 841-848.
  5. Redwine DB. Laparoscopic hysterectomy compared with abdominal and vaginal hysterectomy in a community hospital. J Am Assoc Gynecol Laparosc 1995; 2: 305-310.
  6. Harris MB, Olive DL. Changing hysterectomy patterns after introduction of laparoscopically assisted vaginal hysterectomy. Am J Obstet Gynecol 1994; 171: 340-344.
  7. Boike GM, Elfstrand EP, DelProire G, et al. Laparoscopically assisted vaginal hysterectomy in a university hospital: report of 82 cases and comparison with abdominal and vaginal hysterectomy. Am J Obstet Gynecol 1993; 168: 1691-1701.
  8. O'Shea RT, Petrucco OM. Laparoscopically-assisted vaginal hysterectomy -- Adelaide complication audit 1991-94 [abstract]. In: Abstract Book, Annual Scientific Meeting of the Australian Gynaecological Endoscopy Society. 1996 Sep; Queenstown, SA. Morphettville, SA: The Society, 1996. (Abstract No. 23.)
  9. Baggish MS. The most expensive hysterectomy. J Gynaecol Surg 1992; 8: 57-58.
  10. Nezhat C, Bess O, Admon D, et al. Hospital cost comparison between abdominal, vaginal and laparoscopically-assisted hysterectomies. Obstet Gynecol 1994; 83: 713-716.
  11. Molloy D, Crosdale S. National trends in gynaecological endoscopic surgery. Aust N Z J Obstet Gynecol 1996; 36: 27-31.
  12. Richardson RE, Bournas N, Magos AL. Is laparoscopic hysterectomy a waste of time? Lancet 1995; 345: 36-41.
  13. Summitt RL, Stoval TG, Lipscombe GH, Ling FW. Randomized comparison of laparoscopy-assisted vaginal hysterectomy with standard vaginal hysterectomy in an outpatient setting. Obstet Gynecol 1992; 80: 895-901.

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Author

  • Barbara A Hall