Hysterectomy can be performed in different ways. The oldest known technique is abdominal incission. Subsequently the vaginal (performing the hysterectomy through the vaginal canal) and later laparoscopic vaginal (with additional instruments inserted through a small hole, frequently close to the navel) techniques were developed.
Most hysterectomies in the United States are done via laparotomy (abdominal incission, not to be confused with laparoscopy). A transverse (Pfannenstiel) incision is made through the abdominal wall, usually above the pubic bone, as close to the upper hair line of the individual's lower pelvis as possible, similar to the incision made for a caesarean section. This technique allows doctors the greatest access to the reproductive structures and is normally done for removal of the entire reproductive complex. The recovery time for an open hysterectomy is 4–6 weeks and sometimes longer due to the need to cut through the abdominal wall. Historically, the biggest problem with this technique were infections, but this aspect is of little relevance as of today. An open hysterectomy provides the most effective way to explore the abdominal cavity and perform complicated surgeries. Before the refinement of the vaginal and laparoscopic vaginal techniques it was also the only possibility to achieve subtotal hysterectomy, meanwhile any of the techniques can be used for subtotal hysterectomy.
Vaginal hysterectomy is performed entirely through the vaginal canal and has clear advantages over abdominal surgery such as less complications, shorter hospital stays and shorter healing time. Abdominal hysterectomy, the most common method, is used in cases such as after caesarean delivery, when the indication is cancer, when complications are expected or surgical exploration is required.
With the development of the laparoscopic techniques in the 1970-1980s, the "laparoscopic-assisted vaginal hysterectomy" (LAVH) has gained great popularity among gynecologists because compared with the abdominal procedure it is less invasive and the post-operative recovery is much faster. It also allows better exploration and slightly more complicated surgeries then the vaginal procedure. LAVH begins with laparoscopy and is completed such that the final removal of the uterus (with or without removal of the ovaries) is via the vaginal canal. Thus, LAVH is also a total hysterectomy, the cervix must be removed with the uterus.
The "laparoscopic-assisted supracervical hysterectomy" (LASH) was later developed to remove the uterus without removing the cervix using a morcellator which cuts the uterus into small pieces that can be removed from the abdominal cavity via the laparoscopic ports.
Total laparoscopic hysterectomy (TLH) is performed solely through the laparoscopes in the abdomen, starting at the top of the uterus. The entire uterus is disconnected from its attachments using long thin instruments through the "ports". Then all tissue to be removed is passed through the small abdominal incisions.
Supracervical (subtotal) laparoscopic hysterectomy (LSH) is performed similarly like the total laparoscopic surgery but the uterus is amputated between the cervix and fundus.
"Robotic hysterectomy" is a variant of laparoscopic surgery using special remotely controlled instruments that allow the surgeon finer control as well as three-dimensional magnified vision.
Comparison of techniques
The abdominal technique is very often applied in difficult circumstances or when complications are expected. Given this circumstances the complication rate and time required for surgery compares very favorably with other techniques, however time required for healing is much longer.
Vaginal hysterectomy was shown to be superior to LAVH and some types of laparoscopic surgery (sufficient data was not available for all types of laparoscopic surgery), causing fewer short- and long-term complications, more favorable effect on sexual experience with shorter recovery times and fewer costs. It is however not possible or very difficult to perform some more complicated surgeries using this technique.
A recent Cochrane review recommends vaginal hysterectomy over other variants where possible. However, the study did not mention robotic hysterectomy. Laparoscopic surgery offers certain advantages when vaginal surgery is not possible but has also the disadvantage of significantly longer time required for the surgery.
In direct comparison of abdominal (laparotomic) and laparoscopic techniques laparoscopic surgery causes longer operation time and substantially higher rate of major complications while offering much quicker healing.
Vaginal hysterectomy is the only available option that is feasible without total anaesthesia or in outpatient settings (although so far recommended only in exceptional cases).
Time required for completion of surgery in the eVAL trial is reported as following:
- abdominal 55.2 minutes average, range 19-155
- vaginal 46.6 minutes average, range 14-168
- laproscopic (all variants) 82.5 minutes average, range 10-325 (combined data from both trial arms)
Large multifibroid uteri and subtotal hysterectomies did previously require abdominal incision but
with the use of in situ morcellation they can be sometimes also performed using laparoscopic or vaginal techniques. Even impacted fibroid uteri with severe adhesions, oblitered cul-de-sac and no motion whatsoever on pelvic exam can be removed laparoscopically by experienced laparoscopic surgeons.
Non-robotic laparoscopic hysterectomy has a higher likelihood a requiring a large incision and conversion to open technique than robotic hysterectomy. In addition blood loss and duration of hospital stay were lower when using robotic technique when compared to non-robotic laparoscopic hysterectomy.
The other techniques are not long enough in use to allow a general assessment, it appears that laparoscopic subtotal hysterectomy (LSH) is a promising technique.
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