Hysterectomy is the commonest procedure performed in gynecology. Traditionally various routes for removal of the uterus have been used. Abdominal hysterectomy was undoubtedly the most popular with a 70:30 ratio for abdominal versus vaginal route.1,2 Laparoscopic assisted vaginal hysterectomy (LAVH) enjoyed its place in the last decade when it had become fashionable to perform a hysterectomy with the technically superior laparoscope. However, gynecologists were soon to learn that hysterectomy could be performed more easily, faster, with least complications and with excellent patient recovery when the vaginal route was used. In fact revival of this route must be attributed to the widespread use of the laparoscopic approach. Anyone who has performed LAVH will agree that majority of the procedure is accomplished vaginally! In fact some gynecologists condemn LAVH as a dangerous and unnecessary operation that is often substituted for vaginal hysterectomy.2 The latest randomized study to evaluate the role of vaginal, abdominal and laparoscopic hysterectomy in routine gynecological practice concluded that various parameters, such as blood loss, postoperative pain, time taken for surgery, intraoperative and postoperative complications and total hospital stay were less in the vaginal hysterectomies compared to LAVH group and abdominal group.32
The vaginal approach to hysterectomy has been the hallmark of the gynecological surgeon. The impetus to extend the advantages and explore the limits of the vaginal route came from hands-on experience with patients who were desperate to avoid an abdominal incision. Vaginal surgery allows the surgeon to operate by the least invasive route of all, utilizing an anatomical orifice. Favorable factors for a Non-descent vaginal hysterectomy are a mobile uterus with normal dimensions, large pelvis to allow manoeuvrability, single, large accessible fibroid, counseling for a tentative vaginal hysterectomy and experience. In the absence of obvious contraindications, but with doubt concerning the route of hysterectomy, gynecologists should consider scheduling patients for a tentative vaginal hysterectomy, a situation analogous to obstetricians performing a trial of forceps. Advantages of vaginal hysterectomy are multiple: esthetic, shorter hospitalization, quicker recovery. The low rate of vaginal hysterectomy on nonprolapsed uterus with non malignant disease is linked with the lack in training of surgeons for the vaginal approach.
Evidence supports that VH is superior; it also supports the use of AH only when documented pathologic conditions preclude the vaginal route.4–9 Conventional limiting factors for NDVH need to be addressed, because in most of the cases it can be overcome and hysterectomy can be completed by the vaginal route. It is, therefore, important to individualize the approach for each patient rather than rely on a single technique.
The proponents of laparoscopic surgery claim to overcome the limitations of VH with laparoscopic assistance and convert a potential abdominal to vaginal route of 3hysterectomy. However, advantage of LAVH or total laparoscopic hysterectomy (TLH) has not been established over NDVH. Whereas laparoscopic hysterectomy is associated with increased cost and morbidities related to surgeon's expertise and learning curve, the surgical outcome is similar to NDVH. A Cochrane Review concluded that VH is far superior compared to the other techniques and has the best outcomes; however.9
Despite documented evidence that the vaginal route is superior, why is it that gynecologists shy away from the vaginal route? Is it because abdominal hysterectomy with its large incision and easy access to the uterus is surgically more comfortable or is it because of physician reluctance to change or is it because of inadequate residency training? Kovan by the use of a statistical model in physician decision making showed that various factors, such as residency training, personal experience, and surgical capability greatly influence the selection of abdominal versus vaginal hysterectomy. In their study they showed that physicians' seldom selected the vaginal route despite any clear indication for the abdominal route.4 Current evidence suggests that a physician's comfort and preference is the only consideration in selection of the type of hysterectomy performed!10 This despite documenting that abdominal hysterectomy for less serious conditions unnecessarily subjects women to greater risk of complications, longer recuperation and poorer postoperative quality-of-life outcomes.
It can be rightly said that the father of non-descent vaginal hysterectomy in modern India is certainly Sheth with his experience of 5655 vaginal hysterectomies (VH) done from 1967 to 2001.11 He did all hysterectomies, in private 4practice without laparoscopic assistance. A new concept proposed by him is the ‘trial vaginal hysterectomy’ where a surgeon feels that VH is possible but may prove difficult or fail and recourse to laparoscopy or laparotomy may be necessary. This puts the gynecologist in a comfortable position, as ‘failures’ can occur in certain situations like a large uterus, adnexal pathology, adhesions, etc. The technique requires only standard instruments and sutures and gaining expertise in NDVH would mean serving 80 percent of the world, i.e. developing countries better. Finally, Sheth believes that ‘marketing’ the procedure as ‘scarless surgery’ would make it more popular.
REFERENCES
- Dorsey JH, Steinberg EP, Holtz PM. Clinical indications for hysterectomy route: Patient characteristics or physician preference. Am J Obstet Gynecol. 1995;173:1452–60.
- Maresh MJ, Metcalfe MA, Mcpherson K, et al. The value national hysterectomy study: Description of patients and their surgery. Br J Obstet Gynecol. 2002;109:302–12.
- Nanavati AM, Gokral SB. A prospective randomized comparative study of vaginal, abdominal, and laparoscopic hysterectomies. J Obstet Gynaecol India. 2016;66:389–94.
- Geoff M, Guylaine LG. Vaginal hysterctomy: dispelling the myths. J Obstet Gynaecol Can.2007;29(5):424–8.
- Cardosi RJ, Hoffman MS. Determining the best route for hysterectomy. OBG Manag.2002;14(7):31–8.
- Saha R, Shrestha NS, Thapa M, et al. Non-descent vaginal hysterectomy—safety and feasibility. NJOG.2012;7(2):14–6.
- Kovac SR. Abdominal versus vaginal hysterectomy: a statistical model for determining physician decision making and patient outcome. Med Decis Mak. 1991;11:19–28.
- Nieboer TE, Johnson N, Lethaby A, et al. Surgical approach to hysterectomy for benign gynecological disease. Cochrane Database Syst Rev. 2009;3.CD003677.
- Kovan SR. Clinical opinion: Guidelines for hysterectomy. Am J Obstet Gynecol. 2004;191:635–40.
- Sheth SS. The scope of vaginal hysterectomy. Eur J Obstet Gynecol Reprod Biol. 2004;115:224–30.