Highlights
- •Vaginal hysterectomy has distinct benefits over other routes for hysterectomy.
- •The vaginal route should be considered the preferred choice in women undergoing hysterectomy for benign indications.
- •Formal hysterectomy route decision algorithm promotes the vaginal approach.
Abstract
Objectives
This study was undertaken at the Department of Obstetrics and Gynaecology of the Charlotte
Maxeke Johannesburg Academic Hospital to determine if the use of formal guidelines
and a standardised surgical technique would increase the rate of vaginal hysterectomy
(VH) and result in an overall decline in open abdominal hysterectomy (AH).
Study Design
All women admitted between July 2001 and December 2014 for hysterectomy due to benign
conditions, meeting the guidelines criteria (vaginally accessible uterus, uterus ≤
12 weeks size or ≤ 280 g on ultrasound examination and pathology confined to the uterus)
were included. The surgical route was determined using the Unit surgical decision
tree algorithm. In cases where the pathology was not confined to the uterus or success
in VH was uncertain, laparoscopic assisted vaginal hysterectomy (LAVH) was performed.
The VH procedures were performed by the residents in training, under the supervision
of specialists with large experience in vaginal surgery. In addition to the patient
characteristics and surgical approach to hysterectomy, length of hospital stay, intra-operative
and immediate post-operative complications were also recorded and analysed.
Results
A year before the initiation of the study, the percentage of all VHs undertaken in
the Department was 9.8 % (mainly performed for utero-vaginal prolapse). During the
study period, 1143 vaginal procedures (1017 VHs and 126 LAVHs) were performed. The
most common indications were cervical dysplasia, uterine fibroids, dysmenorrhoea or
abnormal uterine bleeding, adenomyosis, endometrial hyperplasia and chronic pelvic
pain. Introducing a formal clinical decision tree algorithm and a standardised surgical
technique resulted in an increase in the rate of VH to 48.4 % and overall decline
in open AH from 91.2%–51.6%. Thus, the VH/AH ratio increased from 1/9 at the beginning
of the study (July 2001) to 1/1 by its end (December 2014). In all cases, VH was performed
without the need to convert the vaginal to the abdominal route.
Conclusion
The use of institutional guidelines for determining the hysterectomy route and a standardised
VH technique resulted in an increased number of performed VHs. This provided an essential
opportunity for residents to acquire, improve and maintain the skills required to
safely perform VH.
Keywords
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Article info
Publication history
Published online: February 22, 2021
Accepted:
February 20,
2021
Received in revised form:
February 17,
2021
Received:
November 12,
2020
Identification
Copyright
© 2021 Elsevier B.V. All rights reserved.
