Full length article| Volume 259, P133-139, April 2021

Download started.


Formal institutional guidelines promotes the vaginal approach to hysterectomy in patients with benign disease and non-prolapsed uterus

Published:February 22, 2021DOI:


      • 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.



      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.


      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.


      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.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


        • Domingo S.
        • Pellicer A.
        Overview of current trends in hysterectomy.
        Expert Rev ObstetGynecol. 2009; 4: 673-685
        • Garry R.
        The future of hysterectomy.
        BJOG. 2005; 112: 133-139
        • Nieboer T.E.
        • Johnson N.
        • Lethaby A.
        • Tavender E.
        • Curr E.
        • Garry R.
        • et al.
        Surgical approach to hysterectomy for benign gynaecological disease.
        Cochrane Database Syst Rev. 2009; : CD003677
        • Garry R.
        • Fountain J.
        • Mason S.
        • Hawe J.
        • Napp V.
        • Abbott J.
        • et al.
        The eVALuate study: two parallel randomised trials, one comparing laparoscopic with abdominal hysterectomy, the other comparing with vaginal hysterectomy.
        BMJ. 2004; 328: 129-133
        • Miskry T.
        • Magos A.
        Randomized, prospective, double-blind comparison of abdominal and vaginal hysterectomy in women without uterovaginal prolapses.
        Acta Obstet Gynecol Scand. 2003; 82: 351-358
        • Johnson N.
        • Barlow D.
        • Lethaby A.
        • Tavender E.
        • Curr E.
        • Garry R.
        Surgical approach to hysterectomy for benign gynaecological disease.
        Cochrane Database Syst Rev. 2006; : CD003677
        • Aarts J.W.
        • Nieboer T.E.
        • Johnson N.
        • Tavender E.
        • Garry R.
        • Mol B.W.
        • et al.
        Surgical approach to hysterectomy for benign gynaecological disease.
        Cochrane Database Syst Rev. 2015; : CD003677
        • McCracken G.
        • Hunter D.
        • Morgan D.
        • Price J.H.
        Comparison of laparoscopic-assisted vaginal hysterectomy, total abdominal hysterectomy, and vaginal hysterectomy.
        Ulster Med J. 2006; 75: 54-58
        • Spilsbury K.
        • Semmens J.B.
        • Hammond I.
        • Block A.
        Persistent high rates of hysterectomy in Western Australia: a population-based study of 83 000 procedures over 23 years.
        BJOG. 2006; 113: 804-809
        • Pandey D.
        • Sehgal K.
        • Saxena A.
        • Hebbar S.
        • Nambiar J.
        • Bhat R.
        An audit of indications, complications, and justification of hysterectomies at a teaching hospital in India.
        Int J Rep Med. 2014; (online)
        • Harmanli O.H.
        • Byun S.
        • Dandolu V.
        • Gaughan J.P.
        • Grody M.H.
        Vaginal hysterectomy for the enlarged uterus.
        Gynaecol Obstet Invest. 2006; 61: 4-8
        • Tohic A.L.
        • Dhainaut C.
        • Yazbeck C.
        • Hallais C.
        • Levin I.
        • Madelenat P.
        Hysterectomy for benign uterine pathology among women without previous vaginal delivery.
        Obstet Gynecol. 2008; 111: 829-837
        • Kdous M.
        • Diari J.
        • Braham M.
        • Ferchiou M.
        • Zhioua F.
        Hysterectomy in patients with previous caesarean section: comparison between laparoscopic and vaginal approaches. A prospective randomized controlled study.
        Donn J Med Sci. 2015; 2: 103-107
        • Olah K.
        Vaginal hysterectomy in the absence of prolapse.
        Obstet Gynaecol. 2005; 7: 233-240
        • Moen M.D.
        • Richter H.E.
        Vaginal hysterectomy: past, present, and future.
        Int Urogynecol J. 2014; 25: 1161-1165
        • McCracken G.
        • Lefebvre G.
        Vaginal hysterectomy: dispelling the myths.
        J Obstet Gynaecol Can. 2007; 29: 424-428
        • Vessey M.P.
        • Villard-Mackintosh L.
        • McPherson K.
        • Coulter A.
        • Yeates D.
        The epidemiology of hysterectomy: findings in a large cohort study.
        B J ObstetGynecol. 1992; 99: 402-407
        • Coulter A.
        • McPherson K.
        • Vessey M.
        Do British women undergo too many or too few hysterectomies?.
        Soc Sci Med. 1988; 27: 987-994
        • Garry R.
        Initial experience with laparoscopy-assisted vaginal hysterectomy.
        B J Obstet Gynecol. 1992; 99: 402-407
        • Wilcox L.S.
        • Koonin L.M.
        • Pokras R.
        • Strauss L.T.
        • Xia Z.
        Hysterectomy in the United States, 2003.
        Obstet Gynecol. 1994; 83: 549-555
      1. ACOG Committee opinion 444(2009) Choosing the route of hysterectomy for benign disease. American College of Obstetrician and Gynecologists. ObstetGynecol 1145: 1156-1158.

        • Liu F.
        • Pan Y.
        • Liang Y.
        • Zhang C.
        • Deng Q.
        • Li X.
        • et al.
        The epidemiological profile of hysterectomy in rural Chinese women: a population-based study.
        BMJ Open. 2017; 7e015351
        • Jiang J.
        • Ding T.
        • Luo A.
        • Lu Y.
        • Ma D.
        • Wang S.
        Comparison of surgical indications for hysterectomy by age and approach in 4653 Chinese women.
        Front Med (Lausanne). 2014; 8: 464-470
        • Singh A.
        • Arora A.
        Why hysterectomy rates are lower in India.
        Indian J Community Med. 2008; 33: 196
        • Pandey D.
        • Sehgal K.
        • Saxena A.
        • Hebbar S.
        • Nambiar J.
        • Bhat R.
        An audit of indications, complications, and justification of hysterectomies at a teaching hospital in India.
        Int J Reprod Med. 2014; 2014: 1-6
        • Toma A.
        • Hopman W.
        • Gorwill R.
        Hysterectomy at a Canadian tertiary care facility: results of a one year retrospective review.
        BMC Womens Health. 2004; 4: 10
        • Augusto K.
        • Brilhante A.
        • Modesto G.
        • Saboia D.
        • Rocha C.
        • Karbage S.
        • et al.
        Costs and mortality rates of surgical approaches to hysterectomy in Brazil.
        Revista de SaúdePública. 2018; 52: 25
        • Sheth S.
        The scope of vaginal hysterectomy.
        Eur J Obstet Gynecol Reprod Biol. 2004; 115: 224-230
        • Burkett D.
        • Horwitz J.
        • Kennedy V.
        • Murphy D.
        • Graziano S.
        • Kenton K.
        Assessing current trends in resident hysterectomy training.
        Female Pelvic Med Reconstr Surg. 2011; 17: 210-214
        • Chrysostomou A.
        • Djokovic D.
        • Edridge W.
        • van Herendael B.J.
        Evidence-based practical guidelines for vaginal hysterectomy of International Society for Gynecologic Endoscopy(ISGE).
        Eur J Obstet Gynecol Reprod Biol. 2020; 231: 262-267
        • Sanei-MoggadhamA Ma T.
        • Goughnour S.L.
        • Edwards R.P.
        • Lounder P.J.
        • Ismail N.
        • Comerci J.T.
        • et al.
        Changes in hysterectomy trends after implementation of a clinical pathway.
        Obstet Gynecol. 2016; 127: 139-147
        • Kovac S.R.
        Decision-directed hysterectomy: a possible approach to improve medical and academic outcomes.
        Int J Gynaecol Obstet. 2000; 71: 159-169
        • Kovac S.R.
        • Cruikshank S.H.
        • Patwari A.
        • O’Meara P.
        28 years of using hysterectomy guidelines to determine the feasibility of vaginal hysterectomy.
        Gynecol Obstet (Paris). 2016; 6: 1-6
        • Kovac S.R.
        Clinical opinion: guidelines for hysterectomy.
        Am J Obstet Gynecol. 2004; 191: 635-640
        • Doucette R.C.
        • Sharp H.T.
        • Alder S.C.
        Challenging generally accepted contraindications to vaginal hysterectomy.
        Am J ObstetGynecol. 2001; 184: 1361-1391
        • Porges R.F.
        Changing indications for vaginal hysterectomy.
        Am J ObstetGynecol. 1980; 136: 153-158
        • Jain S.B.
        • Chandrakar K.D.
        Non-decent vaginal hysterectomy in rural setup of MP: a poor acceptance.
        J ObstetGynaecol India. 2016; 66: 459-504
        • AAGL Advancing Minimally Invasive Gynecology Worldwide
        AAGL position statement: route of hysterectomy to treat benignuterine disease.
        J Minim Invasive Gynecol. 2011; 18: 1-3
        • Jacoby V.L.
        • Autry A.
        • Jacobson G.
        • Domush R.
        • Nakagawa S.
        • Jacoby A.
        Nationwide use of laparoscopic hysterectomy compared with abdominal and vaginal approaches.
        Obstet Gynecol. 2009; 114: 1041-1048
      2. Donnez O., Jadoul P., Squifflet J., Donnez J. A series of 3190 laparoscopic hysterectomies for benign disease from 1990 to 2006: evaluation of complications compared with vaginal and abdominal procedures. BJOG. 116(4):492–500.

        • Schmitt J.J.
        • Carranza Leon D.A.
        • Occhino J.A.
        • Weaver A.L.
        • Dowdy S.C.
        • Bakkum-Gamez J.N.
        • et al.
        Determining optimal route of hysterectomy for benign indications: clinical decision tree algorithm.
        Obstet Gynecol. 2017; 129: 130-138
        • Brummer T.H.I.
        • Jalkanen J.
        • Fraser J.
        • Heikkinen A.M.
        • Kauko M.
        • Makinen J.
        • et al.
        FINHYST, a prospective study of 5279 hysterectomies: complications and their risk factors.
        Hum Reprod. 2011; 26: 1741-1751
        • Morelli M.
        • et al.
        Studi di Catanzaro, Italy “Total laparoscopic hysterectomy versus vaginal hysterectomy: a prospective randomised trial”.
        Minerva Ginecol. 2007; 559: 99-105
        • Teeluckdharry B.
        • Gilmour D.
        Urinary tract injury at benign gynaecologic surgery and therole of cystoscopy.
        Obstet Gynecol. 2015; 126: 1161-1169
      3. Stang A., Merril R.M., Kuss O. Nationwide rates of conversion from laparoscopic or vaginal hysterectomy to open abdominal hysterectomy in Germany. Eur J Epidem; 26(2):125-133.

        • David-Montefiore E.
        • Rouzier R.
        • Chapron C.
        • Darai E.
        Surgical routes and complications of hysterectomy for benign disorders: a prospective observational study in French university hospitals.
        Hum Reprod. 2007; 22: 260-265
        • Chrysostomou A.
        • Djokovic D.
        Preferred and actual methods of hysterectomy: a survey of current practices among members of the South African Society of Obstetricians and Gynaecologists.
        S Afr J Obstet Gynaecol. 2020; 26 (published online https//
        • Kovac S.R.
        • Cruikshank S.H.
        • Retto H.F.
        Laparoscopy-assisted vaginal hysterectomy.
        J Gynecol Surg. 1990; 6: 185-193
        • Chrysostomou A.
        Implications of performing laparoscopic assisted vaginal hysterectomyversus abdominal hysterectomy on suitable patients in a South African hospital setting.
        SAfr JOG. 2008; 14: 70-74
        • Antosh D.D.
        • Gutman R.E.
        • Iglesia C.B.
        • Sokol A.I.
        • Park A.J.
        Resident opinions on vaginal hysterectomy training.
        Female Pelvic Med ReconstrSurg. 2011; 17: 314-317
        • Okeke T.C.
        • Ikeako L.C.
        • Ezenyeaku C.C.T.
        Underexposure of residents in training in the art of vaginal hysterectomy in Nigeria.
        Am J Clin Med Res. 2014; 2: 22-25