Comparison of laparoscopic-assisted vaginal hysterectomy, total abdominal hysterectomy and vaginal hysterectomy.

Abstract

Hysterectomy is one of the most commonly performed major operations. Approximately 600,000 hysterectomies are performed in the United States each year 1 and 20% of women in the UK undergo hysterectomy before the age of sixty.2 Historically the uterus has been removed by either the abdominal or vaginal route. The vaginal operation is preferable when there are no contraindications because of lower morbidity and quicker recovery.3 The VALUE Study 4 suggested that 67% of surgeons still used the abdominal approach as the operation of choice, particularly when dealing with pelvic pathology or carrying out oophorectomy. Since it was first reported by Reich et al in 1989 5 laparoscopically assisted vaginal hysterectomy (LAVH) has gained widespread acceptance. Laparoscopic dissection of the para-uterine tissues to the level of the uterine arteries (LAVH) or to include the uterine arteries (laparoscopic hysterectomy), also permits oophorectomy or dissection of adhesions under direct vision more easily than this can be achieved at vaginal hysterectomy (VH). Farquhar and Steiner 6 found that between 1990 and 1997, in the USA, there was a growth in the number of hysterectomies performed with laparoscopic assistance (0.3-9.9%) with an associated decline in the proportion of hysterectomies performed abdominally. Recently the eVALuate Study concluded that LAVH was associated with a significantly higher rate of major complications than abdominal total hysterectomy (TAH). LAVH took longer to perform but was associated with less pain, quicker recovery and better short term quality of life measures. The arm of the trial involving VH was underpowered and inconclusive although VH did take less time than LAVH.6 In contrast to this the study by Lumsden et al 7 did not show any difference in post-surgery recovery, satisfaction with the outcome of the operation or quality of life four weeks post-operatively between TAH and LAVH. The aims of our study were to compare LAVH with TAH and VH in a retrospective non-randomised analysis and to evaluate intra and post-operative complication rates and patient recovery times.