2) Critically evaluate the routes of hysterectomy for benign gynecological conditions. (100 marks)
Answer
1. Hysterectomy is one of the most commonly performed surgical procedures worldwide. (2marks)
2. Routes of hysterectomy; VH, LH and Open AH (2marks)
3. Select the safest route of hysterectomy to maximize benefits and minimize risks according to the clinical
situation (2marks)
4. Route selection for hysterectomy for benign causes can be influenced by the following factors
I. Size and shape of the vagina and uterus;
II. Accessibility to the uterus
III. Extent of extra-uterine disease such as adnexal pathology, severe endometriosis, adhesions, or an
enlarged uterus may preclude VH.
However, in these cases, another minimally invasive approach, rather than an open abdominal approach, still may be possible.
IV. The need for concurrent procedures;
V. Surgeon training and experience;
VI. Average case volume;
VII. Available hospital technology, devices, and support;
VIII. Whether the case is emergent or scheduled; and
IX. Preference of the informed patient. (any 7X2=14 marks)
5. VH and LH are considered “minimally invasive” approaches as they don’t need a large abdominal incision
(3marks)
6. Minimally invasive approach should be selected, whenever feasible, due to their advantages (shortened
hospitalization and postoperative recovery times) over AH. (3marks)
7. The vaginal approach is preferred among the minimally invasive approaches. (3marks)
8. The relative advantages and disadvantages of the approaches to hysterectomy should be discussed with the
patient (3marks)
9. In some circumstances, the best course of action could be referral to another surgeon capable of providing the
patient with the desired approach to hysterectomy (3marks)
Vaginal Hysterectomy
1. VH usually can be safely performed using the vaginal approach in nulliparous women and women with a history
of one or more prior cesarean deliveries. (3 marks)
2. During VH, techniques to reduce the uterine size intraoperatively or laparoscopic assistance can be
incorporated in patients with extra-uterine pathology (3marks)
3. Plans to perform an opportunistic salpingectomy should not alter the intended route of hysterectomy. BSO can
be performed in majority of cases at VH (3marks)
4. VH compared with TLH
i. Lower overall costs
ii. Shorter operating time
iii. No difference in patient satisfaction (4X2=8 marks)
iv. No evidence of difference in return to normal activities, urinary tract injury, complications
5. VH compared with abdominal hysterectomy
I. Shorter duration of hospital stay
II. Faster return to normal activity
III. Better functional capacity and improved pain assessment (4X2=8marks)
IV. No evidence of difference in satisfaction, intraoperative injury, or complications
V. No studies evaluated costs
Laparascopic Hysterectomy
1. TLH is a preferable alternative to open TAH for those patients in whom a VH is not indicated or feasible.
2. Training, experience, and technical difficulty are the potential barriers to performing a TLH
3. In contrast to elective BSO, prophylactic BSO procedures require a laparoscopic or abdominal approach in
order to obtain necessary tissue margins and proper inspection of peritoneal surfaces and the abdominal cavity
4. For supra-cervical hysterectomy, a laparoscopic or open abdominal approach is most appropriate
5. Power morcellation may be associated with the risk of intraperitoneal dissemination of malignant tissue,
particularly uterine sarcoma. However, the risk of death from disseminated cancer associated with laparoscopic
hysterectomy with power morcellation must be weighed against the increased risk of morbidity and
hysterectomy-related deaths associated with open abdominal hysterectomy in low- risk cases (5X3=15marks)
6. TLH Compared with TAH
I. Faster return to normal activity
II.Shorter duration of hospital stay
III. Fewer wound or abdominal wall infections
IV. Longer operating time
V. Higher rate of lower urinary tract (bladder and ureter) injuries
VI. Improved quality of life in the first months and at 4 years post-surgery
VII. No evidence of difference in satisfaction or major long-term complications
VIII. No evidence of difference in overall cost (limited studies) (8X2=16marks)
7. TLH compared with Robot-Assisted TLH
No evidence of difference in any of the measured outcomes
No studies evaluated costs (2X2=4 marks)
Open Abdominal Hysterectomy
1. Although minimally invasive approaches to hysterectomy are the preferred route, open abdominal hysterectomy
remains an important surgical option for some patients. Open abdominal hysterectomy may be necessary
a. when the vaginal or laparoscopic approach is not appropriate to manage the patient’s clinical
situation,
b. when facilities cannot support less invasive surgical approaches, or
c . when an attempt at a minimally invasive route to hysterectomy fails intraoperatively.
(3X5=15marks)
Total 100marks
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