Each year in the United States, approximately 500,000 hysterectomies are performed. The main indications for hysterectomy are symptomatic uterine leiomyomas (40.7 percent), endometriosis (17.7 percent), and prolapse (14.5 percent). With the advances in skill and technology, this once predominantly abdominal surgery has moved to be much more commonly performed in a minimally invasive fashion. The American College of Obstetrics and Gynecology (ACOG) recommends performing hysterectomy using the most minimally invasive route possible. The preferred route has always been vaginal hysterectomy; however, with advances in laparoscopic skills and instruments as well as the addition of robotics to the field, many hysterectomies that once needed to be performed abdominally due to size, adhesions, or other complicating factors can now be done without a large abdominal incision. Given the nature of large fibroid uteri and other associated conditions, there are still many women who will continue to need abdominal hysterectomies. The approach to and care of these women will be the scope of this chapter.
Scope of the Problem
It is hard to completely identify the numbers of hysterectomies done minimally invasively versus open given changes in billing codes over time. Recent data looking at trends from 2000 to 2010 on the mode of hysterectomy was published by Magee-Womens Hospital. This report demonstrated a 43.4 percent rate of laparoscopic hysterectomy in 2010 compared to 3.3 percent in 2000, which paralleled a decrease in abdominal hysterectomy from 74.5 percent in 2000 to 36.3 percent in 2010.
There are many implications for these decreasing abdominal hysterectomy numbers, many of them positive in the form of more rapid return to normal activity, decreased length of hospital stay, decreased number of wound infections, and intraoperative blood loss. However, the majority of the decrease in numbers is due to increased laparoscopic cases, which also have associated increased surgical length and higher rates of urinary tract injury. A potentially negative implication of decreased rates of abdominal hysterectomy due to advances in minimally invasive technique and equipment as well as improved medical management options (i.e., progesterone IUD) is the decreased exposure in residency training to gain the skills needed to perform complicated cases. Recent analysis of ACGME resident training numbers showed that while the total number of hysterectomies performed did not decrease significantly between 2002 and 2012, the median number of abdominal hysterectomies decreased from 85 to 56.