GUIDELINES TO DETERMINE THE ROUTE OF HYSTERECTOMY

Objective: To 1) test the validity of a method of assigning patients prospectively to a vaginal, abdominal, or laparoscopy-assisted vaginal approach to hysterectomy for benign disease; 2) compare the outcomes of these options from the day of surgery to the first day of returning to normal activities; and 3) estimate the proportion of hysterectomies by each route when patients were assigned according to this system, and the impact on hospital charges. Methods: Six hundred seventeen women were assigned to a route of hysterectomy on the basis of uterine size (greater or less than 280 g), presumptive risk factors, and uterine or adnexal immobility or inaccessibility. Data regarding the success of the procedure, complications, length of hospital stay and convalescence, and hospital charges were compiled. Results: Vaginal hysterectomy alone (n = 548) or in conjunction with laparoscopy (n = 63) was successful in 99.5% of women assigned to these groups. Patients in whom the vaginal route was successful included 94% of those with uterine weights exceeding 280 g and 97% of those having risk factors often cited as reasons for selecting abdominal hysterectomy. Laparoscopic surgery was necessary to permit a transvaginal operation in only 12 of 63 patients (19%). Use of the guidelines produced a potential savings of 615 hospital days, $1,317,434 in hospital charges, and 7250 convalescent days relative to the 3:1 ratio of abdominal to vaginal hysterectomies prevalent in the United States. Conclusions: Specific guidelines for uterine size, risk factors, and uterine and adnexal mobility and accessibility are useful in selecting the operative approach to hysterectomy and will significantly reduce the number of abdominal operations performed. Laparoscopy is valuable in properly selected patients to determine the route of hysterectomy, but the need for laparoscopic techniques to permit a vaginal operation may be considerably less than some investigators have proposed.