Choosing the Route of Hysterectomy for Benign Disease

Hysterectomy is one of the most frequently performed surgical procedures in the United States. Selection of the route of hysterectomy for benign causes can be influenced by the size and shape of the vagina and uterus; accessibility to the uterus; extent of extrauterine disease; the need for concurrent procedures; surgeon training and experience; average case volume; available hospital technology, devices, and support; whether the case is emergent or scheduled; and preference of the informed patient. Vaginal and laparoscopic procedures are considered “minimally invasive” surgical approaches because they do not require a large abdominal incision and, thus, typically are associated with shortened hospitalization and postoperative recovery times compared with open abdominal hysterectomy. Minimally invasive approaches to hysterectomy should be performed, whenever feasible, based on their well-documented advantages over abdominal hysterectomy. The vaginal approach is preferred among the minimally invasive approaches. Laparoscopic hysterectomy is a preferable alternative to open abdominal hysterectomy for those patients in whom a vaginal hysterectomy is not indicated or feasible. Although minimally invasive approaches to hysterectomy are the preferred route, open abdominal hysterectomy remains an important surgical option for some patients. The obstetrician–gynecologist should discuss the options with patients and make clear recommendations on which route of hysterectomy will maximize benefits and minimize risks given the specific clinical situation. The relative advantages and disadvantages of the approaches to hysterectomy should be discussed in the context of the patient’s values and preferences, and the patient and health care provider should together determine the best course of action after this discussion. Recommendations and Conclusions The American College of Obstetricians and Gynecologists makes the following conclusions and recommendations: • Vaginal hysterectomy is the approach of choice whenever feasible. Evidence demonstrates that it is associated with better outcomes when compared with other approaches to hysterectomy. • Laparoscopic hysterectomy is a preferable alternative to open abdominal hysterectomy for those patients in whom a vaginal hysterectomy is not indicated or feasible. • For an individual patient, the surgeon should account for clinical factors and determine which route of hysterectomy will most safely facilitate removal of the uterus and optimize patient outcomes, given the clinical situation and surgeon training and experience. • Selection of the route of hysterectomy for benign causes can be influenced by the size and shape of the vagina and uterus; accessibility to the uterus (eg, descensus, pelvic adhesions); extent of extrauterine disease; the need for concurrent procedures; surgeon training and experience; average case volume; available hospital technology, devices, and support; whether the case is emergent or scheduled; and preference of the informed patient. • The obstetrician–gynecologist should discuss the options with the patient and make clear recommendations on which route of hysterectomy will maximize benefits and minimize risks given the specific clinical situation. • The relative advantages and disadvantages of the approaches to hysterectomy should be discussed in the context of the patient’s values and preferences COMMITTEE OPINION Number 701 • June 2017 (Replaces Committee Opinion Number 444, November 2009) Committee on Gynecologic Practice This Committee Opinion was developed by the American College of Obstetricians and Gynecologists’ Committee on Gynecologic Practice in collaboration with committee members Kristen A. Matteson, MD, MPH and Samantha F. Butts, MD, MSCE. This document reflects emerging clinical and scientific advances as of the date issued and is subject to change. The information should not be construed as dictating an exclusive course of treatment or procedure to be followed.