Hysterectomy—Should all residents learn to perform it?

摘要

Hysterectomy for benign gynecological conditions has been offered to women throughout the last century for many reasons and performed using various different surgical techniques. Formerly, the vaginal route for hysterectomy was thought to be the safest, because the transabdominal incision was associated with a high number of infections and complications. Subsequently, other techniques have been introduced, the most recent being robotic assisted laparoscopic hysterectomy. Currently, we are facing a worldwide shift from quite simple procedures like vaginal or abdominal hysterectomy to the advanced three-dimensional (3D) laparoscopic hysterectomy and its robotically assisted equivalent. Upon closer look at the data dealing with this shift, it is obvious that this change is unlikely to be reversed. Due to higher resolution with (3D) High Definition and 4K, the surgical field and pathology are simply more visible. In the past, the numbers of hysterectomies increased incrementally for years, but recent literature shows an actual decline. In the USA, the number of hysterectomies has dropped substantially over the past decade by more than 40%. Among a total of 7 438 452 women who underwent inpatient hysterectomy between 1998 and 2010, the number declined most in women diagnosed with leiomyoma (−47.6%), abnormal bleeding (−28.9%), benign ovarian mass (−63.1%), endometriosis (−65.3%), and pelvic organ prolapse (−39.4%).1 Other data suggest a similar decrease in the rate of hysterectomies in Europe. In Denmark, all hysterectomies are registered in a national database. It appears from this database that the number of hysterectomies declined from 6127 hysterectomies in 2005 to 4008 in 2016, thus comprising a decrease of 35% comparable to the numbers observed in the USA.2 Similar changes have also been observed in other European countries such as the Netherlands and Belgium. Although no recent national data are available due to a lack of readily accessible central registration in the Netherlands and in Belgium, several annual reports on surgical procedures within different hospitals show a considerable decrease in hysterectomies over the past years.3, 4 The reason for the decline is probably related to several factors such as the introduction of other minimal invasive surgical procedures or medical treatment. In Denmark, however, the numbers of minimally invasive endometrial surgery do not explain this fall, since data from the national Danish database (where all endometrial resections/ablations are registered) show that these numbers are more or less the same during the observation period up to 2016. These data include both 1st and 2nd generation ablation techniques including resection. One valid explanation may be the introduction of the levonorgestrel intrauterine device (LNG-IUS). Both the intrauterine device and resection provide viable treatment alternatives to hysterectomy for benign conditions. Although the insertion of a LNG-IUS is less invasive than resection, resection may reduce menstrual bleeding slightly more than LNG-IUS, and systemic side effects are more likely to occur with LNG-IUS.5 However, LNG-IUS should be considered as the first line treatment before resorting to hysterectomy. Furthermore, the introduction of new modalities such as uterine artery embolization and high-intensity-focused ultrasound (HIFU), which have been widely used (mostly in China) to treat patients with uterine fibroids and adenomyosis, may also decrease the number of benign hysterectomies. The question of whether to perform total or subtotal hysterectomy in benign cases is still controversial. Recently, the Danish Health Authority supported a national evaluation on the subject,6 with the purpose of establishing a clinical guideline. The literature was reviewed by a group of specialists who rated the quality of evidence according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE). The review, based on the limited availa