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Hysterectomy and the Alternatives
Hysterectomy and the Alternatives
Preface Hysterectomy and the Alternatives
John A. Occhino, MD, MS Emanuel C. Trabuco, MD, MS Editors
We are excited to devote this entire issue of Obstetrics and Gynecology Clinics of North America to all aspects of hysterectomy. Despite recent trends showing decreasing numbers, hysterectomy remains one of the most common surgical procedures performed in North America. Nevertheless, since the mid-2000s, there has been a shift toward increasing robotic hysterectomy utilization. Although originally intended to replace abdominal hysterectomy, the introduction of robotic surgery has led to nationwide declines in all other approaches. This is despite the available evidence that vaginal hysterectomy is not only feasible in the vast majority of cases undergoing surgery for benign indications but also less expensive and less morbid when compared with other approaches, including robotic hysterectomy. These trends have been shown to have a negative impact on both resident training and postgraduate maintenance of surgical skills. We begin with a discussion of alternatives to hysterectomy, specifically focusing on management of uterine fibroids and abnormal uterine bleeding. Next, individual routes of hysterectomy for benign disease are explored with a detailed description of techniques, applications, and complications for abdominal, vaginal, laparoscopic, and robotic approaches to hysterectomy written by experts in each category. We provide an evidence-focused review of the comparative literature among different modes of hysterectomy that not only dispel the myth of many commonly considered “contraindications” to vaginal surgery but also demonstrate that vaginal hysterectomy remains the safest and most cost-effective approach. Though rare, cesarean hysterectomy is often emergent and presents unique challenges to the obstetrician/gynecologist. We have chosen to dedicate an article to cesarean hysterectomy, presenting nonsurgical management of uterine atony in a stepwise manner. Subsequent criteria for reaching the decision point to move to peripartum hysterectomy are explored. Following hysterectomy discussions, we focus on evidence-based management of the fallopian tubes and ovaries at the time of benign hysterectomy, further exploring the role of Obstet Gynecol Clin N Am 43 (2016) xiii–xiv http://dx.doi.org/10.1016/j.ogc.2016.06.001 0889-8545/16/$ – see front matter Ó 2016 Published by Elsevier Inc.
obgyn.theclinics.com
xiv
Preface
salpingectomy in ovarian cancer prevention. Enhanced recovery, a novel and highly successful approach to the perioperative and postoperative management of the hysterectomy patient, is also presented, showing how changes introduced led to significant decreased length of stay, narcotic use, and hospital costs. As hysterectomy utilization continues to decline, surgical simulation will likely serve as an important adjunct to resident training and postgraduate maintenance of surgical skills. In this article, we describe the state-of-the-art in surgical simulation and provide tools for evaluation of surgical competency in various modes of hysterectomy. We finish with an article on current hot-topic issues facing the gynecologic surgeon, including uterine morcellation and reimbursement implications, with changing regulations following implementation of health care reform. Our hope is that this issue provides readers with an evidence-based approach to the management of women with benign uterine disease: from uterine-preserving treatment to selecting the optimal management of adnexa and mode of uterine removal. John A. Occhino, MD, MS Department of Obstetrics and Gynecology Division of Gynecologic Surgery Mayo Clinic 200 First Street SW Rochester, MN 55905, USA Emanuel C. Trabuco, MD, MS Department of Obstetrics and Gynecology Division of Gynecologic Surgery Mayo Clinic 200 First Street SW Rochester, MN 55905, USA E-mail addresses: [email protected] (J.A. Occhino) [email protected] (E.C. Trabuco)
Preface Hysterectomy and the Alternatives
John A. Occhino, MD, MS Emanuel C. Trabuco, MD, MS Editors
We are excited to devote this entire issue of Obstetrics and Gynecology Clinics of North America to all aspects of hysterectomy. Despite recent trends showing decreasing numbers, hysterectomy remains one of the most common surgical procedures performed in North America. Nevertheless, since the mid-2000s, there has been a shift toward increasing robotic hysterectomy utilization. Although originally intended to replace abdominal hysterectomy, the introduction of robotic surgery has led to nationwide declines in all other approaches. This is despite the available evidence that vaginal hysterectomy is not only feasible in the vast majority of cases undergoing surgery for benign indications but also less expensive and less morbid when compared with other approaches, including robotic hysterectomy. These trends have been shown to have a negative impact on both resident training and postgraduate maintenance of surgical skills. We begin with a discussion of alternatives to hysterectomy, specifically focusing on management of uterine fibroids and abnormal uterine bleeding. Next, individual routes of hysterectomy for benign disease are explored with a detailed description of techniques, applications, and complications for abdominal, vaginal, laparoscopic, and robotic approaches to hysterectomy written by experts in each category. We provide an evidence-focused review of the comparative literature among different modes of hysterectomy that not only dispel the myth of many commonly considered “contraindications” to vaginal surgery but also demonstrate that vaginal hysterectomy remains the safest and most cost-effective approach. Though rare, cesarean hysterectomy is often emergent and presents unique challenges to the obstetrician/gynecologist. We have chosen to dedicate an article to cesarean hysterectomy, presenting nonsurgical management of uterine atony in a stepwise manner. Subsequent criteria for reaching the decision point to move to peripartum hysterectomy are explored. Following hysterectomy discussions, we focus on evidence-based management of the fallopian tubes and ovaries at the time of benign hysterectomy, further exploring the role of Obstet Gynecol Clin N Am 43 (2016) xiii–xiv http://dx.doi.org/10.1016/j.ogc.2016.06.001 0889-8545/16/$ – see front matter Ó 2016 Published by Elsevier Inc.
obgyn.theclinics.com
xiv
Preface
salpingectomy in ovarian cancer prevention. Enhanced recovery, a novel and highly successful approach to the perioperative and postoperative management of the hysterectomy patient, is also presented, showing how changes introduced led to significant decreased length of stay, narcotic use, and hospital costs. As hysterectomy utilization continues to decline, surgical simulation will likely serve as an important adjunct to resident training and postgraduate maintenance of surgical skills. In this article, we describe the state-of-the-art in surgical simulation and provide tools for evaluation of surgical competency in various modes of hysterectomy. We finish with an article on current hot-topic issues facing the gynecologic surgeon, including uterine morcellation and reimbursement implications, with changing regulations following implementation of health care reform. Our hope is that this issue provides readers with an evidence-based approach to the management of women with benign uterine disease: from uterine-preserving treatment to selecting the optimal management of adnexa and mode of uterine removal. John A. Occhino, MD, MS Department of Obstetrics and Gynecology Division of Gynecologic Surgery Mayo Clinic 200 First Street SW Rochester, MN 55905, USA Emanuel C. Trabuco, MD, MS Department of Obstetrics and Gynecology Division of Gynecologic Surgery Mayo Clinic 200 First Street SW Rochester, MN 55905, USA E-mail addresses: [email protected] (J.A. Occhino) [email protected] (E.C. Trabuco)