QuizMe 9

Surgical Route

A 40-year-old woman, para 3, presents with a 2-year history of progressive dysmenorrhea. After a trial of failed medical management, she would like to discuss a more surgical approach. Her obstetric history includes a normal delivery, cesarean delivery for breech presentation and a vaginal birth after cesarean delivery. Her BMI is 26. Pelvic examination reveals a small, mobile, anteverted uterus. After discussion with her gynecologist, surgical management was proposed

  • Persistent dysmenorrhea
  • Failed medical management
  • Single-port laparoscopic
  • Vaginal
  • Abdominal
  • Laparoscopic
  • Robot-assisted

Vaginal hysterectomy

Following agreement with a  patient upon a hysterectomy for the management of benign conditions, the gynecologist should make clear recommendation on the route that maximizes benefit and reduces risk in a given clinical scenario.

 

Clinical factors that influence the decision of the preferred route of hysterectomy include:

  • the size and mobility of the uterus
  • the caliber of the vagina
  • previous pregnancies
  • route of obstetric deliveries
  • Previous surgical history.
  • Surgeons skills & availabe resources

 

Vaginal hysterectomy should be the first approach to consider in cases without contraindications. If not feasible or indicated, the laparoscopic approach should be considered next.

 

In cases of benign diseases, the decision to perform salpingo-oopherectomy should be based upon the long-term health effects. The pendulum has swung toward ovarian conservation in patients under age 51. Consent to the salpingo-oopherectomy should be taken prior to the surgery if decided upon.

  • Committee Opinion No 701: Choosing the Route of Hysterectomy for Benign Disease, Obstetrics & Gynecology: June 2017 – Volume 129 – Issue 6 – p e155-e159
  • doi: 10.1097/AOG.0000000000002112
  • Schmitt JJ, Baker MV, Occhino JA, McGree ME, Weaver AL, Bakkum-Gamez JN, Dowdy SC, Pasupathy KS, Gebhart JB. Prospective Implementation and Evaluation of a Decision-Tree Algorithm for Route of Hysterectomy. Obstet Gynecol. 2020 Apr;135(4):761-769. doi: 10.1097/AOG.0000000000003725. PMID: 32168206.
  • Lee SH, Oh SR, Cho YJ, Han M, Park JW, Kim SJ, Yun JH, Choe SY, Choi JS, Bae JW. Comparison of vaginal hysterectomy and laparoscopic hysterectomy: a systematic review and meta-analysis. BMC Womens Health. 2019 Jun 24;19(1):83. doi: 10.1186/s12905-019-0784-4. PMID: 31234852; PMCID: PMC6591934.
  • ACOG. ACOG Practice Bulletin No. 89. Elective and risk-reducing salpingo-oophorectomy. Obstet Gynecol. 2008 Jan;111(1):231-41. doi: 10.1097/01.AOG.0000291580.39618.cb. PMID: 18165419.
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