Total Abdominal Hysterectomy is becoming out-dated
When I started my work as a gynaecological surgeon in Queensland in 2003, I was keen to see Total Abdominal Hysterectomy (TAH) be replaced by Laparoscopic Hysterectomy by the time I retire. I thought that opening of the abdomen to remove a small uterus is unnecessary and like overreacting; it may achieve some good but at a far too high price. I still believe that today.
In Australia, we recently published data from the LACE trial that compared laparoscopic with open hysterectomy. These data were on endometrial cancer but they can be applied to benign, non-cancerous conditions as well. Those recent data show that …
- Patients who had a TAH suffer from the negative consequences of their surgical recovery not only short-term but even after 6 months from surgery (Janda et al. Lancet Oncol. 2010 Aug;11(8):772-80)
- Patients who had a TAH have a 70% higher chance of a severe surgical complication than patients who had a laparoscopic procedure (Obermair et al. Eur J Cancer. 2012 May;48(8):1147-53)
- Compared to TAH, a laparoscopic hysterectomy saves the taxpayer almost $4,000 in direct surgical costs (data submitted for publication).
Will those data change the way we treat patients? I think they could because still too many patients receive a laparotomy and TAH.
Here are some data from QLD Health. In essence they show that …
- The number of hysterectomies has not changed over the last 10+ years. Not sure where the “Mirena” effect has gone.
- Laparoscopic hysterectomies have increased from 2003 onwards and are now at approximately 12% of all hysterectomies. This increase came at a cost to open hysterectomy, which has declined by the same amount. The number of vaginal hysterectomies has not changed.
Surely, the decline of TAH has begun. But still more than 2000 women in Queensland will have their abdomen opened for a uterus removal this year. Within this large group of patients are those with very large pelvic or uterine masses, aggressive cancers and other conditions that make a laparoscopic procedure impossible. I do suspect, though that the majority are still the ones, where a vaginal hysterectomy is not possible (e.g., history of caesarean sections) and the surgeon goes to laparotomy straight away.
Tony McCartney from Perth who influenced the way I developed my surgery used to say that surgeons will need to get clear in their mind first what their default surgical approach is. If a surgeon’s default approach were open, s/he would do the majority of hysterectomies through open techniques and only do the occasional laparoscopic procedure.
By contrast, if the surgeon’s default approach is laparoscopic, the surgeon will aim to do all but a few hysterectomies laparoscopically unless there is a very good reason not to do it laparoscopically. In that case, the surgeon will have to accept that some laparoscopic operations need to be converted to laparotomies but the majority of cases will get completed laparoscopically with great outcomes.
What will expedite the demise of TAH?
- First and foremost, consumers will become a significant driver of change. They will become increasingly informed, exchange information amongst them and will finally refer themselves to gynaecologists who offer less invasive procedures. She will also stop believing that she needs to have an open operation because she had caesarean section(s) previously.
- Young gynaecologists are driven by their desire to offer better service, organise their upskilling and arrange for their own postgraduate surgical training. Training courses like the one described last week will be offered more regularly. Offering just TAH will not get young gynaecologists through to retirement. Surgeons also work out that it is also better on themselves when patients recover with less surgical complications.
- The Health Department in Queensland introduced a new incentive-based payment (Activity-Based Funding) scheme recently. For every laparoscopic procedure, the hospital will save $4000. I assume the Hospital Boards will put pressure on surgeons to spend the very limited funds wiser.
Will TAH become an extinguished operation?