Surgical approach to hysterectomy and barriers to using minimally invasive methods

Janda, Monika; Armfield, Nigel R; Kerr, Gayle; Kurz, Suzanne; Jackson, Graeme; Currie, Jason; Page, Katie; Weaver, Edward; Yazdani, Anusch; Obermair, Andreas

doi:10.1111/ajo.12824

Cited by 8 publications

(9 citation statements)

References 17 publications

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“… 8 The key focus therefore, rather than being between LH and RH, should instead be on reducing the OH rate to a minimum. Although there are only a few absolute contraindications for OH, the number of cases that are performed through open surgery is still high in some institutions and there has been much discussion how this could be reduced through greater surgical training 28 or centralisation of cases to hospitals and surgeons with high MIS rates. 29 A reduction in OH can also be achieved through reducing the number of conversions from LH/RH to a minimum.…”

Section: Discussionmentioning

confidence: 99%

Economic evaluation of different routes of surgery for the management of endometrial cancer: a retrospective cohort study

Moss

Morgan²,

Martin³

et al. 2021

BMJ Open

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ObjectivesThe benefits of minimally invasive surgery (MIS) for endometrial carcinoma (EC) are well established although the financial impact of robotic-assisted hysterectomy (RH) compared with laparoscopic hysterectomy (LH) is disputed.DesignRetrospective cohort study.SettingEnglish National Health Service hospitals 2011–2017/2018.Participants35 304 women having a hysterectomy for EC identified from Hospital Episode Statistics.Primary and secondary outcome measuresThe primary outcome was the association between route of surgery on cost at intervention, 30, 90 and 365 days for women undergoing an open hysterectomy (OH) or MIS (LH/RH) for EC in England. The average marginal effect was calculated to compare RH versus OH and RH versus LH which adjusted for any differences in the characteristics of the surgical approaches. Secondary outcomes were to analyse costing data for each surgical approach by age, Charlson Comorbidity Index (CCI) and hospital MIS rate classification.ResultsA total of 35 304 procedures were performed, 20 405 (57.8%) were MIS (LH: 18 604 and RH: 1801), 14 291 (40.5%) OH. Mean cost for LH was significantly less than RH, whereas RH was significantly less than OH at intervention, 30, 90 and 365 days (p<0.001). Over time, patients who underwent RH had increasing CCI scores and by the 2015/2016 year had a higher average CCI than LH. Comparing the cost of LH and RH against CCI score identified that the costs closely reflected the patients’ CCI. Increasing disparity was also seen between the MIS and OH costs with rising age. When exploring the association between provider volume, MIS rate and surgical costs, there was an association with the higher the MIS rate the lower the average cost.ConclusionsFurther research is needed to investigate costs in matched patient cohorts to determine the optimum surgical modality in different populations.

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Section: Discussionmentioning

confidence: 99%

Economic evaluation of different routes of surgery for the management of endometrial cancer: a retrospective cohort study

Moss

Morgan²,

Martin³

et al. 2021

BMJ Open

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“…Previous studies examined the relationships between surgical approach to hysterectomy and women’s quality of life, for both benign and oncologic conditions ( 14 – 19 ). Most studies compared laparoscopic and open abdominal surgery ( 9 – 13 ), while 1 study compared TLH, VH, and TAH ( 8 ), and 4 TLH versus RH, reviewed in Albright et al ( 20 ). These studies all concluded that minimally invasive surgical approaches were associated with better postoperative quality of life.…”

Section: Discussionmentioning

confidence: 99%

“…To better understand reasons for this, we explored the views of both surgeons and patients. Among 285 Australian obstetrics and gynecology specialists, the dominating barrier to practicing less invasive surgery was a lack of surgical training and mentoring (9). Among women who had a hysterectomy in the previous 2 years, the majority (62%) followed their doctor's advice on the surgical approach, and very few (<15%) sought a second opinion (10).…”

Section: Introductionmentioning

confidence: 99%

Patient-Reported Experiences After Hysterectomy: A Cross-Sectional Study of the Views of Over 2300 Women

Janda

Armfield

Kerr

et al. 2019

Journal of Patient Experience

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Objective: To evaluate women’s experiences after hysterectomy and predictors of their contentment and regret with the surgical approaches. Methods: Cross-sectional, Patient-Reported Experience Measures survey in 2319 Australian women aged 21 to 90 years (median age of 52 years) who had received hysterectomy in the preceding 2 years. Results: Overall, the vast majority of women (>96%) did not regret having had the hysterectomy. Women who received an open abdominal hysterectomy reported slower recovery with about 7% of women still not fully recovered after 12 months compared to those whose surgery was through a less invasive approach. Women who reported no adverse events, having been given a choice of type of hysterectomy, women who received an alternative to open abdominal hysterectomy, and women who felt prepared for discharge from hospital were significantly more likely to be content with their hysterectomy and report positive patient experiences. Conclusions: Compared with those who received a less invasive approach to hysterectomy, women who received open surgery were more likely to express negative experiences relating to their hospital stay and recovery from surgery. The results inform future improvements of care for women planning a hysterectomy.

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“…In previous work, we interviewed and surveyed Australian gynaecologists 27. It is apparent that Australian gynaecologists prefer to offer the hysterectomy through a vaginal approach; however, if a vaginal approach is infeasible, many resort to an open, abdominal surgical approach.…”

Section: Discussionmentioning

confidence: 99%

“…To investigate why TAH was still commonly used, a survey of Australian and New Zealand gynaecologists identified two main barriers impeding the uptake of TLH: (1) surgeons’ lack of procedural skills for TLH and (2) the limited availability of structured training and mentoring opportunities to assist practising surgeons to gain those skills 27. Women who have had a hysterectomy were surveyed and reported that they commonly follow the advice of their doctor with regards to the type of hysterectomy, and rarely reported to seek a second opinion 28…”

Section: Rationalementioning

confidence: 99%

How to train practising gynaecologists in total laparoscopic hysterectomy: protocol for the stepped-wedge IMAGINE trial

Obermair

Armfield

Graves³

et al. 2019

BMJ Open

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IntroductionHysterectomy is the most common major gynaecological procedure in women and minimally invasive approaches should be used wherever possible; total laparoscopic hysterectomy (TLH) is one such surgical approach which allows removal of the uterus entirely laparoscopically. However, lack of surgical training opportunities is impeding its increased adoption. This study will formally test a surgical outreach training model to equip surgeons with the skills to provide TLH as an alternative to total abdominal hysterectomy (TAH).Methods and analysisStepped wedge implementation trial of a surgical training programme for practising obstetrician gynaecologist specialists in four hospitals.Primary outcomesChange in the proportion of hysterectomies performed by TAH, measured between preintervention and postintervention; we aim to reduce TAH by at least 30% in 75% of the trainees.Secondary outcomes(1) Number of hospitals screened, eligible, agree to training and complete the training; (2) number of surgeons screened for eligibility, eligible, agree to training, who complete training and achieve proficiency; (3) proportion of trainees achieving proficiency in correct theatre setup, vascular exposure, mobilisation and surgery closure; change in proportion proficient over time; (4) adverse events (conversion from TLH to TAH, anaesthetic incident, intraoperative visceral injury, red cell transfusions, hospital stay >7 days, incidental finding of malignancy, unplanned readmission, admission to intensive care, return to theatre, postoperative pulmonary embolism or deep vein thrombosis, development of a fistula, vault haematoma, vaginal vault dehiscence or pelvic infection); (5) hospital length-of-stay; (6) cost-effectiveness and (7) trainee surgeon proficiency with TLH.Ethics and disseminationThe study has been approved by the Royal Brisbane and Women’s Hospital Human Research Ethics Committee and has received site-specific approval from all participating hospitals. Results will be submitted for publication in a peer-reviewed journal.Trial registration numberNCT03617354; Pre-results.

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Surgical approach to hysterectomy and barriers to using minimally invasive methods

Cited by 8 publications

References 17 publications

Economic evaluation of different routes of surgery for the management of endometrial cancer: a retrospective cohort study

Economic evaluation of different routes of surgery for the management of endometrial cancer: a retrospective cohort study

Patient-Reported Experiences After Hysterectomy: A Cross-Sectional Study of the Views of Over 2300 Women

How to train practising gynaecologists in total laparoscopic hysterectomy: protocol for the stepped-wedge IMAGINE trial

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