Hysterectomy is the second most commonly performed surgery after cesarean section. The majority of patients (90%) undergoing hysterectomy do not have cancer.
Uterine fibroids (Myoma uteri) are the most common cause, followed by endometriosis, prolapsed uterus, abnormal endometrial hyperplasia, endometrial polyps, cervical intraepithelial neoplasia, and cancers of the female reproductive organs.
Techniques of hysterectomy currently include 4 methods:
- Vaginal hysterectomy
- Laparoscopic hysterectomy
- Minilaparotomy hysterectomy (small abdominal incision, less than or equal to 6 cm)
- Abdominal hysterectomy
According to medical evidence to date, vaginal hysterectomy yields better outcomes than laparoscopic and abdominal hysterectomy in terms of safety, cosmetic results, recovery period, hospital stay, and cost-effectiveness.
Laparoscopic hysterectomy has better outcomes than abdominal hysterectomy regarding shorter recovery period, shorter hospital stay, and fewer wound infections. However, laparoscopic hysterectomy has a longer operation time and higher risk of urinary tract and bladder injuries.
Vaginal hysterectomy is the removal of the uterus without any external scars (scarless hysterectomy). It is considered a surgical innovation for hysterectomy in Thailand.
Vaginal hysterectomy was first performed worldwide by a German physician named Langenbeck in 1813. Initially, this technique was only used for patients with uterine and pelvic floor prolapse. Later, surgical techniques were developed to allow vaginal hysterectomy in cases without uterine or pelvic floor prolapse.
Besides being a scarless surgery, medical evidence to date shows that vaginal hysterectomy provides better outcomes than laparoscopic and abdominal hysterectomy in terms of safety and hospital stay duration.
The American Congress of Obstetricians and Gynecologists (ACOG) published a committee opinion in the November 2009 issue of Obstet & Gynecol recommending vaginal hysterectomy as the procedure of choice for non-cancerous indications. It is the safest and most cost-effective method, with fewer surgical complications and shorter recovery compared to laparoscopic and abdominal hysterectomy.
The Cochrane Collaboration, a leading organization for meta-analysis and RCT medical studies, compared vaginal hysterectomy with laparoscopic and abdominal hysterectomy. They found vaginal hysterectomy superior in all measured outcomes and recommended it as the first choice for non-cancerous hysterectomy cases.
Up-To-Date, one of the most updated and reliable medical information programs worldwide, summarizes that vaginal hysterectomy is less invasive, more cosmetic due to no external scars, has fewer complications, shorter hospital stays, lower cost, and shorter recovery time compared to other hysterectomy methods.
With advances in surgical techniques and technology, vaginal hysterectomy can now be performed in almost all cases without the need for uterine or pelvic floor prolapse, such as uterine fibroids, adenomyosis, abnormal endometrial hyperplasia, cervical dysplasia, and abnormal uterine bleeding. Being single, nulliparous, or having a history of cesarean section are not limitations for vaginal hysterectomy (many studies show most patients in these groups can undergo vaginal hysterectomy). Success depends on the skill, experience, and expertise of the gynecologic surgeon.
Limitations of vaginal hysterectomy include:
- Undiagnosed pathology of the adnexa
- Dense pelvic adhesions
- Skill and expertise of the gynecologic surgeon
In Thailand, vaginal hysterectomy without uterine or pelvic floor prolapse is rarely performed due to lack of formal training.
Some expert gynecologic surgeons in the US, Europe, and India report performing vaginal hysterectomy in up to 90% of all hysterectomies for non-cancerous indications. In the author’s experience, 90-95% of all hysterectomies can be performed vaginally.
Dr. Kitti Tujinda
Obstetrician and Gynecologic Laparoscopic Surgery Specialist
Women’s Health Center, Phyathai 2 Hospital
