Hysterectomy—Should all residents learn to perform it?

Hysterectomy for benign gynecological conditions has been offered to women throughout the last century for many reasons and performed using various different surgical techniques. Formerly, the vaginal route for hysterectomy was thought to be the safest, because the transabdominal incision was associated with a high number of infections and complications. Subsequently, other techniques have been introduced, the most recent being robotic assisted laparoscopic hysterectomy. Currently, we are facing a worldwide shift from quite simple procedures like vaginal or abdominal hysterectomy to the advanced three-dimensional (3D) laparoscopic hysterectomy and its robotically assisted equivalent. Upon closer look at the data dealing with this shift, it is obvious that this change is unlikely to be reversed. Due to higher resolution with (3D) High Definition and 4K, the surgical field and pathology are simply more visible. In the past, the numbers of hysterectomies increased incrementally for years, but recent literature shows an actual decline. In the USA, the number of hysterectomies has dropped substantially over the past decade by more than 40%. Among a total of 7 438 452 women who underwent inpatient hysterectomy between 1998 and 2010, the number declined most in women diagnosed with leiomyoma (−47.6%), abnormal bleeding (−28.9%), benign ovarian mass (−63.1%), endometriosis (−65.3%), and pelvic organ prolapse (−39.4%).1 Other data suggest a similar decrease in the rate of hysterectomies in Europe. In Denmark, all hysterectomies are registered in a national database. It appears from this database that the number of hysterectomies declined from 6127 hysterectomies in 2005 to 4008 in 2016, thus comprising a decrease of 35% comparable to the numbers observed in the USA.2 Similar changes have also been observed in other European countries such as the Netherlands and Belgium. Although no recent national data are available due to a lack of readily accessible central registration in the Netherlands and in Belgium, several annual reports on surgical procedures within different hospitals show a considerable decrease in hysterectomies over the past years.3, 4 The reason for the decline is probably related to several factors such as the introduction of other minimal invasive surgical procedures or medical treatment. In Denmark, however, the numbers of minimally invasive endometrial surgery do not explain this fall, since data from the national Danish database (where all endometrial resections/ablations are registered) show that these numbers are more or less the same during the observation period up to 2016. These data include both 1st and 2nd generation ablation techniques including resection. One valid explanation may be the introduction of the levonorgestrel intrauterine device (LNG-IUS). Both the intrauterine device and resection provide viable treatment alternatives to hysterectomy for benign conditions. Although the insertion of a LNG-IUS is less invasive than resection, resection may reduce menstrual bleeding slightly more than LNG-IUS, and systemic side effects are more likely to occur with LNG-IUS.5 However, LNG-IUS should be considered as the first line treatment before resorting to hysterectomy. Furthermore, the introduction of new modalities such as uterine artery embolization and high-intensity-focused ultrasound (HIFU), which have been widely used (mostly in China) to treat patients with uterine fibroids and adenomyosis, may also decrease the number of benign hysterectomies. The question of whether to perform total or subtotal hysterectomy in benign cases is still controversial. Recently, the Danish Health Authority supported a national evaluation on the subject,6 with the purpose of establishing a clinical guideline. The literature was reviewed by a group of specialists who rated the quality of evidence according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE). The review, based on the limited available literature and the corresponding quality of evidence according to GRADE suggests that subtotal hysterectomy is associated with several disadvantages such as persistent cyclic vaginal bleeding and should only be preferred over total hysterectomy after careful consideration. This particular review also found that vaginal hysterectomy should be offered rather than conventional laparoscopic hysterectomy for non-prolapsed uteri when feasible. Finally, the beneficial effect of robot-assisted laparoscopic hysterectomy was questionable and should only be preferred over conventional laparoscopic hysterectomy after careful consideration. One should then expect that vaginal hysterectomy would be reintroduced, but this did not happen, most likely due to the afore-mentioned factors in combination with the loss of routine in vaginal surgery. Jeppson et al7 recently demonstrated that the proportion of hysterectomies performed vaginally has decreased since the introduction of robotic technology. Furthermore, the proportion of hysterectomies with resident involvement was less with a robotic approach than any other route. Resident exposure is therefore substantially downsized by the rapid increase in total laparoscopic hysterectomy/robotic assisted hysterectomy, which now makes up above 80% of all benign hysterectomies in several departments. Taking all this information into consideration, hysterectomy seems to be offered less and the procedures that are offered appear to be getting more and more specialized. Since hysterectomy is one of the cornerstones of gynecological surgery, this development constitutes a growing problem for residents who may not be able to perform the obligatory number of procedures to complete their training. Furthermore, the new technologies used for hysterectomy may require far more training. Thus, Sandadi et al8 previously demonstrated that robotic assisted hysterectomy required a minimum of 50 total cases to be able to independently complete a robotic hysterectomy. A solution as to how to overcome this problem is not clear. According to the Danish fellowship program in gynecology, the fellow has to be able to perform hysterectomy by independently choosing surgical methods without supervision. So far, most fellows do not meet this criterion, since the average number of procedures performed is currently 25. Unfortunately, several of these procedures are only partly performed by the resident due to inexperience and the need for assistance from a supervisor. Moreover, in the Netherlands the minimum number of 40 hysterectomies of any kind, (partly) self-performed, appears to be under more and more pressure, with some residents graduating without achieving this number. For this reason, in BOEG, the Dutch education plan for gynecologists in training, these numbers are no longer called minimum numbers, but target numbers. In Belgium, the minimum number of hysterectomies (abdominal, vaginal and/or laparoscopic) that trainees should have performed by the end of their training is 30, of which at least five abdominal hysterectomies are performed independently. However, some trainees experience problems reaching this number. The professional society and the specialist training recognition committee for obstetrics and gynecology in Belgium are well aware of this problem, and a modification of the existing training program is currently being discussed. One proposal under consideration is that trainees, after their basic training, could be offered an additional 1 or 2 years of final training with a focus on either obstetrics or gynecology. The reduced number of available hysterectomies will thus be offered to those who opt for gynecology, which may prepare them for a potential fellowship in benign gynecology or gynecological oncology. Additional training modalities need to be implemented in fellowship programs in order to overcome the scarcity in training opportunities. One way to achieve this is to gain skills with the help of new technology. For instance, practicing on 3D simulators may offer fellows a realistic, hands-on experience at no risk to the patient and without time limits. Several studies indicate that the use of even simple video and laparoscopic trainers make trainees equally proficient in laparoscopic skills. The training programs may even become available on smart phones and tablets. Another option is that residents subspecialize at an earlier stage of their training. This will secure surgical procedures to those aiming for benign or onco-gynecology subspecialties. As a consequence, however, this may leave an educational gap in basic surgical training for those choosing other subspecialties. Taking the above into account, it is urgent to rethink surgical training since the number of procedures will likely decline even further in the future, and the surgery that remains will be more complex. Several societies are already implementing training certification but such training also needs to be implemented at a national level in order to secure standardized training for all fellows. Nevertheless, the most delicate question will need to be answered in the near future: do all trainees in obstetrics and gynecology still need to learn to perform hysterectomy?