Comparison of hysterectomy techniques and cost-benefit analysis

The first description of the removal of gangrenous and inverted uteri goes back to the third century ad. 1 However, it was not until 1813 when a German surgeon Conrad Langenbeck described the first intentional complete vaginal hysterectomy in which the patient survived. In those days the operative mortality rate was close to 90%. The first reports of abdominal hysterectomies were accidental hysterectomies at the time of ovariectomy, mostly with conservation of the cervix. The first abdominal hysterectomy where the patient survived was reported by an American surgeon, Walter Burnham, in the American Lancet in 1854. 2 Another American surgeon, Harry Reich, reported the first laparoscopic-assisted vaginal hysterectomy in 1989. 3 Hysterectomy is now the most frequently performed major gynecologic operation, with millions of procedures annually performed throughout the world. 4 Abdominal hysterectomy has traditionally been the surgical approach for gynecologic malignancy, in cases where pelvic pathology such as endometriosis or adhesions is suspected and in the presence of a large uterus. Abdominal hysterectomy remains the ‘fallback option’ if the uterus cannot be removed by another approach. The vaginal approach was originally used for prolapse, but has become more widely used for abnormal uterine bleeding when the uterus is of fairly normal size with or without a small degree of descent. Compared to abdominal hysterectomy, successful vaginal hysterectomy is considered as less invasive and can be performed under spinal anesthesia, whereas abdominal and laparoscopic hysterectomy will mostly require general anesthesia.