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912
MD,
Michael A. Finan,
MD,
LEVEL OF EVIDENCE: II
ysterectomy is one of the most frequently performed surgical procedures in the United States.1
There are three approaches to hysterectomy; abdominal
hysterectomy, vaginal hysterectomy, and laparoscopic
hysterectomy with or without robotic assistance.1,2
A minimally invasive approach for hysterectomy is
more favorable as a result of its well-known benefits
including less blood loss, fewer perioperative complications, less postoperative pain, shorter hospital stay,
quicker recovery time, and better cosmesis.2,3
Different factors affect the surgeons decision on
the route chosen for hysterectomy, including safety
and cost-effectiveness.1 The American College of Obstetricians and Gynecologists considers the vaginal
approach to be the ideal route for performance of
benign hysterectomy when feasible.1 Additionally, the
American Association of Gynecologic Laparoscopists
RESULTS
During the study period, the total number of patients
who underwent hysterectomy for benign indications
who met our inclusion criteria was 18,810. The
number of TAH was 9,852 (52.4%), TVH was 5,146
(27.4%), LAVH was 2,296 (12.2%), and TLH was
1,516 (8.0%). The distribution of these cases during
the study period is shown in Table 1. Between 2007
and 2011, there was a more than 20% decline in the
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Study sample
(n=18,810)
Records with missing body
mass index values
(n=57)
Fig. 1. Flowchart of inclusion criteria. ICD-9, International Classification of Diseases, 9th Revision; CPT, Current Procedural
Terminology; TAH, total abdominal hysterectomy; TVH, total vaginal hysterectomy; LAVH, laparoscopically assisted vaginal
hysterectomy; TLH, total laparoscopic hysterectomy.
Mikhail. Obesity and Surgical Trends for Hysterectomy. Obstet Gynecol 2015.
20052006
2007
2008
2009
2010
2011
94 (69.6)
41 (30.4)
0
0
135
510 (69.3)
226 (30.7)
0
0
736
1,400 (57.6)
672 (27.6)
290 (11.9)
69 (2.8)
2,431
1,905 (53.7)
1,012 (28.5)
421 (11.9)
212 (5.9)
3,550
2,432 (51.2)
1,315 (27.7)
643 (13.5)
358 (7.5)
4,748
3,511 (48.7)
1,880 (26.1)
942 (13.1)
877 (12.2)
7,210
Total
9,852
5,146
2,296
1,516
18,810
(52.4)
(27.4)
(12.2)
(8.0)
(100)
TAH, total abdominal hysterectomy; TVH, total vaginal hysterectomy; LAVH, laparoscopically assisted vaginal hysterectomy; TLH, total
laparoscopic hysterectomy.
Data are n (%).
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Mikhail et al
35
Estimated percent
(95% confidence interval)
Estimated percent
(95% confidence interval)
70
65
60
55
50
30
25
20
15
45
Ideal
Overweight
Obese
Morbidly obese
Ideal
Obese
Morbidly obese
14
10
Estimated percent
(95% confidence interval)
Estimated percent
(95% confidence interval)
Overweight
13
12
11
10
6
Ideal
Overweight
Obese
Morbidly obese
Ideal
Overweight
Obese
Morbidly obese
Fig. 2. Trends of different route of hysterectomy performed between 2005 and 2011 stratified by body mass index. Total
abdominal hysterectomy (A), total vaginal hysterectomy (B), laparoscopically assisted vaginal hysterectomy (C), total laparoscopic hysterectomy (D).
Mikhail. Obesity and Surgical Trends for Hysterectomy. Obstet Gynecol 2015.
Table 2. Number of Hysterectomies Performed Between 2005 and 2011 Classified by Route and Body
Mass Index
BMI Classification
Hysterectomy Route
TAH
TVH
LAVH
TLH
(45.7)
(32.7)
(13.3)
(8.7)
Overweight
2,797
1,674
646
420
(50.5)
(30.2)
(11.7)
(7.6)
Obese
3,623
1,520
767
487
Morbid Obesity
(56.6)
(23.8)
(12.0)
(7.6)
1,158
320
218
172
(62.0)
(17.1)
(11.7)
(9.2)
OR (95% CI)
1.257
0.773
0.952
0.986
(1.2191.295)
(0.7470.799)
(0.9100.997)
(0.9331.041)
,.001
,.001
.04
.61
BMI, body mass index; OR, odds ratio; CI, confidence interval; TAH, total abdominal hysterectomy; TVH, total vaginal hysterectomy; LAVH,
laparoscopically assisted vaginal hysterectomy; TLH, total laparoscopic hysterectomy.
Ideal body weight, BMI less than 25; overweight, BMI 2529.9; obese, BMI 3039.9; morbid obesity, BMI 40 or greater.
P is for Wilcoxon test for trend.
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Table 3. Selected Perioperative Outcomes of Patient Stratified by Body Mass Index and Route of
Hysterectomy
BMI Classification
Hysterectomy Route
TAH (n59,852)
TVH (n55,146)
LAVH (n52,296)
TLH (n51,516)
Variable
Overweight
Obese
Morbid Obesity
101.9652.7
18 (0.8)
4 (0.2)
91.2654.3
6 (0.4)
2 (0.1)
117.4660.2
3 (0.5)
1 (0.2)
134.7661.9
1 (0.2)
0 (0.0)
108.6658.6*
41 (1.5)*
6 (0.2)
99.4659.5*
8 (0.5)
1 (0.1)
120.0657.4
7 (1.1)
1 (0.2)
145.0658.9*
5 (1.2)
0 (0.0)
117.7662.9*
102 (2.8)*
25 (0.7)*
100.0657.7*
14 (0.9)
5 (0.3)
128.3661.9*
7 (0.9)
1 (0.1)
146.8658.2*
3 (0.6)
2 (0.4)
134.3670.9*
75 (6.5)*
24 (2.1)*
102.9656.6*
4 (1.3)
0 (0.0)
141.8667.3*
4 (1.8)
0 (0.0)
166.4674.5*
1 (0.6)
0 (0.0)
BMI, body mass index; TAH, total abdominal hysterectomy; TVH, total vaginal hysterectomy; LAVH, laparoscopically assisted vaginal
hysterectomy; TLH, total laparoscopic hysterectomy.
Data are mean6standard deviation or frequency (%) of occurrence.
The distribution of the data were tested for normality.
Ideal body weight, BMI less than 25; overweight, BMI 2529.9; obese, BMI 3039.9; morbid obesity, BMI 40 or greater.
* P,.001 compared with ideal body weight.
DISCUSSION
In this study, it was found that minimally invasive
hysterectomy procedures such as TVH, LAVH, and
TLH are being performed less frequently in patients
with increased BMI. Obesity is associated with
increased rate of TAH despite a national trend that
shows an overall decline in the rate of TAH between
2007 and 2011. As a result of the known benefits
of minimally invasive gynecologic surgery and the
increasing prevalence of obesity in the general U.S.
population, gynecologic surgeons should be trained and
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16. Boyd LR, Novetsky AP, Curtin JP. Effect of surgical volume on
route of hysterectomy and short-term morbidity. Obstet Gynecol 2010;116:90915.
17. Muffly TM, Kow NS. Effect of obesity on patients undergoing
vaginal hysterectomy. J Minim Invasive Gynecol 2014;21:16875.
18. Choban PS, Flancbaum L. The impact of obesity on surgical
outcomes: a review. J Am Coll Surg 1997;185:593603.
19. Osler M, Daugbjerg S, Frederiksen BL, Ottesen B. Body mass
and risk of complications after hysterectomy on benign indications. Hum Reprod 2011;26:15128.
20. Chopin N, Malaret JM, Lafay-Pillet MC, Fotso A, Foulot H,
Chapron C. Total laparoscopic hysterectomy for benign uterine
pathologies: obesity does not increase the risk of complications.
Hum Reprod 2009;24:305762.
21. Kondo W, Bourdel N, Marengo F, Botchorishvili R, Pouly JL,
Jardon K, et al. Whats the impact of the obesity on the safety of
laparoscopic hysterectomy techniques? J Laparoendosc Adv
Surg Tech A 2012;22:94953.
22. Heinberg EM, Crawford BL III, Weitzen SH, Bonilla DJ. Total
laparoscopic hysterectomy in obese versus nonobese patients.
Obstet Gynecol 2004;103:67480.
23. OHanlan KA, Dibble SL, Fisher DT. Total laparoscopic hysterectomy for uterine pathology: impact of body mass index on
outcomes. Gynecol Oncol 2006;103:93841.
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625.3 Dysmenorrhea
233.2 Carcinoma in situ nonspecified
614, 614.1, 614.2, 614.4, 614.6 Salpingitis, oophoritis, pelvic adhesions
617 Endometriosis
617.1 Endometriosis of the ovary
617.3 Endometriosis of the pelvic peritoneum
617.9 Endometriosis nonspecified site
618.01 Cystocele
618.1 Uterine prolapse
618.9 Unspecified genital prolapse
620 Ovarian cyst
620.1 Corpus luteum cyst
620.2 Unspecified ovarian cyst
620.5 Ovarian torsion
621 Disorder of the uterus
621.2 Enlarged uterus
621.3 Endometrial hyperplasia
621.31 Simple endometrial hyperplasia without atypia
621.32 Complex endometrial hyperplasia without
atypia
621.33 Endometrial hyperplasia with atypia
621.4 Hematometra
621.8 Nonspecified disorder of the uterus
622.1 Disorder of the cervix
622.11 Mild cervical dysplasia
622.12 Moderate cervical dysplasia
625 Pain associated with female genital organs
625.6 Stress incontinence
625.8 Other specified disorder of female genital organs
625.9 Unspecified disorder of female genital organs
626.4 Irregular menstrual cycle
626.9 Disorder of menstruation
627 Menopausal disorder
627.1 Postmenopausal bleeding