Barriers of adopting laparoscopic hysterectomy

Tagged Hysterectomy, Complications, TLH; Posted 11 years ago

I am asking for your help with a research study. My team and I would like to explore the barriers of implementing laparoscopic hysterectomy. My research is not industry sponsored and I am on no position to offer remuneration for your input.

In Australia, gynaecologists perform approximately 30,000 hysterectomies per year for a variety of indications. Benign indications such as fibroids or menorrhagia outweigh at least 7 to 10 times indications for gynaecological cancer.

While the evidence supports less invasive (vaginal, laparoscopic) surgical approaches to hysterectomy, approximately 40% of all hysterectomies are still done through open surgery and the adoption of laparoscopic hysterectomy is slow.

Recently, I sent a newsletter about the cost effectiveness of laparoscopic hysterectomy to my referrers and received a letter from a gynaecologist in a non-metropolitan area who made me aware of some of the barriers of advanced laparoscopic surgery.

Some of those barriers included:

“I have not received formal training”

“My assistant is in his seventies and completely unfamiliar with laparoscopic surgery”

“My anaesthetist is unwilling to give me head-down position so that I can do the surgery”

“My hospital does not provide me with the necessary equipment” or

“My nurses want me to finish quickly and are not happy with my long operating time if I attempt a laparoscopic case”.

I would like to collate all possible objections to laparoscopic hysterectomy, which will then form the basis for a survey amongst Australian and New Zealand O&G specialists. The survey will be able to quantify the objections.

Subsequently, I plan to get a number of stakeholders in one room to discuss how these objections against laparoscopic surgery can be addressed. Some of these objections can be solved by providing a laparoscopic workshop. However, if your hospital does not give you access to modern technology a laparoscopic workshop is not going to assist that individual.

There is a truly interesting precedence in Finland (Makinen et al, BMJ Open 2013) (http://www.ncbi.nlm.nih.gov/pubmed/24165027) . In 1996 the Finnish recorded a 58% rate of abdominal hysterectomy (vaginal 18%, laparoscopic 24%), which dropped to 24% within a ten-year period. Instead, laparoscopic hysterectomy increased to 32% and vaginal hysterectomy increased to 44%.  

Most remarkably though, surgical hysterectomy complications dropped significantly. The overall complication rates fell in laparoscopic hysterectomy and markedly in vaginal hysterectomy (from 22.2% to 11.7%, p<0.001).

The overall surgery-related infectious morbidity decreased in all groups and significantly in vaginal hysterectomy (from 12.3% to 5.2%, p<0.001) and abdominal hysterectomy (from 9.9% to 7.7%, p<0.05). The incidence of bowel lesions in vaginal hysterectomy sank from 0.5% to 0.1% and of ureter lesions in laparoscopic hysterectomy from 1.1% to 0.3%. In 2006 there were no deaths compared with three in 1996.

If we are able to reduce the rate of abdominal hysterectomy from currently 40% to 15%, this could have a significant impact on surgical complications. By providing better service we would even save health care costs.

If you have any further ideas on objections to laparoscopic hysterectomy – either from yourself or through others – I would like to know. You can post them here or if you wish to email me, please do so at Obermair at gyncan dot org.

Should you be a patient who had or is planning to have an open hysterectomy (through an abdominal incision) my research team and I would be interested to hear what lead to the decision of an open operation, as opposed to a vaginal or laparoscopic hysterectomy. I'd be very intersted to hear any patients objections to laparoscopic hysterectomy as well. 

I am grateful for any help you can offer. 

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