Investments are needed for better hysterectomies

Tagged Hysterectomy, Research, cost; Comments 1 ; Posted 11 years ago

A recent ABC News feature suggested that the eradication of open hysterectomy and converting them to laparoscopic hysterectomy would save the Australian government  $50 million straight away. However, it would require some investment first to reap subsequent benefits.

Laparoscopic hysterectomy is no novel procedure. Numbers for laparoscopic hysterectomy started to take off in 2003 and are very slowly climbing year by year. It is well documented and unfortunate that laparoscopic hysterectomy has a slow take-on rate. Only 10% of some 30,000 hysterectomies done these days in Australia are laparoscopic.

In our research centre we studied laparoscopic hysterectomy for women with early endometrial cancer. Not only we found that recovery is improved when women had a laparoscopic procedure, postsurgical adverse events were less – we also found that laparoscopic hysterectomy was cost effective.

While the procedure will incur higher theatre costs of $500 (surgical equipment and personnel cost), the reduced length of hospital stay and the reduced incidence of adverse event made laparoscopic operation cheaper.

Nick Graves, who wrote the most recent paper on cost effectiveness believes that with every case of open hysterectomy the direct monetary loss is $3700 per case. In our state Queensland this amounts to $10 million straight away if laaproscopic procedures could be performed instead of open hysterectomies; Australia-wide cost savings would amount to $50 million every year if one would swap open for laparoscopic hysterectomies. 

As a response to a newsletter I sent to my referrers a couple of weeks ago, one of my referring gynaecologists sent me a letter making me aware that it is not just the gynaecologists’ inability to do laparoscopic surgery. There are a lot more aspects that would need to be addressed before laparoscopic hysterectomy can be rolled out on a large scale.

He says that he operates with a 70-year old surgical assistant who is very unfamiliar with laparoscopic surgery. That is no surprise given that laparoscopic procedures in gynaecology took off on a large scale only about 15 years ago, which was when his surgical assistant retired form his day job.

His laparoscopic equipment allows him to do only very basic laparoscopic procedures. I sympathise with that.  When we ran the LACE trial, we were surprised to learn that some of the laparoscopic equipment in major tertiary hospitals in NSW apparently was way inferior to what we are able to use in Qld.

His anaesthetist would not give him enough head-down positioning; hence, the bowel falls in his way all the time and laparoscopic surgery develops into a plainly painful and dangerous exercise.

Last but not least – the writer of the letter stated that he could not possibly deal with the fact that he works with a different team of nurses at practically every surgical list he does. That must be very frustrating and hard to put up with. It looks as if I am very privileged having a team of 5 to 6 regular nurses working along and with me almost every single list.

The first TLH I did at my hospital took me several hours. I thought I was good at this kind of surgery but the nurses had no idea what we were doing when we started. Now, they are so good at it. Surgery is teamwork. We need nurses, anaesthetists, and surgical assistants working with and along us. These people don’t just watch me doing it. They are very actively involved, contributing massively to the success of the procedure.

To establish laparoscopic surgery will require an investment as the recent ABC News article correctly points out. If we want to cut down on the 40% open hysterectomy rate, we need buy-in from stakeholders. We need commitment from gynaecologists, the hospitals and their CEOs, the nurses and we need to communicate very clearly our expectations to our anaesthetic colleagues. Surgical training and workshops alone will not cut it. 

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