Hysterectomy trialled as day surgery
Obstetrics and gynaecology
Obstetrics and gynaecology
The increasing practice of performing surgical procedures as day cases not only reduces treatment costs but is also less disruptive to patients' lives.
I was interested therefore to read that one gynaecological unit in Wales has trialled vaginal hysterectomy as a day case procedure.
The Cardiff team performed hysterectomies using the vaginal route. They did not exclude women with uterine enlargement up to the size of a 20 weeks uterus, women with a history of endometriosis or women listed for oophorectomy. However, the team did exclude women with significant uterovaginal prolapse.
Seventy-one women agreed to day case surgery, which was defined as a ‘24-hour stay basis'. The main indication for hysterectomy in 28 women (39.4%) was dysfunctional uterine bleeding. Sixteen women (22.5%) also had significant fibroids greater than 12-week size and concurrent menorrhagia. In four cases surgery was performed for intractable premenstrual syndrome. The mean age of the women was 41 years (range 29-53) and mean BMI was 27 kg/m2 (range 17-38).
Thirty women (42.2%) had undergone previous abdominal surgery, including 14 who had undergone Caesarean section.
Hysterectomy was performed laparoscopically in seven cases and laparoscopic assistance was employed in a further 35. Oophorectomy was performed in almost half (49.3%) of the cases.
Sixty-five of the 71 women were discharged within 24 hours as planned. One woman suffered a perforation of the bladder, which was repaired. She was discharged with a catheter within 24 hours. Of the six who remained in hospital for more than 24 hours, three stayed for post-operative anaesthetic assessment, one had a suspected pulmonary embolism and two had bleeding (one of whom required a laparotomy). Four of the 65 women who were discharged as planned required readmission for mild postoperative infection.
The results from this trial are impressive. However, how transferable they are to other units remains to be seen as the Cardiff team were obviously enthusiasts with exceptional surgical skills.
From a primary care point of view I think that there are benefits for early discharge after vaginal (rather than abdominal) hysterectomy in carefully selected cases, but only as long as the surgical unit guarantees postoperative assessment and readmission when necessary. How often are patients telephoning the ward after surgery told to contact their GP.
Penketh R, Griffiths A, Chawathe S. A prospective observational study of the safety and acceptability of vaginal hysterectomy performed in a 24-hour day case surgery setting. BJOG 2007;114:430-436Reviewer
Dr Chris Barclay