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type=\u0022text\/css\u0022 rel=\u0022stylesheet\u0022 href=\u0022\/\/d282kpwvnogo5m.cloudfront.net\/sites\/default\/files\/advagg_css\/css__ce2QY63WIanKyr8eSq7eavr1XQRRmFD6ZSmwpyJi8lM__zXwFqpqmxrZOXXcd_TpBQpjuELbmIP9wBR5UuTDWAO4__YJWWMMdfCJuAFm5cUEp88OsodhO3ZA-2lzRfoBsSlk4.css\u0022 media=\u0022all\u0022 \/\u003E\n\u003Clink rel=\u0027stylesheet\u0027 type=\u0027text\/css\u0027 href=\u0027\/sites\/all\/modules\/contrib\/panels\/plugins\/layouts\/onecol\/onecol.css\u0027 \/\u003E\u003C\/head\u003E\u003Cbody\u003E\u003Cdiv class=\u0022panels-ajax-tab-panel panels-ajax-tab-panel-sageoa-tab-art\u0022\u003E\u003Cdiv class=\u0022panel-display panel-1col clearfix\u0022 \u003E\n  \u003Cdiv class=\u0022panel-panel panel-col\u0022\u003E\n    \u003Cdiv\u003E\u003Cdiv class=\u0022panel-pane pane-highwire-markup\u0022 \u003E\n  \n      \n  \n  \u003Cdiv class=\u0022pane-content\u0022\u003E\n    \u003Cdiv class=\u0022highwire-markup\u0022\u003E\u003Cdiv xmlns=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022 id=\u0022content-block-markup\u0022 xmlns:xhtml=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022\u003E\u003Cdiv class=\u0022article fulltext-view \u0022\u003E\u003Cspan class=\u0022highwire-journal-article-marker-start\u0022\u003E\u003C\/span\u003E\u003Cdiv class=\u0022section abstract\u0022 id=\u0022abstract-1\u0022\u003E\u003Ch2\u003ESummary\u003C\/h2\u003E\n            \u003Cp id=\u0022p-1\u0022\u003EVaginal hysterectomy (VH) is the most minimally invasive approach for hysterectomy in women with benign gynecologic disease. During the Donald F. Richardson Memorial Lecture, Rosann M. Kho, MD, formerly of the Mayo Clinic, Scottsdale, Arizona, USA, stated that it is time to transform the view of VH to increase its use and provide benefit to more women, most of whom would qualify for this approach. This requires defining new patient selection criteria while incorporating new surgical technologies, devices, and techniques to overcome the traditional challenges that have limited the use of VH.\u003C\/p\u003E\n         \u003C\/div\u003E\u003Cul class=\u0022kwd-group\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003EDiagnostic \u0026amp; Surgical Procedures\u003C\/li\u003E\u003C\/ul\u003E\u003Cul class=\u0022kwd-group clinical-trial\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003EDiagnostic \u0026amp; Surgical Procedures\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EObstetrics \u0026amp; Gynecology\u003C\/li\u003E\u003C\/ul\u003E\u003Cp id=\u0022p-2\u0022\u003EVaginal hysterectomy (VH) is the most minimally invasive approach for hysterectomy in women with benign gynecologic disease. In the Donald F. Richardson Memorial Lecture, Rosann M. Kho, MD, formerly of the Mayo Clinic, Scottsdale, Arizona, USA, stated that it is time to transform the view of VH to increase its use and provide benefit to more women, most of whom would qualify for this approach. This requires defining new patient selection criteria while incorporating new surgical technologies, devices, and techniques to overcome the traditional challenges that have limited the use of VH.\u003C\/p\u003E\u003Cp id=\u0022p-3\u0022\u003EThe current evidence demonstrates that VH, compared with the other approaches, is associated with improved outcomes and fewer complications, according to a statement from the American College of Obstetrics and Gynecology [ACOG Committee. \u003Cem\u003EObstet Gynecol\u003C\/em\u003E 2009].\u003C\/p\u003E\u003Cp id=\u0022p-4\u0022\u003EYet, the national rates of inpatient hysterectomy are declining, including a significant decline in VH, from \u0026gt;25% of all hysterectomies in 2000 to \u0026lt;17% in 2010 (\u003Ca id=\u0022xref-fig-1-1\u0022 class=\u0022xref-fig\u0022 href=\u0022#F1\u0022\u003EFigure 1\u003C\/a\u003E) [Wright JD et al \u003Cem\u003EObstet Gynecol\u003C\/em\u003E 2013]. Furthermore, surgeon volume is decreasing, with \u0026gt;80% of surgeons performing \u0026lt;5 VH annually and \u0026lt;5% performing \u0026gt;10 VH annually [Rogo-Gupta LJ et al. \u003Cem\u003EObstet Gynecol\u003C\/em\u003E 2010]. Data from Wright and colleagues [\u003Cem\u003EJAMA\u003C\/em\u003E 2013] showed that from 2007 through 2010 the rates of abdominal hysterectomy declined by 14% and VH by 2%, while rates of laparoscopic hysterectomy decreased by 6% and robotically assisted hysterectomy increased by 9.5%. This shift in approach to hysterectomy is associated with increased cost. One institution reported in 2009 that when compared to the vaginal approach, abdominal, laparoscopic, and robotic approaches cost $12 000 to $18 000 more per patient [Wright KN et al. \u003Cem\u003EJSLS\u003C\/em\u003E 2012].\u003C\/p\u003E\u003Cdiv id=\u0022F1\u0022 class=\u0022fig pos-float  odd\u0022\u003E\u003Cdiv class=\u0022highwire-figure\u0022\u003E\u003Cdiv class=\u0022fig-inline-img-wrapper\u0022\u003E\u003Cdiv class=\u0022fig-inline-img\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/7\/4\/F1.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u0022Rates of Hysterectomy in the United States by Surgical Approach, 1998 Through 2010\u0022 class=\u0022fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-857429607\u0022 data-figure-caption=\u0022Rates of Hysterectomy in the United States by Surgical Approach, 1998 Through 2010\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003E\u003Cimg class=\u0022fragment-image\u0022 alt=\u0022Figure 1.\u0022 src=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/7\/4\/F1.medium.gif\u0022\/\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cul class=\u0022highwire-figure-links inline\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/7\/4\/F1.large.jpg?download=true\u0022 class=\u0022highwire-figure-link highwire-figure-link-download\u0022 title=\u0022Download Figure 1.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload figure\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/7\/4\/F1.large.jpg\u0022 class=\u0022highwire-figure-link highwire-figure-link-newtab\u0022 target=\u0022_blank\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EOpen in new tab\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/15966\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003Cdiv class=\u0022fig-caption attrib\u0022\u003E\u003Cspan class=\u0022fig-label\u0022\u003EFigure 1.\u003C\/span\u003E \n            \u003Cp id=\u0022p-5\u0022 class=\u0022first-child\u0022\u003ERates of Hysterectomy in the United States by Surgical Approach, 1998 Through 2010\u003C\/p\u003E\n         \u003Cq class=\u0022attrib\u0022 id=\u0022attrib-1\u0022\u003EReproduced from Wright JD et al. Nationwide trends in the performance of inpatient hysterectomy in the United States. \u003Cem\u003EObstet Gynecol.\u003C\/em\u003E 2013;122(2, pt 1):233\u2013241. With permission from Lippincott, Williams and Wilkins.\u003C\/q\u003E\u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cp id=\u0022p-6\u0022\u003EExperience in performing VH during residency is also decreasing, from 35 cases in 2002 to 19 cases in 2012 per resident over 4 years [Washburn EE. \u003Cem\u003EJ Minim Invasive Gynecol\u003C\/em\u003E 2013]. Dr. Kho called this a national health care crisis, with ob-gyn residents insufficiently trained to provide the benefit of this preferred minimally invasive surgical approach, which in turn increases the burden on the health care system.\u003C\/p\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-1\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003EADDRESSING TECHNICAL CHALLENGES IN VH\u003C\/h2\u003E\n         \u003Cp id=\u0022p-7\u0022\u003EAccording to Dr. Kho, multiple studies in the literature have demonstrated that the traditional challenges for VH can be addressed. Lessons learned from the laparoscopic and robotic approaches can be applied to address these technical challenges in the vaginal approach. Common challenges have been poor exposure (including previous pelvic surgery), inadequate hemostasis, difficult entry into the anterior cul-de-sac, large uterus (\u0026gt;12 weeks), poor vaginal descent or no prior vaginal delivery, avoiding bladder and ureteral injury, and removal of ovaries or fallopian tubes. She proposed that these surgical environments are often used as reasons to avoid performing VH and excuses for achieving inadequate training.\u003C\/p\u003E\n         \u003Cp id=\u0022p-8\u0022\u003EDr. Kho notes that exclusion criteria for VH are pain (other than menses related) and suspicion of cancer. Patients with infiltrating endometriosis benefit from a laparoscopic or robotic approach to hysterectomy. Morcellation through any route, including a minimally invasive approach, should not be performed in patients with a high index of suspicion of cancer.\u003C\/p\u003E\n         \u003Cp id=\u0022p-9\u0022\u003EA first step in addressing the technical challenges is improving ergonomics for the surgeon and the entire team. Dr. Kho recommends ensuring that the chairs for the surgeon and assistant be at eye level of the operating field, with shoulders in a comfortable position and elbows at the side, and that a footstool be used as needed for stabilization. A magnetic pad is useful to hold surgical tools at hand. A monitor facilitates the procedure and education by permitting the entire surgical team to view the procedure. Recording the procedure for education via headgear with an attached camera is also recommended.\u003C\/p\u003E\n         \u003Cp id=\u0022p-10\u0022\u003EDr. Kho advises that the surgeon deconstruct the procedure to anticipate all possible difficulties and to have the necessary equipment and devices available. Approaches to improve exposure include use of the Magrina-Bookwalter vaginal retractor, fiberoptic light, Mayo modified long and extra-long Deaver retractors, long instruments, and a single long pack to keep the bowel away.\u003C\/p\u003E\n         \u003Cp id=\u0022p-11\u0022\u003ERoutine intraoperative cystoscopy should be used during hysterectomy, regardless of the approach, because multiple studies have shown that intraoperative injury to the bladder and ureters can be diagnosed before the patient leaves the operating room.\u003C\/p\u003E\n         \u003Cp id=\u0022p-12\u0022\u003EEntry into the anterior cul-de-sac is facilitated by delaying it until better descensus is achieved, by sharply lysing bladder adhesions, sealing and dividing the uterine arteries and cardinal ligaments, and starting morcellation. Regarding the challenge of the large uterus, Dr. Kho stated that the principles remain the same for a 12-week-sized uterus, as with any larger uterus. This includes use of morcellation, only after the uterine arteries are ligated, by bivalving the cervix and performing a wedge excision with a long curved knife. Avoidance of digging into an area that is not well visualized and having adequate light can also aid with larger uteri. Many tools have been modified with a light to improve visualization, but she noted that the tools can be hot; thus, caution should be used to avoid leaning them against the vaginal wall.\u003C\/p\u003E\n         \u003Cp id=\u0022p-13\u0022\u003EDr. Kho indicated the signs that the vaginal procedure should be converted to a minilaparotomy or laparoscopic approach to complete the hysterectomy: excessive bleeding, inability to bilaterally secure uterine arteries, a portion of loose bowel that obscures the surgeon\u0027s view, excessive debris from morcellation, or a large anterior fibroid that will not move down into the pelvic canal.\u003C\/p\u003E\n         \u003Cp id=\u0022p-14\u0022\u003EProphylactic salpingectomy can be performed vaginally for women with \u003Cem\u003EBRCA1\u003C\/em\u003E or \u003Cem\u003EBRCA2\u003C\/em\u003E gene mutations that increase their risk of ovarian cancer. In November 2013, the Society of Gynecological Oncology released a statement on the use of salpingectomy in this regard [SGO Statement 2013], because of increasing evidence that the fallopian tubes may be the source of pelvic serous carcinomas.\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cul class=\u0022copyright-statement\u0022\u003E\u003Cli class=\u0022fn\u0022 id=\u0022copyright-statement-1\u0022\u003E\u00a9 2014 MD Conference Express\u00ae\u003C\/li\u003E\u003C\/ul\u003E\u003Cspan class=\u0022highwire-journal-article-marker-end\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Cspan id=\u0022related-urls\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Ca href=\u0022http:\/\/mdc.sagepub.com\/content\/14\/7\/4.abstract\u0022 class=\u0022hw-link hw-link-article-abstract\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView Summary\u003C\/a\u003E\u003C\/div\u003E  \u003C\/div\u003E\n\n  \n  \u003C\/div\u003E\n\u003C\/div\u003E\n  \u003C\/div\u003E\n\u003C\/div\u003E\n\u003C\/div\u003E\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_figures.js?nzp8y2\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_openurl.js?nzp8y2\u0022\u003E\u003C\/script\u003E\n\u003C\/body\u003E\u003C\/html\u003E"}