LAS VEGAS – Gynecologists who completed their residency more than 20 years ago are half as likely as more recent graduates to perform a laparoscopic hysterectomy, a survey has shown.
Total abdominal hysterectomy was the most commonly performed route for 35% of respondents, with 24% preferring a vaginal approach, and only 8% reporting total laparoscopic hysterectomy as their preferred method.
Dr. Terri Febbraro
"Rates of laparoscopic hysterectomy are increasing, but as seen in other studies, the abdominal approach is still the preferred method," Dr. Terri Febbraro said at the 41st AAGL Global Congress.
Both a 2009 American College of Obstetricians and Gynecologists (ACOG) committee opinion and a 2010 AAGL position statement favor vaginal hysterectomy as the preferred route. Laparoscopic hysterectomy can be used as an alternative in the minority of cases when the vaginal approach is not feasible or indicated.
Still, the disconnect continues.
Total abdominal surgeries account for roughly two-thirds of hysterectomies in the United States (Obstet. Gynecol. 2007;110;1091-5), although that number may be declining. Only 8% of gynecologists, however, would choose an abdominal hysterectomy for themselves or their spouse (J. Minim. Invasive Gynecol. 2010;17:167-75), said Dr. February, a fourth-year resident at Brown University in Providence, R.I.
To explore the perceived barriers and contraindications among gynecologists to providing minimally invasive surgery (MIS), Dr. Febbraro and her associates sent a cross-sectional survey via the Web and mail to 802 ACOG fellows from October 2008 to May 2009. A total of 417 surveys (52%) were returned.
The majority of respondents practiced general ob.gyn. (94%) and were in private practice (82%). Almost half, or 42%, graduated residency more than 20 years ago and 31% graduated in the last 10 years. There was an equal gender split, and all geographic districts were represented.
Three-fourths of respondents (78%) reported performing an average of one to five hysterectomies per month, and 8% performed six or more, which was defined as high volume for the analysis.
In addition to the three approaches described above, 19% of respondents preferred laparoscopic-assisted vaginal, 11% supracervical laparoscopic, and 3% supracervical abdominal (3%) hysterectomy.
Physicians who reported performing laparoscopic hysterectomies most often were significantly more likely to have graduated from residency in the previous 10 years than were physicians who performed vaginal hysterectomies most often (52% vs. 26.2%; P = .03).
The odds of performing MIS, either vaginally or laparoscopically, increased with surgical volume (OR, 8.37) and specialized training (OR, 9.37). This was even more pronounced among physicians who reported performing laparoscopic hysterectomies most often (OR, 12.0, and OR, 16.4), Dr. Febbraro said.
Providers graduating from residency more than 20 years ago were half as likely to prefer a laparoscopic approach as were those graduating less than 10 years ago (OR, 0.44).
Providers who preferred an open abdominal approach were significantly more likely than those using MIS to cite minimal descent, narrow introitus, and a uterus more than 12 weeks in size as perceived contraindications to a vaginal hysterectomy, she said.
Prior exploratory laparotomy, endometriosis, and a uterus larger than 12 or 16 weeks were significantly more likely to be cited as contraindications to laparoscopic hysterectomy by providers preferring an open approach.
Those providers who preferred an abdominal approach also reported significantly more contraindications than did MIS providers to vaginal hysterectomy (mean 4.4 vs. 3.4; P = .0003) and laparoscopic hysterectomy (mean, 1.5 vs. 0.8; P less than .0001). The lower number of contraindications to laparoscopic hysterectomy is noteworthy, given that this approach was preferred by fewer respondents than either open or vaginal surgery, Dr. Febbraro noted.
"As surgical volume and specialized training increase, it is likely that perceived barriers and contraindications will decrease, prompting providers to offer minimally invasive surgeries more readily," she said. "Training programs addressing these factors could have an impact on providers’ choice of surgical approach."
During a discussion of the study, Dr. Febbraro said that she and her colleagues did not distinguish between rural and urban providers, but that no regional differences were observed.
Dr. Febbraro reported no relevant financial disclosures. One of her coauthors is an ACOG employee.