Hysterectomy is one of the most common major surgical procedures performed in gynaecology. The operation can be carried out via three routes, vaginal (VH), abdominal (AH) and laparoscopic (LH) for varying indications. The introduction of the laparoscopic hysterectomy as a less invasive approach to reduce the number of patients requiring a laparotomy and thus reducing hospital stay and post-operative recovery sparked comparison between hysterectomy routes. Our aim was to analyse trends in hysterectomy route for benign indications over a 10-year period in a large, UK teaching hospital and determine if more hysterectomies could have been carried out via the vaginal route.

A retrospective, cohort study of 8457 women coded as ‘hysterectomy’ between 2008 and 2018. Route of hysterectomy was determined for all 8457 cases. 4989 were identified as oncology cases and excluded from further analysis leaving 3468 cases of hysterectomy for benign indications. Data was then collected from PPM+ (electronic patient record) on indication, uterine size/weight, removal/conservation of adnexae and hospital stay for all benign, laparoscopic hysterectomies. A set of criteria required for vaginal hysterectomy was produced from existing literature and our data was reviewed against the criteria to determine if more cases had the potential for vaginal hysterectomy.

Over the 10-year study period, there were 1511 vaginal, 1547 abdominal and 410 laparoscopic hysterectomies carried out for benign indications. Overall numbers of hysterectomy are declining from 360 in 2008 to 157 in 2018. In 2008, there were 185 vaginal, 172 abdominal and 3 laparoscopic hysterectomies performed compared with 38, 77 and 42 respectively in 2018. The commonest indications for laparoscopic hysterectomy were heavy menstrual bleeding (HMB) and dysmenorrhoea, which remained constant over the study period and the average hospital stay reduced from 2 to 1 night. In 2018, 23% of laparoscopic hysterectomies had no contra-indications to the vaginal route compared with none in 2008.

Fewer hysterectomies are being performed for benign indications compared with 10 years ago with the advent of endometrial ablation and the Mirena intrauterine system, with NICE quoting hysterectomy as third line treatment for HMB due to cost and complications compared to less invasive options. Despite the introduction of laparoscopic hysterectomy to reduce the number of laparotomies, in our hospital it has also reduced the number of vaginal hysterectomies. Confidence of surgeon, lack of training for trainees, eagerness to practice new skills and the view that vaginal hysterectomy is reserved for prolapse are frequently quoted explanations for the declining numbers of vaginal hysterectomy.

Route of hysterectomy is changing with a significant decrease in vaginal hysterectomy, gradual decline in abdominal hysterectomy and a large increase in laparoscopic hysterectomy. In recent years, a growing number of hysterectomies were performed laparoscopically that had no contra-indications to the vaginal route. The question is, should they have been performed vaginally? Are we making a skilled, cheap operation very expensive?