Most are aware that being overweight increases the risk of undergoing a surgical procedure. A new study has quantified the increased risk of a hysterectomy for overweight women and also pointed out which method was safest (e.g., abdominal, vaginal, or laparoscopic). The findings were published in the March edition of the journal Obstetrics & Gynecology by researchers at: University of Iowa Hospitals and Clinics, Iowa City, Iowa; Brigham and Women’s Hospital and Harvard Medical School; and Harvard School of Public Health, Boston, Massachusetts.
The study authors note that a hysterectomy is the most common major gynecologic surgery performed in the US with approximately 600,000 women undergoing the procedure each year. Despite the American College of Obstetricians and Gynecologists’ (ACOG) recommendations that “vaginal hysterectomy is the approach of choice whenever feasible” and “laparoscopic hysterectomy is an alternative to abdominal hysterectomy for those patients in whom a vaginal hysterectomy is not indicated or feasible,” a majority of hysterectomies in the US is still performed through the abdominal approach. Recent estimates note that two thirds of American women are overweight (body mass index [BMI] 25 or higher), with approximately half of those meeting standards for obesity (BMI 30 or higher). The overall heightened surgical morbidity (complications) in obese individuals is well described; however, the literature regarding perioperative complications after a hysterectomy in obese women is limited and inconsistent, particularly when assessing the laparoscopic and vaginal approaches.
Only a handful of large studies have focused on surgical complications after abdominal, laparoscopic, and vaginal hysterectomy in obese women. The American College of Surgeons (ACS) National Surgical Quality Improvement Program was established in 2004 as a validated database with the goal of measuring and improving surgical outcomes in all specialties. Preoperative, intraoperative, and 30-day postoperative data are directly obtained from randomly selected patient medical records by specially trained personnel at each participating hospital. Using the ACS National Surgical Quality Improvement Program data, the authors of the new study attempted to: (1) examine the association between a woman’s BMI and her complication rate when given a chosen surgical approach to hysterectomy; and (2) determine whether the association varies among the abdominal, laparoscopic, and vaginal approaches.
The study comprised 55,409 women who underwent hysterectomy for benign (non-malignant) conditions from January 2005 through December 2012. The relationships among BMI, surgery time, and morbidity were examined; the results were adjusted for age, race, ethnicity, year of surgery, smoking, diabetes, and American Society for Anesthesiologists physical classification. The adjusted data was subjected to statistical analysis.
The researchers found that BMI positively correlated with risk of wound complications and infection in women undergoing abdominal hysterectomy. Compared to women with a normal BMI, women with BMIs 40 or higher had five times the risk of wound dehiscence (2.1% vs. 0.3%), five times the risk of wound infection (8.9% vs.1.4%), and 89% higher risk of sepsis (generalized infection) (1.3% vs. 0.6%). The degree of the association between wound infection and BMI was less after vaginal hysterectomy, and no increased risk of wound complications or sepsis were found with a laparoscopic approach despite longer surgery times. Surgery time increased with BMI regardless of surgical approach. No associations were found between BMI and hospital stay or thromboembolism (blood clots).
The authors concluded that obesity is associated with increased wound complications and infection in women undergoing abdominal hysterectomy and with longer surgery times regardless of surgical approach. They recommended that laparoscopic hysterectomy should be performed whenever possible.
Take home message:
In many cases, a hysterectomy for benign conditions is not urgent; thus, an overweight woman has the option of dieting before the procedure to lower the risk regardless of approach. In the hands of a surgeon well-trained in vaginal surgery, a vaginal hysterectomy is the best choice for women who do not have contraindications (reasons to avoid) to that approach. It usually requires less surgery time than laparoscopy, a factor that influences complication rates.