Hysterectomy: All obstetrician‐gynecologists should learn to perform it

Abstract

Sir, Rudnicki et al1 described that as a result of the increasing popularity of various nonsurgical modalities and laparoscopic/robotic-assisted hysterectomies, the number of hysterectomies that a trainee can perform has decreased. They ask “Do all trainees in obstetrics and gynecology still need to learn to perform hysterectomy?” In our opinion, yes, all trainees still need to learn to perform abdominal hysterectomy. Obviously, in the near future, some specialists will receive more training in laparoscopic/robotic-assisted hysterectomy and will be unaccustomed to conventional abdominal hysterectomy. Such specialists may not be able to expeditiously manage catastrophic bleeding during a laparoscopic/robotic-assisted hysterectomy because laparoscopic hemostasis may be unsuccessful with vascular injuries, which require immediate laparotomy to achieve hemostasis. A lack of self-confidence and familiarity with abdominal hysterectomy may prevent or delay conversion to laparotomy. Experience with abdominal hysterectomy is mandatory for being able to perform cesarean hysterectomy, such as for placenta accreta spectrum (PAS) disorders. Differing from surgery in other fields, obstetric operations do not always proceed in a step-by-step manner.2 Obstetricians must perform cesarean section (hop), cesarean hysterectomy (step), and, then, PAS-hysterectomy (super-jump). Our team established the “universally achievable” cesarean/PAS-hysterectomy.3 Obstetricians can accomplish this if they can perform a standard abdominal hysterectomy.3, 4 These two operations are sometimes unexpectedly required. It is difficult to predict who requires a cesarean hysterectomy, and PAS often goes undiagnosed preoperatively. Hence, we believe that every doctor dealing with deliveries should have experience in abdominal hysterectomy. We, the older generation of obstetricians and gynecologists, first learned abdominal hysterectomy and then began to perform laparoscopic/robotic-assisted hysterectomy. Thus, even if we encounter severe bleeding during laparoscopic/robotic-assisted hysterectomy, we immediately convert to laparotomy and stop the bleeding. Many are also capable of performing cesarean/PAS-hysterectomy because of abundant experience in abdominal hysterectomy. Rudnicki et al stated the concept that a reduced number of hysterectomies should be offered to trainees in “gynecologic” surgery specialties. The same concept was stated in the discussion of how to grow PAS-surgery specialists.5 Widening these concepts, training different types of hysterectomies could be offered to selected ambitious/talented trainees, both in gynecologic and obstetric specialties. If such specialists are available 24/7, this may be effective. However, in many centers, this may not be the case. The number of abdominal hysterectomies performed will continue to decrease but trainees must learn this fundamental procedure. Until some definite solutions are found, we recommend: (a) simulation-training for abdominal hysterectomy should be given to all trainees, (b) even if not directly participating, watching abdominal hysterectomies is encouraged, and (c) two trainees can participate in an abdominal hysterectomy, each one operating on one side, doubling the chance for participation in this procedure. This issue should be more widely discussed.