HISTERECTOMIA OBSTETRICA PORRO

Open publication - Free publishing

HV

HV

HISTERECTOMIA VAGINAL

AAGL Recommends Vaginal or Laparoscopic Approach for Hysterectomies CME


16 de noviembre 2010 - La Academia Americana de Laparoscopistas Ginecológica (AAGL) recomienda métodos quirúrgicos mínimamente invasivos como la histerectomía vaginal (HV) y la histerectomía laparoscópica (HL) para la enfermedad uterina benigna, según un comunicado publicado en Internet la posición 7 de noviembre en el Journal of Ginecología Mínimamente Invasiva.

"Cuando los procedimientos son necesarios para el tratamiento de trastornos ginecológicos, la AAGL se ha comprometido a los principios de la elección informada del paciente y la prestación de opciones mínimamente invasivas", dijo Franklin D. Loffer, MD, vicepresidente ejecutivo y director médico de la AAGL, en una noticia puesta en libertad. "Cuando la histerectomía es necesaria, la seguridad demostrada, la eficacia y costo-efectividad de VH y el mandato de LH que sean los procedimientos de elección. Cuando la histerectomía se realiza sin una laparotomía, aprobación de la gestión institucional precoz es factible y seguro, en muchos casos dentro de la primeras 24 horas. "

En los Estados Unidos, aproximadamente 600.000 histerectomías se realizan cada año por enfermedades benignas de la pelvis, y más de dos terceras partes se realizan a través de un abordaje abdominal. En algunos países, sin embargo, tan sólo el 24% de las histerectomías se realizan abdominal.

Para reducir el riesgo de morbilidad y acelerar la recuperación, el AAGL recomienda un abordaje vaginal o laparoscópica a la histerectomía para enfermedad benigna. los riesgos quirúrgicos son bajos para estos procedimientos mínimamente invasivos, que a menudo se puede hacer de forma ambulatoria o con una corta estancia hospitalaria.

Por el contrario, la incisión abdominal relativamente grande necesarios para la histerectomía abdominal (AH) puede dar lugar a más complicaciones, especialmente asociadas a infecciones de la herida abdominal, dando lugar a mayor tiempo de hospitalización y la discapacidad antes de las actividades normales se pueden reanudar.

La obesidad y un parto por cesárea anterior se pensó una vez que las contraindicaciones a la LH. Sin embargo, la seguridad y eficacia de la LH son similares en pacientes obesos y no obesos, aunque los tiempos de operación son más largos en pacientes obesos. En comparación con otras técnicas, la LH puede estar asociada con un mayor riesgo de cistostomía, pero el riesgo general es bajo. El AAGL recomienda que el parto por cesárea anterior ya no debe ser considerada una contraindicación para cualquiera VH o LH.

Aun cuando el útero es grande, un número de cirujanos sea viable y segura realizar VH. LH parece ser una alternativa segura preservar la mayor parte de las ventajas de la HV frente, y se puede realizar cuando la enfermedad uterina tamaño u otras consideraciones quirúrgicas o coexistentes impide el desempeño de VH.

Los costos directos de cualquiera de VH o LH son menores que los de AH, pero los costos institucionales de la LH puede ser más alto frente al VH dependiendo de lo que la instrumentación se utiliza. En comparación con AH, LH parece reducir los costos indirectos de la histerectomía en un 50%, basado en evidencia de alta calidad a partir de varios ensayos controlados aleatorios.

En los estudios oncológicos varios LH AH vs ha demostrado que el riesgo de morbilidad más baja, sin comprometer la eficacia clínica en las mujeres con carcinoma de cuello de útero o del endometrio.

"Dadas las ventajas que ofrecen VH y LH a las mujeres, sus familias, sus empleadores, y el sistema de atención de la salud en general, parece conveniente para optimizar su aplicación en las mujeres que requieran una histerectomía debido a condiciones benignas del útero," los autores de la declaración de posición escribir. "La histerectomía abdominal se debe reservar para la minoría de mujeres en las que por vía laparoscópica o vaginal no es apropiado. Estas situaciones no son comunes."

Mujeres en las que LH no es apropiado puede incluir lo siguiente:

* Las personas con enfermedades cardiopulmonares u otras condiciones médicas en las que los riesgos son inaceptables, ya sea para la anestesia general o de aumento de la presión intraperitoneal asociadas con la laparoscopia.
* Aquellos en quienes morcelación, o cortar el tumor en pedazos antes de la retirada, que se conoce o que puedan ser necesarios y los tumores malignos del útero se conoce o sospecha.

Situaciones en las que la LH y VH no son apropiadas pueden incluir los siguientes:

* Aunque la histerectomía se indica, no hay acceso a los cirujanos o las instalaciones necesarias para VH o LH, y la referencia no es factible.
* Los cirujanos expertos en cualquiera de VH o técnicas LH considerar la vía vaginal o laparoscópica puede ser peligroso o irrazonable debido a una enfermedad del útero o las adherencias que distorsionan de manera significativa la anatomía.

"Es la posición de la AAGL que la mayoría de las histerectomías por patología benigna se debe realizar ya sea por vía vaginal o por vía laparoscópica y que los continuos esfuerzos deben ser adoptadas para facilitar estos métodos," los autores de la declaración de posición escribir. "Los cirujanos, sin la formación necesaria y las habilidades requeridas para el desempeño seguro de VH o LH debe contar con la ayuda de colegas que hacen o deberían derivar a los pacientes que requieran una histerectomía a esas personas para su atención quirúrgica".

J Gynecol Mínimos invasoras. Publicado en Internet el 07 de noviembre 2010.
Contexto Clínico

Para el tratamiento quirúrgico de los trastornos benignos de la pelvis, aproximadamente 600.000 histerectomías se realizan en los Estados Unidos cada año. A pesar de una incisión abdominal, se utiliza en más de dos tercios de estos procedimientos, tan sólo el 24% de las histerectomías se realizan abdominal en algunos países.

El AAGL tanto, emitió una declaración de posición comprometida con los principios de la elección informada del paciente y la prestación de opciones mínimamente invasivas, y la recomendación de VH o LH para reducir el riesgo de morbilidad y el tiempo de recuperación. Debido a los riesgos quirúrgicos son bajos, VH o LH a menudo se puede realizar en forma ambulatoria o con una corta estancia hospitalaria.
Estudio pone de relieve

* VH y LH son seguros, eficaces y costo-efectiva enfoques a la histerectomía.
* Evitar la laparotomía permite el alta precoz, institucional fuerte, a menudo dentro de las primeras 24 horas y / o como un procedimiento ambulatorio.
* Riesgos quirúrgicos de VH y LH son bajos, mientras que AH requiere una incisión abdominal relativamente grande.
* Infecciones de la herida abdominal y otras complicaciones de la HTA puede provocar la estancia hospitalaria más larga y retraso en el retorno a las actividades habituales.
* Aunque la obesidad se pensó una vez para ser una contraindicación para la LH, la seguridad y eficacia de la LH son similares en pacientes obesos y no obesos.
* Los tiempos de Operativo de LH son más largos en los pacientes obesos frente a los pacientes no obesos.
* LH frente a otras técnicas pueden estar asociados con un mayor riesgo de cistostomía, pero el riesgo general es bajo.
* Parto por cesárea anterior ya no debe ser considerada una contraindicación para cualquiera de VH o LH.
* VH puede ser factible y segura en las manos de cirujanos expertos, incluso cuando el útero es grande.
* Cuando la enfermedad uterina tamaño u otras coexistentes o quirúrgico consideraciones hacen VH no es viable, LH parece ser una alternativa segura, con la mayoría de las ventajas de VH en AH.
* Los costos directos de cualquiera de VH o LH son menores que los de AH.
* Los costos institucionales de la LH puede ser mayor que el de VH, dependiendo de la instrumentación.
LH * tiene aproximadamente la mitad de los costos indirectos de la AH.
* En mujeres con carcinoma de cuello de útero o del endometrio, la LH vs AH tiene un riesgo menor morbilidad, pero una eficacia comparable.
* LH puede no ser apropiado para las mujeres con enfermedad cardiopulmonar o de otras condiciones médicas representan un riesgo inaceptable para la anestesia general o de aumento de la presión intraperitoneal por laparoscopia.
* LH puede ser inadecuado en las mujeres que necesitan morcelación de malignidad uterina.
* Ni la LH ni la VH puede ser apropiada si se carece de acceso a los cirujanos o las instalaciones necesarias, o si estos métodos no son seguros o no razonable debido a una enfermedad del útero o las adherencias que distorsionan de manera significativa la anatomía.
* Los cirujanos que carecen de la formación y las habilidades necesarias para realizar con seguridad VH o LH deberían colaborar con o derivar a los pacientes a los cirujanos con estos requisitos.

Implicaciones clínicas

* El AAGL ha emitido una declaración de posición de recomendar procedimientos quirúrgicos mínimamente invasivos, tales como VH y LH para la enfermedad benigna del útero debido a que estos procedimientos ofrecen ventajas frente a AH a las mujeres, sus familias, sus empleadores, y el sistema de salud en general.
AH * debe ser reservada para aquellos que son pocas las mujeres en los que una LH o VH no es apropiado. Estas situaciones no son comunes.

SURGICAL TECHNIQUES

SURGICAL TECHNIQUES

The difficult vaginal hysterectomy:
5 keys to success

Challenges can be overcome by ensuring overall surgical expertise, adequate exposure, proper entry into the anterior cul-de-sac, good mobility, and competent morcellation

Fast Track To help avert bladder injury during entry into the anterior culde-sac in a patient who has a history of cesarean delivery, stay on the uterus during dissection into the vesicovaginal space

IN THIS ARTICLE Entry into the anterior cul-de-sac When cystotomy happens Good morcellation technique

John A. Occhino, MD

Dr. Occhino is Assistant Professor in the Department of Obstetrics and Gynecology at the University of Missouri in Columbia, Mo.

John B. Gebhart, MD, MS

Dr. Gebhart is Associate Professor in the Department of Obstetrics and Gynecology, Division of Gynecologic Surgery, and Fellowship Program Director at the Mayo Clinic in Rochester, Minn.

Drs. Occhino and Gebhart report no financial relationships relevant to this article.

CASE: Is the vaginal route appropriate?

A 46-year-old woman (para 2 with 1 cesarean delivery) who has a history of benign menorrhagia comes to your office seeking definitive treatment after medical therapy fails to alleviate her bleeding. pelvic examination reveals a uterus of 14-weeks’ size that descends to the distal vagina, with good vaginal access. What options for hysterectomy do you offer to the patient?

There are few absolute contraindications to a vaginal approach to hysterectomy. Among them are advanced pelvic malignancy, severe endometriosis, and a suspicious adnexal mass. Contraindications do not include a history of pelvic surgery, cesarean delivery, or an enlarged uterus. Such circumstances may increase the challenges involved in performing vaginal hysterectomy, but data suggest that it is achievable in these settings.^1-7

Vaginal hysterectomy offers substantial benefits, making the challenges worthwhile in most cases. It is the original minimally invasive approach to hysterectomy. It yields outcomes, postoperative discomfort levels, and recovery times similar to those of laparoscopic-assisted vaginal hysterectomy, total laparoscopic hysterectomy, and robotic- assisted hysterectomy—but the vaginal approach is more cost-effective.^3,8-11

This article focuses on strategies and techniques for accomplishing the difficult vaginal hysterectomy, describing five keys to success:

• surgical experience

• adequate exposure

• entry into the anterior cul-de-sac

• uterine mobility (or the ability to create it)

• good morcellation technique.

For clarity throughout this article, we assume that hysterectomy is being performed for benign indications.

Surgical experience

Vaginal hysterectomy can be performed successfully in the setting of nulliparity, uterine enlargement, and a history of cesarean delivery, provided the surgeon has the appropriate skill set, assistance, and patience. Little is lost if the operation is attempted vaginally but needs to be converted to a laparoscopic or open approach. If the surgeon persists in attempting to complete each hysterectomy vaginally, he or she will gradually improve in skill and eventually gain the ability to complete tougher cases without the need to convert.

Chen and colleagues developed and validated the Vaginal Surgical Skills Index (VSSI), identifying 13 aspects of successful vaginal surgery:

• inspection

• incision

• maintenance of visibility

• use of assistance

• knowledge of instruments

• tissue and instrument handling

• electrosurgery

• knot-tying and ligation

• hemostasis

• procedure completion

• time and motion

• flow and forward planning

• knowledge of the procedure.¹²

Thirty-seven trainees from two institutions were evaluated during 76 surgical procedures. The trainees were supervised by five surgeons, who completed the evaluations immediately after each procedure. A sixth surgeon from a different institution watched videos of each procedure and acted as a blinded external reviewer.

Chen and colleagues found good inter-rater and intra-rater reliability and high internal consistency for the VSSI, one of the first tools to objectively assess vaginal surgery skills.

2 Obtaining adequate exposure

Good anesthesia, proper lighting, and fixed retraction are invaluable when operating vaginally. A weighted speculum with Deaver retractors at 3, 9, and 12 o’clock provide good visualization if assistants are available. Self- retaining retractors are also useful (FIGURE 1).

FIGURE 1 Fixed retraction A Magrina-Bookwalter fixed vaginal retractor in place at the time of surgery.

We prefer to empty the bladder before making the vaginal incision, although no data suggest that doing so helps to avoid inadvertent bladder injury.

3 Entry into the anterior cul-de-sac

We prefer to enter the anterior cul-de-sac first. The pertinent risk in vaginal hysterectomy is injury to the bladder. Because anatomic planes are undisturbed at this point, we feel entry into the anterior cul-de-sac gives the surgeon the best opportunity to avoid injury. If it is a struggle or lack of uterine descent makes it difficult, then start with entry into the posterior cul-de-sac (see “gaining mobility”).

FIGURE 2 Palpate the bladder reflection A. Use the index finger to palpate the bladder reflection. B. Note it with a marking.

In a patient who does not have a history of surgery, palpation of the bladder reflection on the anterior uterus can help determine the appropriate site for the initial incision (FIGURE 2). Place a Deaver retractor anteriorly to assist with retraction. It is important to make the first incision deep enough to set up entry into the anterior cul-de-sac (FIGURE 3).

FIGURE 3 Incise the vaginal epithelium A sharp and deep incision aids in identification of the appropriate plane.

With traction on the uterus, grasp the anterior vaginal epithelium and elevate it to allow sharp dissection and mobilization of the bladder (FIGURE 4). We prefer sharp dissection rather than blunt dissection because it maintains surgical planes and is more precise.

FIGURE 4 Dissect the bladder free of the uterus We recommend sharp dissection to free the bladder from the uterus.

Once the peritoneum is identified, grasp, elevate, and incise it (FIGURE 5). Insert scissors through the peritoneal defect, spread the tips widely, and place the anterior Deaver retractor intraperitoneally (FIGURE 6) so that bowel can be visualized (FIGURE 7).

FIGURE 5 Use traction and counter-traction Sharp entry into the peritoneal cavity is enhanced through the use of traction and counter-traction.

FIGURE 6 Open the peritoneal defect Place scissors into the peritoneal defect and spread the blades wide.

FIGURE 7 Visualize the bowel Visualization of the bowel confirms an intraperitoneal location.

WATCH THE VIDEO: Vaginal hysterectomy with entry into the anterior cul-de-sac

If the patient has a history of cesarean delivery, entry into the anterior cul-de-sac can be more challenging. Several maneuvers can help avert bladder injury:

• Stay on the uterus during dissection into the vesicovaginal space. It is better to stay deep and cut into the uterus than to dissect superficially and end up with a cystotomy.

• Retrograde fill the bladder to identify the plane between the bladder and the uterus.

• Postpone entry into the anterior cul-desac until after posterior entry, ligation of the uterosacral ligaments, and the first “bite” of the cardinal ligaments.

• Use a uterine sound, bent into a “U” shape, passing it through the urethra into the bladder and allowing the point to come back toward the surgeon (while it is in the bladder). Manipulation of this sound through external palpation should make it possible to identify the bladder reflection.

• In the setting of a small uterus, after entering the posterior cul-de-sac, pass a finger along the back of the uterus, around the fundus, and back toward the surgeon. This maneuver identifies the optimal spot for dissection between the bladder and the uterus.

When cervical elongation is encountered during entry into the cul-de-sac, the peritoneal reflection will be higher (both anteriorly and posteriorly), and additional bites on the pedicles, as well as additional dissection, may be required before entry is accomplished (FIGURE 8).

FIGURE 8 When the cervix is elongated When the cervix is elongated, the peritoneal reflection, both anteriorly and posteriorly, is much higher on the uterus (near the small myoma).

When cystotomy happens

If cystotomy occurs during an attempt to enter the anterior cul-de-sac, a number of steps can lead to successful repair. Rather than repair the defect immediately, mark it with a suture for later identification. Once the uterus is removed, inspect the bladder carefully to identify any additional injuries, then repair the cystotomy using absorbable 2-0 suture on a tapered needle (we prefer chromic suture).

Begin by taking a full-thickness bite of tissue, just lateral to the edge of the cystotomy. Then run the suture, incorporating the bladder epithelium into the closure. Place a second, imbricating layer of the same suture. Last, if possible, sew the peritoneum beneath the bladder over the repair for an additional layer of reinforcement.

WATCH THE VIDEO: Transvaginal cystotomy repair

Cystoscopy helps to visualize the repair and test for water-tightness, and assess ureteral patency.

Keep the bladder on catheter drainage for 10 to 14 days.

4 Gaining mobility

In the setting of nulliparity or a small, well-supported uterus, it may be necessary to create mobility to accomplish the hysterectomy vaginally. Begin by entering the posterior cul-de-sac and cutting and suture ligating the uterosacral ligaments. Then take the first bite of the cardinal pedicles bilaterally. This typically facilitates uterine descent, making it possible to enter the anterior culde-sac and accomplish the hysterectomy.

On occasion, once the uterine arteries have been secured, you can split (bi-valve) the uterus to gain access to the utero-ovarian pedicles and complete the hysterectomy.

Don’t settle on a route prematurely It is important to understand the individual patient’s anatomy and underlying disease process before deciding on an appropriate surgical route. For this reason, a general medical and surgical history and a focused physical exam should precede any decision to operate. During the pelvic examination, note the size and mobility of the uterus, any associated uterovaginal prolapse, the presence of any adnexal mass or tenderness, vaginal capacity, and the adequacy of the pubic arch. If you are unable to determine the size of the uterus on examination, owing to the patients’ body habitus or discomfort, pelvic ultrasonography may be helpful. When office examination is difficult, or when it is impossible to gather substantial information about uterine characteristics, an examination under anesthesia is an excellent way to help determine the optimal route of hysterectomy. Provided the patient is properly apprised about this examination beforehand, the surgeon can then proceed to the appropriate surgical route once the exam is completed. Ensure consent for all aspects of the procedure As for any surgery, the informed consent discussion is important. Regardless of the hysterectomy approach, this discussion should include a mention of risks, benefits, and alternatives to surgery; the possible need for additional procedures (in the setting of unexpected pathology); and consent or decline of blood products, if needed. if photography or videotaping of the procedure is desired, this option needs to be discussed as well. When a vaginal approach is planned, there is always a small chance that it will have to be converted to a laparoscopic or open approach. This possibility should be relayed to the patient during the preoperative discussion. Inevitably, some cases fall on the border between the vaginal approach and another route. When this happens, we prefer to ask the patient to consent to the aforementioned examination under anesthesia, with the understanding that we may proceed as indicated to hysterectomy, based on the findings of that exam. For example, in the opening case, the informed consent discussion would likely go something like this: Mrs. Smith, because of fibroids, your uterus is enlarged to about the size of a small cantaloupe. Because you have had a vaginal delivery and your uterus is mobile, I think I will be able to remove it through the vagina. If vaginal removal is possible, you are likely to have a shorter recovery and a lower risk of complications than if a different approach is required. However, if I am unable to do a vaginal hysterectomy, an abdominal operation may need to be performed and would involve either a laparoscopy or an incision in the lower abdomen. I would like to evaluate things after you are asleep in the operating room. At that time, I will make the final decision about the best route for your hysterectomy. For the exam, the anesthetized patient should be placed in the dorsal lithotomy position with her legs in stirrups. Often, there is greater vaginal access and uterine mobility at this time.

5 Good morcellation technique

Morcellation facilitates removal of the large uterus. As experience with morcellation increases, the surgeon will be able to remove larger and larger uteri vaginally. However, it is critical to secure the uterine vessels before morcellation begins, and it is preferable to have entered both cul-de-sacs as well. Once those steps have been accomplished, bi-valve the cervix in the midline, following the endocervical canal to stay in the midline (FIGURES 9,10). Use a tenaculum to grasp bites of the uterus in an anterior and posterior fashion (FIGURE 11). This step reduces uterine size until the fundus can be inverted and the utero-ovarian pedicles secured. Be sure to excise uterine tissue under direct visualization to avoid inadvertent injury to the bowel and bladder.

FIGURE 9 Begin morcellation Once the uterine vessels have been controlled, morcellation may begin.

FIGURE 10 Bi-valve the cervix Bi-valve the cervix in the midline, following the endocervical canal.

FIGURE 11 Excise the fibroid Fibroids may be excised sharply with the aid of a scalpel and traction supplied by a tenaculum.

WATCH THE VIDEO: Vaginal hysterectomy with morcellation for the enlarged uterus

We need to do more vaginal procedures

Of the roughly 600,000 hysterectomies performed each year in the United States, roughly 60% are performed abdominally.^13,14 More and more hysterectomies are being done laparoscopically or with robotic assistance, and fewer straight vaginal hysterectomies are performed.¹⁵ Recent graduates are less likely than their predecessors to be up-to-date on this important skill set—a fact that may lead to further decreases in the number of hysterectomies performed vaginally each year.¹⁶

We need to make every effort to increase the rate of vaginal hysterectomy. Not only is it better for the patient; it saves precious health-care dollars.

CASE: resolved

The vaginal approach was chosen for this patient. after ligation of the uterine vessels, morcellation allowed for a successful hysterectomy without complication.

DON’T MISS THE 3 VIDEOS RELATED TO THIS ARTICLE 1. Vaginal hysterectomy with entry into the anterior cul-de-sac 2. Transvaginal cystotomy repair 3. Vaginal hysterectomy with morcellation for the enlarged uterus

We want to hear from you! Tell us what you think.

References

1. Figueiredo O, Figueiredo EG, Figueiredo PG, Pelosi MA 3rd, Pelosi MA. Vaginal removal of the benign nonprolapsed uterus: experience with 300 consecutive operations. Obstet Gynecol. 1999;94(3):348–351.

2. Rooney CM, Crawford AT, Vassallo BJ, Kleeman SD, Karram MM. Is previous cesarean section a risk for incidental cystotomy at the time of hysterectomy? A case-controlled study. Am J Obstet Gynecol. 2005;193(6):2041–2044.

3. Sesti F, Calonzi F, Ruggeri V, Pietropolli A, Piccione E. A comparison of vaginal, laparoscopic-assisted vaginal, and minilaparotomy hysterectomies for enlarged myomatous uteri. Int J Gynaecol Obstet. 2008;103(3):227–231.

4. Sheth SS, Malpani AN. Vaginal hysterectomy following previous cesarean section. Int J Gynaecol Obstet. 1995;50(2):165–169.

5. Kovac SR. Guidelines to determine the route of hysterectomy. Obstet Gynecol. 1995;85(1):18–23.

6. Unger JB, Meeks GR. Vaginal hysterectomy in women with history of previous cesarean delivery. Am J Obstet Gynecol. 1998;179(6 Pt 1):1473–1478.

7. Paparella P, Sizzi O, Rossetti A, De Benedittis F, Paparella R. Vaginal hysterectomy in generally considered contraindications to vaginal surgery. Arch Gynecol Obstet. 2004;270(2):104–109.

8. Schindlbeck C, Klauser K, Dian D, Janni W, Friese K. Comparison of total laparoscopic, vaginal and abdominal hysterectomy. Arch Gynecol Obstet. 2008;277(4):331–337.

9. Nazah I, Robin F, Jais JP, et al. Comparison between bisection/ morcellation and myometrial coring for reducing large uteri during vaginal hysterectomy or laparoscopically assisted vaginal hysterectomy: results of a randomized prospective study. Acta Obstet Gynecol Scand. 2003;82(11):1037–1042.

10. Wexner SD, Bergamaschi R, Lacy A, et al. The current status of robotic pelvic surgery: results of a multinational interdisciplinary consensus conference. Surg Endosc. 2009;23(2):438–442.

11. Johnson N, Barlow D, Lethaby A, Tavender E, Curr E, Garry R. Surgical approach to hysterectomy for benign gynaecological disease. Cochrane Database Syst Rev. 2006;(2):CD003677.

12. Chen CC, Korn A, Klingele C, et al. Objective assessment of vaginal surgical skills. Am J Obstet Gynecol. 2010;203(1):79.e1–8.

13. Keshavarz H, Hillis SD, Kieke BA, Marchbanks PA. Hysterectomy surveillance—United States, 1994-1999. MMWR CDC Surveill Summ. 2002;51(SS05):1–8. http://www.cdc.gov/mmwr/preview/mmwrhtml/ss5105a1.htm. Published July 12, 2002. Accessed October 3, 2010.

14. Whiteman MK, Hillis SD, Jamieson DJ, et al. Inpatient hysterectomy surveillance in the United States, 2000-2004. Am J Obstet Gynecol. 2008;198(1):34.e1–7.

15. Merrill RM. Hysterectomy surveillance in the United States, 1997 through 2005. Medical Science Monitor. 2008;14(1):CR24–31.

16. Julian TM. Vaginal hysterectomy: an apparent exception to evidence-based decision making. Obstet Gynecol. 2008;111(4):812–813.

HISTERECTOMIA

Histerectomia Vaginal

View more presentations from Kevin Dickens.