The first hysterectomy described in the literature was performed by Conrad Langenbeck through vaginal approach in 1813. The first abdominal hysterectomy was conducted in Manchester by Charles Clay in 1863 and involved a supracervical approach. The laparoscopically assisted vaginal hysterectomy was first performed in 1989 by Harry Reich and he also performed the first total laparoscopic hysterectomy. Robotic-assisted hysterectomies have been performed since 1998.
The advantages of laparoscopic hysterectomy over abdominal hysterectomy include reduced intraoperative bleeding, shorter hospitalization time, lower morbidity and faster recovery. Therefore, laparoscopic hysterectomy started to gain popularity in the 1990s in some states.
After 2010, comparative data showed that vaginal hysterectomy is significantly superior as a therapeutic surgical approach to laparoscopic and abdominal hysterectomy. Vaginal approach is preferred nowadays due to lower rates of complications such as postoperative febrile episodes and due to faster recovery. If vaginal hysterectomy is not an option, laparoscopic approach is more suitable than laparotomy due to the same advantages mentioned before (faster recovery of patients, less postoperative febrile episodes), as well as for lower abdominal wall complication rates. The main disadvantage of laparoscopic hysterectomy is the higher duration.
Compared to vaginal hysterectomy, the laparoscopic approach has several disadvantages, related to urinary tract injury, longer training period and higher costs. However, total laparoscopic hysterectomy benefitted from a significant technological evolution after the introduction of uterine manipulators and bipolar instruments of dissection and coagulation into current practice. Thus, the rate of intraoperative complications and the duration of the intervention were significantly reduced.
Uterine morcellation became controversial after various studies conducted since 2014 due to the possible spread of pathological tissue within the peritoneal cavity. The rate of surgical interventions requiring laparoscopic morcellation such as subtotal hysterectomy began to decrease, with total laparoscopic hysterectomy becoming more increasingly used.
Vaginal hysterectomy, the only major surgery specific for the gynecologist, is commonly conducted in the case of genital prolapse. Vaginal approach can also be achieved in the absence of genital prolapse with suitable surgical instruments after short-term training.
In cases where vaginal hysterectomy is considered difficult, laparoscopic approach will be considered to establish whether the procedure can be performed through vaginal approach. Total laparoscopic hysterectomy cannot replace vaginal hysterectomy, but it is an alternative to abdominal hysterectomy.
Finally, the appropriate surgical approach to hysterectomy will be decided in accordance to the surgeon’s experience and the patient’s decision.