when vaginal hysterectomy ( vh ) is not possible , many surgeons are reluctant to use laparoscopic techniques on obese patients and instead use the abdominal approach .
current evidence suggests that there is no significant difference in outcomes for normal weight versus obese women undergoing laparoscopic hysterectomy ( lh ) .
however , more gynecologic surgeons will have to master new skill sets to offer this route universally . a growing body of evidence advocates the use of laparoscopic rather than open surgery in obese individuals .
the general surgery literature shows a preference for performing bariatric surgery with a laparoscopic rather than open approach .
a small case series in europe suggests that surgical and anesthetic complications are reduced when laparoscopy is used preferentially to abdominal approaches in gynecologic surgery .
o'hanlan et al suggest that a study comparing the outcomes of normal weight and obese women undergoing lh and abdominal hysterectomy ( ah ) would contribute to the gynecologic literature .
the objective of this study was to compare the surgical outcomes of obese and normal weight women having hysterectomy according to the route of the procedure .
an analysis was performed of patients who had surgery by faculty offering all 3 approaches ( ah , vh , lh ) .
hysterectomy procedures from june 6 , 2001 ( the date of the first total laparoscopic hysterectomy offered in the institution ) through february 9 , 2006 were analyzed .
all hysterectomies performed by these surgeons during this time period are included in this study .
the indication for surgery , operative time , anesthesia time , complications , estimated blood loss , change in hematocrit , conversion of route , uterine weight , wound complications , and transfusion events were tabulated .
demographics and medical history information were also collected including age , race , gravidity , parity , weight , height , and history of prior uterine scar ( including cesarean delivery , myomectomy , or other incision into the uterine myometrium ) .
the study procedures were performed by 1 of 2 faculty surgeons and a resident in obstetrics and gynecology at a tertiary care center .
the faculty surgeons performing these cases trained in the same institution and operated together during the development of the total laparoscopic technique .
no formal changes were made in surgical technique , such as additional training or new equipment , through the evaluation period .
procedures were classified as abdominal ( ah ) , which included total and subtotal abdominal hysterectomy ; vaginal ( vh ) , which included total and laparoscopically assisted vaginal hysterectomy ; and laparoscopic ( lh , ) which included total and subtotal laparoscopic hysterectomy as well as robotically assisted laparoscopic hysterectomy . for a procedure to be designated as lh , the entire procedure including colpotomy and vaginal cuff closure had to have been performed laparoscopically .
those procedures that required conversion to an abdominal route from the vaginal or laparoscopic approach were included in the group of the initial approach .
obesity defined as body mass index ( bmi ) 30 was calculated by dividing the weight of the patient in kilograms by the patient 's height in meters squared .
obesity has been defined by the world health organization as a bmi value of > 30 .
patients were divided into 6 groups : obese and normal weight ah , obese and normal weight vh , and obese and normal weight lh .
complications were identified in the dictated operative note and from review of the medical record during the hospital stay and in clinical follow - up visits .
data were compiled in microsoft excel ( microsoft corporation , redmond , washington ) and evaluated using the number cruncher statistical system ( ncss , kaysville , utah ) to perform an analysis of variance ( anova ) .
a newman - keuls multiple comparison test was used to evaluate which pairs of data differed by a statistically significant amount ( f - ratio > 1 ) .
the distribution of patient race versus route of procedure was evaluated using chi - square analysis .
we identified 293 cases : 68 ah , 95 vh , and 130 lh . in the ah group , 37 of 68 patients , or 54% , were obese .
in the vh group , 51 of 95 , or 54% , were obese . in the lh group , 69 of 130 , or 53% , were obese .
indications for surgery included symptomatic leiomyomata ( 51% ) , chronic pelvic pain ( 17% ) , dysfunctional uterine bleeding ( 17% ) , recurrent cervical dysplasia ( 8% ) , endometrial hyperplasia ( 1% ) , management of intraoperative hemorrhage ( < 1% ) , management of pelvic inflammatory disease ( < 1% ) , management of ovarian mass ( < 1% ) , and pelvic organ prolapse ( < 1% ) .
no statistically significant difference existed in patient ages among the ah , vh , and lh groups .
women in the vh group had higher average gravidity and parity than women had in the ah or lh groups , a difference that was statistically significant .
the ah and lh groups were not significantly different from each other for gravidity and parity . demographic data by route of hysterectomy denotes statistical significance from other groups ( race differences discussed in results ) .
the majority of women evaluated in the study were african - american followed by caucasian and hispanic .
the ah group had significantly more african - american women than did the vh or lh groups .
the lh group had significantly more caucasian women than did the ah or vh groups .
the rate of supracervical hysterectomy was noted to be 22% in the ah group and 15% in the lh group .
the rate of salpingo - oophorectomy was 79% in the ah group , 22% in the lh group , and 20% in the vh group .
conversions to an abdominal approach were experienced in 1 lh case and 4 vh cases .
additional procedures performed at the same time of ah were 2 appendectomies and one suburethral sling procedure .
one appendectomy , one anterior and posterior colporrhaphy , and 2 suburethral sling procedures were performed at the time of vh .
one appendectomy and 2 suburethral sling procedures were performed at the time of lh . in the analysis of surgical history , the vh group had a significantly lower number of prior cesarean deliveries per patient ( 0.3 ) compared with the ah ( 0.6 ) and lh ( 0.8 ) groups .
however , the lh group had significantly more total abdominal surgery per patient ( 2.0 ) than ah ( 1.3 ) or vh ( 1.3 ) had .
three complications in obese women occurred : a cystotomy during vh and 2 enterotomies during ah .
nine complications in normal weight women occurred : 2 cystotomies during lh , 2 cystotomies during ah , 1 cystotomy during vh , laceration of the inferior epigastric artery during lh , puncture of the sigmoid colon during lh , and 2 cases of hemorrhage requiring intraoperative transfusion during lh and ah .
the ah group had a significantly higher average uterine weight ( 608 grams ) versus the vh ( 159 grams ) or lh ( 207 grams ) .
the longest surgical times and anesthesia times were recorded in obese women in the lh group . however , these times were not significantly different from times for obese women in the ah group .
obese women in the vh group had the shortest cases of the obese women in the study .
similar trends were noted for normal weight women in the lh , ah , and vh groups .
normal weight women having vh had the shortest anesthesia and surgery times of any group , a statistically significant difference .
mean anesthesia and surgery times by route of hysterectomy and weight category hospital stay data , outlined in table 3 , revealed that obese women in the lh group spent 2.5 days in the hospital on average , compared with obese women in the ah group who stayed 4.2 days , a significant difference .
there was a statistically significant increase in hospital stay in the ah group versus vh or lh , for both obese and normal weight women .
there was no significant difference in hospital stay in the vh and lh groups , whether obese or normal weight weight .
all postoperative care was delivered by the same faculty physicians and residents in the same hospital , ensuring that the discharge criteria were consistent among all groups .
hospital length of stay by route of hysterectomy and weight category estimated blood loss ( ebl ) , outlined in table 4 , was highest in normal weight women in the ah group ( 478ml ) followed by obese women in the ah group ( 455ml ) .
the blood losses seen in the obese versus normal weight lh and obese versus normal weight vh groups were not significantly different .
the difference in estimated blood loss was significant between ah and the other groups for both obese and normal weight women .
estimated blood loss by hysterectomy route and weight category the change in hematocrit data was not reliable for analysis .
for this reason , estimated blood loss was used as the primary evaluation of surgical blood loss .
surgical management of the obese patient continues to be a challenge to the gynecologic surgeon .
lh appears to be a safe procedure for obese women but has a short history , leaving its role in certain clinical situations unclear .
lh has been found in large randomized trials to be generally inferior to vh in terms of operative time and anesthesia complications , but superior to open procedures in recovery time and complications .
a critical evaluation of these trials suggests lh is a more effective tool when surgical expertise is considered .
the results from this study suggest that lh is a favorable alternative to ah in obese women who , for whatever reason , are judged unsuitable for vh . in this retrospective study , obese women having lh versus ah had significantly shorter hospital stays and less blood loss but similar surgery and anesthesia times .
while recovery data were not collected for this study , the experience of the surgeons is that the lh patients return to normal activities sooner than ah patients do , whether obese or not .
these data also agree with data from other studies , suggesting vh is preferable to ah or lh when possible .
patients who had vh spent the fewest days in the hospital , experienced the shortest surgery and anesthesia times , and had the lowest ebl .
the decision to proceed with any given surgical approach was made clinically by the surgeon .
the abdominal approach would likely have been selected for a case with a high degree of anticipated difficulty due to uterine size .
this evaluation period captures the introduction of laparoscopic hysterectomy at the study institution , and as such demonstrates an initial bias toward ah in patients with large uteri , until increased experience with lh made these cases feasible .
the abdominal approach may also have been selected in obese patients with large uteri causing significant distortion of normal anatomic relationships .
the selection bias for route of procedure in the patient with a large uterus is suggested by the much higher mean uterine weight in the ah group .
the rationale for this inclusion was based on the original intention of the surgical team  to remove the uterus vaginally , with a variable degree of laparoscopic assistance . in similar fashion ,
those vaginal or laparoscopic procedures that required conversion to laparotomy were analyzed in the group of the initial route ( intent to treat ) .
confounders such as patient disease , including diabetes and asthma , were not specifically evaluated in this study .
such patient conditions may have influenced the chosen route of surgery and therefore the comparisons .
the distribution of complications , favoring normal weight women in the abdominal hysterectomy group , may suggest that the selection of the abdominal approach was based on risk factors for operative difficulty ( history of prior surgery or uterine scar ) .
the vh group was more likely to have fewer such predictors for difficult surgery compared with women in the ah or lh group .
this bias is consistent with studies describing larger and more symptomatic myomata in african - american women , leading to more frequent selection of the abdominal route .
the vh group contained more hispanic women , but the sample size was too small to draw definitive conclusions for this finding .
this distribution is consistent with the patient population served by the university in which the study was performed .
the number of patients evaluated did not allow for further stratification by bmi to determine whether the severity of obesity was consistent across all groups .
these data capture the experience of the faculty surgeons from the very first lh procedure performed at the institution . neither faculty surgeon received training in laparoscopic hysterectomy during residency .
, it did not appear that obesity biased selection of the route of surgery , as approximately half of the patients in each group were obese .
intuitively , surgeons selecting patients for a new procedure might tend to choose straightforward surgical cases .
however , it is promising that , even with the inclusion of the learning curve , the laparoscopic route benefited obese patients with shorter hospital stays , less blood loss , and fewer complications .
these data suggest that in obese patients , vaginal hysterectomy be considered first because these patients had the shortest hospital stay , surgery , and anesthesia times .
surgeons in private and academic practice environments should continue to regard vh as the route of choice in obese patients thanks to favorable outcomes and operating times .
lh should be selected over ah in obese patients for whom a vaginal approach is not feasible .
 objective : our objective was to compare the surgical outcomes of obese women having hysterectomy according to the route ( abdominal , vaginal , or laparoscopic ) of the procedure.methods:a chart review of 293 hysterectomy procedures was performed . 
 data were collected including operative and anesthesia time , estimated blood loss , change in hematocrit , hospital stay , complications , conversion to laparotomy , transfusion , and body mass index . 
 an analysis of variance and a newman - keuls multiple comparison test were performed.results:obese women experienced a significant decrease in hospital days ( 2.5 versus 4.2 ) and reported blood loss ( 204 ml versus 455 ml ) in the laparoscopic hysterectomy and vaginal hysterectomy groups compared with the abdominal hysterectomy group . 
 no significant difference was found in obese women between laparoscopic and abdominal hysterectomy for time spent in surgery and under anesthesia . for obese and normal weight women , 
 vaginal hysterectomy offered the shortest surgery , anesthesia times , and hospital stays.conclusions:for normal and obese women , vaginal hysterectomy offered the shortest hospital stay and surgery time . in obese patients for whom 
 vaginal hysterectomy is not possible , laparoscopic hysterectomy should be considered before abdominal hysterectomy , because the laparoscopic route reduced hospital time and blood loss . 
INTRODUCTION
MATERIALS AND METHODS
RESULTS
DISCUSSION
CONCLUSION