Changes in Hysterectomy Route and Adnexal Removal for ...downloads.hindawi.com/journals/mis/2018/5828071.pdf · MinimallyInvasiveSurgery Abdominal Vaginal Laparoscopic 0 500 1000

Research ArticleChanges in Hysterectomy Route and AdnexalRemoval for Benign Disease in Australia 2001ndash2015A National Population-Based Study

Natalie De Cure1 and Stephen J Robson 2

1Centenary Hospital for Women and Children PO Box 11 Woden ACT 2606 Australia2Department of Obstetrics and Gynaecology Australian National University Medical School PO Box 5235Garran ACT 2605 Australia

Correspondence should be addressed to Stephen J Robson stephenrobsonanueduau

Received 21 January 2018 Revised 7 April 2018 Accepted 26 April 2018 Published 31 May 2018

Academic Editor Saad Amer

Copyright copy 2018 Natalie De Cure and Stephen J Robson This is an open access article distributed under the Creative CommonsAttribution License which permits unrestricted use distribution and reproduction in any medium provided the original work isproperly cited

Objective Hysterectomy rates have fallen over recent years and there remains debate whether salpingectomy should be performedto reduce the lifetime risk of ovarian cancer We examined trends in adnexal removal and route of hysterectomy in Australiabetween 2001 and 2015Methods Data were obtained from the national procedural dataset for hysterectomy approach (vaginal VHabdominal AH and laparoscopic LH) and rates of adnexal removal as well as endometrial ablation The total female populationin two age groups (ldquoyounger age grouprdquo 35 to 54 years and ldquoolder age grouprdquo 55 to 74 years) was obtained from the AustralianBureau of Statistics Results The rate of hysterectomy fell in both younger (617 versus 45210000year 119901 lt 0005) and older (388versus 33210000year 119901 lt 0005) age groups In both age groups there were significant decreases in the incidence rates for VH (by53 in the younger age group and 29 in the older age group) and AH (by 53 and 55 respectively) The rates of LH increasedby 153 in the younger age group and 307 in the older age group Overall the proportion of hysterectomies involving adnexalremoval increased (31 versus 65 in the younger age group 119901 lt 0005 44 versus 58 in the older age group 119901 lt 0005) Theincrease occurred almost entirely after 2011 Conclusion Hysterectomy is becoming less common and both vaginal and abdominalhysterectomy are being replaced by laparoscopic hysterectomy Removal of the adnexae is now more common in younger women

1 Introduction

Hysterectomy for benign conditions remains a commonprocedure in Australia and internationally Prior to 2000the lifetime risk of hysterectomy in Australian womenwas estimated to be approximately 35 [1] similarto the rate in other developed countries [2 3] Since2000mdashassociated with the introduction of treatmentssuch as the levonorgestrel-releasing intrauterine system(Mirena) and second-generation endometrial ablationtechniquesmdashthe rate of hysterectomy has fallen [4] Overthe same period nonsurgical treatments for fibroids such asuterine artery embolization and focussed ultrasound alsomight be expected to reduce further the rate of hysterectomy[5 6]

A trend to decreased use of hysterectomy has beenidentified in some European countries and in North America[7 8] As treatments for heavy menstrual bleeding (HMB)have evolved so has the surgical approach to hysterectomyUpdating previous evidence [9 10] a recent systematic reviewcomparing total laparoscopic hysterectomy (TLH) with vagi-nal hysterectomy (VH) included 24 studies published toFebruary 2016 and reported no difference between the twotechniques in the rate of major or minor complications riskof ureter and bladder injuries intraoperative blood loss andlength of hospital stay [11] VH was associated with a shorteroperative time and lower rates of vaginal cuff dehiscence andconversion to laparotomy However vaginal access and uter-ine size impose limitations on uptake of vaginal hysterectomyand there is a body of evidence supporting a laparoscopic

HindawiMinimally Invasive SurgeryVolume 2018 Article ID 5828071 6 pageshttpsdoiorg10115520185828071

2 Minimally Invasive Surgery

approach as more appropriate where a vaginal approach isdifficult [9 10]

Further complicating the change in surgical paradigmis an evolving body of evidence that cells of the fallopiantube may be the origin of many high-grade serous ovariantumours [12] For this reason some professional societies nowrecommend discussion of opportunistic salpingectomy at thetime of hysterectomy for benign conditions to reduce thisrisk [13 14] A systematic review of opportunistic salpingec-tomy identified ten comparative studies that cumulativelydemonstrated a small to no increase in operative time andno additional blood loss hospital stay or complicationsattributable to salpingectomy at the time of hysterectomy forbenign disease [15] However salpingectomy can be morechallenging at VH and this has a potential to influence thechoice of approach for hysterectomy [16]We set out to deter-mine how these factors might have influenced hysterectomyin Australia over the last 15 years We wanted to determineif there had been a significant change in the incidence rateof hysterectomy whether there had been changes in theapproach to hysterectomy and whether there has been anincreasing trend to removal of the adnexae

2 Materials and Methods

Data regarding hysterectomy and endometrial ablation wereobtained from the Australian Institute of Health and Welfare(AIHW) national procedural database The AIHW nationalprocedural database holds information collected throughthe National Health Information Agreement as required byand specified in the National Minimum Data Set relatingto hospitals The data are supplied by all Australian stateand territory health authorities Procedures use an agreednational standard the Australian Classification of HealthInterventions (ACHI) which is based around the AustralianNational Medical Benefits Schedule (MBS) Validation stud-ies of the AIHW dataset have reported 995 agreementwith ldquotruerdquo morbidity in a female population (kappa 086)[17] We selected data from 2001 to 2015 using procedurescoded according to the ICD-10-AMACHI guidelines asdetailed in Box 1 Data were extracted only for benign diseasehysterectomy code numbers specific for malignant diseasewere identified but not extracted and were not included inthe study dataset

To provide a denominator annual point estimates for thetotal female population in two age bandsmdash35 to 54 years(the ldquoyounger age grouprdquo) and 55 to 74 years (the ldquoolderage grouprdquo)mdashwere obtained from the Australian Bureauof Statistics (ABS) All extracted data were entered intoExcel spreadsheets and statistical analysis was performedin GenStat (httpswwwvsnicouksoftwaregenstat) Poly-nomial linear regressions were performed to calculate thecoefficient of determination (1198772 values) as measures ofthe closeness of fit and 119901 values The study receivedprospective approval from the Human Research EthicsCommittee of the Australian National University (protocol2015347)

3 Results

The overall incidence rate of hysterectomy at a national levelfell (from 547 to 40710000year 119901 lt 0005) and this changeoccurred in both the younger (from 617 to 45210000year119901 lt 0005) and older (from 388 to 33210000year 119901 lt0005) age groups over the study period (Figure 1) Over thesame time period the rate of endometrial ablation in theyounger age group increased from 110 to 22410000year(119901 lt 0005)

The total number of hysterectomies performed in Aus-tralia by each route is presented in Figure 2 (the younger agegroup) and Figure 3 (the older age group)

The incidence rates for the individual routes of hysterec-tomy (vaginal abdominal and laparoscopic) also changed inboth age groups In the younger age group (Figure 4) therates fell for VH by 53 (from 189 to 8910000year 119901 lt0005) and for AH also by 53 (from 351 to 16510000year119901 lt 0005) while that of LH increased by 153 (from 78 to19710000year 119901 lt 0005) In the older age group (Figure 5)the rate of VH fell by 29 (from 200 to 14310000year119901 lt 0005) and for AH by 55 (from 159 to 7110000year119901 lt 0005) The rate of LH increased by 307 (from 29 to11810000year 119901 lt 0005)

The proportion of hysterectomies involving removal ofadnexal structures increased significantly over the studyperiod in the younger age group for each route of hysterec-tomy (Figure 6) by 623 in VH (from 22 to 159 119901 lt0005) by 44 in AH (from 466 to 669 119901 = 009)and by 50 in LH (from 342 to 845 119901 = 0012) Inthe older age group (Figure 7) for AH the rate of adnexalremoval was high and remained unchanged (from 915 to919 119901 = 011) The rate in LH increased from 76 to 95(119901 lt 0005) and in VH the rate was low but increased from26 to 106 (119901 lt 0005)

For hysterectomy by all approaches the proportion per-formed with associated adnexal removal has increased inboth the younger (from 31 to 65 119901 lt 0005) and older(from 44 to 58 119901 lt 0005) (Figure 8) However thisincrease has occurred almost entirely after 2011 there was nosignificant increase in the rate of adnexal removal from 2001to 2011 in either the younger (119901 = 041) or older (119901 = 032)age groups

4 Discussion

The findings of this study are consistent with publisheddata from Europe and North America that have shownthat hysterectomy is being undertaken less commonly indeveloped countries [2 3] Despite a weight of evidencesupporting a vaginal approach [9 10] the proportion ofhysterectomies performed vaginally has fallen overall withthe greatest decrease has been seen in the younger age groupImportantly the proportion of hysterectomies performedwith associated adnexal removal has increased in the youngerage group but across both age groups there is a low rate withVH

The findings of our study provide a comparison to othersimilar countries A study from Denmark using data from

Minimally Invasive Surgery 3

Descriptor XIII ldquoGynaecological proceduresrdquoldquoUterusrdquo Blocks 1259ndash1273

Block 1263 Destructive procedures of uterus15622-0 Endoscopic endometrial ablation

Block 1268 Abdominal ℎ119910119904119905119890119903119890119888119905119900119898119910lowast35653-00 Subtotal abdominal hysterectomy35653-01 Total abdominal hysterectomy35653-02 Abdominal hysterectomy with unilateral salpingo-oophorectomy35653-03 Abdominal hysterectomy with bilateral salpingo-oophorectomy35653-04 Abdominal hysterectomy with removal of adnexae

Block 1269 Vaginal ℎ119910119904119905119890119903119890119888119905119900119898119910lowast35657-00 Vaginal hysterectomy35673-00 Vaginal hysterectomy with unilateral salpingo-oophorectomy35673-02 Vaginal hysterectomy with removal of adnexae35673-01 Vaginal hysterectomy with bilateral salpingo-oophorectomyLaparoscopic ℎ119910119904119905119890119903119890119888119905119900119898119910lowast35750-00 Laparoscopically-assisted vaginal hysterectomy35753-00 Laparoscopically-assisted vaginal hysterectomy with unilateral salpingo-oophorectomy35753-01 Laparoscopically-assisted vaginal hysterectomy with bilateral salpingo-oophorectomy35766-00 Laparoscopically-assisted vaginal hysterectomy proceeding to abdominal hysterectomy35766-03 Laparoscopically-assisted vaginal hysterectomy proceeding to abdominal hysterectomy with removal of adnexaeFrom 200890448-00 Subtotal laparoscopic abdominal hysterectomy90448-01 Total laparoscopic abdominal hysterectomy90448-02 Total laparoscopic abdominal hysterectomy with removal of adnexae

Box 1 Search strategy lowastOnly descriptors for benign disease extracted

Endometrial Ablation

Age 55 to 74

Age 35 to 54

0

10

20

30

40

50

60

Proc

edur

es p

er 1

0000

wom

en

2003 2005 2007 2009 2011 2013 20152001Year

y = 00724x2 minus 15877x + 40527R2 = 07659

y = 01101x2 minus 2968x + 59835

R2 = 09507

y = 007x2 minus 03001x + 11906R2 = 09536

Figure 1 Age-stratified incidence rates of hysterectomy in Australia(procedures per 10000 women) for women aged 35ndash54 years and55ndash74 years and incidence rate of endometrial ablation in womenaged 35ndash54 years

a 35-year period until 2011 revealed that although there wasconsiderable local variation there had been only a smallreduction in the overall rate of hysterectomy [7] That studyalso revealed a trend away from abdominal surgery withan increased uptake of laparoscopic approaches but nochange in the rate of vaginal hysterectomy since 2003 Inthe United States where the rate of hysterectomy has alsofallen the initial uptake of LH was slow [8] but there now

Abdominal

Vaginal

Laparoscopic

0

2000

4000

6000

8000

10000

12000

14000

Num

ber o

f Pro

cedu

res p

er y

ear

2003 2005 2007 2009 2011 2013 20152001Year

y = 16094x3 minus 41344x2 + 55547x + 68406R2 = 09848

y = 41433x3 minus 89535x2 + 3305x + 12633

R2 = 0967

y = 11981x3 + 11502x2 minus 10554x + 30524

R2 = 09866

Figure 2 Absolute number of hysterectomies by different routes (Xvaginal ◼ abdominal and 998771 laparoscopic) in Australia in womenaged 35ndash54 years

has been acceleration in the use of laparoscopic and robotichysterectomy [18]

The increase in removal of adnexal structures notedin this study mirrors a similar trend noted in the UnitedStates The change is likely to reflect the evolving literaturedescribing a clear association between dysplastic changesoccurring in the distal fallopian and their relationship toovarian malignancy [12 19] Our study showed low rates ofadnexal removal associated with VH in younger womenThetechnical challenges in performing adnexal surgery at the

4 Minimally Invasive Surgery

Abdominal

Vaginal

Laparoscopic

0

500

1000

1500

2000

2500

3000

3500

4000

Num

ber o

f Pro

cedu

res p

er y

ear

2003 2005 2007 2009 2011 2013 20152001Year

y = 06914x3 minus 17692x2 + 14718x + 29705R2 = 01699

y = 0182x3 minus 47438x2 minus 21346x + 2471R2 = 08516

y = 05646x3 + 32881x2 minus 20164x + 52689

R2 = 09877

Figure 3 Absolute number of hysterectomies by different routes (Xvaginal ◼ abdominal and 998771 laparoscopic) in Australia in womenaged 55ndash74 years

Laparoscopic

Vaginal

Abdominal

0

5

10

15

20

25

30

35

40

Proc

edur

es p

er 1

0000

wom

en

2003 2005 2007 2009 2011 2013 20152001Year

y = minus0004x2 minus 07215x + 20538R2 = 09832

y = 00322x2 minus 20022x + 38635R2 = 09658

y = 00944x2 minus 0723x + 91946

R2 = 09803

Figure 4 Age-stratified incidence rates for different routes ofhysterectomy (X vaginal ◼ abdominal and 998771 laparoscopic) inAustralia (procedures per 10000 women) for women aged 35ndash54years

Abdominal

Vaginal

Laparoscopic

0

5

10

15

20

25

Proc

edur

es p

er 1

0000

wom

en

2003 2005 2007 2009 2011 2013 20152001Year

y = minus00027x2 minus 03756x + 20473

R2 = 07609

y = 00113x2 minus 07983x + 16381

R2 = 09598

y = 00638x2 minus 04138x + 36731

R2 = 09796

Figure 5 Age-stratified incidence rates for different routes ofhysterectomy (X vaginal ◼ abdominal and 998771 laparoscopic) inAustralia (procedures per 10000 women) for women aged 55ndash74years

Vaginal

Abdominal

Laparoscopic

0102030405060708090

Perc

enta

ge o

f Pro

cedu

res

2003 2005 2007 2009 2011 2013 20152001Year

y = 00911x2 minus 0689x + 39102

R2 = 09093

y = 03256x2 minus 4451x + 55211

R2 = 07597

y = 04654x2 minus 41797x + 41073

R2 = 09726

Tubes

Figure 6 Percentage of procedures involving removal of theadnexae by route of hysterectomy (X vaginal ◼ abdominal and 998771laparoscopic) in Australia for women aged 35ndash54 years The epochin which guidance advised opportunistic salpingectomy is shaded

Vaginal

Laparoscopic

Abdominal

0102030405060708090

100Pe

rcen

tage

of P

roce

dure

s

2003 2005 2007 2009 2011 2013 20152001Year

y = 00454x2 minus 03079x + 37681

R2 = 08415

y = 00011x2 minus 0123x + 92102

R2 = 01832

y = minus00046x2 + 13069x + 75861

R2 = 08946

Tubes

Figure 7 Percentage of procedures involving removal of theadnexae by route of hysterectomy (X vaginal ◼ abdominal and 998771laparoscopic) in Australia for women aged 55ndash74 years The epochin which guidance advised opportunistic salpingectomy is shaded

55 to 74 years

35 to 54 years

0

10

20

30

40

50

60

70

Perc

enta

ge o

f Pro

cedu

res

2003 2005 2007 2009 2011 2013 20152001Year

y = 00023x4 minus 00319x3 + 01423x2 minus 05891x + 321

R2 = 09809

y = minus00002x4 + 00125x3 minus 0089x2 minus 00383x + 44576

R2 = 08561

Tubes

Figure 8 Percentage of all hysterectomies involving removal of theadnexae by age group (35 to 54 years 55 to 74 years) for the period2001 to 2015 in Australia The epoch in which guidance advisedpossible opportunistic salpingectomy is shaded

Minimally Invasive Surgery 5

time of VH are well-recognised with authors commentingthat with ldquothe decreasing rate of [vaginal hysterectomy] the vaginal approach and [the added] complexity of a salp-ingectomymaymake this approach seem less appealingrdquo [17]A population-based study from Sweden reported that womenwho had undergone salpingectomy during hysterectomy forbenign disease had a decrease in subsequent risk for ovariancancerwith a hazard ratio of 065 and thatwomenundergoingbilateral salpingectomy had 50 lower risk than those under-going unilateral salpingectomy [12]Those authors concludedthat removal of the fallopian tubes is an effective measure toreduce ovarian cancer risk in the general population

While systematic reviews continue to report that theVH is preferable for hysterectomy in benign disease theideal route for women unsuitable for a vaginal approachremains to be determined [9] Meta-analysis of publishedrandomised controlled trials favours LH but with the trade-off of a longer operating time [20] Despite evidence that VHis associated with the best outcome the use of VH has fallenThe Cochrane review group concluded that VH should beperformed where possible but where VH is not consideredpossible LH may have advantages over AH However thelength of the surgery increases as the extent of the surgeryperformed laparoscopically increases

The trend to an increasing prevalence of obesity indeveloped countries is likely to affect both the operatingtime and the rate of complications associated with LHWomen who are obese have an increased risk of developinggynaecological conditions such as endometrial hyperplasiaand heavy menstrual bleeding making them more likelyto require hysterectomy [21] Over the period of our studythe proportion of women with a body mass index (BMI) of30Kgm2 in Australia was estimated to have increased bymore than 13 up to a prevalence of 559 [22]Womenwitha high bodymass index (BMI) are likely to be overrepresentedin the hysterectomy group and their operations are likely touse more operative time A high BMI increases the durationof abdominal hysterectomy [23] and even after adjustmentfor patient age parity history of open surgery previouscaesarean section and menopausal status a significantlylonger operating timemdashas much as doublingmdashwas noted inthe case of obese patients [24] Indeed the operating time forLH increases almost linearly with increasing BMI [25]

There are two important limitations to this study Firstlyit is not possible to determine background rates of preexistinghysterectomy so the population incidence rates reported arefor women irrespective of whether they have a uterus or notThe age-related likelihood that a woman has already under-gone hysterectomy is obviously cumulative so the incidencerates we have reported underestimate the true rate of hys-terectomy inwomen eligible for the procedure that is womenwho still have a uterus The second limitation is that codingin the national dataset reflects nonspecific data regardingwhether ldquoremoval of adnexal structuresrdquo was undertakenand we were not specifically able to determine whethereither isolated salpingectomy or salpingo-oophorectomy wasperformed at the hysterectomy However it seems likely thatthis change in the younger age group reflects salpingectomy

alone since Australian guidance is explicit in discouragingoophorectomy before women reach their 1960s [14]

5 Conclusion

This study has confirmed the findings of other internationalstudies that hysterectomy is becoming less common [7 8]and that both vaginal and abdominal hysterectomy are beingreplaced by laparoscopic hysterectomy At the same timeremoval of the adnexae at the time of hysterectomy is nowbecoming more common in younger women

Data Availability

The data used to support the findings of this study areavailable from the corresponding author upon request

Conflicts of Interest

The authors declare that they have no conflicts of interest

Acknowledgments

The authors wish to thank Dr Steven Lyons for his carefulreview of the manuscript and very helpful advice

References

[1] K Spilsbury J B Semmens I Hammond and A BolckldquoPersistent high rates of hysterectomy in Western Australia apopulation-based study of 83 000 procedures over 23 yearsrdquoBJOGAn International Journal of ObstetricsampGynaecology vol113 no 7 pp 804ndash809 2006

[2] R M Merrill ldquoHysterectomy surveillance in the United States1997 through 2005rdquoMedical Science Monitor vol 14 pp CR24ndashCR31 2008

[3] C Lundholm C Forsgren A L V Johansson S CnattingiusandDAltman ldquoHysterectomyonbenign indications in Sweden1987-2003 a nationwide trend analysisrdquo Acta Obstetricia etGynecologica Scandinavica vol 88 no 1 pp 52ndash58 2009

[4] L J Middleton R Champaneria J P Daniels et al ldquoHysterec-tomy endometrial destruction and levonorgestrel releasingintrauterine system (Mirena) for heavy menstrual bleedingSystematic review and meta-analysis of data from individualpatientsrdquo BMJ vol 341 no 7769 Article ID c3929 p 379 2010

[5] E Liang B Brown R Kirsop et al ldquoEfficacy of uterineartery embolization for treatment of symptomatic fibroids andadenomyosis ndash an interim report on an Australian experiencerdquoAustralian andNew Zealand Journal of Obstetrics and Gynaecol-ogy vol 52 pp 106ndash112 2012

[6] G A Vilos C Allaire P Y Laberge N Leyland et al ldquoThemanagement of uterine leiomyomasrdquo Journal of Obstetrics andGynaecology Canada vol 37 pp 157ndash181 2015

[7] R Lykke J Blaakaer B Ottesen andH Gimbel ldquoHysterectomyin Denmark 1977-2011 changes in rate indications and hospi-talisationrdquo European Journal of Obstetrics and Gynecology andReproductive vol 171 pp 333ndash338 2013

[8] J M Wu M E Wechter E J Geller T V Nguyen andA G Visco ldquoHysterectomy rates in the United States 2003rdquoObstetrics amp Gynecology vol 110 no 5 pp 1091ndash1095 2007

6 Minimally Invasive Surgery

[9] J W M Aarts T E Nieboer N Johnson et al ldquoSurgicalapproach to hysterectomy for benign gynaecological diseaserdquoCochrane Database of Systematic Reviews vol 8 p CD0036772015

[10] N Johnson D Barlow A Lethaby et al ldquoMethods of hys-terectomy systematic review and meta-analysis of randomisedcontrolled trialsrdquo BMJ vol 330 pp 1478ndash1485 2005

[11] E M Sandberg A R H Twijnstra S R C Driessen andF W Jansen ldquoTotal laparoscopic hysterectomy versus vaginalhysterectomy a systematic review and meta-analysisrdquo JournalofMinimally Invasive Gynecology vol 24 no 2 pp 206ndash217e222017

[12] H Falconer L Yin H Gronberg and D Altman ldquoOvariancancer risk after salpingectomy a nationwide population-basedstudyrdquo Journal of the National Cancer Institute p 107 2015

[13] Committee on Gynecologic Practice ldquoCommittee opinion no620 Salpingectomy for ovarian cancer preventionrdquo Obstetricsand Gynecology vol 125 pp 279ndash281 2015

[14] RANZCOG ldquoManaging the adnexae at the time ofhysterectomy for benign gynaecological conditionsrdquo 2014httpwwwranzcogeduau

[15] R M Kho and M E Wechter ldquoOperative outcomes ofopportunistic bilateral salpingectomy at the time of benignhysterectomy in low-risk premenopausal women a systematicreviewrdquo Journal of Minimally Invasive Gynecology vol 24 no 2pp 218ndash229 2017

[16] M Robert D Cenaiko J Sepandj and S Iwanicki ldquoSuccessand complications of salpingectomy at the time of vaginalhysterectomyrdquo Journal ofMinimally InvasiveGynecology vol 22no 5 pp 864ndash869 2015

[17] C L Roberts C A Cameron J C Bell C S Algert andJ M Morris ldquoMeasuring maternal morbidity in routinelycollected health data development and validation of a maternalmorbidity outcome indicatorrdquo Medical Care vol 46 no 8 pp786ndash794 2008

[18] L C Turner J P Shepherd L Wang C H Bunker andJ L Lowder ldquoHysterectomy surgery trends a more accuratedepiction of the last decaderdquoAmerican Journal ofObstetrics andGynecology vol 277 no 2 pp e1ndashe7 2013

[19] S H Yoon S N Kim S H Shim S B Kang and S J LeeldquoBilateral salpingectomy can reduce the risk of ovarian cancerin the general population a meta-analysisrdquo European Journal ofCancer vol 55 pp 38ndash46 2016

[20] CAWalsh S RWalsh T Y Tang andM Slack ldquoTotal abdom-inal hysterectomy versus total laparoscopic hysterectomy forbenign disease a meta-analysisrdquo European Journal of Obstetricsand Gynecology and Reproductive vol 144 pp 3ndash7 2009

[21] S Pandey and S Bhattacharya ldquoImpact of obesity on gynecol-ogyrdquoWomenrsquos Health vol 6 pp 107ndash177 2010

[22] Australian Bureau of Statistics ldquo4364055001 - NationalHealth Survey First Results 2014-15 Overweight and obesityrdquohttpwwwabsgovauausstats

[23] OHarmanli V Dandolu J Lidicker R Ayaz U R Panganama-mula and E F Isik ldquoThe effect of obesity on total abdominalhysterectomyrdquo Journal of Womenrsquos Health vol 19 no 10 pp1915ndash1918 2010

[24] N Chopin J M Malaret M-C Lafay-Pillet A Fotso HFoulot and C Chapron ldquoTotal laparoscopic hysterectomy forbenign uterine pathologies obesity does not increase the risk ofcomplicationsrdquo Human Reproduction vol 24 no 12 pp 3057ndash3062 2009

[25] D Bardens E Sotomayer S Baum et al ldquoThe impact ofthe body mass index (BMI) on laparoscopic hysterectomy forbenign diseaserdquo Archives of Gynecology and Obstetrics vol 289pp 803ndash807 2014

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