The SAVVY Study: SGS/AAGL Survey of Barriers for Vaginal Access Surgery

Abstract

Purpose: The aim was to study vaginal hysterectomy practices, factors enabling or hindering its performance, and factors affecting its teaching. Vaginal hysterectomies for benign conditions are linked to fewer intra-operative injuries, fewer long-term complications, and lower costs compared to other methods. Nonetheless, the number of vaginal hysterectomies and training opportunities has decreased over the past decade. This study was established to develop strategies to improve training and utilization of vaginal hysterectomies.

Methods: We conducted a mixed-method study involving qualitative and quantitative approaches. Members of American Association of Gynecologic Laparoscopists and Society of Gynecologic Surgeons participated in a survey exploring their views on hysterectomy practice patterns and factors affecting vaginal hysterectomy and its teaching. Responses were used to develop a qualitative interview guide for further exploration. Surgeons who completed the survey were invited to participate in interviews until thematic saturation was achieved. All interviews were recorded, de-identified, and transcribed. Two independent researchers coded the transcript line by line. Grounded Theory was utilized to develop new codes and data analysis was completed utilizing STATA and NIVO.

Results: 505 gynecologic surgeons who practice across the world participated in the survey. The mean age was 50.8 +/- 12.7 years. 34.5% of participants performed 1-10 vaginal hysterectomies per year and 23% of participants performed over 30 hysterectomies. Most surgeons agreed that vaginal hysterectomies are important to women’s health (82.8%), that all gynecologic surgeons should be able to perform vaginal hysterectomies (66.3%), and disagreed that other modalities get better outcomes (67.5%). Common barriers to performing vaginal hysterectomy included preference for other surgical routes, previous training experience, low surgical volume, and lack of assistance in the operating room. Surgeons reported that pathology impacted their ability in performing vaginal hysterectomy more than the requirement for morcellation, ability to obtain or control hemostasis, and ability to perform anterior and/or posterior repair. Higher surgical volumes were the only intervention rated by most as enabling the performance of vaginal hysterectomy. Surgeons suggested that creating institutions that specialize in vaginal hysterectomy and funneling patients to surgeons with specialized training would increase volume. In terms of medical education, surgeons thought that residents should be required to achieve competency for vaginal hysterectomies prior to graduation (71.7%) and disagreed that we should eliminate residency graduation requirements for vaginal hysterectomy numbers (56%); however, recent data shows that laparoscopy is comparable in safety to vaginal hysterectomies. Since there is a decreasing trend in vaginal hysterectomy numbers, many surgeons believe that it is best to focus on laparoscopy so that residents can graduate competent in at least one form of minimally invasive hysterectomy.

Conclusions: The study reveals that many surgeons choose to perform laparoscopy despite believing that vaginal hysterectomy is the best surgical option. Some surgeons believed that concentrating efforts on laparoscopic hysterectomy was in the best interest for the specialty. The study gathered preliminary data on facilitators and inhibitors to perform and teach vaginal hysterectomy. Future research needs to focus on the design and implementation of programs that can address barriers and enhance facilitators of vaginal hysterectomies.

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