Declining trend in major gynaecological surgery in The Netherlands during 1991-1998. Is there an impact on surgical skills and innovative ability?

Objectives To assess the number of major surgical procedures in gynaecology over a period of eight years in The Netherlands and to detect possible tre nds. Relevance of the trends and the possible impact on surgical skills and on innovative ability are discussed. Design Observational study. Setting Hospital care in The Netherlands. Sample Data from a national hospi tal discharge database, from all 119 hospitals in The Netherlands. Methods When a patient is discharged from the hospital, data on the diagnos is and treatment are registered by local medical officers and administrator s. Registration of surgical procedures is based on the International Classi fication of Procedures in Medicine (ICPM, WHO 1978), the so-called WCC-stan dard. All hospitals but one (a cancer centre) in The Netherlands participat e in this registration, resulting in 99.3 % of all admissions. Data on gyna ecological manpower were obtained from the Dutch College of Obstetricians a nd Gynaecologists. In order to standardise the frequency numbers per 1000 w omen, yearly data of the female population according to age were obtained f rom the Central Office for Population Statistics. Results The female population aged 20 years of age and older increased 3% b etween 1991 and 1998, from 5.8 million to 6.0 million. In the same period t he number of gynaecologists grew from 604 to 625, also an increase of 3%. T he total number of hysterectomies dropped from 21,433 in 1991 to 16,320 (-2 4 %) in 1998 (X' for trend 1245.1, P < 0.001) Surgery of the uterine cavity , either performed hysteroscopically or blind, increased from 311 to 1,958 (+ 625 %) cases per year (chi (2) for trend 2459.2, P < 0.001). No trend ha s been detected in the numbers of adnexal operations, including surgical tr eatment of tubal pregnancy (tubotomy or tubectomy). In 1998, 12% of all ova rian surgery and 28% of all surgery for ectopic pregnancies was performed l aparoscopically. Surgery for female urinary incontinence experienced a stro ng decline of 46% in the studied period. The frequency of vaginal repair de creased with 1354 (-16 %) cases. The abdominal prolapse surgery (abdominal sacral colpopexy, obliteration of the Douglas pouch) is steadily increasing , although the absolute numbers are small, In 1998 seven hundred and forty- three women underwent an abdominal approach of their prolapse repair, compa red with 7239 that had the vaginal repair. Conclusions The declining trend of major gynaecological surgery in combinat ion with the increasing number of gynaecologists will result in more diffic ulty for gynaecologists to acquire and maintain surgical skills and may the refore affect their ability to innovate within the surgical profession.