Efficacy of laparoscopic subtotal hysterectomy in the management of menorrhagia: 400 consecutive cases

Abstract

Efficacy of laparoscopic subtotal hysterectomy in the management of menorrhagia: 400 consecutive cases Sir, I read with interest the article by Erian et al. 1 on laparoscopic subtotal hysterectomy for menorrhagia.There are methodological issues. While the title revolves around efficacy in dealing with menorrhagia, the abstract concentrates on safety and patient satisfaction. Similarly, the article begins by defining the primary outcome measure as patient satisfaction although there is no mention of this in the method. There is no power calculation. Four hundred might sound large enough, but with certain rare complications of subtotal hysterectomy, this might not be enough. Menorrhagia not responding to medical treatment is the same as dysfunctional uterine bleeding not responding to hormonal treatment. It is notable that pain, rather than menorrhagia, was the indication in some women. Operating time should be from induction of anaesthesia, rather than pneumoperitoneum. An early follow up or a recovery diary would have been more accurate in assessing postoperative pain and return to work.The presentation of the results needs attention. Numerical data are described using both parametric and nonparametric tests and some numbers are given without percentage. All the private cases stayed overnight and all those from the NHS went home the same day. If the technique was so comfortable, then one would have expected most private patients to go home the same day. At the end of the day, any cost saving should apply to private patients, either insured or selfpaying. Preoperative transfusion is not a complication of the operation and should not have been included in that category. Performing a large loop excision of the transformation zone (LLETZ) at the same time is interesting as the patient could have had a total hysterectomy. No information was given as to why was the LLETZ performed nor what was the histological diagnosis. The talk about future data collection should not be in the results section. The possibility of abdominal leiomyomatosis following morcellation of fibroids needs to be addressed.It is important to put the findings in perspective. Information as to the numbers of total hysterectomy (vaginal, laparoscopic and abdominal) as well as the number of mirena insertions and ablations carried out at the same time interval at the hospital would have given an indication to the proportion of cases that can benefit from the technique. This is particularly important, given the high number of women having subtotal hysterectomy included in the study. A comparison of complications would have helped even more. Certainly, the relative value of this technique would have been better demonstrated through a randomised controlled trial against another technique of laparoscopic subtotal hysterectomy. Likewise, an idea about how many women declined the technique would help appreciating patient acceptability.There is no reference to back the estimated number of hysterectomies carried out in the UK or the claim that laparoscopic su...