Surgical approach to hysterectomy for benign gynaecological disease

Abstract

Significantly improved outcomes suggest VH should be performed in preference to AH where possible. Where VH is not possible, LH may avoid the need for AH, however the length of the surgery increases as the extent of the surgery performed laparoscopically increases, particularly when the uterine arteries are divided laparoscopically and laparoscopic approaches require greater surgical expertise. The surgical approach to hysterectomy should be decided by a woman in discussion with her surgeon in light of the relative benefits and hazards. Further research is required with full reporting of all relevant outcomes, particularly important long-term outcomes, in large RCTs, to minimise the possibility of reporting bias. Further research is also required to define the role of the newer approaches to hysterectomy such as TLH.

Objective assessment of vaginal surgical skills

“…11 Vaginal surgery is considered the approach of choice for most patients requiring hysterectomy because morbidity is lower with the vaginal approach than with any other method. 12,13 Furthermore, vaginal surgery requires a unique set of surgical skills because of limited exposure, limited assistance, and operating in a narrow cavity. Therefore, it is essential to have a specific instrument for assessment of vaginal surgical skills.…”

Laparoscopic hysterectomy and ureteric injury: a comparison of the initial 275 cases and the last 1,000 cases using staples

“…The Review found that the ureteric injury rate was higher with LH than AH (10 out of 796 vs. 1 out of 512) with OR of 3.83 (0.94, 15.57) [20].…”

“…The recent Cochrane Review [20] on the different surgical approaches to hysterectomy for benign gynaecological diseases compares ureteric injuries from LH and AH, with the Review citing four published trials [21][22][23][24][25].…”

“…In the trial by Lumsden et al [23], 76 of the 95 patients in the LH arm had the "uterine arteries divided using the Endo GIA disposable stapling device" and yet the Review [20] classified the LHs in this trial as "non-categorisable". The Review [20] makes important errors with regard to ureteric injuries in this trial by quoting two ureteric injuries in the LH arm and one in the AH arm (see Fig.…”

“…The Review [20] makes important errors with regard to ureteric injuries in this trial by quoting two ureteric injuries in the LH arm and one in the AH arm (see Fig. 27 in [20]), whereas in fact there were no ureteric injuries after LH and two after AH.…”