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Sir,

I read with interest the paper by Mary Ann Lumsden and her colleagues, which raises several points:

1. Although the authors try to compare two techniques which enable oophorectomy more easily than simple vaginal hysterectomy, it does not appear that oophorectomy was an indication in many of these cases, and it is sad that women have been randomised to an abdominal procedure, when probably simple vaginal hysterectomy would have been the treatment of choice in many.

2. The incidence of ureteric damage of 1% must raise concerns when there does not appear to be any gross pathology in any of these cases.

3. Many minimal access surgeons in this country have long stopped using staple guns because of cost and morbidity. The cost of staple guns does make laparoscopic-assisted vaginal hysterectomy more expensive, and necessitates the use of larger abdominal incisions, possible trauma to tissues and therefore, increased morbidity in the short and long term, delaying recovery.

4. It must also be of concern that the mean duration of laparoscopic-assisted vaginal hysterectomy for individual surgeons was assessed during the study, as it was thought that time may decrease with increasing experience. Earlier in the study, it had been suggested that all the surgeons were experienced, and therefore such a reduction would not have been anticipated. If this analysis was perceived as necessary, it does suggest that there was a perception that experience was not as great as that anticipated before the study.

5. It was also sad to see in the analysis that the median difference was stated first with the mean in brackets, yet the mean difference in costs was used to demonstrate the financial advantage of total abdominal hysterectomy over laparoscopic-assisted vaginal hysterectomy. If the data are analysed looking at the median costs and excluding the cost of disposables (which many surgeons would not use), then laparoscopic-assisted vaginal hysterectomy actually is financially cheaper.