We read with much interest the paper by Lakeman et al., published in the November 2012 issue of BJOG. In so doing, they are helping to promote vaginal hysterectomy (VH) for the non-descent uterus. This procedure hitherto remains the domain of a minority of gynaecological surgeons, despite being the recommended route.[2, 3] We cannot but stress the importance of this gynaecological operation.
Moreover, we would have been keen to learn about the uterine pathologies involved in their study as well as the overall rate of VH. We have changed from laparoscopically assisted VH to straight VH, and have performed over 800 such procedures for uterine fibroids ranging between 200 and 700 g in weight. We have attained a VH rate of 50% or more for hysterectomies involving non-descent uteri.
We would like to point out that securing the uterosacrals and cardinal ligaments, as well as myoreduction (viz. morcellation, wedge resection, intramyometrial coring, etc.), steps that are necessary to complete the surgical intervention, are the more cumbersome and time-consuming aspects of the procedure.
Suitable clamps and correct needle placement are primordial for conducting VH safely and avoiding complications. In proficiently trained hands ligaturing the large pedicles (>7 mm) encountered should be as quick as, if not quicker than, bipolar coagulation. There is also a question mark regarding bipolar coagulation of atheromatous vessels. We are of the opinion that trainees would benefit most by practising to conventionally secure pedicles, which requires a high level of skill and dexterity in many a tight situation encountered during VH.
More often than not VH also allows for the early discharge of patients within 48–72 hours, thus further curtailing expenses.
In the present cost-conscious climate, we find it hard to justify the additional costs despite the advantages mentioned.