I am grateful to Mr Rankin for his comments. I agree that one of the benefits of the current interest in laparoscopic surgery is to turn our profession's awareness to surgical topics. Gynaecologists are once again thinking about and experimenting with many aspects of surgical technique, including vaginal surgery.
Vaginal hysterectomy has been available for more than 150 years. Year after year in this country, however, only about 20% of the total number of hysterectomies performed are completed by the vaginal route. One of the main indications for laparoscopic assistance with hysterectomy is to avoid a large laparotomy incision. If Mr Rankin can achieve a safe and straightforward vaginal hysterectomy whatever the pathology on every occasion then he does not need to develop any additional laparoscopic skills.
Most other gynaecologists have found that the vaginal approach to hysterectomy is at times far from simple and safe.
This is especially the case in the presence of pelvic pathology such as endometriosis or pelvic adhesions, particularly if also associated with restricted vaginal access and restricted uterine descent.
My philosophy is to use the laparoscope first to determine the nature and extent of pelvic pathology. Why do some vaginal surgeons believe that there is some advantage in not knowing what is present in the pelvis before performing a hysterectomy? Just as hysteroscopy marks a real advance over “blind” D&C, so laparoscopic assisted vaginal hysterectomy is an advance over “blind” vaginal hysterectomy. LAVH permits the gynaecologist to know more precisely what pathology is present and to thereby tailor more accurately the surgery to the pathology.
All stages of a hysterectomy can be completed with vaginal techniques and all stages can also be performed completely with laparoscopic techniques. Not all steps are equally simple with each approach. Most gynaecologists find that the lower supports of the uterus including the uterine arteries are most readily secured with vaginal procedures, but that the upper pedicles particularly the infundibulo-pelvic ligaments and any extra-uterine disease are more readily dealt with by laparoscopic techniques. I believe the optimum approach is to perform the steps which are simplest to do laparoscopically by that route and the steps which are simplest to perform vaginally by that route. The proportion of each will vary according to the experience and aptitude of the surgeon and also according to the pelvic findings at the time of surgery.
I share with Mr Rankin the belief that avoiding the abdominal route for hysterectomy is preferable when possible. I, however, believe that laparoscopic assistance will enable more gynaecologists to avoid more abdominal hysterectomies than simply exhorting them to try harder with vaginal techniques.