We would like to thank Pierre et al. for their interesting comments on our article. They are correct in stating that, at present, it is impossible to conclude which method of developing a pneumoperitoneum is the safest. In order to reach this conclusion massive randomised controlled trials involving hundreds of thousands of women would be necessary to demonstrate only small reductions in complication rates1.
The point out from unpublished data that 8.43% of French laparoscopies are “open” and responsible for 14% of intestinal injuries and two vascular injuries. Unfortunately they do not provide us with further details of this data. It could well be the case that surgeons unfamiliar with the open method are selecting this for high risk patients likely to suffer complications.
We are somewhat surprised by their mention of a fatality from a major vessel injury as it is widely accepted that a correctly performed open laparoscopy should eliminate the risk of vascular damage. We acknowledge that bowel perforations could still occur with the open method but are certain they are more likely to be recognised, resulting in less morbidity and mortality than those associated with the closed method. Their letter perhaps best illustrates an advantage of the French, in that they keep a register of laparoscopic complications, something that we would urge generally.
We would also like to thank de Courcy-Wheeler and Shehata for their support of our thoughts and echo their call for all gynaecologists to learn the technique of open laparoscopy. We would recommend that as the very minimum, if previous surgery suggests that closed laparoscopic entry is more hazardous, then an alternative entry method is employed, be that open or the use of Palmers point, and reiterate our call for these to be taught on basic surgical courses.