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Author’s Reply

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Sir,

We do not agree with the remarks of Gandhi and Saha1 and would like to set the record straight.

Indeed, in stating that ‘all of these studies are retrospective and by their nature are «chart reviews» and subject to recall bias’, Gandhi and Saha are clearly unaware that, in Belgium, a registry of complications was initiated in 1990 to record the complication rate in the three main institutions where laparoscopic hysterectomy was first developed.

In 1995, during the ESGE Congress in Brussels, the complication rate of laparoscopic hysterectomy issued by the registry was reported and discussed. A comparison was made with vaginal and abdominal hysterectomy, but failed to detect any significant difference. At St Luc’s University Hospital, we decided to continue reporting all complications prospectively.

Our study is therefore not a retrospective study subject to recall bias, as Gandhi and Saha claim. It is an analysis of all complications, carefully and prospectively reported, reanalysed from written accounts and recorded videos.

We dispute the need for a robust multicentre, multinational RCT ‘to increase the validity of Donnez et al.’s hypothesis of the safety of the laparoscopic approach’. Gandhi and Saha are clearly referring to the NICE Guidelines paper published in 2007 (cited in 1).

Once again, this paper, in which the higher risk of urinary tract injury and severe bleeding with laparoscopy compared to open surgery was obviously due to the relatively limited experience of some of the laparoscopic surgeons involved, is being cited as some kind of standard.

Once again, papers by Bojahr et al., Karaman et al. and Wattiez et al. (cited in our manuscript)2 are simply being disregarded.

Moreover, Gandhi and Saha fail to mention the Finnish study, which included 56 130 hysterectomies,3 with a ureteral complication rate of just 0.3% after laparoscopic hysterectomy.

Are Gandhi and Saha trying to cast doubt on all these studies, including the very formidable Finnish series? It is time they accepted that the higher complication rate in the eVALuate study was because of the learning curve.

We maintain that the parachute remains a good example.4 Indeed, a bad surgeon is like a bad parachute and the complication rate will be higher in both instances!

Gynecologists were the pioneers of laparoscopic surgery after all, long before general surgeons got in on the act. Frangenheim, Palmer, Semm, Bruhat, to name but a few, laid the ground and opened the doors to a laparoscopic approach. General surgeons only caught up some time later.

I strongly suggest that Gandhi and Saha take a close look at some of the more recent publications, books and videos by general surgeons. They will see that these surgeons are now ready to take over all manner of surgical procedures of the peritoneal cavity, without any hesitation whatsoever.

If gynaecologists like Gandhi and Saha continue to advocate open surgery instead of laparoscopic surgery for cases that can easily be managed by laparoscopy, we should not be surprised to see general surgeons routinely performing hysterectomies in the future!

To cite a case in point, twenty years ago, uterine prolapse surgery was carried out exclusively by gynaecologists by the vaginal route. Now, it is laparoscopically performed by surgeons, urologists and gynecologists alike.

We should know what we want—and improve our skills accordingly—before we get left behind!

References

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  2. Author’s Reply
  3. References
  • 1
    Gandhi P, Saha A. Have the safety concerns about laparoscopic hysterectomy been fully addressed? BJOG 2009;116:1272.
  • 2
    Donnez O, Jadoul P, Squifflet J, Donnez J. A series of 3190 laparoscopic hysterectomies for benign disease from 1990 to 2006: evaluation of complications compared with vaginal and abdominal procedures. BJOG 2008;116:492500.
  • 3
    Brummer T, Seppälä T, Härkki PS. National learning curve for laparoscopic hysterectomy and trends in hysterectomy in Finland 2000–2005. Hum Reprod 2008;23:8405.
  • 4
    Donnez J, Squifflet J, Jadoul P, Donnez O. EBM and laparoscopic hysterectomy—commentary on ‘The best way to determine the best way to undertake a hysterectomy’. BJOG 2009;166:4767.