Sir,-the Paper

SIR,--We have read with interest the article by Mr. E. E. Rawlings and Mr. B. Baligobin (29 March, p. 727) and agree that their results of laparoscopic sterilization are depressing and raise doubts about the usefulness of this procedure. We feel, however, that there are several reasons for the high incidence of complications and that it would be a pity to decry the operation on the basis of such a small number of patients and without analysing more carefully the reasons for this high complication rate. Firstly, though the operators were experienced gynaecological surgeons, we do not think they could be called experienced laparoscopists. In 1971, 121 laparoscopic sterilizations were performed 'by "three gynaecological teams," and if a tearm is presumed to consist of a consultant and registrar this means that each operaftor performs an average of only 20 laparoscopic sterilizations per year. This is simply not enough cases to achieve expertise. There is an oft-repeated aphorism that laparoscopy becomes easy after the first 100 cases; these operators might take five years to gain that experience (which is the time afiter which two of the teams gave up doing the operations). The occurrence of four pregnancies (1-6%) after laparoscopic sterilization does not compare unfavourably with the frequently quoted incidence of 1% following open sterilization. The authors do not state whether the patients had dilatation and currettage carried out at the ti,me of operation to exclude an early pregnancy, whether the tu,bes were found to have recanalized, or whether the wrong structures (for example, the round ligaments) had been cauterized and severed. The high incidence of laparotomy in 1971 deserve.s further analysis. There were four cases of haemorrhage from the mesosalpinx; in our experience this can almnost always be successfully arrested by cautery using the laparoscope. Laparotomy would not be the universally agreed treatment for severe postoperative pain (one case) or for pelvic abscess (two cases). All patients having laparoscopy should be warned of the possibility of a laparotomy in case of technical difficulty, but if patients are carefully selected it should not be necessary in many cases; an incidence of 2-4% does not seem too excessive. It is not clear why their patients remained in hospital for an average of 3-4 days, but in this department about 650 laparoscopic sterilizations are performed annually on a day-case basis, and patients find this a great advantage. The economnic advantage is obvious. We hope shortly to publish the results of one year's experience of day-case laparoscopy (about 700 cases), which we think will give a very different impression of the usefulness and patient acceptability of this operation.-We are, etc.,