Laparoscopic Hysterectomy, Total Abdominal Hysterectomy, Vaginal Hysterectomy; Uk Study

For much of the twentieth century hysterectomy has stood as one of the cornerstones of gynaecological surgery. There has been a relatively stable and effective approach to technique and all gynaecologists were trained to master the abdominal and vaginal approaches and their relative advantages and indications. If anything any controversy associated with hysterectomy has been related to the fate of the ovaries and to the indications for the operation, hysterectomy rates varying widely in international comparisons. The closing years of the century have been a time of substantial experimentation in techniques resulting from the endoscopic surgery revolution. These developments demand investment in new skills and equipment so are being explored only by a subgroup of gynaecologists many of whom see endoscopic approaches to gynaecological surgery as the way of the future. Another relatively recent trend is to manage some benign indications for hysterectomy using conservative approaches which can be endocrine (e.g. levonorgestrel IUS), radiological (e.g. fibroid embolisation) or surgical (e.g. endometrial ablation). It is certain that a substantial proportion of the present generation of gynaecologists will continue to practise in the established tradition and not take on the newer endoscopic approaches to hysterectomy. It is also unlikely that those developing endoscopic hysterectomy will return to open surgery for such cases and many trainees wish to develop those skills. It is very possible that the next generation will see hysterectomy as a very technically diverse subject with many different surgical approaches possible with few able to offer the whole range of options. The challenge is to devise training schemes to fit with this new world and to seek to ensure that the future consensus is based on good evidence and for this we require comparative trials. Optimally these should be randomised controlled trials and could then be disseminated in our work in the Menstrual Disorders and Subfertility Group of the Cochrane Collaboration. It is well recognised that surgical trials are considerably more difficult to organise that trials of medical interventions but the culture in favour of surgical trials is changing for the better.