A randomised comparison and economic evaluation of laparoscopic‐assisted hysterectomy and abdominal hysterectomy

Sir, Professor Garry writes a comprehensive letter commenting on our paper comparing laparoscopic and abdominal hysterectomy. Although I would agree that the study was not perfect, I feel that we can support the conclusions that we drew. Professor Garry’s first comment was on the power calculation used for the study. We made no attempt to hide the fact that we were unable to recruit the number that we had hoped because we found that, towards the end of the study, women increasingly expressed a preference. We had also based the power calculation on the published complication rates, which were higher than those we found in our study. Obviously, we were pleased that this was the case, as I believe it makes our findings more robust. However, we were not able to comment on a difference in complication rates and I agree entirely with Professor Garry that a much larger study, such as the one he is co-ordinating, is required to do this. It is very important that such a study is completed and published, as it will provide a lot of additional information over our own small study. We do not draw any conclusions regarding complication rates except to say that we believe that our level of complications was acceptable and that overall both routes are safe. It cannot deny that more and more gynaecological surgeons are moving away from the staple guns. This is to be expected due to the considerable cost of these instruments, and it is likely that the use of cheaper or reusable instruments will reduce the cost. Again, it is probable that Professor Garry will be able to investigate these aspects in his larger study. However, I think one should bear in mind that many women having abdominal hysterectomy now go home on day 3, as in Glasgow, with the woman receiving a visit as required from nursing staff at home. This is having a considerable impact on the cost of the procedure since the care required by the nurse is minimal. Unfortunately, any research is always slightly out of date by the time of publication. I agree wholeheartedly with Professor Garry’s comments on suggesting that larger studies are essential, as they will provide additional information regarding complication rates. However, it does mean that those will be very large, and I am sure Professor Garry will agree that co-ordinating studies of this nature is extremely difficult and the standard of the participating surgeons is likely to vary considerably. The VALUE study, which is a large national prospective survey in the UK, will provide different information. The difficulty with such surveys is completeness, and there is a concern that some complications will not be reported. Hopefully, this will be minimal. I think that the data provided by our study support our conclusions. Our study did not support change from abdominal to laparoscopic hysterectomy. We do not say that laparoscopic hysterectomy has no place in gynaecological practice, but we feel that its place maybe somewhat smaller than we had anticipated.