Hysterectomy Revisited

EDITORIAL COMMENT: : There is something about vaginal hysterectomy that provokes argument. Most gynaecologists enjoy performing the operation, especially when all goes well, and there is no difficulty encountered with haemorrhage when the uterus is reluctant to descend, even after the uterosacral and transverse cervical ligaments have been divided. Most gynaecologists have experienced such a complication, which may render them reluctant to perform the operation in the absence of prolapse. This paper will interest readers ‐ it presents quite excellent results in 279 women, without uterine prolapse, having vaginal hysterectomy in a practice where more than 80% of hysterectomies are performed by the vaginal route. This paper cites the Mercy Maternity Hospital experience where over the 16 years, 1971–1986, the ratio of abdominal to vaginal hysterectomy has risen from 3:1 to 7.5:1. This sentence summarizes the practice of more than 20 gynaecologists and in the Editor's opinion should not be lightly dismissed. Mr Leslie Gleadell, a senior Melbourne gynaecologist well‐known to many readers of this Journal, was one of the first Australians trained in Vienna to perform vaginal hysterectomy but in his latter years he was fond of describing the procedure as a ‘young man's operation!’ We have had this paper reviewed by several senior gynaecologists and their opinions were not unanimous. Dr. A. G. Bond ‘agreed in principle with the content of the paper, and considered the same results could be obtained by any gynaecologist given suitable training’. Doyen (1859–1916) stated ‘no man can call himself a gynaecologist until he can perform a vaginal hysterectomy’ and ‘the gynaecologist shall be capable of applying as faultless a technique per vaginam as he would if performing per abdomen!’ Dr. Bond consulted his own records and reported ‘that between 1981 and 1990 in my private practice, 1 carried out 875 hysterectomies, 720 by the vaginal approach (82%). However, I carried out some vaginal repair on most of the patients, even if there was no symptomatic prolapse, as I consider most parous patients have sufficient prolapse to warrant a prophylactic repair. My results would be much as those reported in this paper!’ The Editor has reviewed his own experience of consecutive Repatriation General Hospital patients treated by him between 1976 and 1990. No patient had a vaginal hysterectomy without repair, and the relative numbers of operations were: abdominal hysterectomy 227, vaginal hysterectomy and repair 146, anterior and/or posterior repair 135, Manchester repair 114. Summary: : This paper summarizes the results obtained in 279 vaginal hysterectomies performed in the 5 years 1985–1989 in the public and private practices of a single gynaecologist. It is suggested that it is feasible and safe to perform a hysterectomy vaginally in preference to the abdominal route in the majority of women, even in the absence of uterine descent. It is essential that registrars in training continue to be thoroughly versed in the techniques of vaginal surgery if such techniques are not to be forgotten.