Centres that do not offer TLH as their primary method of hysterectomy should be considered outdated and not Fit for Purpose: AGAINST: To allow one their informed choice may mean others have no choice at all.

Abstract

The delivery of a laparoscopic hysterectomy service presents many challenges, not all of which can be met by every centre. The availability of appropriately trained doctors is limited by access to Advanced Training Skills Modules (ATSMs) in Benign Gynaecology and Advanced Laparoscopy, which not all consultants have yet undertaken. In addition to the doctors, theatre personnel who know how to use and maintain the equipment are also essential. Affordability is another factor given that laparoscopic hysterectomies use more consumables and operative time. Training has a long learning curve and time taken to complete surgery can be many hours per case. Most health economic arguments that support this approach assume that all operators are equally skilled and take similar operative time, when we know that not to be true. Operative time is a finite and expensive resource, and targets from referral to definitive management currently drive the service more than quality-of-life outcomes. They also assume that all patients who have laparoscopic surgery only stay for 1 day. Remuneration is not the same across all institutions. Currently the tariff for laparoscopic hysterectomy is lower than for open hysterectomy. They also do not account for the cost of acquisition, amortisation, and maintenance, nor for the cost of higher complication rates, both in terms of re-operations and prolonged stays in hospital. As the surgical techniques are refined, the cases for which they are advocated increase in both number and complexity, with a commensurate increase in the equipment required delivering it. With time the cost of delivery can only rise. All these factors make affordability a major issue in most centres. The patient's anatomy, performance status, and pathology of the condition to be managed also have an influence. Treatments such as the intrauterine system (IUS), endometrial ablation, and hysteroscopic surgery means that hysterectomy is reserved for more challenging pathology, such as fibroids and endometriosis. Sometimes an open approach is intrinsically safer. It is no longer acceptable to reduce a fibroid in size in order to aid its removal because of the risk of disseminating previously unrecognised cancer. The US Food and Drug Administration (FDA) estimates this risk to be 1/350, and although this figure is debated, it would be a foolhardy surgeon that ignores it. Thus a fibroid that obstructs safe access to the uterine vessels, pelvic sidewall or cannot be removed intact is not suitable. Only surgeons trained in advanced laparoscopic techniques can manage rectosigmoid disease and dense adhesions safely. Advanced ovarian cancer will usually require an open approach. The needs and priorities of health care vary widely in resource-rich and resource-poor countries. The quality-of-life outcomes have little relevance when maternal and perinatal mortality is high. Training in these countries is quite appropriately focused on the improvement of maternity care. The supply of basics such as sutures, swabs, and an electrical supply are more pressing matters than the ability to deliver complex minimal-access surgery. In a state-provided service, the needs of the population supersede those of the individual. Thus an individual patient's ‘rights’ should be seen within the context of safety and affordability. To allow one their informed choice may mean others have no choice at all. None declared. Completed disclosure of interests form available to view online as supporting information. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.