Laparoscopic hysterectomy.

The first laparoscopic hysterectomy using only laparoscopic techniques was performed around 10 years ago by Harry Reich. Such total laparoscopic hysterectomy (TLH) approach is surgically elegant but technically difficult. A number of alternative laparoscopic techniques to perform all or some of the hysterectomy have since been introduced to simplify the surgical technique but retain the major advantages of the approach, which is to avoid the use of a large laparotomy wound. The advantages of this approach have been well documented, but so far the laparoscopic route has been little used by the general gynecologic surgical community. Although it has been possible in some units to reduce the laparotomy rate for hysterectomy to 10%, there is evidence from the United Kingdom and the United States that still more than 70% of all hysterectomies are still being performed by the laparotomy approach. This chapter seeks to explain why this should be so and how appropriate training and acquisition of the necessary skills in operative laparoscopy and vaginal surgery can be achieved to ensure that all patients who may benefit by avoiding a laparotomy incision are given the opportunity to do so.