Advances in laparoscopic surgery have made vaginal hysterectomy in the absence of prolapse obsolete: FOR: The laparoscopic approach is suitable for almost all hysterectomies

Total laparoscopic hysterectomy (TLH) is no longer a new and experimental procedure and is now common practice in most hospitals. Experienced, trained and specialised gynaecologists perform these procedures and train residents to do so as well. The new generation of gynaecologists will have had a lot of training in and exposure to this procedure, enabling them to undertake it in a safe and efficient way, making it the operation of choice. In the absence of prolapse, TLH should be considered the superior method of performing a hysterectomy. Removing a uterus utilising laparoscopy gives a better view of the pelvis to diagnose pathology such as adhesions, endometriosis and pelvic masses. The risks of complications from a vaginal hysterectomy (VH) are a result of unexpected intra-abdominal adhesions between the bowel or bladder. The laparoscopic procedure also magnifies the operative field, providing better visualisation than the naked eye during open surgery. Laparoscopy gives better surgical access when dealing with a larger uterus such as those caused by fibroids, and uterine abnormalities such as bicornuate uterus. The VH is difficult to perform with a bulky uterus. The vaginal approach will be even more challenging if the descent is inadequate. If there is a reason to remove or to treat other genital organs, laparoscopy gives better surgical access. In the future it is likely that some women who have a hysterectomy will want to remove their tubes but keep their ovaries. The treatment of additional intra-abdominal pathology is difficult to perform with the vaginal approach. There is less likelihood of post-operative intra-abdominal bleeding, as haemostasis can be assessed more thoroughly via the laparoscope as opposed to vaginal route. With all the advantages of TLH there is hardly an indication for VH left, apart from prolapse. The opportunity to become and stay experienced in performing VH will decrease. A very experienced surgeon will perhaps succeed in performing VH without a serious complication. However, these surgeons are rare. Results of the performed RCTs comparing TLH with VH do not apply to the new generation of well-trained laparoscopic surgeons. The Cochrane meta-analysis concludes that VH proved to be the superior procedure because it was associated with the quickest return to normal activities and the earliest discharge from hospital (Aarts et al. Cochrane Systematic Reviews 2015). However, advances in laparoscopic surgery show that TLH can be performed as a day case, which will reduce hospital stay (Candiani et al. Curr Opin Obstet Gynecol 2010;22:304). Furthermore, VH was more likely to be associated with substantial bleeding. The most important RCT in this Cochrane review is the Evaluate trial, which was performed more than 10 years ago (Garry et al. BMJ 2004;328:129). The results in 2015 are likely to be markedly different. In the Cochrane review, most advantages of VH over TLH are related to skill and will change if surgeons have more exposure to TLHs than VHs. I believe that the laparoscopic approach is suitable for (almost) all hysterectomies. Skills will be preserved. Therefore TLH is the hysterectomy of choice. 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.