Nicholas Pairaudeau has been an Obstetrician and
Gynecologist in practice since 1976. He trained in Obstetrics and Gynecology in
the United Kingdom, Kings College Hospital, London University and transferred
to The University of Toronto in 1973. In 1976 He took up his specialist
practice at North York General Hospital, an affiliate of the University of
Toronto. He still has a very busy practice of both Gynecology and Obstetrics,
teaching, mentoring, as well as striving to be innovative in practice. He
travels extensively, particularly in China, where he has visited from the North
to the South, and he has been involved in teaching, mentoring, and
assisting. He is also a member of the
Royal Society of Medicine, Royal of Surgeons Canada, SOGC, ESGE, AAGL, as well
as an active member of the SLS, which is an organization based out of Florida
in the USA.
Hysterectomy is one of the most widely performed operations on Woman, yet the jury is still out as to the best way to remove the uterus. Though through advances with technology, the uterus can be removed through small incisions, the cost for these operations can be increasingly high, and third world countries have neither the resources or the training for these operations. The other issue is that with longer operations the effects on the body increase, and the time taken to operate increases the waiting list.
Historically, the earliest known hysterectomy recorded in the English literature was apparently by a Charles Clay in Manchester UK in 1843.(1) There were subsequently other gynecologists who performed hysterectomy and these were recorded in the medical literature of the Day.(2) In 1929 Dr Richardson published a complete full hysterectomy, including cervix as well ovaries(3). Since then various approaches have been described, including the original subtotal by laparotomy, to the more complete operations, with various techniques.(4)
With the pioneering work of Palmer in Paris, (5) with laparoscopy, in the late 1930s this became the modern and increasingly popular route for pelvic and abdominal surgery in the 1960s, after competing against culdoscopy in the USA. This set up Dr Semm(6) in Germany , and Dr Harry Reich in The USA to show that MIS, (minimally invasive surgery), laparoscopy hysterectomy was not only possible, but had many advantages over the more traditional way that was carried out over the world. They taught many gynecologists throughout the world, who later made various changes to the way that they taught.
BY 2000, the Robot began to be incorporated into nonmilitary, non-battlefield surgery, with mostly prostate surgery. By 2005, FDA approval, (7) was given for the Da Vinci Robot to be used in gynecological surgery. As time went on, the operations that could be performed with the robot mushroomed.
However, with all MIS, minimally invasive surgery, there were significant startup costs, and then there was the maintenance of the equipment.(8) Disposables contributed greatly to the cost of each operation, but there was no alternative to this system until recently. With the Senhance system. (9) Interesting variations in the technology needed for successful safe robotic surgery were and are still being developed.
However with all medical treatments there is a cost. NO wealth no health is well known to persons in the third world. Gradually, modern gynecology surgery began to deviate with the original core approach to hysterectomy, laparotomy, to being replaced by more modern techniques, but leaving the third world with the challenge of no money and lack of the skills to complete the more advanced procedures. Most conferences tend to focus on the latest, innovative, but also more expensive technology to remove the uterus. There is little enthusiasm for looking backwards, when gleaming new equipment that with experienced operators and assistants, can make these operations very impressive, with results that suggest that recovery is quicker and easier.
There is NO doubt that that in busy centres with highly skilled surgeons there are lower complications. And centres that embark upon regular reviews of performance are all too few. Only when we get some sort of level playing field, with studies that are not biased, superficial and lacking very basic data, are we able to really answer the question, what is the best way for a hysterectomy.