Gynaecological surgery

I like to highlight the improved knowledge from findings of research reports on gynaecological surgery in this issue of BJOG.

The length of post-operative stay following a hysterectomy has reduced considerably over the last 4 decades following the introduction of the minimally access surgical approach. Many of us may not remember patients used to routinely stay for 5–7 days post-operatively following this procedure when it was performed either via a laparotomy or vaginally. Since then, the use of the laparoscopic approach has reduced this duration to 2 days routinely with a significant reduction in the number of hospital beds required to deliver this service. Dedden and colleagues conducted a randomised controlled trial to compare the physical function of patients at 7 days post-operatively when patients were either discharge home within the same day or the next day follow a total laparoscopic hysterectomy for benign gynaecological indications (pages 1762–1770). The study concluded that this outcome was non-inferior between same and next day discharge from hospital. The study also reported that the post-operative complication rate at 6 weeks post-operatively, re-admission rate and the number of post-operative patient reviews at both hospital and primary care were not statistically significantly different between both study groups. The data also showed that the level of physical function 6 weeks after surgery is still below that measured pre-operatively, suggesting that full recovery from this type of surgery requires a longer time period. Hence, patients undergoing an unremarkable laparoscopic and possibly robotic assisted hysterectomy can be feasibly discharged on the same day after surgery, especially when early mobilisation and other aspects of enhanced surgical recovery are also implemented.

There remains uncertainty with the effectiveness of surgical excision to cure the pelvic pain from endometriosis. Currently there is an ongoing randomised clinical trial comparing pelvic pain following surgical excision versus placebo for patients with superficial peritoneal disease¹. On pages 1793–1804, Lewin and colleagues analysed data from an international database on the effectiveness of surgical excision alone versus excision plus hysterectomy with or without bilateral oophorectomy for improving pelvic pain and quality of life in women with deep recto-vaginal endometriosis. When compared to women who undergone excision alone, non-cyclical pain, dyspareunia, back pain and quality of life scores at 24 months post-operatively were significantly improved in those women who had the endometriosis excised plus hysterectomy without oophorectomy. Those women who had surgical excision together with hysterectomy and bilateral oophorectomies also had significant improvement in these outcomes compared to those with excision alone. Women who had the removal of both ovaries during a hysterectomy at the time of the surgical excision has improved non-cyclical pelvic pain and quality of life compared to those with their ovaries conserved but there remains some uncertainty due to the loss to follow up. Patients undergoing excision plus ovarian conservation also had significant improvement in faecal urgency and diarrhoea compared to those women undergoing surgical excision alone. However, these benefits from improvement in pelvic pain with hysterectomy come with a higher odds of a peri-operative surgical complication compared to surgical excision alone. Evidence from randomised controlled trials may eventually provide some definitive answers but the rarity of the disease and the limited availability of the surgical expertise to treat this disease pose significant challenges to the successful execution such a study.

The BJOG has a dedicated article type called Operative Techniques' to highlight new and innovative surgical procedures. These articles provide an opportunity for authors to describe and illustrate their surgical methods. We encourage authors to submit still illustrations or video clips of the surgical procedure described in their manuscripts. The word count for such articles is limited to 1800 words and a block abstract consisting of no more than 100 words is required with the submission. We also require authors to provide some clinical outcome data for a reasonable sized series of the procedure described. We therefore tend not to accept submission which merely describe or illustrate the procedure without any surgical outcome information.

Lastly, I just like to wish the readership a very merry Christmas and all the best for 2025 from the BJOG editorial team.

PC is a member of the trial steering committee of the ESPriT2 study.