This chapter summarises the evidence of the benefits and harm of surgical
therapies for benign gynaecological disease. We have limited the discussion in this chapter to three gynaecological conditions -
menorrhagia,
endometriosis and benign ovarian tumours - with a further section on the different surgical approaches for performing a
hysterectomy for
menorrhagia due to
dysfunctional uterine bleeding and pelvic masses such as
fibroids and benign adnexal masses. The currently available evidence suggests that there is little to choose between the four first-generation endometrial destruction techniques -
laser ablation, transcervical resection of endometrium, vaporisation ablation and rollerball ablation - in terms of clinical efficacy and patient satisfaction. There is a paucity of evidence with regards to the comparison of the different second-generation endometrial-destruction techniques but current evidence suggests that bipolar
radiofrequency ablation is more effective than thermal balloon ablation for treating
menorrhagia. Overall, the second-generation techniques are at least as effective as first-generation methods but are easier to perform and can be done under local rather than general anaesthesia in some circumstances. Hysteroscopic
endometrial ablation is an alternative to
hysterectomy and should be offered to women with
menorrhagia because of its high satisfaction rates, shorter operation time, shorter
hospital stay, earlier recovery and reduced postoperative complications;
hysterectomy remains the surgical option of choice for women with intractable
menorrhagia despite repeated
endometrial ablations and for those who do not wish under any circumstances to continue to have menstrual
bleeding. The combined use of laparoscopic
laser ablation, adhesiolysis and uterine nerve ablation has been shown to have a beneficial effect on
pelvic pain associated with mild to moderate
endometriosis. Current evidence also supports the use of laparoscopic treatment of minimal and mild
endometriosis to improve the on-going pregnancy and live birth rate in infertile patients. The current available evidence suggests that the laparoscopic approach is superior to
laparotomy for the surgical management of benign
ovarian cysts. It results in less
postoperative pain and a shorter postoperative
hospital stay; it also costs less. With regards to the surgical approach for performing a
hysterectomy for
menorrhagia and benign pelvic masses,
vaginal hysterectomy should be performed over laparoscopic and abdominal
hysterectomy when possible. Where it is not possible to perform the
hysterectomy vaginally, then laparoscopic
hysterectomy can be employed instead of abdominal
hysterectomy to avoid a
laparotomy scar. There appears to be no significant advantage in performing a subtotal
hysterectomy instead of the total removal of the uterine corpus and cervix.