Like other major surgeries in women, hysterectomy has been no stranger to controversy, not least in terms of its necessity. In terms of outcome, it has long been recognized that vaginal hysterectomy has a faster recovery with less pain for women than the abdominal approach. It is hardly surprising then, that the evolution of laparoscopic surgery, with its avoidance of pain and lengthy hospitalization, has been an appealing option.

Laparoscopic hysterectomy (LH), whether as an adjunct to the vaginal approach or a substitute, faced some controversy in its early days which arose in part from rapid adoption of this new technology, without the necessary training in all cases. Furthermore, LH was an expensive, if less invasive, option, limiting its uptake and impeding training. Its early adopters faced criticism in terms of the operating time required, especially in settings where operating room time is at a premium. However, minimally invasive surgery is now becoming the norm driven in part by the search for alternatives to costly inpatient care and overall costs, explored in the book, are comparable to traditional approaches. At this time, cost is a significant barrier to the extensive use of robotics, but continued evolution would be expected to result in improved and ultimately less expensive technology.

The potential if controversial role of laparoscopic hysterectomy for indications such as gynaecologic malignancy or in obese women is explored in the chapter by Dr. Ceana Nezhat, in terms of the emerging use of LH for radical hysterectomy and exenteration. As skills and technologies evolve, the outcome data will inform best practice on an individualized basis.

The resurgence of supracervical hysterectomy is the focus of three chapters, though the rationale for this approach today is not only to avoid ureteric and other injuries. Having fallen into disrepute because of concerns about cervical cancer in the stump, the current debate includes yet unproven concepts such as the importance of preservation of innervation. It remains to be seen whether the rationale will ultimately be substantiated making it an option comparable to LH and laparoscopically assisted vaginal hysterectomy LAVH.

Despite the exciting developments of new technologies and resurgence of old surgical approaches, the book makes it clear that there is no evidence to support LH if the vaginal approach is safe. For vaginal hysterectomy (VH), it is difficult to match the experience of Professor Sheth, who offers pearls of wisdom from his vast experience in surgical technique and understandably makes a strong case, supported by the literature, to make VH the first choice in terms of an approach.

Professor Mettler, as editor and author, illustrates her ability to challenge herself and others to continue pushing the envelope of what is possible, while critically evaluating progress and saving the best of existing knowledge. There is currently no evidence to support abandoning VH for new 9technologies that may be challenging to implement globally or in certain clinical situations in the foreseeable future. The applicability of LH in low resource countries in the public setting will continue to be especially challenging.

This book is a stimulus to ask some difficult questions about when and where abdominal hysterectomy is indicated, based on the evidence, and for continued advances in technology and surgical procedures, with the associated training and evaluation to ensure optimal outcome. It is an appropriate topic to mark a time of reflection on an illustrious career.

In 1988 no one was thinking about doing hysterectomy by laparoscopy. The major centers in the world doing laparoscopic surgery were in Clermont Ferrand, France and in Kiel, Germany. I acknowledge that Kurt Semm, Liselotte Mettler, Maurice Bruhat, and Hubert Manhes were great influences because they also knew no boundaries.

I have known Lilo and Kurt Semm for over 20 years. They were the only show in town in the early days of operative laparoscopic surgery. When I met Kurt Semm in 1986 he observed desiccation of the ovarian blood supply with reserve. He encouraged me to learn how to suture. For that I thank him very much. I think that he was right: the ability to suture defines a laparoscopic surgeon. Please realize that these operations were done with the operating surgeon visualizing the operative field with the eye with minimal assistance before 1986. Also, please realize that publication of laparoscopic gynaecological operations was very difficult in the 80s as few of the pioneers were in academic positions. Laparoscopic hysterectomy was unpublishable in 1988 and before. This has been a major struggle. Many papers of substance on laparoscopic surgery in the early 90s were in a journal that never got Index Medicus acceptance: Gynaecological Endoscopy.

Professor Mettler has been a star before, during, and after her long association with Kurt Semm. Her passion for laparoscopic surgery led to its development around the world.

I remember Lilo telling me that I indirectly helped Kurt and Lilo in the development of CISH, which stimulated interest in laparoscopic supracervical hysterectomy worldwide. He believed that there must be a better way to do a laparoscopic hysterectomy after watching me do one in Baltimore in 1991.

Recent papers by Clayton and the Cochrane database reviewed evidence-based hysterectomy studies and conclude that vaginal hysterectomy (VH) is preferable to abdominal hysterectomy (AH). There is no evidence to support the use of LH if VH can be done safely. Compared to AH, LH is associated with less blood loss, shorter hospital stay, speedier return to normal activities, but it takes longer, costs more, and urinary tract injuries are more likely. Vaginal hysterectomy should be the preferred route when applicable. Laparoscopic hysterectomy should be considered as an alternative to abdominal hysterectomy.

Abdominal hysterectomy is the preferred method of treatment based on training and remuneration. Laparoscopic hysterectomy is a substitute for abdominal hysterectomy and not for vaginal hysterectomy. Why are there so few laparoscopic hysterectomies done today? It is a major problem!11

Lilo has done much to develop minimally invasive surgery, but we have a long way to go. With much respect, Lilo deserves to be honoured with this book…and a lot more! I look forward with great pleasure to the complete version of this volume honouring Liselotte Mettler.

The decision to perform a hysterectomy is always taken jointly by the patient and her gynaecologist. Culture, religion and lifestyle can influence this decision. All hysterectomy procedures – laparotomic; vaginal; laparoscopic subtotal, total and radical approaches – are well described in the literature and every gynaecologist is free to select, within the limits of “good standard practice”, the hysterectomy modality he/she chooses. This decision is also influenced by other factors, such as the location of the hospital, the instrumentation available and whether the patient can be seen again as an outpatient.

This book provides a survey of the technical possibilities for hysterectomies in the first decade of the 21st century. The editor knows quite well that worldwide the laparotomic hysterectomy approach still prevails; however, these chapters document the current hysterectomy modalities in the hope that a scientifically-based consensus for hysterectomies can be found in the years to come.