As robotic and laparoscopic surgery increasingly shape perceptions of ‘advanced’ gynaecological care, vaginal surgery, despite being a time-tested, incision-less and cost-effective approach to procedures such as hysterectomy, is steadily losing ground among younger gynaecologists in India.
Expressing concern at the trend, vaginal surgeons said the decline is not because vaginal surgery has lost its clinical relevance but because it lacks the visibility, technology-driven appeal and commercial ecosystem surrounding newer surgical procedures.
“Moreover, many patients are also unaware that it may be the best option for them in many gynaecologically related health issues. It is important for the patients to ask their surgeon about all available surgical choices—including whether a vaginal hysterectomy is appropriate in their case,” said Dr VP Paily, National President, Society of Vaginal Surgeons of India (SOVSI).
Talking to the Health Outlook on the sidelines of a recently concluded two-day SOVSI conference organised in collaboration with Yatharth Super Speciality Hospital, Model Town, Delhi, he said. “It is the safest and cheapest route for procedures like hysterectomy. However, it is losing its glamour because there are no promoters, as it is not a money-minting route for hospitals and doctors when compared to the laparoscopic or robotic procedure.”
However, he made it clear that the argument was not against newer techniques. “It (vaginal surgery) is not against laparoscopy or robotic surgery, but the patients must know an established surgical route can be less invasive, less equipment-dependent and more affordable.”
Earlier, addressing the event, Dr Randeep Guleria, former director, AIIMS Delhi, and Chairman, Dept of Internal Medicine, Pulmonary & Critical Care, Medanta the Medicity, Gurgaon, too echoed similar sentiments as he highlighted the importance of vaginal surgery.
“With its emphasis on an original ‘incisionless’ minimally invasive approach, patient comfort, faster recovery, cosmetic advantage and excellent outcomes, vaginal surgery remains an important and valuable component of modern gynaecological practice.”
However, since hospitals invest heavily in advanced equipment like a robot or a sophisticated laparoscopic system, while manufacturers provide training and technology support for patients, the presence of such high-tech gadgets can also become a visible marker of advanced treatment, the participants at the symposium noted.
Vaginal surgery, in contrast, depends less on expensive technology and more on the surgeon’s training, experience and ability to operate through the natural vaginal route.
The veterans in the sector pointed out that the vaginal route is particularly established for hysterectomy in appropriately selected women. Instead of making an abdominal incision or inserting laparoscopic ports, the uterus can be removed through the vagina. This can mean no abdominal scar and, depending on the patient and procedure, early mobilisation and recovery.
Dr PC Mahapatra, National Advisor, SOVSI, strongly felt this is also why the vaginal surgery approach is relevant to India, where access to sophisticated surgical infrastructure remains not only uneven but also a financial burden.
Laparoscopic surgery uses small abdominal incisions and specialised instruments. Robotic surgery uses an advanced robotic platform controlled by the surgeon. But vaginal surgery can avoid abdominal incisions altogether in suitable cases.
That does not make one route universally better than another. The appropriate approach depends on the condition, anatomy, previous surgeries, size and position of the uterus, the patient’s overall health and the surgeon’s expertise, said Dr Mahapatra.
As Dr Guleria too said in his address, “Most international guidelines continue to advocate the natural orifice vagina approach whenever clinically feasible.”
To bring home the point, Dr Sonal Bathla, Organising Chairperson, SOVSI, and Director and Head of Department, Obstetrics and Gynaecology, Yatharth Super Speciality Hospital, Model Town, Delhi, compared vaginal surgery with another familiar surgical procedure.
“If you are removing a tonsil, you won’t have to make a cut from outside the cheek and remove it. You will go through your mouth and remove it. So similarly, why remove the uterus through laparoscopy or through robots or through the abdomen? Why not from the natural route which God has given us, i.e., the vagina?"
The surgeons at the seminar too felt that vaginal surgery deserves to remain part of the conversation rather than becoming a skill practised by only a shrinking pool of specialists. Dr Mahapatra pointed to its potential relevance beyond major cities.
“When you plan for laparoscopy or robotic surgery, a patient has to look towards gadget-equipped tertiary hospitals. But vaginal surgery can be done at a PHC, at the Taluka level or at the district hospital,” he said.
The point, Dr Mahapatra said, is that since vaginal procedures require less specialised equipment, it could potentially be offered closer to where women live when the necessary expertise and facilities are available.
The issue, however, is not simply about cost, he clarified. It is also about maintaining surgical skills across levels of the healthcare system. Dr Mahapatra stressed that surgeons should not become committed to one technology.
"Science should not be dogma in science. I do everything. Laparoscopy also we do. Open also we do. Vaginal also, we do. It is the need of the patient, not the mood of the gynaecologist,” he said.
However, if younger doctors are predominantly trained in laparoscopic and robotic techniques while receiving limited exposure to vaginal procedures, the expertise needed to offer the latter could gradually become concentrated among fewer senior surgeons, opined Dr Bathla. She suggested that corporate social responsibility (CSR) programmes could support training centres and fellowships for gynaecologists, particularly to build surgical capacity in vaginal surgery outside major metropolitan hospitals.
“Such programmes could help younger doctors acquire hands-on experience under senior surgeons rather than allowing the skill to become concentrated in a small number of specialists.” Dr Bathla also said that the SOVSI has been conceived with the idea to provide a platform for young gynaecologists and emerging vaginal surgeons, nurturing their skills, understanding decision-making in real time and developing an academic spirit to carry forward the legacy of this time-tested procedure.
At the conference, the doctors also discussed how varied conditions like infertility, cervical polyps and some cervical or lower uterine abnormalities can sometimes be treated through vaginal approaches. Similarly, procedures for cervical insufficiency may be considered in selected patients depending on their clinical circumstances. The key, they stressed, is appropriate patient selection rather than promoting one route for everyone.
The surgeons also cited selected procedures involving the uterus, ovarian cysts and other pelvic conditions where the vaginal route may be considered. They also highlighted procedures for pelvic organ prolapse and stress urinary incontinence, a common problem in which women leak urine while coughing, sneezing or exercising.
The aim, doctors maintained, is not to replace one technology with another but to widen the choices available to women.
As Dr Mahapatra puts it, the question should not be, “Why didn't you do robotic or laparoscopic surgery?” It should first be: Which route is safest and most appropriate for this particular woman?
