British Journal of Obstetrics and Gynaecology November 2000, Vol107, pp.

1380-1385

Three methods for hysterectomy: a

randomised, prospective study of short term
outcome Christian Ottosen Consultant, Garan Lingman Consultant, Lena Ottosen
Research Nurse Department of Obstetrics and
Gynaecology, Hospital of Helsingborg, Sweden Objective To

detect differences in clinical short term outcome between total abdominal hysterectomy,
Design Randomised controlled trial. Setting Department of Obstetrics and
Gynaecology,
Hospital of Helsingborg, Sweden. Sample
One hundred-twenty women scheduled for hysterectomy for various indications. Methods
Randomisation into three treatment arms: total abdominal hysterectomy (n = 40); vaginal
hys- terectomy (n = 40) and laparoscopic assisted vaginal hysterectomy (n = 40).
During traditional abdominal and vaginal surgery, laparoscopic assistance was kept to a
minimum. Substantial number of cases needed
volume-reducing manoeuvres due to uterine size.
vaginal hysterectomy and laparoscopic assisted vaginal hysterectomy. Main outcome
measures Results Mean duration (range) of surgery was
significantly longer for laparoscopic assisted vaginal hys- terectomy
compared with vaginal hysterectomy and total abdominal hysterectomy, 102 min
(50-175), 81 min (35-135) and 68 min (28-125), respectively. Mean stay in hospital
andmean time to recovery was
hysterectomy compared with vaginal hys- terectomy
laparoscopic assisted vaginal hysterectomy. The difference between hysterec- tomy and
laparoscopic assisted vaginal hysterectomy was not significant. It was possible
remove uteri under 600 g with all three methods. Four laparoscopic
hysterectomies and one vaginal hysterectomy were converted to open
surgery. Reoperation and
blood transfusion were required after two vaginal
hysterectomies and one laparoscopic assisted vaginal hysterectomy. One woman needed
blood transfusion after total abdominal hysterectomy. Conclusions Traditional vaginal
hysterectomy proved to be feasible and the faster operative technique compared with
vaginal hysterectomy with laparoscopic assistance. The abdominal technique was
somewhat faster, but time spent in theatre was not significantly

shorter.Abdominalhysterectomy required on average a longer hospital stay of one day and

additional week of convalescence com- pared with traditional
vaginal hysterectomy. Vaginal hysterectomy
should be a primary method for uterine removal. Duration of
surgery, anaesthesia, time in hospital and recovery time.

INTRODUCTION
Hysterectomy
is
a
major
gynaecological operative procedure
commonly
indicated
for
women with dysfunctional bleeding, uterine
leiomyomas, prolapse,
endometriosis and adenomyosis, pelvic pain, premalignant conditions
and cancer.2.

In
Sweden,
about

9000
hysterectomies
are performed each year
and
the number
has
been
increasing during the last ten-year
period.
Laparoscopic
assisted, vaginal
hysterectomy was
introduced
in
Scandinavia
in
the
early

1990s,
but
most
hysterectomies
in
Sweden are still performed as total
abdominal
hysterectomy3-s.
In
other countries
the
great
Correspondence:
Dr
C.
Ottosen,
Department
of
Obstetrics and
Gynaecology,
Hospital
of
Helsingborg,
SE-25
187
Helsingborg,
Sweden.

interest
for
minimally invasive
surgery has
made
an
impact
on
the
incidence
of
traditional vaginal
hysterect0my~5~.
The
vaginal technique

is
regarded
by many
gynaecologists as
the
most
cost-effe~tive~~~.
There
are
few
randomised controlled
trials
to compare results
of
different surgical techniques for
hysterectomy,
and to
date
only
uncontrolled
or
case-controlled
studies
have
compared all the three

method^"^^'^-'^.
The
objectives
of
this study were to evaluate clinical
short term outcomes
in
these methods
when
performed
by many surgeons.
Sample size
calculation was based
on
the time
in
hospital after
surgery.

METHODS
The
Department
of
Obstetrics
and
Gynaecology at the
Hospital of Helsingborg serves
a
female population
of
1380
0
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2000
British
Journal
of

Obstetrics
and
Gynaecology
THREE METHODS FOR HYSTERECTOMY

1381
80,000-90,000 women. About

250
hysterectomies are
performed per
year.
This
study
includes
120
women
scheduled
for hysterectomy for anticipated
benign
causes
between
January 1996
and
May
1998. The
inclusion

criteria
were
menorrhagia, leiomyomas

<
15
cm
in
diameter,
dysplasia, endometrial atypia
and
pain. Indications for
surgery
are
shown
in
Table
1.
Women
with
ovarian
pathology, uterus
larger
than
16
weeks
of
gestational
size, previously known dense adhesions,
narrow
vagina or obvious
inaccessible
uterus
were
all
excluded.
Patient
characteristics are
shown
in
Table
1.

Patients were
informed about
the study
several
weeks
before surgery and
those
who
gave
their
informed consent were
randomised the day before the operation.
The
operations
were
performed
by
one
of
fifteen gynaecological
surgeons with
assistants in a not
specified
distribution.
The experience
of
the
surgical
team
varied and
residents performed
under supervision. The local ethical
committee approved the
study.

Operative
techniques
During total abdominal hysterectomy the abdomen
was opened
and
closed

in
different
ways
according
to
the surgeon's preference.
The
uterus
was removed
by
extrafascial technique
and
the
vagina closed and
covered
by
peritoneum. During vaginal hysterectomy,
the
vault
was
injected
with
20
mL
of
mepivacaidadrenalin
before incision in order
to
minimise bleeding.
The
peritoneal folds were opened
and
ligaments
and
uterine
vessels were
divided.
If
at
this
time the uterine
size

did
not
allow easy
exteriorisation, bisecting, coring,
morcellation, enucleation or combinations
of
these volume-reducing
techniques
were
perf~rmed'~.'~.
The peritoneum was
closed, followed
by
suturing
of
the
sacrouterine
ligaments
and
vaginal vauItl8.
During
laparoscopic
assisted vaginal
hysterectomy
we
minimised the laparoscopic
part
in accordance
with the
conclusions
of
the
study
by
fichardsson
et

al.".
The degree
of

laparoscopic assistance
was
classified according to
Johns
and
Diamond".
Troacars
were
left
in
place
and
after closing the
vaginal wall
the
surgeon returned
to the
laparoscopic
view
to confirm haemostasis. The
surgery
was
performed
under general anaesthesia
in
109/120
cases,
in
spinal
blockade in
31120
cases or in combination with
epidural
blockade
in
8/120 cases. Patients
had
an
indwelling
catheter during
the procedures and until
the

next day.
All
patients had
at
least one dose
of
prophylactic
antibiotic
peroperatively, namely
cefuroxim 1
a5

g intravenously
and
metronidazol
1
g
rectally.
A
daily
dose
of
enoxaparin
20
mg
subcutaneously
was
given
as
thromboembolic prophylaxis throughout
the
hospital
stay.
The
time
for surgery
was
measured from the first
incision
until
the
last

dressing
was
applied.
Time
for
anaesthesia
was
defined as the
time
from
induction until
the patient
left the operating
room.
The
amount
of
bleeding
was
estimated in a routine
manner
by
the
anaesthesiology
staff.
All these
data
were
taken from
the
anaesthesiologist chart at the end
of
each operation
and
agreed with
the
staff
involved. The weight
of
the
uterus
was
obtained in the theatre using a digital

scale.
The
haemoglobin
level was
checked
on
the
second postoperative day to rule
out
occult post-operative
bleeding.
Post-operatively,
we
encouraged the patients
to leave
hospital
when
they
felt comfortable
and were without
severe
pain with
established micturition.
Hospital
stay
was
defined as the number
of
days
in
hospital
after
surgery excluding the day
of
surgery.
Patients
were
on
sick leave for
two weeks
regardless
of

their occupation
or
the
performed
procedure.
All
patients were
seen after
two weeks
in the outpatient clinic for examination
to
detect complications
and
to evaluate their
need

for
further sick
leave.
This period

of
convalescence
was
defined as number
of
days after discharge
from hospital
until full
recovery.

Statistical
analysis
The sample size
was based
on
reported hospital
stay
for
vaginal and
abdominal hysterectomy
of
2.3
and

4
days,
respectively.
If
1.5
is
the standard deviation for
hospital
stay,
40
patients
should
be randomised
to achieve
a
power
of
80%
at

=
0.054v'29'3.
Patients
were randomly
allocated to one
of
the three operating
methods
in
four
blocks
of
30
to ensure a balanced number
of
patients
throughout
the
study period.
An
interim
analysis

was
done after
25
patients
were
randomised
in
each group.
The randomisation procedure
was based
on
computergenerated numbers
and
information about
the
allocation
schedule was
kept
in
sealed
opaque envelopes
prepared
by
and
successively opened
by
the research
nurse. Analyses were on
an
intention-to-treat basis.
The three
treatment
groups were
compared using
a
one-way
analysis
of
variance
(ANOVA)
followed

by
Tukey's
HSD
for
post
hoc
comparisons
of
the
mean
values. A significance
level
of
5%
was used
for
all tests20.

RESULTS
There were no differences
between
the three
groups
regarding patients' age, height
and weight
(Table
1).
The
duration
of
surgery,
anaesthesia, hospital
stay
and
sick
leave for
the
three techniques are
shown
in Table
2,
It
shows shorter

duration
of
surgery
for total
abdominal
hysterectomy
compared with vaginal hysterectomy,
which
was
shorter
than
laparoscopic assisted
vaginal
hysterectomy. Duration
of
anaesthesia
(time
in
theatre)
was
longer for laparoscopic assisted
vaginal hysterectomy
than
for vaginal hysterectomy
and
total
abdominal
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1382
C.
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ET
AL.

Table
1.
Patients' characteristics,
indications

for
hysterectomy
and
histopathological findings.
Values
are
given
as mean
(range).
TAH
=
total
abdominal
hysterectomy;
VH
=

vaginal
hysterectomy;
LAVH
=
laparoscopic
assisted
vaginal
hysterectomy;
BMI
=

body
mass index.
TAH
(n
=

40)
VH
(n
=

40)
LAVH
(n
=
40)
Age
(years)
Weight
(kg)
Height
(cm)
BMI
Previous
caesarean
section
Nulliparity

Uterine
weight
(g)
Main
indications
Uterine
leiomyomas
Menorrhagia pain
Premalignant
conditions
Histopathological findings
Uterine
leiomyomas
Adenomyosis
Uterine malignancy, hyperplasia
Normal
47
(28-67)

64
(45-92)
165 (150-176)
23.7
(18.3-33.8)
6
4
258
(43-1025)
18
17
5
21
8
3
8
49
(39-61)
70
(48-98)
165
(152-178)
25.8 (17.3-36.4)
2
7
266
(861175)
21
15
4
31
2
5

2
48
(34-83)
68
(52-98)
166
(157-176)
24.8
(19.1-33.3)
3
2
263
(61471)
21
13
6
23
8
5
4

hysterectomy.
Vaginal
hysterectomy and
total abdominal hysterectomy
did not differ significantly
in
that
respect.
There
was
a one
day
shorter
stay
in
hospital for
vaginal hysterectomy
and
laparoscopic assisted
vaginal
hysterectomy
and
one
week
shorter convalescence com-

pared
with
total abdominal
hysterectomy.
The
weight
of
the
removed uterus and
the blood loss
were
the
same
for
all three
methods.
Twenty
out
of
40
laparoscopic assisted vaginal
hysterectomies
were
stage
0,
meaning only laparoscopy
before the vaginal
part
of
the
proced~re'~.
Volume
reducing manoeuvres
were
needed
in
20/40 vaginal
hysterectomies
and
in
16/40
laparoscopic assisted vaginal
hysterectomies. Four

women
randomised
to laparoscopic assisted vaginal
hysterectomy
were
converted
to total
abdominal
hysterectomy, two because
of
a large
uterus
(procedure
number

35
and
95),
one because
of
adhesions (number
58)
and
one due to
bleeding
(number

50).
One vaginal
hysterectomy
was
converted
to
total abdominal hysterectomy because
of
a large cervical
myoma
(number
107).
One patient
in
the total abdominal hysterectomy
group

had
a laparoscopic assisted
vaginal
hysterectomy
due to protocol violation,
but was
analysed according to
intention to
treat.
Two
vaginal
hysterectomies
and
one
laparoscopic
assisted
vaginal hysterectomy
were
reoperated
and
transfused due to
bleeding.
One total
abdominal hysterectomy
was
transfused.
A
bladder
tear occurred
in
a
vaginal
hysterectomy
and
was
repaired uneventfully.
One
cuff
haematoma
was
found
in

one
total abdominal
hysterectomy
and
one vaginal
hysterectomy.
In
addition
to
a paralytic ileus,
an
abdominal
wall
infection and two
febrile events complicated the
course
of
total abdominal
hysterectomy, compared with three
febrile
events
in
one
vaginal hysterectomy
and
two in laparoscopic
assisted
vaginal
hysterectomies.

DISCUSSION
The
aim
of
the study
was
to
compare three
surgical
methods
for
hysterectomy
in
an

everyday clinical setting

with
several surgeons.
Since
1992
we
perform laparoscopic
assisted vaginal hysterectomy
and
vaginal hysterectomy
as
alternatives to total
abdominal
hysterectomy.
Table
2.
Main
outcome.
Values
are
given
as mean
(SD)
[range].
TAH
=
total abdominal
hysterectomy;
VH

=
vaginal
hysterectomy;
LAVH
=
laparoscopic
assisted
vaginal
hysterectomy.
TAH
VH
LAVH
(n
=

40)
(n
=

40)
(n
=
40)
Duration
of
surgery
(min)
68'
(23)
[28-1251
81'
(28)
[35-1351
102'(31)
[50-175]
Duration
of
anaesthesia (min)
110
(25)
170-1901
118
(32)
[60-1951
146'
(32)
[90-2451
Stay in hospital
(days)
Sick leavehecovery (days)
28.1*
(95)
[7-551
21.3
(85)
[544]
19.7
(7
5)
[444]
3.7"
(1

0)
[2-71
2.8
(1
1)
[l-61
3.1
(1

4)
[l-81
Peroperative
blood
loss
(mL)
225
(178)
125-8001
287
(211)
[25-8001
3
11

(305)
[50-1400]
Significance
level
0.050;
Multiple
Range Tests: Tukey's-HSD test.

0
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385
THREE METHODS
FOR
HYSTERECTOMY

1383
The operations are
shared between

15
gynaecological
surgeons
of
varying
experience.
By
the start
of
this
study
we

felt
that
the
most
experienced
surgeons had
progressed beyond
the initial part
of
their
learning curve
allowing
us
to embark
on
a
study.
The
consecutive time
for
surgery
for the three methods
was
analysed, suggesting
that
the group
of
surgeons
was
not
in the steep part
of
the
learning
c~rve~l-~~.
The
amount
of
laparoscopic assistance
was
not
decided

a
priori,
as
we
believed in individualising
according
to the surgical situation. In our practice the
main
role
of
the laparoscopy is to judge accessibility
of
the uterus,
rule out presence
of
problems (e.g. adhesions)
and then
turn to the vaginal part. Such
an
approach
was
recommended
by
Richardsson
et

al.13.
Although it
could be argued that
this
just
adds
time
to
a
vaginal hysterectomy,
the
knowledge
of
'clear conditions' could be
of
value to the comfort

and
confidence
of
the surgeon.
Leaving the troacars
in
place
makes
the
check
for intra-abdominal haemostasis quick
and easy,
which
might
be
of
benefit
to
the patient.
The
types
of
complications and the reasons for conversion
to
open
surgery
are similar
to
those described in the literature.
The
primary
reason for conversions
in
other studies
was
limited access to
the pedicles because
of
obstructing
leiomy~rnata'~.~~,~~.
We
believe that
this study

demonstrates the feasibility

of
vaginal
hysterectomy
and
laparoscopic assisted
vaginal
hysterectomy
in a
broad
clinical setting, even
when
considered
'contraindicated'
by
traditional criteria. The
study was
designed
to
compare clinical data
and
its size
does
not allow
conclusions
as to
the
frequency
of
complications.
All patients were followed
up.
The
sizes

of
standard
deviations in the
study were
comparable to
those used
in the power estimation.

The
results are in agreement
with
other
studies which
showed that
laparoscopic assisted vaginal hysterectomy
requires
longer time for anaesthesia
and
s~rgery~.'~.'~-'~.
Total
abdominal hysterectomy
had
the shortest
time
for
surgery.
However,
it
should
be
noted that
we
included
patients with
large uteri, a procedure
that
requires more
time
and
patience during the
vaginal
approach. One
of
the difficulties during vaginal
hysterectomy,
as
well
as
in laparoscopic assisted vaginal
hysterectomy,
is the

exteriorisation
of
a
large uterus
necessitating volume
red~ction'~.'~.
This
was
the case in a substantial
number
of
our
patients,
and
more
often during
vaginal hysterectomy
than
laparoscopic assisted
vaginal hysterectomy.
Lower segment caesarean section has
been
reported to
impede
vaginal
surgery,
as
does nulliparity2'.
The
latter
results in lesser laxity
of
uterine ligamentous support
and narrower
vagina. These factors are frequently combined
in
the same patient
and
are

of
more

importance
during
vaginal
than during abdominal
surgery.
The
randomised groups
were not
well balanced
in
this
respect
(Table
1).
The skill
and
experience
varied between
surgeons
and many
cases
were performed
by
residents
under supervision. This
may be
perceived as a
problem
in
our
design. One
might
prefer
only
one
surgeon performing all operations, however, this
would
not be
realistic

in
our clinical context.
In
order to
address
the importance
of
individual surgeon's experience
we
looked
at
the five
surgeons
who
did
75%
of
all cases. The
major
endpoints in
this subgroup were
analysed and
no significant differences
in
the outcomes were detected.
If
only
one
or
a few experts
did
the
surgery
results
would possibly
improve. This
was
not feasible
in
our department.
We

think this
diversity
in
the
design makes
the
study
robust
enough
and
it
strengthens our conclusions about vaginal
hysterectomy
as the overall preferable procedure.
This
study
is
not
large enough to
allow
firm
conclusions about
safety.
Complication rates are
of
great
importance
to
women undergoing
surgery.
If
one
method is safer, this
could compensate for longer
operating time. Perhaps laparoscopic assisted
vaginal hysterectomy carries a higher risk
of
conversion
to

abdominal
surgery than
does
vaginal hysterectomy.
Laparoscopic assisted vaginal hysterectomy
might
be
better for patients
with
symptoms other
than
bleeding,
but
this
study
did
not
include long
term
outcome
measures
to
confirm
such
opinionz6.
Patients operated
with
total abdominal
hysterectomy
had
stayed in hospital one
day
longer
and needed
an
extra
week
to
recover.
It
is
possible that these

figures are
biased
by
our traditional practice,
but
the hospital
stay
for
patients operated on
by
the abdominal route
was
short compared
with
other previous randomised studies3*4,10,12-15. This might also
be
due to
differences
in
information
and
patients' expectations,
as
it
had been
reported that the
new
technique
makes
a positive
impact
on traditional hospital

are^^-^'.
Table
3.
Complications
and
conversions.
Values
are
given
as
n.

TAH
=
total abdominal
hysterectomy;
VH
=
vaginal
hysterectomy;
LAVH

=
laparoscopic assisted vaginal hysterectomy.

TAH
VH
LAVH
(n
=

40)

(n
=
40)

(n
=

40)
Reoperation
and
transfusion
Transfusion
1
Bladder
tear
Paralytic
ileus
1
F'yrexia
1
Urinary
tract
infection
1
Vaginal
cuff
haematoma
1
Urinary
and
vaginal

cuff
infection
Abdominal
wall infection
1

Prolonged
catheter time
Converted
to
TAH
2
1
1
11

1
11
1
1
1
4
0

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107,1380-1385
1384
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OTTOSEN
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All patients were seen at

an
early follow
up
visit
by
the surgeons.
This is a possible source for observer bias
but
regarded
as important
to
ensure continuity
of
care.
Bias
from
the principal investigator

(C.O.)

was
sought
for
and
not
found
by
analysing outcome measures
with
and
without
his
contribution.
Histopathological
findings are
shown
in
Table
1.
The
morbidity is
of
the same kind
and
order
as
previously
rep~rted~~~.
The
risks
of
bleeding, blood transfusion
and
relaparotomy
are
possibly
higher during
vaginal
hysterectomy
and
laparoscopic assisted vaginal hysterectomy.
Drop

in post-operative haemoglobin did

not
indicate biased estimates
of
blood-loss
or
significant
occult
intra-abdominal
bleeding. One consultant
was
involved
in
the five
cases with
major complications
and
the protocol violation.
To
our
knowledge this study
is the first
randomised
trial
to
compare
total abdominal hysterectomy, vaginal
hysterectomy and
laparoscopic assisted vaginal hysterectomy.
The shortest operating time
was
for
total abdominal
hysterectomy and
the longest for laparoscopic assisted
vaginal hysterectomy.
We
demonstrated benefits
of
vaginal
hysterectomy and

laparoscopic assisted vaginal

hysterectomy
on length
of
patients stay
in
hospital
and
their
recovery time.
Vaginal
hysterectomy seems to be
a safe,
feasible
and
patient-friendly method
in our
clinical
setting.
The
laparoscopic assistance
was
of
no
obvious benefit.
There are no
long
term outcome data
(e.g.
prolapse or
hernia rates)
comparing
these methods
and
a
direct comparison
of
the
effect

of
these techniques on long-term outcome
is
still lacking. Although
we
did not include
economical parameters, there should
be
a
potential
of
economical advantage
with
vaginal hysterectomy
because
of
shorter duration
of
surgery,
reusable instruments and less
need
for
high tech equipment.
Classic vaginal
surgery
for
hysterectomy should
not
be regarded
an
exquisite
but
a basic gynaecological
skill. The improved
short
term
outcomes
measured
in
this report suggest
the advantage

of
this
approach. Educational programmes must
continue
to
train gynaecologic surgeons to maintain this
operation in their basic
armamentarium
of
operations for uterine removal.

Acknowledgements
The authors
would
like to thank Dr

P.-E.
Isberg, Lecturer,
Department
of
Statistics,
Lund
University for
statistical advice
and
analysis. The
study
was
supported
by
grants
from the
Thelma
Zotgas
Foundation
and
the Stig
and
Ragna Gorthons
Foundation. There are
no

conflicts
of
interest.
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Auld
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Clinch
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Obstet
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107,1380-1385

Raxita Patel
et al
.
Laparoscopic
Hysterectomy Versus Vaginal Hysterectomy

335
International Journal of Medical Science and Public
Health | 2014 | Vol 3 | Issue 3

COMPARATIVE STUDY OF LAPAROSCOPIC

HYSTERECTOMY VERSUS
VAGINAL HYSTERECTOMY
Raxita Patel
1

,
Nisha Chakravarty
2
1

Department of
Obstetrics & Gynecology,
Smt
. NHL
Municipal Medical College, Ahmedabad,
Gujarat

, India
2

Department of
Obstetrics & Gynecology,
GCS Medical College, Ahmedabad
,
Gujarat
, India
Correspondence to:
Raxita Patel
(
drhirenparmar@gmail.com
)
DOI:
10.5455/ijmsph.2013.
0
2
012014
1
Received Date:
05
.1
2
.2013
Accepted Date:
1
2
.0
2
.2014
ABSTRACT
Background:
Hysterectomy is the most common performed major abdominal surgery among gynaecologic
surgeons and the decision is
generally based on indications for surgery, surgeons training and preference,
uterine size, presence and absence of any associated pelvic
pathologies and patients choice. By avoiding laparotomy, laproscopic procedures are
associated with less post
operative pain, shorter
hospitalization, and with lower infectious morbidity rate tha
n laparotomy.
Aims & Objective:
(1)
To compare duration of surgery, blood loss and complications during surgery and post
operative pain in each
type of hysterectomy.
(2)
To evaluate the safety, simplicity and acceptability of each type of hysterectomy bot
h to the patient as well as

the surgeon.
Materials and Methods:
Patients undergoing both the types of hysterectomy i.e. LH and NDVH during May 2009 to
September 2011 at
Smt
.
SCL
General Hospital, Saraspur, Ahmedabad were included in the study. Those patien
ts having malignancy as diagnosed by Pap
smear or by D &C were excluded from the study. All the patients were investigated thoroughly
for their cardio respiratory sta
tus, fitness
for surgery and other medical conditions. Patients were obs
erved vigilantly d
uring the pre
operative
, intra
operative
and post
operative
period for any complications.
Results:
In this study 56% of patients underwent AH, 20% had VH for prolapse, 13% had NDVH and
10% had LH. Majority of patients
belongs to age group 40
49years in bo
th the groups. Fibroid and DUB were the most common indications of hysterectomy in LH group
while DUB was the most common indication in NDVH group. Bladder injury was found in one
case of NDVH and 2 cases of LH group
and
bowel injury in 1 case of LH which
was managed by expert by laparotomy. Patients of LH and 4 of NDVH had vaginal bleeding but
it was
minimal and did not require any surgical management. The average duration of surgery was 2
to 4 hours in TLH group, 30 minute
s to 2
hours in LAVH group and 1
to 2 h
ou
rs in NDVH patients. Average amount of blood loss in LH was 100 to 200 ml and it was 100 to
300 ml
in NDVH group. Blood loss in NDVH group was less. The difference in the pain scores of LH
and NDVH is statistically significa
nt showing
2.24 Z value.
Conclusion:

LH can be considered an alternative to AH for those in whom VH is not feasible. TLH may be
comparable to NDVH in terms
of post
operative parameters and satisfaction, but it has significantly longer operating time and requires
laparoscopic surg
ical skills.
Recent advances in equipment, surgical techniques and training have made TLH a well
tolerated and efficient technique. The future place
of LH will be determined by the increased familiarity and skill of surgeons with vaginal
procedure, stimula
ted by doing the difficult part
of LAVH. Hence in normal uncomplicated uterus LAVH or even VH has no disadvantages and
remain an excellent option.
Key Words:
Laparoscopic Hysterectomy
; Vaginal Hysterectomy;
Pap Smear

Introduction
Hysterectomy is the most common performed major
abdominal surgery among gynaecologic surgeons and the
decision is generally based on indications for surgery,
surgeons training and preference, uterine size, presence
and absence of any associated pelvic pathologies and
patients choice. By avoiding lapa
rotomy, laproscopic
procedures are associated with less post
operative pain,
shorter hospitalization, and with lower infectious
morbidity rate than laparotomy. Present study was done at
our institute to compare vaginal hysterectomy with
various types of la
proscopic hysterectomies.
[1]

We have
attempted the scientific scrutinization of entire clinical
picture of cases with detailed consideration important
operative steps and
post
operative
observation with follow
up. So, that a gynecologist can give the best
possible
treatment option to patient.

Materials and Methods

This is a prospective study aimed to compare vaginal
hysterectomy and laparoscopic hysterectomy from all
angles. For that cases of both types of hysterectomies were
scrutinized thoroughly, durin
g May 2009 to September
2011,
Smt
.
SCL
General Hospital, Ahmedabad. The aims
and objectives are as follows:
(1)
To compare duration of
surgery, blood loss and complications during surgery and
post
operative pain in each type of hysterectomy.
(2)
To
evaluat
e the safety, simplicity and acceptability of each
type of hysterectomy both to the patient as well as the
surgeon.
All these patients were admitted after proper
examination, investigations and fulfilling selection criteria
and Pap smear examination to
rule out malignancy.
Selection
Criteria
:
(A) For
non
descent vaginal
hysterectomy:
(i)
Adequate lateral space in fornices
; (ii)

RESEARCH
ARTICLE
Raxita Patel
et al
.

Laparoscopic
Hysterectomy Versus Vaginal Hysterectomy

336
International Journal of Medical Science and Public
Health | 2014 | Vol 3 | Issue 3
Size of uterus 12 wks; (iii)
Cases with previous surgery
were included after proper clinical evaluation.
(B)
F
or
laparoscopic
hysterectomy: same as NDVH plus:
(i)
No
umbilical hernia
; (ii)
No local abdominal skin infection.
All cases were investigated thoroughly for their
cardiorespiratory status and fitness for surgery. All
patients were operated under spinal and epidural or
general anesthesia as decided by anesthetist whichever
was best for individual case.Total follow up was 6 months
period.
Operative steps at a glance:
Preoperative preparation:
After admission & counselling, consent of patient and her
relatives was taken.
They were counselled about the pros
and cons of both the types of surgeries and were free to
make a choice for themselves. For LH axelyte solution 200
ml mixed with 750 ml of lemon water or limca to avoid
nausea and vomiting was given in the evening of pre
vious
day. This was done for bowel preparation. For NDVH
proctoclysis enema twice before surgery 10 h
ou
rs apart
was given.
Patients were kept nil by mouth from 10 pm of
previous night.
Vaginal hysterectomy was done using
standard technique.
[2]

Laparoscopic

hysterectomy was
done using standard technique
[3]

with few specific steps

:
(i)
Mobilise the bladder: The anterior and posterior leaves
of the broad ligament are separated with the help of
Maryland forceps. The vesicouterine peritoneal fold is
identified a
nd hydro dissection done in which 20
30 ml of
saline is introduced with needle in the vesicouterine space
for dissection of bladder.
(ii)
Vaginal cuff closure: it is done
either vaginally or Laproscopically with the help of vicryl
no 1 taking figure of ei
ght stitches one at each angle and
one at the centre.
Post
operative
management:
(i)
IV fluids for 24
36 hrs to
maintain hydration
; (ii)
Catheter was kept in situ for 48
hrs in majority. Only in a few patients catheter was kept for
longer period either due to
a
repair or bladder injury
; (iii)
antibiotics given parenterally for 2 days and then orally for
5 days to prevent infection.
(iv)
Pat
ient was encouraged for
early ambulation and regular diet.
(v)
Adequate analgesic

was given
. (vi)
Most of the patients were discharged on 4
th

or 5
th

post
operative day in case of non
descent VH while
on 3
rd

or 4
th

day in case of LH as per the general condi

tion
of the patient.

Results
In this study 56% of patients underwent AH, 20% had VH
for prolapse, 13% had NDVH and
10% had LH
(Table 1)
.
In
this study majority of patients belongs to age group 40
49
years in both the groups since incidence of menstrual
disorders is more during this age group. Mean age in LH
47.8 years
(Table 2)
.
Fibroid and DUB were the most
common indications of hysterectomy in LH group while
DUB was the most common indication in NDVH group. The
most common indication of hysterectomy
in both the
groups was fibroid
(Table 3)
.
Mean
operating time NDVH
55 min.

Average duration of surgery for NDVH

54.4
minutes and that for LH
104.4 minutes
(Table 4)
.
Mean
blood loss in NDVH

100
ml
.
Mean blood loss in TLH

250
ml and in LAVH

300 ml.
Blood loss was comparativ
ely
less in LH than in NDVH.
Mean blood loss in LH and NDVH
respectively were 204.40ml and 187.01ml. Z value of blood
loss is 1.01 which is not statistically significant
(Table 5)
.
Post
operative pain was determined by visual anal
ogue
scale on a grade of 1

10 as no pain to worst possible pain.

Pain scoring was done at 24 hours and at one week. Post
operative pain was less in LH group as compared to the
NDVH group
(Table 6)
.
Table
1: Incidence of hysterectomy
Incidence
Present

Study
Aniuliene et al (2007)
[4]

Total no. of hysterectomies

433
602
AH
243 (56.12%)
348 (57.8%)
VH (2
nd

&3
rd

degree prolapse)
90 (20.78%)
203 (33.7%)
NDVH
57 (13.16%)
LAVH
34 (7.85%)
51 (8.5%)
TLH
09 (2.07%)
Table
2: Distribution of patients
according to age
Mean
age
Present Study
KK Roy et al, 2010
[5]

TLH
(n=08)
LAVH
(n=35)
NDVH
(n=57)
TLH
(n=30)
LAVH
(n=30)
NDVH
(n=30)
43.87
42.11
42.07
41.9
43.4
43.7
Table
3
:
Indications of LH and NDVH
Indication
Present

Study
Matthew Morton
et
al, 2008
[7]

KK Roy et al,
2010
[5]

LH
(n=43)
NDVH
(n=57)
LH
(n=109)
NDVH
(n=43)
LH
(n=60)
NDVH
(n=30)
DUB
16 (34%)
25 (41%)
12 (12%)
11 (11%)
24 (40%)
08 (26%)
Fibroid
18 (42%)
15 (27%)
70 (63%)
14 (33%)
30 (50%)
22 (74%)
Adenomyosis
08 (18%)
10
(19%)
19 (17%)
04 (09%)
04 (07%)
Chronic
pelvic pain
01 (02%)
04 (07%)
Postmenopau
sal bleeding
01 (02%)
03 (06%)
-

Others
08 (08%)
14 (33%)
02 (03%)
Table
4:
Mean operative time
Mean
Operative
Time
(Min)
Present Study
KK Roy
et al, 2010
[5]

TLH
LAVH
NDVH
TLH
LAVH
NDVH
190
97.28
97.71
100
85
60
Table
5: Average blood loss
Mean blood loss
Present study
Matthew Morton
et al, 2008
[7]

LH
NDVH
LH
NDVH
204.40 ml
187.01 ml
141 ml
114 ml
Table
6:
Post
operative
pain scoring
Pain score

Present Study
KK Roy et al, 2010
[5]

TLH
LAVH
NDVH
TLH
LAVH
NDVH
0

3
02
18
13
14
14
18
4

6
05
13
34
14
12
12
>6
01
04
10
02
02
-

Raxita Patel
et al
.
Laparoscopic
Hysterectomy Versus Vaginal Hysterectomy

337
International Journal of Medical Science and Public
Health | 2014 | Vol 3 | Issue 3

Discussion
At our institute, lower trend of LAVH and TLH in this study
is probably reflecting that it is a preliminary study of
implement. 56% of patients in present study had history of
previous surgery and most of them were operated
successfully. This indicates tha
t both LH and NDVH can be
performed safely even if the patient has been operated
previously. Patients with previous history of LSCS,
laparotomy and appendicectomy were selected for NDVH

only after proper evaluation. Intra operative complication

is higher i
n LH than in NDVH group. In this preliminary
study, these may be attributed to our less exposure and
experience to this technology, instrumentation and
associated anatomical alterations. Bladder injury was
found in one case of NDVH and 2 cases of LH group
and
bowel injury in 1 case of LH which was managed by expert
by laparotomy. 2 patients of LH and 4 of NDVH had vaginal
bleeding but it was minimal and did not require any
surgical management. No other significant complication
found. The average duration of
surgery was
2 to 4 hours in
TLH group, 30 minutes to 2 hours in LAVH group and 1 to
2 hrs in NDVH patients. This means in laparoscopic
surgery when all clamps were applied laparoscopically as
in TLH the duration of surgery increased significantly due
to g
reater technological difficulties. In this study, he
concluded that the operating time in LAVH was less than
that in TLH.
[9]

The difference between duration of surgery

for TLH and NDVH is statistically significant showing 5.71
Z value. The duration of surg
ery in LAVH and NDVH is not
proved to be statistically significant showing 0.05 Z value.
Average amount of blood loss in LH was 100 to 200 ml and
it was 100 to 300 ml in NDVH group. Blood loss was more
than 400 ml in 3 patients of LH, 2 of which had bladde
r
injury and 1 had bowel injury. Blood loss in NDVH group
was less due to the traditional technique of saline
infiltration with adrenaline. Patients in LH group
experienced less pain than NDVH and hence they required
mild analgesics as compared to NDVH pat
ients. The greater
incidence of
post
operative
pain in NDVH group may be
attributed to more stretching of ligaments during the

surgery. Patients undergoing TLH experienced less

post
operative
pain and required less analgesic drugs as
compared to NDVH patie
nts. They concluded that there
was no significant difference in pain scores between LAVH
and TLH.
[11]

The difference in the pain scores of LH and

NDVH is statistically significant showing 2.24 Z value.
Hence the patients undergoing laparoscopic hysterectom
y
experience less pain as compared to those undergoing
NDVH.

Conclusion
NDVH is associated with less handling of intestines, less
exposure to general anaesthesia, no need of any
specialized instruments, as compared to LH. On the other
hand LH is
associated with small scar of surgery, less
morbidity and less post
operative pain. LH can be a better
route of surgery in obese patients in whom NDVH may be
difficult. LH can be considered an alternative to AH for
those in whom VH is not feasible. TLH may
be comparable
to NDVH in terms of post
operative parameters and
satisfaction, but it has significantly longer operating time
and requires laparoscopic surgical skills.Recent advances
in equipment, surgical techniques and training have made
TLH a well
tole
rated and efficient technique. The future
place of LH will be determined by the increased familiarity
and skill of surgeons with vaginal procedure, stimulated by
doing the difficult part of LAVH. Hence in normal
uncomplicated uterus LAVH or even VH has no
disadvantages and remain an excellent option.

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Cite this article as:
Patel
R
, Chakravarty
N

.
Comparative study of
laparoscopic hysterectomy versus vaginal hysterectomy
.
Int J Med Sci
Public Health
2014
;
3
:
33
5
3
3
7
.
Source of Support: Nil
Conflict of
interest: None declared