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 pro- cedure commonly indicated for women with dysfunc- tional bleeding, uterine leiomyomas, prolapse, endometriosis and adenomyosis, pelvic pain, premalig- nant 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 intro- duced in Scandinavia in

the early 1990s, but most hys- terectomies 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 hysterec- t0my~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 RCOG 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

inclu- sion criteria were menorrhagia, leiomyomas < 15 cm in diameter, dysplasia, endometrial atypia and pain. Indi- cations for surgery are shown in Table 1. Women with ovarian pathology, uterus larger than 16 weeks of gesta- tional 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 con- sent were randomised the day before the operation. The operations were performed by one of fifteen gynaeco- logical surgeons with assistants in a not specified distri- bution. 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 cov- ered 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 vol- ume-reducing techniques were perf~rmed'~.'~. The peri- toneum was closed, followed by suturing of the sacrouterine ligaments and vaginal vauItl8. During laparoscopic assisted vaginal hysterectomy we min- imised the laparoscopic part in accordance with the con- clusions 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 combina- tion 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 intra- venously and metronidazol 1 g rectally. A daily dose of enoxaparin 20 mg subcutaneously was given as throm- boembolic 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 post- operative 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 fur- ther 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 a = 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 computer- generated numbers and information about the allocation schedule was kept in sealed opaque envelopes prepared by and successively opened by the research nurse. Anal- yses 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 val- ues. 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 hysterec- tomy than for vaginal hysterectomy and total abdominal 0 RCOG 2000 Br J Obstet Gynuecol 107,138CL1385 1382 C. OTTOSEN 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 abdomi- nal 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 hys- terectomy, 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 hys- terectomy 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 hys- terectomy 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 laparo- scopic assisted vaginal hysterectomy and vaginal hys- terectomy 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 RCOG 2000 Br J Obstet Gynaecol 107,1380-1 385 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, suggest- ing 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. adhe- sions) 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 condi-

tions' 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 vagi- nal 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 com- plications. 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 hysterec- tomy 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 com- bined in the same patient and

are of more importance during vaginal than during abdominal surgery. The ran- domised groups were not well balanced in this respect (Table 1). The skill and experience varied between sur- geons 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 per- forming all operations, however, this would

not be real- istic in our clinical context. In order to address the importance of individual sur- geon's experience we looked at the five surgeons who did 75% of all cases. The major endpoints in this sub- group 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 diver- sity 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 conclu- sions about safety. Complication rates are of great importance to women undergoing surgery. If one method is safer, this could compensate for longer oper- ating time. Perhaps laparoscopic assisted vaginal hys- terectomy 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 mea- sures 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 stud- ies3*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 1 1 1 1 1 1 1 1 4 0 RCOG 2000 Br J Obstet Gynaecol 107,1380-1385 1384 C. OTTOSEN ET AL

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 hys-

terectomy. 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 hysterec- tomy. The shortest operating time was for total abdominal hysterectomy and the longest for laparoscopic assisted vaginal hysterectomy. We demonstrated benefits of vagi-

nal hysterectomy and laparoscopic assisted vaginal hys- terectomy 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 set- ting. The laparoscopic assistance was of no obvious bene- fit. There are no long term outcome data (e.g. prolapse or hernia rates) comparing these methods and a direct com- parison of

the effect of these techniques on long-term out- come 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 instru- ments 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. Edu- cational programmes must continue to train gynaeco- logic 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, Lec- turer, Department of Statistics, Lund University for sta- tistical 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. References 1 Bachmann GA. Hysterectomy. A critical review. J Reprod Med 1990 35: 839-862. Carlson KJ, Nichols DH, Schiff I. Indications for hysterectomy. N Engl J Med 1993; 328: 856-860. Langebrekke A, Eraker R, Nesheim B-I, Umes A, Busund B, Spon- land G. Abdominal hysterectomy should not be considered as a pri- mary method for uterine removal. A prospective randomised study

of 100 patients referred to hysterectomy. Acra Obsrer Gynecol Scand 1996; 75: 404-407. Olsson JH, Ellstrom M, Hahlin M. A randomised prospective trial comparing laparoscopic and abdominal hysterectomy. Br J Obstet Gynaecoll995; 103: 34.5-3.50. Ellstrom M. Evaluation of new surgical technique in gynaecology [dissertation]. Gothenburg, Sweden: University of Gothenburg, 1998. Querleu D, Cosson M, Parmentier D, Debodinance P. The impact of laparoscopic surgery on vaginal hysterectomy. Gyn Endosc 1993; 2: 89-9

1. Harris MB, Olive DL. Changing hysterectomy patterns after intro- duction of laparoscopically assisted vaginal hysterectomy. Am J Obsrer Gynecoll994; 171: 340-344. Meeks GR, Hams RL. Surgical approach to hysterectomy: abdomi- nal, laparoscopy-assisted or vaginal. Clin Obsret Gynecol 1997; 40: Dorsey JH, Holtz PM, Griffiths RI, McGrath MM, Steinberg EP. Cost and charges associated with three alternative techniques of hys- terectomv. N End J Med 1996: 335: 476482. 886-894. 10 Nezhat

6, NezhYat C, Gordon’ S,

Wilkins S. Laparoscopic versus abdominal hysterectomy. J Reprod Med 1992; 37: 247-250. 11 Summitt RL, Stovall TG, Lipscomb GH, Ling FW. Randomized comparison of laparoscopy-assisted vaginal hysterectomy with stan- dard vaginal hysterectomy in an outpatient setting. Obsret Gynecol 12 Raju KS, Auld BJ. A randomised prospective study of laparoscopic vaginal hysterectomy versus abdominal hysterectomy each with bilateral salpingo-oophorectomy. Br J Obstet Gynaecol 1994; 101: 1992; SO: 895-901. 13 14 15 16 17 18 19 20 21 22 23 24 2.5

26 1068-107 1. Richardson RE, Bournas N, Magos AL. Is laparoscopic hysterec- tomy a waste of time? Lancet 1995; 345: 36-41. Summitt RL, Stovall TS, Steege JF, Lipscomb GH. A multicenter randomized comparison of laparoscopically assisted vaginal hys- terectomy and abdominal hysterectomy in abdominal hysterectomy candidates. Obstet Gynecol 1998; 92: 321-326. Falcone T, Paraiso MFR, Mascha E. Prospective randomized clini- cal trial of laparoscopically assisted vaginal hysterectomy versus total abdominal hysterectomy. Am J Obsrer Gynecol 1999; 180: Grody MHT. Vaginal hysterectomy:

the large uterus. J Gynecol Surg Magos AL, Bournas N, Sinha R, Richardson RE, O’Connor H. Vagi- nal hysterectomy for the large uterus. Br J Obster Gynaecol 1996; 103: 246-25 1. ‘V%ga Vaginalt’ (a film about vaginal hysterectomy in Swedish [videocassette]). MediaService/AV, University Hospital, Lund, Sweden, 1997. Johns D, Diamond M. Laparoscopically assisted vaginal hysterec- tomy. J Reprod Med 1994; 39: 424428. Montgomery DC, editor. Design and Analysis of Experiments. New York: Wiley,

1997. Rosen DMB, Cario GM, Carlton MA, Lam AM, Chapman M. An assessment of the learning curve for laparoscopic and total laparo- scopic hysterectomy. Gynaecol Endosc 1998; 7: 289-293. Hakki-Siren P, Sjoberg J. Evaluation and the learning curve of the first one hundred laparoscopic hysterectomies. Actu Obster Gynecol Scand 1995; 74: 638-641. Bolger BS, Lopes T, Monaghan JM. Laparoscopically assisted vagi- nal hysterectomy: a report of the first 300 completed procedures. Gynaecol Endosc 1997; 6: 77-81. Cristoforoni PM, Palmieri A, Gerbaldo D, Montz FJ. Frequency and cause of aborted laparoscopic-assisted vaginal hysterectomy.

J Am Assoc Gynecol Laparosc 1995; 3: 33-37. Sheth SS, Malpani AN. Vaginal hysterectomy following previous caesarean section. Int J Gynecol Obstet 1995; 50: 169-169. Gamy R. Towards evidence-based hysterectomy. Gynaecol Endosc 1998: 7: 225-233. 955-962. 1989; 5: 301-312. 0 RCOG 2000 Br J Obstet Gynaecol 107,13861 385 27 Clinch J. Length of hospital stay after vaginal hysterectomy. Br J 28 Hancock KW, Scott JS.

Early discharge following vaginal hysterec- 29 Rankin GLS. Length of stay after vaginal hysterectomy. Br J Obstet 30 Reiner IJ. Early discharge after vaginal hysterectomy. Obstet Obstet Gynaecoll994; 101: 253-254. tomy. BrJ Obstet Cynoecol1993; 100: 262-264. Gynaecoll994; 102: 172. Gynecoll988; 71: 416-418. THREE METHODS FOR HYSTERECTOMY

1385 31 Meikle SF, Weston Nugent E, Orleans M. Complications and recov- ery from laparoscopy-assisted vaginal hysterectomy compared with abdominal and vaginal hysterectomy. Obstet Cynecol 1997; 89 304-3 1

1. 32 Hams WJ. Complications of hysterectomy. Clin Obstet Gynecol 1997; 40: 928-938. Accepted 3 August 2000 0 RCOG 2000 Br J Obstet Gynaecol 107,1380-1385

Raxita Patelet al. Laparoscopic Hysterectomy Versus Vaginal Hysterectomy335International Journal of Medical Science and PublicHealth | 2014 | Vol 3 | Issue 3

COMPARATIVE STUDY OF LAPAROSCOPIC HYSTERECTOMY VERSUS VAGINAL HYSTERECTOMYRaxita Patel1

, Nisha Chakravarty21

Department of Obstetrics & Gynecology, Smt

. NHL Municipal Medical College, Ahmedabad, Gujarat, India2

Department of Obstetrics & Gynecology, GCS Medical College, Ahmedabad, Gujarat, IndiaCorrespondence to: Raxita Patel(drhirenparmar@gmail.com)DOI: 10.5455/ijmsph.2013.020120141Received Date: 05.12.2013Accepted Date: 12.02.2014ABSTRACT Background:Hysterectomy is the most common performed major abdominal surgery among gynaecologic surgeons and the decision is generally based on indications for surgery, surgeon’s training and preference, uterine size, presence and absence of any associated pelvic pathologies and patient’s choice. By avoiding laparotomy, laproscopic procedures are associated with less post-operative pain, shorter hospitalization, and with lower infectious morbidity rate than 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 both 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.SCLGeneral Hospital, Saraspur, Ahmedabad were included in the study. Those patients 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 status, fitness for surgery and other medical conditions. Patients were observed vigilantly during the pre-operative, intra-operativeand 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 both 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 minutes to 2 hours in LAVH group and 1 to 2 hours 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 significant 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 surgical 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, 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.Key Words:Laparoscopic Hysterectomy; Vaginal Hysterectomy;Pap SmearIntroductionHysterectomy is the most common performed majorabdominal surgery among gynaecologic surgeons and the decision is generally based on indications for surgery, surgeon’s training and preference, uterine size, presence and absence of any associated pelvic pathologies and patient’s choice. By avoiding laparotomy, 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 laproscopic hysterectomies.[1]

We have attempted the scientific scrutinization of entire clinical picture of cases with detailed consideration important operative steps and post-operativeobservation with follow up. So, that a gynecologist can give the best

possible treatment option to patient.Materials and MethodsThis 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, during May 2009 to September 2011,Smt.SCLGeneral 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 evaluate 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)

RESEARCHARTICLERaxita Patel

et al. Laparoscopic Hysterectomy Versus Vaginal Hysterectomy336International Journal of Medical Science and PublicHealth | 2014 | Vol 3 | Issue 3Size of uterus ≤ 12 wks; (iii) Cases with previous surgery were included after proper clinical evaluation.(B) For laparoscopichysterectomy: 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 previous day. This was done for bowel preparation. For NDVH proctoclysis enema twice before surgery 10 hours apart was given.Patients were kept nil by mouth from 10 pm of previous night.Vaginal hysterectomy was done using standard technique.

[2]

Laparoscopichysterectomy 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 and 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 eight stitches one at each angle and one at the centre.Post-operativemanagement: (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 arepair or bladder injury; (iii) antibiotics given parenterally for 2 days and then orally for 5 days to prevent infection.(iv) Patient was encouraged for early ambulation and regular diet.

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

or 5th

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

or 4th

day in case of LH as per the general condition of the patient.ResultsIn this study 56% of patients underwent AH, 20% had VH for prolapse, 13% had NDVH and10% had LH(Table 1).In this study majority of patients belongs to age group 40-49years 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).Meanoperating 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 –100ml.Mean blood loss in TLH –250 ml and in LAVH –300 ml.Blood loss was comparatively 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 analogue 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 hysterectomyIncidencePresent StudyAniuliene et al (2007)[4]

Total no. of hysterectomies433602AH243 (56.12%)348 (57.8%)VH (2nd

& 3rd

degree prolapse)90 (20.78%)203 (33.7%)NDVH57 (13.16%)LAVH34 (7.85%)51 (8.5%)TLH09 (2.07%)Table-2: Distribution of patients according to ageMean agePresent StudyKK Roy et al, 2010[5]

TLH (n=08)LAVH (n=35)NDVH (n=57)TLH (n=30)LAVH (n=30)NDVH (n=30)43.8742.1142.0741.943.443.7Table-3:

Indications of LH and NDVHIndicationPresent StudyMatthew 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)DUB16 (34%)25 (41%)12 (12%)11 (11%)24 (40%)08 (26%)Fibroid18 (42%)15 (27%)70 (63%)14 (33%)30 (50%)22 (74%)Adenomyosis08 (18%)10 (19%)19 (17%)04 (09%)04 (07%)-Chronic pelvic pain01 (02%)04 (07%)----Postmenopau-sal bleeding01 (02%)

03 (06%)----Others--08 (08%)14 (33%)02 (03%)-Table-4: Mean operative timeMeanOperativeTime(Min)Present StudyKK Roy et al, 2010[5]

TLHLAVH NDVHTLH LAVHNDVH19097.2897.711008560Table-5: Average blood lossMean blood lossPresent studyMatthew Mortonet al, 2008[7]

LHNDVHLHNDVH204.40 ml187.01 ml141 ml114 mlTable-6: Post-

operativepain scoringPain scorePresent StudyKK Roy et al, 2010[5]

TLHLAVHNDVH TLHLAVHNDVH0 –30218131414184 –6051334141212>60104100202-Raxita Patelet al. Laparoscopic Hysterectomy Versus Vaginal Hysterectomy337International Journal of Medical Science and PublicHealth | 2014 | Vol 3 | Issue 3DiscussionAt 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 that 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 in 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 ofsurgery was2 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 greater 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 surgery 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 bladder 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 patients. 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-operativepain and required less analgesic drugs as compared to NDVH patients. 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 hysterectomy experience less pain as compared to those undergoing NDVH.ConclusionNDVH 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 maybe 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-tolerated 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.References1.Bruhat MA, Mage G, Chapron C, Pouly JL, Canis M, Wattiez A.Presentday endoscopic surgery in gynecology. Eur J Obstet Gynecol Reprod Biol.1991;41:4-13.2.Ottosen C, Lingman G, Ottosen L.Three methods for hysterectomy a randomized prospective study of short term outcome. BJOG.2000;107:1380-1385.3.Hasson H, Rotman C, Rana N, Assakura H. Experience with laproscopic hysterectomy. J Am Asso Gynecol Laparosc.1993;1:1.4.Aniuliene R, VarzgalieneL, Varzgalis M. comparative analysis of hysterectomy.Medicina.2007;43:118-24.5.RoyKK. A prospective study of TLH, LAVH and NDVH. All India institute of medical science. Arch Gynecol Obstet.2011;284:907-12.6.Perino A, Cucinella G, Venezia R, Castelli A, Cittadini E.Total laparoscopic hysterectomy versus total abdominal hysterectomy: an assessment of the learning curve in a prospective randomized study.Hum Reprod. 1999;14(12):2996-9.7.Morton M, Cheung VY, Rosenthal DM.Total laparoscopic versus

vaginal hysterectomy: a retrospective comparison.J Obstet Gynaecol Can. 2008;30(11):1039-44.8.BhadraB, ChoudharyAP, TolasariaA. Non Descent Vaginal Hysterectomy (NDVH): personal experience in 158 cases. Al Ameen J Med sci 2011;4:23-27.9.Long CY, Fang JH, Chen WC, Su JH, Hsu SC.Comparison of total laparoscopic hysterectomy and Laparoscopic Assisted Vaginal Hysterectomy.Gynecol Obstet Invest. 2002;53(4):214-9.10.Chang WC, Huang SC, Sheu BC, Chen CL, Torng PL, Hsu WC, Chang DY. Transvaginal hysterectomy or laparoscopically assisted vaginal hysterectomy for nonprolapsed uteri. Obstet Gynecol.2005;106:321-6.11.Nascimento MC, Kelley A, Martitsch C, Weidner I, Obermair A.Postoperative analgesic requirements -total laparoscopic hysterectomy versus vaginal hysterectomy.Aust N Z J Obstet Gynaecol. 2005;45(2):140-3.Cite this article as: Patel

R, ChakravartyN. Comparative study of laparoscopic hysterectomy versus vaginal hysterectomy. Int J Med Sci Public Health 2014;3:335-337.Source of Support: NilConflict of interest: None declared2