Diagnosis Based Technique of Hysterectomy: Comparison among Laparoscopic and Nondescent Vaginal Hysterectomy

INTRODUCTION

Hysterectomy, the surgical removal of the uterus, stands as the second most prevalent major surgical procedure among females following cesarean section.^1–3 This procedure is indicated for various conditions such as symptomatic uterine leiomyomas (51.4%), abnormal uterine bleeding (41.7%), endometriosis (30%), and prolapse uterus (18.2%). Numerous factors influence the choice of hysterectomy route for benign causes, including uterine factors, surgical technique availability, and surgeon proficiency.⁴ Historically, the vaginal route was primarily employed for uterine prolapse, but contemporary practice extends its use to benign uterine conditions like abnormal uterine bleeding and fibroids with a nondescent uterus (Fig. 1).

Although abdominal hysterectomy offers shorter operating times, it has been associated with prolonged hospital stays, delayed return to normal activity, substantial drop in hemoglobin levels, increased intraoperative blood loss, and higher rates of wound or abdominal wall infections. Despite evidence favoring vaginal hysterectomy when clinically appropriate, guidelines, such as those by ACOG 2017, suggest the vaginal route is most suitable for women with mobile uteri no larger than 12 weeks gestational age (approximately 280 gm). The guidelines recognize that the choice of approach should be based on surgical indication, anatomical conditions, patient preference, and surgeon expertise (Fig. 2).^5–7

Since the introduction of total laparoscopic hysterectomy (TLH) in 1989, minimal access surgery has gained prominence for treating various gynecological conditions. This study comprehensively reviews considerations for hysterectomies and reports outcomes. It evaluates the safety and benefits of TLH and nondescent vaginal hysterectomy (NDVH) within the constraints of a government healthcare setup at a tertiary-level institute in India.^8–11

The objective is to compare the results of TLH and NDVH concerning intraoperative parameters, postoperative outcomes, and patient comfort (Table 1).

MATERIALS AND METHODS

This prospective study spanned 2 years (September 2019 to October 2021) at IGMC, Nagpur, Maharashtra, India. About 44 participants were enrolled in each group, TLH, and NDVH, meeting inclusion criteria for benign uterine conditions, uterus size <12 weeks, age between 30 and 70 years, and mobile uterus. Exclusion criteria included gynecological malignancy, previous cesarean section, endometriosis, prolapsed uterus, and BMI >35 kg/m². Ethical approval was obtained, and written informed consent was obtained from participants (Fig. 3).¹²

Participants were randomly assigned to TLH or NDVH, and intraoperative and postoperative parameters were compared, including operating time, blood loss, bladder/bowel injury, febrile morbidity, urinary tract infections, analgesia requirement, pain score [assessed by visual analogue scale (VAS)], and hospital stay. Statistical analysis employed the Chi-square test (Fig. 4).^13–15

RESULTS

The study involved 88 participants with an average age of 46.44 ± 4.78 years. Total laparoscopic hysterectomy demonstrated significantly shorter operating times (1.52 ± 0.4 hours) compared to NDVH (2.03 ± 0.43 hours) (p < 0.0001). Nondescent vaginal hysterectomy exhibited significantly higher blood loss (206.82 ± 60.61 mL) compared to TLH (134.09 ± 37 mL) (p < 0.0001). Total laparoscopic hysterectomy resulted in lower postoperative pain scores and a shorter hospital stay compared to NDVH (p = 0.0003).

DISCUSSION

Hysterectomy can be performed through various approaches, each tailored to specific requirements and surgical indications. Total laparoscopic hysterectomy demonstrated shorter operating times in this study, aligning with similar findings in the literature. However, TLH presented higher postoperative complications, a longer learning curve, and increased equipment costs.

CONCLUSION

The study suggests that TLH may be the preferred route for hysterectomy when setup, facilities, surgical expertise, and patient indication align. Nondescent vaginal hysterectomy, with its advantages of minimal intraoperative manipulation, better postoperative comfort, and faster recovery, is a viable option, particularly in resource-limited settings.

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