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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 8  |  Issue : 4  |  Page : 342-348

Comparison of intraoperative and postoperative outcomes of nondescent vaginal hysterectomy and total laparoscopic hysterectomy


Department of Obstetrics and Gynaecology, Swami Ramanand Teerth Rural Government Medical College, Ambajogai, Maharashtra, India

Date of Submission08-Jul-2021
Date of Acceptance24-Sep-2021
Date of Web Publication22-Dec-2021

Correspondence Address:
Dr. Priyank Singh Dasila
Department of Obstetrics and Gynaecology, Swami Ramanand Teerth Rural Government Medical College, Ambajogai 431517, Maharashtra.
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mgmj.mgmj_48_21

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  Abstract 

Introduction: Nondescent vaginal hysterectomy (NDVH) and total laparoscopic hysterectomy (TLH) are the two approaches used to perform a hysterectomy in a nonprolapsed uterus based on indication for surgery, size of the uterus, availability of types of equipment, skills of the surgeon, and patient’s preference. Each surgical approach has its own merits and demerits. Materials and Methods: A prospective and comparative study was conducted in the Department of Obstetrics and Gynaecology at a tertiary care center from December 2018 to November 2020 to compare the intraoperative and postoperative outcomes of NDVH and TLH. A total of 80 patients (40 in NDVH and 40 in TLH group) were calculated based on the average number of hysterectomies (mainly TLH). All patients admitted to the hospital for NDVH and TLH were selected based on the selection criteria. Results: The mean age group irrespective of the route of surgery is found to be within the age group of 41–45 years. The majority of the patients who were operated on were diagnosed to have fibroids as the main cause for their complaints followed by adenomyotic changes and hyperplasia. The mean blood loss of NDVH was found less as compared to TLH but not significant as P value >0.05. The mean number of days for a hospital stay for NDVH is 4.26, whereas the hospital stay for TLH patients was found to be 4.7 days that is greater as compared with NDVH. The most common complication irrespective of the type of surgery is urinary tract infection followed by pyrexia. Conclusion: Considering the outcomes and cost-effectiveness of both routes of surgery, it is found that nondescending vaginal hysterectomy is more advantageous over total laparoscopic hysterectomy.

Keywords: Hysterectomy, nondescent vaginal hysterectomy, total laparoscopic hysterectomy


How to cite this article:
Tondge G, Dasila PS, More N, Kale S, Shelke S. Comparison of intraoperative and postoperative outcomes of nondescent vaginal hysterectomy and total laparoscopic hysterectomy. MGM J Med Sci 2021;8:342-8

How to cite this URL:
Tondge G, Dasila PS, More N, Kale S, Shelke S. Comparison of intraoperative and postoperative outcomes of nondescent vaginal hysterectomy and total laparoscopic hysterectomy. MGM J Med Sci [serial online] 2021 [cited 2022 Jan 18];8:342-8. Available from: http://www.mgmjms.com/text.asp?2021/8/4/342/333318




  Introduction Top


Hysterectomy, the word is derived from Greek words “hystera” which means womb, and “ektomia” which means cutting off anything in the human body. Hysterectomy alone is one of the most frequently performed operating room procedures each year in the world,[1] performed through abdominal, vaginal, and laparoscopic routes for various benign uterine pathologies. The techniques of the surgery have been improved significantly from the time it was first performed in the 19th century. A hysterectomy is a major gynecological surgery in women and certain aspects of postoperative morbidity are related to the route for hysterectomy, the surgeon needs an appropriate evidence-based decision to individualize the approach[2] and select the right technique of hysterectomy.

Nondescent vaginal hysterectomy (NDVH) is considered a minimally invasive, very skilled, and scarless surgery. It can be done safely for fibroid size even above 12 weeks and appears to be the preferred method of hysterectomy.[3] NDVH is better in its approach through a natural orifice, faster, and less expensive. In peripheral hospitals where resources are limited, NDVH takes the upper hand over TLH as it is more economic, takes lesser time, is performed with available instruments, and requires fewer surgical techniques in comparison to TLH.[4] The surgical technique causes less discomfort to the patient as compared with the conventional total abdominal hysterectomy. Despite the proven advantage of NDVH, there is a definite hesitation amongst gynecologists to adopt this approach, reasons being technical difficulty, inability to perform oophorectomy, etc.[5]

Total laparoscopic hysterectomy (TLH) is a modern concept. It requires modernized infrastructure and special laparoscopic instruments. TLH is gaining popularity fast due to the obvious advantage of direct visualization of uterus and adnexa before any operative dissection, less morbidity in patients, less hospital stay, and hospital expenses.[6] Suitable training and supervision are of paramount importance before embarking on TLH to minimize complications.[7]

A Cochrane review concluded that vaginal hysterectomy should be preferred over abdominal hysterectomy whenever possible. If a vaginal hysterectomy is not possible, laparoscopic procedures can be used to avoid the disadvantages of a laparotomy because of the more favorable adverse effect profile,[8] same recommendations are given by the American College of Obstetricians and Gynecologists.[1]

This study was conducted to prospectively analyze the intraoperative and postoperative outcomes of NDVH and TLH.

Objectives

  1. To compare the duration of surgery, blood loss, and complications during NDVH and TLH.


  2. To compare postoperative pain in patients undergone NDVH and TLH.



  Materials and methods Top


A prospective and comparative study was conducted in the Department of Obstetrics and Gynaecology at a tertiary care center for 2 years from December 2018 to November 2020. A total of 80 patients (40 in NDVH and 40 in the TLH group) were randomized for the study.

Routine examinations were done for urine analysis, blood grouping, and Rh typing, random blood sugar, blood urea, serum creatinine, ECG, USG abdomen and pelvis, HIV, HBsAg including a complete hierogram. All patients underwent physical examination, ultrasound, and laboratory investigations. All patients admitted to the hospital for NDVH and TLH were selected based on the selection criteria.

Inclusion criteria

For non-descent vaginal hysterectomy

  • i. All women with indications for hysterectomy and having family completed.


  • ii. Patient fit for surgery.


  • iii. Patients who gave their informed consent to participate.


  • iv. Expert surgeon’s availability.


  • v. Absence of pelvic pathology or adnexal pathology.


For total laparoscopic hysterectomy

  • i. All women with indications for hysterectomy and having family completed.


  • ii. Patients who gave their informed consent to participate.


  • iii. Patient fit for surgery.


  • iv. Expert surgeon’s availability.


Exclusion criteria

Non-descent vaginal hysterectomy

  1. Presence of second/third-degree prolapses.


  2. Presence of large pelvic and adnexal pathology.


  3. Unfavorable location of fibroids (deep in Pouch of Douglas or intraligamentary).


  4. Uterine size >18 weeks.


Total laparoscopic hysterectomy

  1. Patient hemodynamically unstable.


  2. Large cystocele or rectocele.


  3. Uterine size >24 weeks.


Steps performed for the surgery

All the patients with skin or other infections (e.g. severe acute pelvic inflammatory disease [PID]) were excluded in both groups. All patients were given prophylactic intravenous antibiotics (ceftriaxone 1 g) preoperatively, 1 h before surgery and bladder catheterization was done.

NDVH was performed on 40 patients based on the standard surgical procedure under spinal anesthesia. Per vaginal examination was done on all the patients before starting the surgery, to assess the size, mobility of the uterus, and presence of an adnexal mass. Afterward, all patients were cleaned and draped following all aseptic measures. The anterior lip of the cervix was held with vulsellum forceps and the posterior lip with long Allie’s forceps. A circular incision was made around the cervix and the pubo-vesico-cervical ligament was cut.[3] The anterior peritoneum was opened carefully with the use of two artery forceps and cutting in between. The posterior pouch was opened subsequently. Uterosacral and cardinal ligaments were clamped, cut, and ligated. Bilateral clamping of uterine vessels was done. Two artery forceps and cutting in between. Utero sacral, Mackenrodt complex was clamped, cut, and transfixed. Bilateral clamping of uterine vessels was done. In the case of the big-sized uterus, debulking techniques like bisection, coring, myomectomy, or a combination of these methods were used to facilitate vaginal delivery of the uterus. Bilateral cornual clamps were applied, and ligation was done systematically. All the pedicles were assessed for any bleeding or oozing. Vaginal packing was done with roller gauze soaked in betadine and the vault was closed meticulously.

All 40 patients for TLH had full bowel preparation with a clear fluid diet for 24 h before surgery. Surgery was performed under general anesthesia. During the procedure, all the patients were placed on modified semi-lithotomy position, with knees flexed in Allen stirrups, and deep Trendelenburg position.[3] To mobilize the uterus and delineate the vaginal fornices, Colpo-Probe vaginal fornix delineator was introduced vaginally. To maintain intraperitoneal pressure at 15 mm Hg throughout the surgery and to achieve carbon dioxide in pneumoperitoneum, Veres needle was used.

Four laparoscopic ports at the specified suprapubic area were used; (i) 10 mm cannula subumbilical, (ii) 5 mm cannula on right side lateral to medial umbilical ligament, (iii) 5 mm cannula on left side lateral to medial umbilical ligament, and (iv) 5 mm cannula midway between the umbilicus and pubic symphysis.

The desiccation and division of round ligaments were done using monopolar needle cautery. The utero-ovarian ligaments were desiccated and transected depending on the removal of ovaries using monopolar cautery. The vesicouterine peritoneum was incised using monopolar needle cautery, at the level of the vaginal fornix. Ensuring the clear exposure of vaginal fornices, the bladder was dissected off the lower uterine segment with the help of the Colpo-Probe device. The uterine vessels were thoroughly desiccated and cut at the level of the lateral fornix. Vagina was incised at the level fornix, continuing laterally and posteriorly freeing the uterus from its vaginal attachments to achieved anterior colpotomy. The specimen was removed vaginally and the vault was closed laparoscopically or vaginally.

Postoperative management

  • (i) The vaginal pack was removed after 24 h.


  • (ii) IV fluids for 24–36 h to maintain hydration.


  • (iii) The catheter was kept in situ for 48 h in the majority of patients while for a few the catheter was kept for a longer period reason being repair or bladder injury.


  • (iv) Parenteral Antibiotics Inj. Ceftriaxone 1 g BD, Inj. Gentamycin 80 mg. BD and Inj. Metronidazole 500 mg BD was administered postoperatively for 2 days and thereafter-oral antibiotics (Tab Clavam 625 bd) were given for 5 days after the surgery to prevent infection.


  • (v) Early ambulation and a regular diet were encouraged for all patients.


  • (vi) Analgesics for NDVH (Tab. Promethazine 25 mg. HS for 2 days) and TLH (Tab Ibuprofen 1 BD for 2 days) were given for pain.


  • (vii) Discharge – from 4th to 5th postoperative day in case of NDVH and on 3rd to 5th postoperative day for TLH patients.


Data collection method

Duration of Surgery (Operating time) taken for vaginal hysterectomy was calculated from the start of incision at the cervicovaginal junction to placement of vaginal pack, whereas for laparoscopic hysterectomy it was calculated from the start of skin incision to closure of skin incision.

The blood loss was estimated by measuring the weight of mops intraoperatively. The complications such as injury to the bowel or bladder or ureter and hemorrhage during the intraoperative period were noted.

The postoperative pain was assessed on the 2nd day of surgery for all the patients using the Visual Analog Scale in both groups. The intensity of pain was recorded between the “no pain at all” and “worst pain imaginable.” All patients were followed up for early postoperative complications like fever, nausea, vomiting, postoperative pain, urinary tract infection, and wound infection. Duration of hospitalization was considered as 4 days of hospital stay after the surgery including the day of surgery. The patients were reviewed in the outpatient department 4 weeks following discharge for postoperative follow-up.


  Results and discussion Top


In this study, intraoperative and postoperative outcomes were studied and compared among 80 patients (40 in NDVH and 40 in the TLH group). They were also followed for 4 weeks after discharge for postoperative follow-ups.

The patients between the two groups were found between ages 41 and 45 years with a mean age of 42.65 years in the NDVH group and 41.45 years in the TLH group. A study by Aratipalli and Bandi[9] reported similar mean age of patients as 42.42 years in NDVH and 41.54 years in the TLH group, whereas a lower mean age of 38.56 years in NDVH and 40.47 years in TLH was found by Nagar et al.[10] The National Family Health Survey 4 Desai et al.[11] in India provided the first nationally representative estimates of hysterectomy among women of age 15–49 years [Table 1].
Table 1: Distribution of patients by age group

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The majority of the patients operated in the current study were diagnosed to have fibroid (NDVH 50% and TLH 52.5%) as the main cause for their complaints followed by adenomyotic changes (NDVH 22.5% and TLH 25%) and hyperplasia (NDVH 27.5% and TLH 20%). Similar findings were also observed in the study conducted by Singh and Soni[12] and Sarada Murali and Khan,[3] whereas the studies conducted by Nagar et al.[10] found the most common HPR finding for both NDVH and TLH was adenomyosis followed by fibroid and hyperplasia, respectively. In the study by Desai et al.[11] excessive menstrual bleeding or pain was self-reported as an indication for hysterectomy by over half of women of age 15–49 years, followed by fibroids (14.2–20.7%) and uterine disorder (rupture) (13.3–14.9%) [Figure 1].
Figure 1: Illustrates that majority of the patients who were operated on were diagnosed to have a fibroid as the main cause for their complaints followed by adenomyotic changes and hyperplasia

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The mean duration of surgery (operating time) for NDVH was found as 55.2 min and 112.5 min and for TLH with the P value <0.001 which indicates the shorter operating time for NDVH. Hwang et al.[13] found that laparoscopic hysterectomy took the longest time to operate followed by total abdominal and then vaginal hysterectomy. A study by Nagar et al.[10] revealed the mean operating time for NDVH as 71.54 min and 100.76 min for TLH (P < 0.001), whereas in a study by Kansara et al.,[4] the mean operating time for NDVH was 45 min and for TLH it was 80 min. (P < 0.005). In the Gupta and Chandnani14] study, the mean operating time in NDVH was 80 ± 10.3 min, and 148.8 ± 25.5 min in the TLH group, respectively, while the study by Gupta et al.[15] concluded the mean operating time for NDVH as 62.73 min and TLH was 91 min (P < 0.01). Sarada Murali and Khan[3] study found 87% of surgeries in the NDVH group were completed within 40 min and 50% of surgeries in the laparoscopic hysterectomy group were completed in 120 min, whereas 37% duration extended up to 240 min in the study. The above studies indicated that the mean operating time for NDVH ranged between 40 min and 90.3 min, whereas for TLH it ranged from 80 min to 120 min and in some cases up to 240 min [Table 2].
Table 2: Comparison of duration of surgery and hospital stay among NDVH and TLH patients

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The mean blood loss during surgery among the patients who underwent NDVH was 202.435 ml and 206.75 ml among TLH patients [Table 3]. Based on preoperative and postoperative hemoglobin, there was no significant difference in blood loss between NDVH and TLH. The mean value of hemoglobin with a 95% confidence interval was between 12 and 13 g % preoperatively and between 11 and 12 g % postoperatively. The mean blood loss in TLH (206.88 ml ± SD 53.32) was found slightly lower as compared to NDVH (202.44s ml ± SD 29.92) but not significant as P value >0.05. The results differ from the findings by Nagar et al.,[10] Shafiq and Jain[16] studies. The retrospective study by Aniuliene et al.[17] found that the amount of blood loss depended on the type of hysterectomy. Less blood was lost during laparoscopic surgery as compared to vaginal (123.4 vs. 195.3 mL with P < 0.01). The comparison of blood loss in referred studies with the present study is as shown in [Table 4].
Table 3: Comparison of blood loss and pain scores among NDVH and TLH patients

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Table 4: Comparison of blood loss during surgery

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The mean days of hospital stay for NDVH were found as 4.26 days, whereas 4.7 days for TLH. The mean duration of hospital stay is less in NDVH as compared with TLH with a P value <0.05 indicating a significant difference in the number of days for a hospital stay. The results of a study by Aratipalli and Bandi[9] are similar in which the NDVH group had 4.46 + 0.973 and in the TLH group, the hospital stay was found as 4.48 + 0.677 days. These findings differ from the study by Kansara et al.[4] where the mean duration of stay between NDVH and TLH was not statistically significant. The difference in mean length of hospital stay in the study by Aniuliene et al.[17] was also found insignificant when comparing laparoscopic and vaginal hysterectomies (P > 0.05).

The most common complication in the current study for both NDVH and TLH was urinary tract infection followed by pyrexia while in the study by Brabdborg and Nikolazsen[18] no complication was found in 54.2% of cases, in others, bleeding, fever, pain, or other problems were reported (incontinence, gas, backache, and cough). The study by Aratipalli and Bandi[9] reported pyrexia followed by urinary tract infection as the most common complication among the two groups. The study also found that in the NDVH group, there was 4% postoperative febrile morbidity and in the TLH group, it was 10%. Gupta and Chandnani[14] Febrile morbidity was found as 12% and 4% in NDVH and LAVH group, bladder and ureteral injuries were seen in 4% and 3% cases of NDVH and AH group and vault complications were higher in TLH group [Table 5].
Table 5: Comparison of postoperative complications among patients after NDVH and TLH surgery

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The conversion to laparotomy (total abdominal hysterectomy) in NDVH was less compared to TLH. Five cases of TLH were converted to total abdominal hysterectomy, the reason being; (a) two cases because of dense adhesions. (b) One case because of torrential hemorrhage. (c) One case because of bladder injury. (d) One case because of instrumental and technical errors. Two NDVH were converted to total abdominal hysterectomy, (a) one case because of dense adhesions. (b) One case because of torrential hemorrhage. Similar results were found in a retrospective study by Jain et al.[19] where conversion to AH was more with TLH caused by hemorrhage in three and bladder injury in one case, in comparison to two cases in NDVH caused by rectal and bladder injury.

Pain in the current study was measured by the Visual Analog Scale after 24 h of surgery. The mean pain score in TLH was 4.42 ± SD 1.39 and in NDVH 3.75 ± SD 1.01. The P value was found significant (<0.05) which shows that pain was less in NDVH than TLH. These findings differ from a study by Chattopadhyay et al.[20] which reported that for NDVH the pain was 9.52, whereas for TLH it was 9. They also found that on the first postoperative day, the mean value for NDVH was 6.56 and that for TLH was 5.35 and overall the patients who underwent TLH had significantly lower postoperative pain as compared to patients undergoing NDVH.


  Conclusion Top


Hysterectomy is always considered an essential armory of gynecological surgeries. Although hysterectomy is the most commonly performed surgery, the ultimate decision for selection of route is based on indication for surgery, size of the uterus, accessibility to the uterus, availability of equipment, skills of the surgeon, and patient’s preference. Removal of the uterus through the NDVH approach is considered a scarless surgery with fewer complications while TLH is found to be a safe and effective procedure.

The patients operated on in NDVH and TLH group had fibroid, adenomyotic changes, and hyperplasia with the meantime taken for surgery NDVH 55.2 min and 112.5 min for TVH. The blood loss in both the surgeries did not have any significant difference and the mean hospital stay for NDVH was found as 4.26 days and 4.7 days in TLH. The most common complication for both NDVH and TLH was urinary tract infection followed by pyrexia. Conversion to laparotomy (total abdominal hysterectomy) in NDVH was less as compared to TLH. The pain was measured after 24 hours of surgery which was found more in TLH patients.

Considering the outcomes of both the routes of hysterectomy, it is concluded that NDVH is considered advantageous over total laparoscopic hysterectomy. TLH requires costly instruments, long OT occupancy, years of training, and experience for the surgeon to master the operating skills. TLH is performed only by the senior surgeon, whereas NDVH is learned faster and can be performed by a junior gynecologist as well.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Ethical consideration

The Institutional Ethics Committee has approved to undertake the research study on “Comparison of Intraoperative and Postoperative Outcomes of Non-Descent Vaginal Hysterectomy and Total Laparoscopic Hysterectomy” vide their letter no. 53 dated 26 October 2018.



 
  References Top

1.
Fingar KR, Stocks C, Weiss AJ, Steiner CA. Most frequent operating room procedures performed in U.S. hospitals, 2003–2012. HCUP Statistical Brief No. 186. Rockville (MD): Agency for Healthcare Research and Quality; 2014.  Back to cited text no. 1
    
2.
ACOG Committee Opinion. Number 311, April 2005. Appropriate use of laparoscopically assisted vaginal hysterectomy. Obstet Gynecol 2005;105:929-30.  Back to cited text no. 2
    
3.
Sarada Murali M, Khan A. A comparative study of non-descent vaginal hysterectomy and laparoscopic hysterectomy. J Obstet Gynaecol India 2019;69:369-73.  Back to cited text no. 3
    
4.
Kansara V, Chaudhari J, Desai A. A comparative study of non-descent vaginal hysterectomy and total laparoscopic hysterectomy. Int J ReprodContraceptObstetGynecol 2020;9:777-81.  Back to cited text no. 4
    
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Goswami D, Kumari N, Gupta V, Chaudhary P. LAVH versus NDVH for benign gynaecological diseases: An experience in tertiary care hospital in Uttarakhand. Int J Med Res Rev 2016;4:679-84. Available from: https://ijmrr.medresearch.in/index.php/ijmrr/article/view/539.  Back to cited text no. 5
    
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Massimo C, Stefano I. Laparoscopic versus vaginal hysterectomy for benign pathology. CurrOpinObstet Gynecol 2010;22:304-8.  Back to cited text no. 6
    
7.
Drahonovsky J, Haakova L, Otcenasek M, Krofta L, Kucera E, Feyereisl J. A prospective randomized comparison of vaginal hysterectomy, laparoscopically assisted vaginal hysterectomy, and total laparoscopic hysterectomy in women with benign uterine disease. Eur J Obstet Gynecol Reprod Biol 2010;148:172-6.  Back to cited text no. 7
    
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Aarts JWM, Nieboer TE, Johnson N, Tayender E, Garry R, Willem B, Kluivers KB. Surgical approach to hysterectomy for benign gynaecological disease. Cochrane Database Sys Rev 2015;2015:CD003677.  Back to cited text no. 8
    
9.
Aratipalli J, Bandi B. Comparison of outcome between total laparoscopic hysterectomy and vaginal hysterectomy in a non- descent uterus in a tertiary care hospital. International Journal of Applied Research 2018;4:197-201.  Back to cited text no. 9
    
10.
Nagar O, Sharma A, Shankar V, Agarwal G, Agarwal S. A comparative study of total laparoscopic hysterectomy and non-descent vaginal hysterectomy for the treatment of benign diseases of the uterus. International Journal of Clinical Obstetrics and Gynaecology 2018;2:63-8.  Back to cited text no. 10
    
11.
Desai S, Shukla A, Nambiar D, Ved R. Patterns of hysterectomy in India: A national and state-level analysis of the Fourth National Family Health Survey (2015–2016). BJOG 2019;126(Suppll4):72-80.  Back to cited text no. 11
    
12.
Singh B, Soni S. Comparative study of different routes of hysterectomy. Obs Gyne Review. J Obst Gynecol 2018;4:89-94. doi:10.17511/joog.2018.i04.04.  Back to cited text no. 12
    
13.
Hwang JL, Seow KM, Tsai YL, et al. Comparative study of vaginal, laparoscopically assisted and abdominal hysterectomies for uterine myoma larger than 6cm in diameter or uterus weighing at least 450g: A prospective randomized study. ActaObstetGynecolScand 2002;81:1132.  Back to cited text no. 13
    
14.
Gupta D, Chandnani K. Study of the route of hysterectomy. Int J Reprod Contracept Obstet Gynecol 2019;8:243-6.  Back to cited text no. 14
    
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Gupta A, Braroo S, Singh G, Gupta A. Comparative evaluation of laparoscopic hysterectomy and non-descent vaginal hysterectomy in women with the benign gynaecological disease. Int J ReprodContraceptObstetGynecol 2018;7:2399-403.  Back to cited text no. 15
    
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Shafiq MA, Jain GA. Prospective randomized study for comparison of total laparoscopic hysterectomy and non-descent vaginal hysterectomy for the treatment of benign diseases of uterus. Scholars Journal of Applied Medical Sciences (SJAMS). J App Med Sci 2018;6:1889-92.  Back to cited text no. 16
    
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Aniuliene R, Varzgaliene L, Varzgalis M. [A comparative analysis of hysterectomies]. Medicina (Kaunas) 2007;43:118-24.  Back to cited text no. 17
    
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Brandsborg B, Nikolajsen L. Chronic pain after hysterectomy. Curr Opin Anaesthesiol 2018;31:268-73.  Back to cited text no. 18
    
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Jain S, Mishra N, Singh N, Jha S. Keyhole to no hole hysterectomy - A retrospective analysis of NDVH and TLH in a teaching hospital. Indian Journal of Obstetrics and Gynecology Research 2018;5:89-92.  Back to cited text no. 19
    
20.
Chattopadhyay S, Patra KK, Halder M, Mandal A, Pal P, Bhattacharyya S. A comparative study of total laparoscopic hysterectomy and non-descent vaginal hysterectomy for the treatment of benign diseases of the uterus. Int J ReprodContraceptObstetGynecol 2017;6:1109-12. Available from: DOI: http://dx.doi.org/10.18203/2320-1770.ijrcog20170594  Back to cited text no. 20
    


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    Tables

  [Table 1], [Table 2], [Table 3], [Table 5], [Table 4]



 

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