Introduction

Hysterectomy is the second common surgery performed by gynaecologists. Traditionally, the uterus has been removed by abdominal route which gives the opportunity to inspect the ovaries and vaginal route was reserved for pelvic organ prolapse. Now emphasis on minimally invasive surgery has led to a resurgence of interest and importance of VH for non-prolapse indications, i.e. non-descent vaginal hysterectomy (NDVH) as the scarless hysterectomy. In this era of robotic and laparoscopic surgery, considering the advantage of minimal invasive surgery along with precision, we did a study on non-descent vaginal hysterectomy (NDVH), which is an art of gynaecological surgeons giving us an edge over general surgeons. NDVH also gives us option of minimal invasion with better access to ligaments of uterus for surgery with less blood loss and minimal analgesic requirements post-surgery and under a relatively safe spinal anaesthesia rather than general anaesthesia with its associated complications. Usual limitation of vaginal hysterectomy in non-descent uterus is its size, but now for uterus with larger sizes, hysterectomy can be facilitated by bisection, myomectomy, wedge debulking and intramyometrial coring (morcellation) [1]. Keeping in view that this approach could substantially decrease cost, duration of hospital stay and morbidity, we decided to study vaginal hysterectomies in women with benign gynaecological disorders, other than prolapse, and compare them with laparoscopic hysterectomies done in our hospital.

Materials and Methods

All patients who required hysterectomy without prolapse, for benign conditions were studied between the periods of January 2017 and December 2017. A total of 95 hysterectomies were performed for benign diseases, 40 were non-decent vaginal hysterectomies, 40 were laparoscopic hysterectomies and 15 were vaginal hysterectomies for the descent of uterus. All the surgeries were performed by the author to avoid bias in results.

Prerequisites for vaginal route were uterine size not exceeding 16 weeks of gravid uterus, adequate vaginal access and uterine mobility. Benign ovarian cysts less than 8 cm in size were included. Patients with severely restricted uterine mobility, complex adnexal mass and suspicion of malignancy were excluded. Informed consent was taken from all cases [4].

All cases in NDVH group were done under regional anaesthesia, spinal. After cleaning and draping, cervix was held with vulsellum. Saline infiltration was done. Circumferential incision was taken around the cervix, and pubo-vesico-cervical ligament was cut and bladder pushed up. Both anterior and posterior pouches were opened. Uterosacral and cardinal ligaments were situated in close proximity to vaginal vault and were clamped, cut and ligated. Clamping the uterine vessels was easy vaginally as its relationship to isthmus remained unchanged. The next step depended upon the size of the uterus. Uterine bisection, debulking, myomectomy or combinations of these are effective morcellation techniques, which were performed when required. After delivery of the uterus in the vagina, hysterectomy was completed in usual fashion [4]. Data regarding age, parity, uterine size, uterine weight and estimated blood loss, length of operation, complications and hospital stay were analysed and evaluated.

Similarly, data were collected from 40 laparoscopic hysterectomy surgeries. All surgeries were done under general anaesthesia with standard operative techniques and similar coagulation devices.

Data from both groups were compared on basic statistical analysis methods. Intraoperative time and blood loss were assessed using Chi-square tests.

Results

Table 1 shows the comparison between both groups in demographic factors like age, parity, indication for surgery and associated co-morbidities.

Table 1 Demographic factors
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Both the groups had similar age distribution.

Multiparity is more common in NDVH group while Para 2 was more common in TLH group.

Fibroid uterus was the most common indication in both groups. Uterus of size up to 16 weeks could be operated by vaginal route. Dysfunctional uterine bleeding was the next common indication.

Both groups were compared equally in co-morbidities, like hypertension and diabetes. NDVH was done for two women with morbid obesity, where general anaesthesia was high risk.

Table 2 shows the intraoperative time between the groups.

Table 2 Operative time
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Eighty-seven per cent of surgeries in NDVH group were completed within 40 min, while only in 13% duration extended up to 80 min. Fifty per cent of surgeries in laparoscopic hysterectomy group were completed in 120 min while in 37% duration extended up to 240 min. Operative time was less in NDVH group which was statistically significant, P < 0.001. Operative time was shorter in NDVH group as it was independent of all biomedical instruments needed for laparoscopic hysterectomy.

Table 3 shows the intra-operative blood loss between both groups.

Table 3 Intraoperative blood loss
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In NDVH group, 35% of surgeries had blood loss of 30–50 ml, while 32% had blood loss of 50–80 ml. In laparoscopic hysterectomy group, 50% had blood loss between 80 and 100 ml, more than NDVH group. Blood loss in NDVH group was less than TLH group, and it was statistically significant P < 0.001.

In six cases of NDVH, bilateral salpingo-oophorectomy was done by vaginal route. Additional advantage was repair of cystocele and rectocele. Similarly in six laparoscopic hysterectomy cases, bilateral salpingo-oophorectomy was done. Adhesiolysis was the other common additional surgery in TLH group.

No cases in NDVH group were converted to laparotomy while three cases in laparoscopic hysterectomy group were converted to laparotomy. There were no intraoperative complications in NDVH group while two cases of bladder injury and one ureteric injury were seen in laparoscopic hysterectomy group, which were converted into laparotomy to deal with complications.

Analgesia requirements and hospital stay were the same in both groups. Average hospital stay was 3 days in both the groups.

In both groups, all patients were ambulated by 6–8 h post-surgery.

While post-op complications were reviewed, two cases in NDVH group had diarrhoea and one patient had pelvic abscess which was treated conservatively. Post-op ileus was seen in two cases of laparoscopic hysterectomy.

Discussion

In the absence of uterine prolapse, most gynaecologists prefer the abdominal to vaginal route of hysterectomy. The common limitations for vaginal hysterectomy in non-prolapsed uterus include size of the uterus, nulliparity, previous pelvic surgery or lower segment caesarean section (LSCS), pelvic adhesions and endometriosis, last but not the least limited exposure during the learning phase of their career. The factors that may influence the route of hysterectomy for any surgical indication include uterine size, mobility, accessibility and pathology confined to the uterus. Multiparity, lax tissues following multiple deliveries and decreased tissue tensile strength provide comfort to vaginal surgeon even in the presence of uterine enlargement [2, 3].

In our study 40–50 years was the common age group for surgery and similarity was also observed in study done by Dewan et al. [4]. The mean parity was 3 in NDVH group and 2 in laparoscopic hysterectomy group which is comparable with Kalpana et al. group, which found mean parity of 3.6 in NDVH group.

Uterine enlargement was the common contraindication for vaginal surgery. In our study, 37.5% of indications for surgery in NDVH group were for fibroid uterus, of which 30% were of size 12–16 weeks. The techniques of bisection, myomectomy and morcellation were used to remove bulky uterus. Davies et al. [5] and Mazdisian et al. [6] also resorted to these techniques.

The mean duration of surgery in NDVH group without debulking was 40 min which was compared with the study done by Kalpana et al., which showed the duration of 36.7 min [2].

The mean blood loss in our study was 50 ml in NDVH group, while 100 ml was blood loss reported by Bhadra et al. [7]. Post-op stay in hospital was 3 days in NDVH group in our study which was compared with the study done by Chakraborthy et al. [8].

Conclusions

Vaginal hysterectomy for non-descent large uterus is safe and feasible provided one is familiar with the technique [9, 10]. Our study shows NDVH can be offered to women with co-morbidities like asthma and high BMI without increasing risk of anaesthesia complications with general anaesthesia for TLH. Operative time and intraoperative blood loss are also very less compared to TLH study group. With experience, NDVH can be done safely for fibroid size even above 12 weeks. Thus, this scarless approach appears to be the preferred method of hysterectomy.