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Updated: Aug 9, 2026
Laparoscopic Extracorporeal Knot-Tying for Uterine Vessel Occlusion during Hysterectomy with Cervical Cerclage in Large Uteri
Published on: September 12, 2025
Surgical approach to hysterectomy for benign gynaecological disease
N Johnson1, D Barlow, A Lethaby
1University of Auckland, Department of Obstetrics & Gynaecology, PO Box 92019, Auckland, New Zealand, 1003. n.johnson@auckland.ac.nz
Insights
Vaginal hysterectomy (VH) offers improved outcomes over abdominal hysterectomy (AH). Laparoscopic hysterectomy (LH) may be an alternative to AH, but requires more surgical expertise and longer operating times.
Area of Science:
- Gynecologic Surgery
- Minimally Invasive Procedures
- Evidence-Based Medicine
Background:
- Hysterectomy, a surgical procedure to remove the uterus, can be performed via abdominal (AH), vaginal (VH), or laparoscopic (LH) approaches for benign conditions.
- Laparoscopic hysterectomy encompasses several techniques, including laparoscopic-assisted vaginal hysterectomy (LAVH), laparoscopic hysterectomy with uterine artery ligation (LH(a)), and total laparoscopic hysterectomy (TLH).
Purpose of the Study:
- To evaluate and compare the effectiveness and safety of different surgical approaches for hysterectomy in patients with benign uterine disease.
Main Methods:
- A systematic review and meta-analysis of randomized controlled trials (RCTs) comparing different hysterectomy surgical approaches.
- Searches were conducted across multiple databases including Cochrane, MEDLINE, and EMBASE up to March 2004.
- Twenty-seven trials involving 3643 participants were included in the analysis.
Main Results:
- Vaginal hysterectomy (VH) demonstrated benefits over abdominal hysterectomy (AH), including shorter hospital stays and faster return to normal activities.
- Laparoscopic hysterectomy (LH) compared to AH showed reduced blood loss, shorter hospital stays, and fewer wound infections, but longer operating times and increased urinary tract injuries.
- No significant benefits of LH over VH were found, with LH associated with longer operating times. Evidence for newer techniques like TLH was limited.
Conclusions:
- Vaginal hysterectomy (VH) is recommended over abdominal hysterectomy (AH) when feasible due to superior outcomes.
- Laparoscopic hysterectomy (LH) can be an alternative to AH, but requires specialized surgical skills and may involve longer operative durations.
- Shared decision-making between patient and surgeon is crucial, considering the benefits and risks of each approach. Further high-quality research on long-term outcomes and newer techniques is needed.
Background:
There are three approaches to hysterectomy for benign disease - abdominal hysterectomy (AH), vaginal hysterectomy (VH) and laparoscopic hysterectomy (LH). Laparoscopic hysterectomy has three further subdivisions - laparoscopic assisted vaginal hysterectomy (LAVH) where a vaginal hysterectomy is assisted by laparoscopic procedures that do not include uterine artery ligation, laparoscopic hysterectomy (which we will abbreviate to LH(a)) where the laparoscopic procedures include uterine artery ligation, and total laparoscopic hysterectomy (TLH) where there is no vaginal component and the vaginal vault is sutured laparoscopically.
Objectives:
To assess the most appropriate surgical approach to hysterectomy.
Search Strategy:
We searched the Cochrane Menstrual Disorders & Subfertility Group's Specialised Register of controlled trials (searched 23 March 2004), CENTRAL (The Cochrane Library Issue 1, 2004), MEDLINE (1966 to Mar 2004), EMBASE (1985 to Mar 2004), Biological Abstracts (1968 to Mar 2004), the National Research Register and relevant citation lists.
Selection Criteria:
Only randomised trials comparing one surgical approach to hysterectomy with another were included.
Data Collection And Analysis:
Twenty-seven trials that included 3643 participants were included. Independent selection of trials and data extraction were employed following Cochrane guidelines.
Main Results:
The benefits of VH versus AH were shorter duration of hospital stay (WMD 1.0 day, 95%CI 0.7 to 1.2 days), speedier return to normal activities (WMD 9.5 days, 95%CI 6.4 to 12.6 days), fewer unspecified infections or febrile episodes (OR 0.42, 95%CI 0.21 to 0.83). The benefits of LH versus AH were lower intraoperative bloodloss (WMD 45.3 mls, 95%CI 17.9 to 72.7 mls) and a smaller drop in haemoglobin level (WMD 0.55g/L, 95%CI 0.28 to 0.82g/L), shorter duration of hospital stay (WMD 2.0 days, 95%CI 1.9 to 2.2 days), speedier return to normal activities (WMD 13.6 days, 95%CI 11.8 to 15.4 days), fewer wound or abdominal wall infections (OR 0.32, 95%CI 0.12 to 0.85), fewer unspecified infections or febrile episodes (OR 0.65, 95%CI 0.49 to 0.87), at the cost of longer operating time (WMD 10.6 minutes, 95%CI 7.4 to 13.8 minutes) and more urinary tract (bladder or ureter) injuries (OR 2.61, 95%CI 1.22 to 5.60). There was no evidence of benefits of LH versus VH and the operating time was increased (WMD 41.5 minutes, 95%CI 33.7 to 49.4 minutes). There was no evidence of benefits of LH(a) versus LAVH and the operating time was increased for LH(a) (WMD 25.3 minutes, 95%CI 10.0 to 40.6 minutes). There was statistical heterogeneity in many of the outcome measures when randomised trials were pooled for meta-analysis. No other statistically significant differences were found. However, for some important outcomes, the analyses were underpowered to detect important differences, or they were simply not reported in trials. Data were notably absent for many important long-term outcome measures.
Authors' Conclusions:
Significantly improved outcomes suggest VH should be performed in preference to AH where possible. Where VH is not possible, LH may avoid the need for AH, however the length of the surgery increases as the extent of the surgery performed laparoscopically increases, particularly when the uterine arteries are divided laparoscopically and laparoscopic approaches require greater surgical expertise. The surgical approach to hysterectomy should be decided by a woman in discussion with her surgeon in light of the relative benefits and hazards. Further research is required with full reporting of all relevant outcomes, particularly important long-term outcomes, in large RCTs, to minimise the possibility of reporting bias. Further research is also required to define the role of the newer approaches to hysterectomy such as TLH.
