Surgical approach to hysterectomy for benign gynaecological disease

Charlotte M Pickett; Dachel D Seeratan; Ben Willem J Mol; Theodoor E. Nieboer; Neil Johnson; Tijmen Bonestroo; Johanna WM Aarts

doi:10.1002/14651858.CD003677.pub6

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Figure 1

Study flow diagram.

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Figure 2

Risk of bias summary: review authors' judgements about each methodological quality item presented as percentages across all included studies.

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Figure 3

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Figure 4

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Figure 5

Funnel plot for length of hospital stay for laparoscopic hysterectomy versus abdominal hysterectomy comparision.

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Figure 6

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Analysis 1.1

Comparison 1: VH versus AH, Outcome 1: Return to normal activities (days)

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Analysis 1.2

Comparison 1: VH versus AH, Outcome 2: Long‐term outcomes: satisfaction (dichotomous)

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Analysis 1.3

Comparison 1: VH versus AH, Outcome 3: Intraoperative visceral injury (dichotomous)

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Analysis 1.4

Comparison 1: VH versus AH, Outcome 4: Long‐term complications (dichotomous)

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Analysis 1.5

Comparison 1: VH versus AH, Outcome 5: Operation time (mins)

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Analysis 1.6

Comparison 1: VH versus AH, Outcome 6: Short‐term outcomes (dichotomous)

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Analysis 1.7

Comparison 1: VH versus AH, Outcome 7: Length of hospital stay (days)

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Study	Description	VH	AH	Conclusion
All outcomes, descriptive data
Quality of life (descriptive data)
Silva Filho 2006	Questionnaire SF‐36. Only data from functional capacity, physical aspect and pain are presented. A high score is a better quality of life	n = 30 1 month after surgery, response rate 100%	n = 30 1 month after surgery, response rate 100%	Functional capacity: VH mean = 95, IQ‐range = 75 to 100. AH mean = 72.5, IQR = 55 to 90 Physical aspect: VH mean = 100, IQ‐range = 25 to 100. AH mean = 37.5, IQR = 0 to 100 Pain: VH mean = 84, IQR = 59.2 to 100. AH mean = 51, IQ‐range = 41 to 65. A higher rate of patients in VH would choose the same therapeutic modality (90% versus 65.5%, P value = 0.021)
Operation time (descriptive data)
Ekanayake 2021		n = 49 Median = 50 mins IQR (35 to 65)	n = 49 Median = 45 mins IQR (36.5 to 60)	Not tested separately
Hwang 2002		With 2nd procedure: median = 93 range = 80 to 110 n = 3 Without 2nd procedure: median = 74 range = 40 to 120 n = 27	With 2nd procedure: median = 117 range = 90 to 190 n = 8 Without 2nd procedure: median = 98 range = 85 to 150 n = 22	Not tested separately
Miskry 2003		Mean 68.8 (range 30 to 180) mins n = 18	Mean 68.2 (range 45 to 174) mins n = 18	‐
Nanavati 2016		n = 50 mean 77.5 mins no IQR/SD given	n = 50 mean 75 mins no IQR/SD given	no P value
Ribeiro 2003		Mean 78 mins n = 20	Mean 109 mins n = 20	No measure of spread stated
Length of hospital stay (descriptive data)
Allam 2015		n = 30 median 1.5 IQR (1.5 to 2)	n = 30 median 1.5 days IQR (1 to 2)	Estimated with the Kruskal–Wallis test P < 0.001
Ekanayake 2021		n = 49 median = 3 days IQR (2 to 3)	n = 49 median = 3 days IQR (2 to 3)	Not tested separately
Hwang 2002		n = 30 median = 4.7 days range (3 to 7)	n = 30 median = 5 days range (4 to 8)	Not tested separately
Nanavati 2016		n = 50 4 days no IQR or SD given	n = 50 6 days no IQR or SD given	No P value
Ribeiro 2003		n = 20 All went home on second postoperative day	n = 20 All went home on third postoperative day	—
Urinary and sexual dysfunction (descriptive data)
Ekanayake 2020	Questionnaire ICIQ‐LUTS. Urinary symptoms pre‐operatively, 6 months and 1 year postoperatively. A high score means experiencing more urinary symptoms	Urinary flow symptoms: Pre‐op: n = 49 median = 3 IQR (2 to 5) 6 months postop: n = 48 median = 2 IQR (0 to 4.75) 1 year postop: n = 45 median = 2 IQR (0.5 to 4) Urinary voiding symptoms: Pre‐op: n = 49 median = 0 IQR (0 to 1) 6 months postop: n = 48 median = 0 IQR (0 to 0.75) 1 year postop: n = 45 median = 0 IQR (0 to 1) Urinary incontinence symptoms: Pre‐op: n = 49 median = 0 IQR (0 to 3) 6 months postop: n = 48 median = 1 IQR (0.75 to 3) 1 year postop: n = 45 median = 0 IQR (0 to 3)	Urinary flow symptoms: Pre‐op: n = 49 median = 2 IQR (1 ‐ 4) 6 months postop: n = 49 median = 1 IQR (0 ‐ 3) 1 year postop: n = 47 median = 1 IQR (0 ‐ 3) Urinary voiding symptoms: Pre‐op: n = 49 median = 0 IQR (0 ‐ 0) 6 months postop: n = 49 median = 0 IQR (0 ‐ 0) 1 year postop: n = 47 median = 0 IQR (0 ‐ 0) Urinary incontinence symptoms: Pre‐op: n = 49 median = 0 IQR (0 ‐ 2) 6 months postop: n = 49 median = 0 IQR (0 ‐ 2) 1 year postop: n = 47 median = 0 IQR (0 ‐ 2)	Urinary flow symptoms: NDVH 6 months postoperative score versus pre‐operative score: P < 0.001 NDVH 1 year postoperative score versus pre‐operative score: P < 0.001 TAH 6 months postoperative score versus pre‐operative score: P < 0.001 TAH 1 year postoperative score versus pre‐operative score: P < 0.001 Urinary voiding symptoms: NDVH 6 months postoperative score versus pre‐operative score: P < 0.05 NDVH 1 year postoperative score versus pre‐operative score: P < 0.05 TAH 6 months postoperative score versus pre‐operative score: P = 0.47 TAH 1 year postoperative score versus pre‐operative score: P = 0.20 Urinary incontinence symptoms: NDVH 6 months postoperative score versus pre‐operative score: P = 0.07 NDVH 1 year postoperative score versus pre‐operative score: P < 0.01 TAH 6 months postoperative score versus pre‐operative score: P = 0.06 TAH 1 year postoperative score versus pre‐operative score: P < 0.01
Ekanayake 2020	Questionnaire ICIQ‐VS. Sexual symptoms pre‐operatively, 6 months and 1 year postoperatively. A high score means experiencing more sexual symptoms	Pre‐operatively: n = 49 median = 0 IQR (0 to 0) 6 months postoperatively: n = 29 median = 0 IQR (0 to 0) 1 year postoperatively: n = 28 median = 0 IQR (0 to 0)	Pre‐operatively: n = 49 median = 0 IQR (0 to 11.5) 6 months postoperatively: n = 23 median = 0 IQR (0 to 10) 1 year postoperatively: n = 22 median = 0 IQR (0 to 14)	NDVH group: 6 months postoperative score versus pre‐operative score: P = 0.69 1 year postoperative score versus pre‐operative score: P = 0.46 TAH group: 6 months postoperative score versus pre‐operative score: P < 0.05 1 year postoperative score versus pre‐operative score: P = 0.08
Ekanayake 2020	Questionnaire ICIQ‐VS. Vaginal symptoms pre‐operatively, 6 months and 1 year postoperatively. A high score means experiencing more vaginal symptoms	Pre‐operatively: n = 49 median = 6 IQR (4 to 8.5) 6 months post‐operatively: n = 48 median = 4 IQR (0 to 8) 1 year post‐operatively: n = 45 median = 5 IQR (0 to 8)	Pre‐operatively: n = 49 median = 6 IQR (2 to 8) 6 months postoperatively: n = 49 median = 4 IQR (0 to 8) 1 year postoperatively: n = 47 median = 4 IQR (0 to 8)	For both the TAH and NDVH group vaginal function domain scores at 6 months and 1 year postoperatively were statistically significant compared to the respective pre‐operative scores (P < 0.001)
Cost (descriptive data)
Benassi 2002	Average cost of the procedure, including hospital stay. The currency being reported is unclear, although the study was conducted in Parma, Italy.	58,581	71,882
Ekanayake 2021	Direct cost in US dollars (USD) (mean, 95% CI)	800 (622 to 1116)	59 (632 to 687)

Analysis 1.8

Comparison 1: VH versus AH, Outcome 8: All outcomes, descriptive data

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Analysis 2.1

Comparison 2: LH versus AH, Outcome 1: Return to normal activities (days)

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Analysis 2.2

Comparison 2: LH versus AH, Outcome 2: Satisfaction

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Analysis 2.3

Comparison 2: LH versus AH, Outcome 3: Bladder injury

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Analysis 2.4

Comparison 2: LH versus AH, Outcome 4: Ureter injury

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Analysis 2.5

Comparison 2: LH versus AH, Outcome 5: Urinary tract (bladder or ureter) injury

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Analysis 2.6

Comparison 2: LH versus AH, Outcome 6: Bowel injury

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Analysis 2.7

Comparison 2: LH versus AH, Outcome 7: Vascular injury

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Analysis 2.8

Comparison 2: LH versus AH, Outcome 8: Fistula

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Analysis 2.9

Comparison 2: LH versus AH, Outcome 9: Urinary dysfunction

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Analysis 2.10

Comparison 2: LH versus AH, Outcome 10: Operation time (mins)

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Analysis 2.11

Comparison 2: LH versus AH, Outcome 11: Bleeding

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Analysis 2.12

Comparison 2: LH versus AH, Outcome 12: Transfusion

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Analysis 2.13

Comparison 2: LH versus AH, Outcome 13: Pelvic haematoma

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Analysis 2.14

Comparison 2: LH versus AH, Outcome 14: Length of hospital stay (days)

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Analysis 2.15

Comparison 2: LH versus AH, Outcome 15: Vaginal cuff infection

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Analysis 2.16

Comparison 2: LH versus AH, Outcome 16: Wound/abdominal wall infection

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Analysis 2.17

Comparison 2: LH versus AH, Outcome 17: Urinary tract infection

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Analysis 2.18

Comparison 2: LH versus AH, Outcome 18: Chest infection

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Analysis 2.19

Comparison 2: LH versus AH, Outcome 19: Febrile episodes or unspecified infection

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Analysis 2.20

Comparison 2: LH versus AH, Outcome 20: Thromboembolism

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Analysis 2.21

Comparison 2: LH versus AH, Outcome 21: Wound dehiscence

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Study	LH	AH	Comments
Return to normal activities (descriptive data)
Langebrekke 1996	n = 46 median = 19.5 days range (0 to 140)	n = 54 median = 36.5 days range (23 to 259)	P value < 0.001 Wilcoxon rank‐sum test
Persson 2006	n = 63 median = 26 days range (3 to 86)	n = 56 median = 33.5 days range (14 to 61)	P value = 0.0081
Raju 1994	n = 40 median = 21 days range = (7 to 35)	n = 40 median = 42 days range (21 to 67)	P value < 0.0001 Mann‐Whitney U test
Schütz 2002	n = 28 median = 42 days	n = 20 median = 42 days	—

Analysis 2.22

Comparison 2: LH versus AH, Outcome 22: Return to normal activities (descriptive data)

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Study	Description	LH	AH	Comments
Long‐term outcomes: quality of life (descriptive data)
Garry 2004	Questionnaire assessment of sexual activity, body image (BIS) and health status (SF‐12) before and after surgery (6 weeks, 4 months and 1 year) SF‐12 scores: difference at each time point (high score = better quality of life) Body Image Scale: difference at each time point (low score = a better body image)	SF scores PHYSICAL COMPONENT SUMMARY (PCS‐12) Baseline (n = 447) Mean = 44.9, SD = 11.7 6 weeks (n = 301) Mean = 46.8, SD = 10.1 4 months (n = 304) Mean = 52.6, SD = 8.6 1 year (n = 330) Mean = 53.6, SD = 8.4 MENTAL COMPONENT SUMMARY (MCS‐12) Baseline (n = 447 Mean = 45.8, SD = 11.7 6 weeks (n = 301) Mean = 50, SD = 11.4 4 months (n = 304) Mean = 50.9, SD = 10.5 1 year (n = 330) Mean = 50.7, SD = 10.7 Body Image Scale Baseline (n = 540) Mean = 8.8, SD = 8.1 6 weeks (n = 357) Mean = 3.7, SD = 4.9 4 months (n = 346) Mean = 3.3, SD = 4.9 1 year (n = 387) Mean = 3.4, SD = 5.2	SF scores PHYSICAL COMPONENT SUMMARY (PCS‐12) Baseline (n = 221) Mean = 45.6, SD = 11.5 6 weeks (n = 148) Mean = 41.7, SD = 9.7 4 months (n = 134) Mean = 51.6, SD = 8.6 1 year (n = 148) Mean = 52.7, SD = 9.3 MENTAL COMPONENT SUMMARY (MCS‐12) Baseline (n = 221) Mean = 45.3, SD = 11.3 6 weeks (n = 148) Mean = 51.9, SD = 10.8 4 months (n = 134) Mean = 51.8, SD = 9.5 1 year (n = 148) Mean = 51.9, SD = 10.2 Body Image Scale Baseline (n = 270) Mean = 9, SD = 7.9 6 weeks (n = 172) Mean = 5.2, SD = 5.9 4 months (n = 159) Mean = 4.4, SD = 6.3 1 year (n = 168) Mean = 4.1, SD = 5.7	SF scores PCS‐12 Baseline: difference (CI) = 0.6 (‐1.2 to 2.5) 6 weeks: difference (CI) = ‐5.1 (‐7.1 to ‐3.2); P value < 0.0001 4 months: difference (CI) = ‐1.0 (‐2.8 to 0.7); P value = 0.25 1 year = difference in (CI) = ‐0.9 (‐2.5 to 0.8); P value = 0.32 MCS‐12 Baseline: difference (CI) = ‐0.5 (‐2.4 to 1.4) 6 weeks: difference (CI) = 1.8 (‐0.4 to 4); P value = 0.11 4 months: difference (CI) = 0.8 (‐1.3 to 2.9); P value = 0.44 1 year: difference (CI) = 1.1 (‐0.9 to 3.2); P value = 0.27 Body Image Scale Baseline: difference (CI) = 0.2 (‐0.9 to 1.4) 6 weeks: difference (CI) = 1.5 (0.5 to 2.4); P value = 0.005 4 months: difference (CI) = 1.1 (0.06 to 2.1); P value = 0.06 1 year: difference (CI) = 0.7 (‐0.2 to 1.7); P value = 0.13 Both LH and AH groups had improvements in the Physical and Mental components of the SF‐12 and Body Image Scale (BIS). These were maintained and improved at 12 months. Significant difference in PCS‐12 at 6 weeks between LH and AH and highly significant difference in BIS at 6 weeks, but this difference did not persist at 4 and 12 months.
Kluivers 2007	Questionnaire RAND‐36. A high score is a better quality of life. Statistical analysis with use of linear mixed model to evaluate the differences between 2 and 12 weeks while accounting for baseline value In Nieboer 2012, the same patients were evaluated with use of the same questionnaire 4 years after surgery	n = 27 at baseline n = 27, 26, 26, 25 and 22 at 1, 2, 4, 6 and 12 weeks respectively n = 23 at 4 years	n = 32 at baseline n = 32, 32, 32, 31, 30 and 30 at 1, 2, 4, 6 and 12 weeks respectively n = 26 at 4 years	Difference (95% CI) in favour of LH (the score range on subscales is 100; the score range on total RAND‐36 scales is 800) over the first 12 weeks: Physical functioning 7.8 (‐0.3 to 15.9) Social functioning 7.0 (‐1.8 to 15.7) Role physical 1.7 (‐7.7 to 11.1) Role emotional 1.5 (‐13.4 to 16.5) Mental health 3.6 (‐2.8 to 9.9) Vitality 12.0 (4.7 to 19.3) Bodily pain 8.4 (‐0.1 to 17.4) General health 0.0 (‐8.1 to 8.1) Total RAND‐36 49.6 (‐5.1 to 104.2) Only the difference in the subscale vitality was statistically significant Analysis over 4 years follow‐up after surgery: total RAND‐36 scores overall mean difference 50.4 points (95% CI 1.0 to 99.7) in favour of LH. Statistically significant higher scores were also found on the domains physical role functioning, social role functioning and vitality
Lumsden 2000	EuroQol Health Questionnaire used to measure women's evaluation of their health state post surgery (1, 6 and 12 months after surgery). Use of a visual analogue thermometer (0 is worst imaginable health state and 100 is best imaginable health state).	1 month (post‐op minus pre‐op): n = 74. Mean = 7, SD = 24.1. Median = 10, range (‐50 to 50) 6 months: n = 62. Mean = 11.3, SD = 23.9. Median = 15, range (‐50 to 60) 1 year: n = 43. Mean = 12.6, SD = 25. Median = 14, range (‐40 to 73)	1 month: n = 76. Mean = 6.8, SD = 19.2. Median = 8, range (‐50 to 60). 6 months: n = 61. Mean = 14.9, SD = 16.7 Median = 15, range (‐20 to 60) 1 year: n = 47. Mean = 15.9, SD = 21. Median = 15, range (‐40 to 60)	Mean difference: 1 month: ‐1.6 (‐7.2 to 6.9) 6 months: 3.7 (‐3.7 to 11) 1 year: 4.9 (‐6.7 to 12.8) No evidence of a significant difference at 1 month, 6 months or 1 year after surgery
Olsson 1996	6 to 8 weeks after surgery participants were asked in an anonymous questionnaire if they considered the duration of their postoperative stay adequate	9% of women in the LAVH group considered their time in hospital following surgery to be too short	17% of women in the AH group considered their time in hospital following surgery to be too short	—
Persson 2006	Questionnaires: Psychological General Wellbeing (PGWI), Women Health Questionnaire (WHQ), Spielberger Trait Anxiety Inventory (STAI) and Beck's Depression Inventory (BDI) A higher score in the PGWB shows a higher degree of wellbeing, whereas in the WHQ, STAI and BDI a higher score shows the more undesirable outcomes. Assessment at baseline, and 5 weeks and 6 months postoperatively. Statistical analysis with the use of ANOVA for repeated measurements Persson 2008 analysed wellbeing on a 0 to 100 VAS and stress coping ability	n = 63 PGWB: Baseline: mean = 96.7, SD = 17.9. 5 weeks: mean = 100.4, SD = 16.7. 6 months: mean = 104.7, SD = 18.5 WHQ: Baseline: mean = 64.9, SD = 13.9. 5 weeks: mean = 54.6, SD = 12.8. 6 months: mean = 55.0, SD = 14.4. STAI: Baseline: mean = 35.6, SD = 9.1. 5 weeks: mean = 32.7, SD = 8.7. 6 months: mean = 33.6, SD = 10.2. BDI: Baseline: mean = 6.6, SD = 5.8. 5 weeks: mean = 4.6, SD = 5.5. 6 months: mean = 5.3, SD = 6.8	n = 56 PGWB: Baseline: mean = 96.5, SD = 16.5. 5 weeks: mean = 102.1, SD = 16.4. 6 months: mean = 106.1, SD = 16.0 WHQ: Baseline: mean = 63.9, SD = 18.2. 5 weeks: mean = 54.3, SD = 17.1. 6 months: mean = 54.2, SD = 17.2 STAI: Baseline: mean = 34.7, SD = 10.1. 5 weeks: mean = 31.7, SD = 10.6. 6 months: mean = 31.7, SD = 9.2 BDI: Baseline: mean = 6.9, SD = 6.1. 5 weeks: mean = 5.0, SD = 6.5. 6 months: mean = 4.0, SD = 5.2	Main effect between groups: PGWB P value = 0.719, WHQ P value = 0.800, STAI P value = 0.418, BDI P value = 0.788. Main effect over time: PGWB P value < 0.0001, WHQ P value < 0.0001, STAI P value = 0.0002, BDI P value = 0.0002 Interaction: PGWB P value = 0.772, WHQ P value = 0.953, STAI P value = 0.762, BDI P value = 0.223 In Persson 2008: no significant difference was found in the day‐by‐day recovery of general wellbeing between the operating methods. Stress coping ability did significantly influence the day‐by‐day recovery of general wellbeing

Analysis 2.23

Comparison 2: LH versus AH, Outcome 23: Long‐term outcomes: quality of life (descriptive data)

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Study	LH	AH	Comments
Operation time (descriptive data)
Ekanayake 2021	n = 49 median = 93 mins IQR (80 to 111)	n = 49 median = 45 mins IQR (36.5 to 60)	TLH vs TAH Not tested separately
Falcone 1999	n = 23 median = 180 mins range (139 to 225)	n = 21 median = 130 mins range (97 to 155)	TLH vs AH Wilcoxon rank‐sum test P value < 0.001
Ferrari 2000	n = 31 median = 135 mins range (115 to 173)	n = 31 median = 120 mins range (98 to 123)	LAVH vs AH P value = 0.001 Calculated from the first incision to closure of all wounds
Garry 2004	n = 584 median = 84 mins range(10 to 325)	n = 292 median = 50 mins range (19 to 155)	non‐categorisable LH vs AH Calculated from first incision to last suture
Hwang 2002	With 2nd procedure n = 13 median = 119 range (80 to 165) Without 2nd procedure n = 17 median = 109 mins range (85 to 175)	With 2nd procedure n = 8 median = 117 mins range (90 to 190) Without 2nd procedure n = 22 median = 98 range (85 to 150)	TLH vs AH Not tested separately
Langebrekke 1996	n = 46 median = 100 mins range (50 to 153)	n = 54 median = 60.5 mins range (22 to 105)	TLH vs AH
Muzii 2007	n = 40 median = 86 mins range (60 to 120)	n = 41 median = 58 mins range (45 to 75)	LAVH vs minilaparotomy AH
Nanavati 2016	n =50 mean 108 mins no IQR/SD given	n = 50 mean 75 mins no IQR/SD given	No IQR/SD given, no P value
Persson 2006	n = 63 median = 99 mins range (50 to 190)	n = 56 median = 64 mins range (35 to 150)	LAVH vs AH P value < 0.0001 (students t test)
Raju 1994	n = 40 median = 100 mins range (61 to 180)	n = 40 median = 57 mins range (25 to 151)	LAVH vs AH P value < 0.0001 Mann‐Whitney U test Calculated from first incision to time all wounds were closed, dressed and urinary catheter inserted
Ribeiro 2003	n = 20 Mean 119 mins (no measure of spread reported)	n = 20 Mean 109 mins (no measure of spread reported)	TLH vs AH
Schütz 2002	n = 28 median = 133 mins range (120 to 160)	n = 20 median = 132 mins range (121 to 145)	LAVH vs AH
Yuen 1998	n = 20 median = 95 mins range (79 to 143)	n = 24 median = 105 mins range (86 to 120)	LAVH vs AH Calculated from first surgical incision to time of last suture

Analysis 2.24

Comparison 2: LH versus AH, Outcome 24: Operation time (descriptive data)

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Study	LH	AH	Comments
Length of hospital stay (descriptive data)
Allam 2015	n = 30 median 0.75 days IQR (0.5 to1.5)	n = 30 median 1.5 days IQR (1 to 2)	P value < 0.001 Kruskal–Wallis test
Ekanayake 2021	n = 49 median = 2 days IQR (1 to 3)	n = 49 median = 3 days IQR (2 to 3)	TLH vs TAH Not tested separately
Falcone 1999	n = 23 median = 1.5 days range (1.0 to 2.3)	n = 21 median = 2.5 days range (1.5 to 2.5)	P value = 0.038 Wilcoxon rank‐sum test
Ferrari 2000	n = 31 median = 3.8 days range (3.8 to 4.0)	n = 31 median = 5.8 days range (5.3 to 6.3)	P value < 0.001
Garry 2004	n = 584 median = 3 days range (1 to 36)	n = 292 median = 4 days range (1 to 36)	—
Hwang 2002	n = 30 median = 4.7 days range (3 to 7)	n = 30 median = 5 days range (4 to 8)	Not tested separately
Langebrekke 1996	n = 46 median = 2 days range (0 to 5)	n = 54 median = 5 days range (3 to 12)	P value < 0.001 Wilcoxon rank‐sum test
Muzii 2007	n = 40 median = 2 days range (1 to 3)	n = 41 median = 3 days range = (1 to 5)	P value = 0.53
Nanavati 2016	n = 50 mean 4.5 no IQR/SD given	n = 50 mean 6 no IQR/SD given	No IQR/SD given no P value
Persson 2006	n = 63 median = 2 days range (1 to 11)	n = 56 median = 3 days range (2 to 7)	P value = 0.0006 In the same population (described in Persson 2008), duration of sick leave was associated with the occurrence of postoperative complications but not with stress‐coping ability
Raju 1994	n = 40 median = 3.5 days range (1 to 6)	n = 40 median = 6 days range (3 to 13)	P value < 0.0001 Mann‐Whitney U test
Ribeiro 2003	n = 20 all home on day 2	n = 20 all home on day 3	—
Schütz 2002	n = 28 median = 6.5 days range (5 to 7)	n = 20 median = 10 days range (8.25 to 11)	—
Yuen 1998	n = 20 median = 4 days range (4 to 5)	n = 24 median = 6 days range (5 to 9)	P value < 0.001 Mann‐Whitney U test

Analysis 2.25

Comparison 2: LH versus AH, Outcome 25: Length of hospital stay (descriptive data)

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Study	Description	LH	AH	Comments
Cost (descriptive data)
Ekanayake 2021	Direct costs, which includes preoperative costs, operative costs, cost of hospital stay and costs up to 6 months after surgery Units of currency = US dollars (USD)	n = 49 Mean = 752 USD 95% CI (719 to 795)	n = 49 Mean = 659 USD 95% CI (632 to 687)	TLH vs TAH The direct cost of TAH was significantly lower compared to TLH
Ellstrom 1998	Analysis of cost over a period of 12 weeks, starting on the day the participant entered the hospital. Direct costs (hospital costs) and indirect costs (loss of production value) were analysed separately. Units of currency = Swedish crowns (SEK)	n = 38 Direct costs (average) = SEK 23,169 Indirect costs (average) = SEK 10,314	n = 38 Direct costs (average) = SEK 22,780. Indirect costs (average) = SEK 20,743.	The change in costs between LH and AH are negligible as approximately 50% of hospital costs are fixed costs
Falcone 1999	Hospital costs (amount a provider must pay for goods and services) were assessed through the hospital accounting system. The direct and indirect costs were calculated for each patient from 3 different components: operating room costs, anaesthesia costs and ward costs	n = 24 Difference in medians (LH‐AH): total hospital costs = USD 277 (CI ‐163 to 1097), P value = 0.21	n = 24 (see LH)	Total hospital costs were not significantly higher in the LH group than the AH group
Lumsden 2000	Single set of unit costs applied to each unit of resource to provide a NHS cost for each woman. 1997/98 prices	n = 95 Total cost (operation, inpatient stay and readmissions): median = GBP 2112, mean = GBP 2479 Cost excluding disposables: median = GBP 1740, mean = GBP 2173	n = 95 Total cost: median = GBP 1667, mean = GBP 1832. Cost excluding disposables: median = GBP 1667, mean = GBP 1832	AH had significantly lower total costs than LH, resulting principally from the difference in operation costs. When the cost of disposable equipment was removed, the difference was non‐significant
Raju 1994	Cost analysis of each type of procedure on the major points of difference between either operation: cost of disposable consumables and the comparative costs of postoperative lengths of stay in hospital	n = 40 Cost of operation (average) = GBP 225 Cost of mean length of stay including operation time and cost of disposable instruments = GBP 1260	n = 40 Cost of operation (average) = GBP 30 Cost of mean length of stay including operation time and cost of disposable instruments = GBP 1750	—
Summitt 1998	Hospital charges for both groups	n = 34 Mean = USD 8161, SD = 3600, range (3061 to 23,591). P value > 0.05	n = 31 Mean = USD 6974, SD = 2843, range (3183 to 16,086). P value > 0.05	Lack of a statistical difference in total hospital charges

Analysis 2.26

Comparison 2: LH versus AH, Outcome 26: Cost (descriptive data)

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Study	Description	LH	AH	Conclusion
Urinary and sexual dysfunction (descriptive data)
Ekanayake 2020	Questionnaire ICIQ‐VS. Vaginal symptoms pre‐operatively, 6 months and 1 year postoperatively. A high score means experiencing more vaginal symptoms	Pre‐operatively: n = 49 median = 4 IQR (2 to 10.5) 6 months postoperatively: n = 48 median = 3 IQR (0 to 6) 1 year postoperatively: n = 47 median = 4 IQR (0 to 10)	Pre‐operatively: n = 49 median = 6 IQR (2 to 8) 6 months postoperatively: n = 49 median = 4 IQR (0 to 8) 1 year postoperatively: n = 47 median = 4 IQR (0 to 8)	For both the TAH and TLH group vaginal function domain scores at 6 months and 1 year postoperatively were statistically significant compared to the respective pre‐operative scores (P < 0.001)
Ekanayake 2020	Questionnaire ICIQ‐LUTS. Urinary symptoms pre‐operatively, 6 months and 1 year post‐operatively. A high score means experiencing more urinary symptoms	Urinary flow symptoms: Pre‐op: n = 49 median = 1 IQR (1 to 4) 6 months postop: n = 48 median = 1 IQR (0 to 3) 1 year postop: n = 47 median = 1 IQR (0 to 3) Urinary voiding symptoms: Pre‐op: n = 49 median = 0 IQR (0 to 0) 6 months postop: n = 48 median = 0 IQR (0 to 0) 1 year postop: n = 47 median = 0 IQR (0 to 0) Urinary incontinence symptoms: Pre‐op: n = 49 median = 0 IQR (0 to 3) 6 months postop: n = 48 median = 0 IQR (0 to 1.75) 1 year postop: n = 47 median = 0 IQR (0 to 2)	Urinary flow symptoms: Pre‐op: n = 49 median = 2 IQR (1 to 4) 6 months postop: n = 49 median = 1 IQR (0 to 3) 1 year postop: n = 47 median = 1 IQR (0 to 3) Urinary voiding symptoms: Pre‐op: n = 49 median = 0 IQR (0 to 0) 6 months postop: n = 49 median = 0 IQR (0 to 0) 1 year postop: n = 47 median = 0 IQR (0 to 0) Urinary incontinence symptoms: Pre‐op: n = 49 median = 0 IQR (0 to 2) 6 months postop: n = 49 median = 0 IQR (0 to 2) 1 year postop: n = 47 median = 0 IQR (0 to 2)	Urinary flow symptoms: TLH 6 months postoperative score versus pre‐operative score: P < 0.01 TLH 1 year postoperative score versus pre‐operative score: P < 0.05 TAH 6 months postoperative score versus pre‐operative score: P < 0.001 TAH 1 year postoperative score versus pre‐operative score: P < 0.001 Urinary voiding symptoms: TLH 6 months postoperative score versus pre‐operative score: P = 0.47 TLH 1 year postoperative score versus pre‐operative score: P < 0.05 TAH 6 months postoperative score versus pre‐operative score: P = 0.47 TAH 1 year postoperative score versus pre‐operative score: P = 0.20 Urinary incontinence symptoms: TLH 6 months postoperative score versus pre‐operative score: P = 0.21 TLH 1 year postoperative score versus pre‐operative score: P < 0.05 TAH 6 months postoperative score versus pre‐operative score: P = 0.06 TAH 1 year postoperative score versus pre‐operative score: P < 0.01
Ekanayake 2020	Questionnaire ICIQ‐VS. Sexual symptoms pre‐operatively, 6 months and 1 year postoperatively. A high score means experiencing more sexual symptoms	Pre‐operatively: n = 49 median = 0 IQR (0 to 0) 6 months postoperatively: n = 23 median = 0 IQR (0 to 0) 1 year postoperatively: n = 22 median = 0 IQR (0 to 4.2)	Pre‐operatively: n = 49 median = 0 IQR (0 to 11.5) 6 months postoperatively: n = 23 median = 0 IQR (0 to 10) 1 year postoperatively: n = 22 median = 0 IQR (0 to 14)	TLH group: 6 months postoperative score versus pre‐operative score: P = 0.06 1 year postoperative score versus pre‐operative score: P < 0.05 TAH group: 6 months postoperative score versus pre‐operative score: P < 0.05 1 year postoperative score versus pre‐operative score: P = 0.08

Analysis 2.27

Comparison 2: LH versus AH, Outcome 27: Urinary and sexual dysfunction (descriptive data)

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Analysis 3.1

Comparison 3: LH versus VH, Outcome 1: Return to normal activities (days)

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Analysis 3.2

Comparison 3: LH versus VH, Outcome 2: Ureter injury

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Analysis 3.3

Comparison 3: LH versus VH, Outcome 3: Bladder injury

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Analysis 3.4

Comparison 3: LH versus VH, Outcome 4: Urinary tract (bladder or ureter) injury

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Analysis 3.5

Comparison 3: LH versus VH, Outcome 5: Bowel injury

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Analysis 3.6

Comparison 3: LH versus VH, Outcome 6: Vascular injury

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Analysis 3.7

Comparison 3: LH versus VH, Outcome 7: Fistula

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Analysis 3.8

Comparison 3: LH versus VH, Outcome 8: Urinary dysfunction

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Analysis 3.9

Comparison 3: LH versus VH, Outcome 9: Operation time (mins)

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Analysis 3.10

Comparison 3: LH versus VH, Outcome 10: Bleeding

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Analysis 3.11

Comparison 3: LH versus VH, Outcome 11: Transfusion

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Analysis 3.12

Comparison 3: LH versus VH, Outcome 12: Pelvic haematoma

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Analysis 3.13

Comparison 3: LH versus VH, Outcome 13: Unintended laparotomy

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Analysis 3.14

Comparison 3: LH versus VH, Outcome 14: Vaginal cuff infection

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Analysis 3.15

Comparison 3: LH versus VH, Outcome 15: Wound/abdominal wall infection

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Analysis 3.16

Comparison 3: LH versus VH, Outcome 16: Urinary tract infection

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Analysis 3.17

Comparison 3: LH versus VH, Outcome 17: Chest infection

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Analysis 3.18

Comparison 3: LH versus VH, Outcome 18: Febrile episodes or unspecified infection

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Analysis 3.19

Comparison 3: LH versus VH, Outcome 19: Thromboembolism

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Analysis 3.20

Comparison 3: LH versus VH, Outcome 20: Length of hospital stay (days)

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Study	LH	VH	Comments
Return to normal activities (descriptive data)
Ekanayake 2020	n= 49 median = 30 range = 25.5 to 45	n = 49 median = 32 range = 24.5 to 60
Richardson 1995	n = 22 mean = 23.1 days range (7 to 56)	n = 23 mean = 22.2 range (7 to 56)
Roy 2011	TLH: n = 30 median = 15 days min‐max = 7 to 30 days LAVH: n = 30 median = 20 days min‐max = 8 to 40 days	n = 30 median = 14 days min‐max = 7 to 25 days	P value = 0.7
Roy 2012	n = 10 median = 20 days min‐max = 10 to 30 days	n = 10 median = 16 days min‐max = 12 to 24 days	P value = 0.05

Analysis 3.21

Comparison 3: LH versus VH, Outcome 21: Return to normal activities (descriptive data)

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Long‐term outcomes: quality of life (descriptive data)

Study

Description

Comment

Roy 2011

Patient satisfaction was evaluated using HRQOL (health‐related quality of life) questionnaire and SF‐12 (12‐item Short Form health survey) and follow‐up visits in outpatient clinic were done at 1, 3 and 6 months

TLH: n = 30

LAVH: n = 30

n = 30

After 6 months of surgery, there was significantly higher satisfaction rate among patients who underwent TLH and NDVH (non‐descent vaginal hysterectomy) than those who underwent LAVH (P value = 0.003). The satisfaction was similar between the TLH and NDVH group.

Analysis 3.22

Comparison 3: LH versus VH, Outcome 22: Long‐term outcomes: quality of life (descriptive data)

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Study	LH	VH	Comments
Operation time (descriptive data)
Ekanayake 2021	n = 49 Median = 93 mins IQR (80 to 111)	n = 49 Median = 50 mins IQR (35 to 65)	TLH vs NDVH Not tested separately
Hwang 2002	With 2nd proc: n = 13 Median = 119 Range (80 to 165) Without 2nd proc: n = 17 Median = 109 Range (85 to 175)	With 2nd proc: n = 3 Median = 93 Range (80 to 110) Without 2nd proc: n = 27 Median = 74 Range (40 to 120)	Kruskal Wallis test: P value = 0.12 P value < 0.001
Nanavati 2016	n = 50 mean 108 mins no IQR/SD given	n = 50 mean 77.5 mins no IQR/SD given	No IQR/SD given, no P value
Ribeiro 2003	n = 20 mean 119 mins (no measure of spread)	n = 20 mean 78 mins (no measure of spread)	—
Richardson 1995	n = 22 mean = 131.4 mins range (76 to 180)	n = 23 mean = 76.7 mins range (35 to 150)	Some of these cases include oophorectomies. Oophorectomy (mean): LH 129.7 mins, VH 95.3 mins; no oophorectomy (mean): LH 132.7 mins, VH 64.7 mins
Roy 2012	n = 10 median = 90 mins min‐max = 60 to 165 mins	n = 10 median = 75 min‐max = 40 to 105	Not statistically significant

Analysis 3.23

Comparison 3: LH versus VH, Outcome 23: Operation time (descriptive data)

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Study	LH	VH	Comments
Length of hospital stay (descriptive data)
Allam 2015	n = 30 median 0.75 days IQR 0.5 to 1.5 days	n = 30 median 1.5 IQR 1.5 to 2 days	Estimated with the Kruskal–Wallis test P < 0.001
Ekanayake 2021	n = 49 Median = 2 days IQR (1 to 3)	n = 49 Median = 3 days IQR (2 to 3)	TLH vs NDVH Not tested separately
Hwang 2002	n = 30 median = 4.7 days range (3 to 7)	n = 30 median = 4.7 days range (3 to 7)	Not tested separately
Nanavati 2016	n = 50 mean 4.5 days no IQR/SD given	n = 50 mean 4 days no IQR/SD given	No IQR/SD given no P value
Richardson 1995	n = 22 mean = 3.2 days range (2 to 7)	n = 23 mean = 3.3 days range (1 to 18)	—
Roy 2011	TLH: n = 30 median = 2 days min‐max = 2 to 12 days LAVH: n = 30 median = 3 days min‐max = 4 days	VH: n = 30 median = 2 days min‐max = 1 to 4 days	P value = 0.15
Roy 2012	n = 10 median = 3 days min‐max = 2 to 4 days	n = 10 median = 2 days min‐max = 2 to 4 days	Not statistically significant

Analysis 3.24

Comparison 3: LH versus VH, Outcome 24: Length of hospital stay (descriptive data)

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Study	Description	LH	VH
Cost (descriptive data)
Ekanayake 2021	Direct costs, which includes preoperative costs, operative costs, cost of hospital stay and costs up to 6 months after surgery Units of currency = US dollars (USD)	TLH n = 49 Median = 752 USD 95% CI (719 to 795)	NDVH n = 49 Median = 800 USD 95% CI (622 to 1116)
Mohammed 2017	The hospital costs were calculated and included: the admission cost, which included the ward fee, pre‐ and postoperative management costs and extra charges for any postoperative complications, the anaesthesia costs which included the drugs and the disposable instruments used by the anaesthesiologist, and the operation cost which included the operative material fee.	LAVH n = 25 Described as mean (SD) 1560.5 USD (220.5 USD)	n = 25 Described as mean (SD) 1060.86 USD (180.09 USD) P > 0.001
Summitt 1992	Mean total hospital charge when surgery was performed on an outpatient basis. Charges consisted of: operating room fee, operating room time, anaesthesia time, charges for disposable staples, scissors, graspers and a charge for recovery in the ambulatory surgery unit, including laboratory fees	n = 29 Mean = 7905 USD, SD = 501 USD, range (7197 to 8289) P value = 0.035	n = 27 Mean = 4891 USD, SD = 355 USD, range (4311 to 5247) P value = 0.035

Analysis 3.25

Comparison 3: LH versus VH, Outcome 25: Cost (descriptive data)

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Study	Description	LH	VH	Conclusion
Urinary and sexual dysfunction (descriptive data)
Ekanayake 2020	Questionnaire ICIQ‐VS. Sexual symptoms pre‐operatively, 6 months and 1 year postoperatively. A high score means experiencing more sexual symptoms	Pre‐operatively: n = 49 median = 0 IQR (0 to 0) 6 months postoperatively: n = 23 median = 0 IQR (0 to 0) 1 year postoperatively: n = 22 median = 0 IQR (0 to 4.2)	Pre‐operatively: n = 49 median = 0 IQR (0 to 0) 6 months postoperatively: n = 29 median = 0 IQR (0 to 0) 1 year postoperatively: n = 28 median = 0 IQR (0 to 0)	TLH group: 6 months postoperative score versus pre‐operative score: P = 0.06 1 year postoperative score versus pre‐operative score: P < 0.05 NDVH group: 6 months postoperative score versus preoperative score: P = 0.69 1 year postoperative score versus pre‐operative score: P = 0.46
Ekanayake 2020	Questionnaire ICIQ‐VS. Vaginal symptoms pre‐operatively, 6 months and 1 year postoperatively. A high score means experiencing more vaginal symptoms	Pre‐operatively: n = 49 median = 4 IQR (2 to 10.5) 6 months postoperatively: n = 48 median = 3 IQR (0 to 6) 1 year postoperatively: n = 47 median = 4 IQR (0 to 10)	Pre‐operatively: n = 49 median = 6 IQR (4 to 8.5) 6 months postoperatively: n = 48 median = 4 IQR (0 to 8) 1 year postoperatively: n = 45 median = 5 IQR (0 to 8)	For both the NDVH and TLH group vaginal function domain scores at 6 months and 1 year postoperatively were statistically significant compared to the respective pre‐operative scores (P < 0.001)
Ekanayake 2020	Questionnaire ICIQ‐LUTS. Urinary symptoms pre‐operatively, 6 months and 1 year post‐operatively. A high score means experiencing more urinary symptoms	Urinary flow symptoms: Pre‐op: n = 49 median = 1 IQR (1 to 4) 6 months postop: n = 48 median = 1 IQR (0 to 3) 1 year postop: n = 47 median = 1 IQR (0 to 3) Urinary voiding symptoms: Pre‐op: n = 49 median = 0 IQR (0 to 0) 6 months postop: n = 48 median = 0 IQR (0 to 0) 1 year postop: n = 47 median = 0 IQR (0 to 0) Urinary incontinence symptoms: Pre‐op: n = 49 median = 0 IQR (0 to 3) 6 months postop: n = 48 median = 0 IQR (0 to 1.75) 1 year postop: n = 47 median = 0 IQR (0 to 2)	Urinary flow symptoms: Pre‐op: n = 49 median = 3 IQR (2 to 5) 6 months postop: n = 48 median = 2 IQR (0 to 4.75) 1 year postop: n = 45 median = 2 IQR (0.5 to 4) Urinary voiding symptoms: Pre‐op: n = 49 median = 0 IQR (0 to 1) 6 months postop: n = 48 median = 0 IQR (0 to 0.75) 1 year postop: n = 45 median = 0 IQR (0 to 1) Urinary incontinence symptoms: Pre‐op: n = 49 median = 0 IQR (0 to 3) 6 months postop: n = 48 median = 1 IQR (0.75 to 3) 1 year postop: n = 45 median = 0 IQR (0 to 3)	Urinary flow symptoms: TLH 6 months postoperative score versus pre‐operative score: P < 0.01 TLH 1 year postoperative score versus pre‐operative score: P < 0.05 NDVH 6 months postoperative score versus pre‐operative score: P < 0.001 NDVH 1 year postoperative score versus pre‐operative score: P < 0.001 Urinary voiding symptoms: TLH 6 months postoperative score versus pre‐operative score: P = 0.47 TLH 1 year postoperative score versus pre‐operative score: P < 0.05 NDVH 6 months postoperative score versus pre‐operative score: P < 0.05 NDVH 1 year postoperative score versus pre‐operative score: P < 0.05 Urinary incontinence symptoms: TLH 6 months postoperative score versus pre‐operative score: P = 0.21 TLH 1 year postoperative score versus pre‐operative score: P < 0.05 NDVH 6 months postoperative score versus pre‐operative score: P = 0.07 NDVH 1 year postoperative score versus pre‐operative score: P < 0.01

Analysis 3.26

Comparison 3: LH versus VH, Outcome 26: Urinary and sexual dysfunction (descriptive data)

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Analysis 4.1

Comparison 4: RH versus LH, Outcome 1: Return to normal activities (days)

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Analysis 4.2

Comparison 4: RH versus LH, Outcome 2: Intraoperative visceral injury (dichotomous)

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Analysis 4.3

Comparison 4: RH versus LH, Outcome 3: Operation time

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Analysis 4.4

Comparison 4: RH versus LH, Outcome 4: Bleeding

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Analysis 4.5

Comparison 4: RH versus LH, Outcome 5: Wound dehiscence

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Analysis 4.6

Comparison 4: RH versus LH, Outcome 6: Transfusion

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Analysis 4.7

Comparison 4: RH versus LH, Outcome 7: Wound/abdominal wall infection

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Analysis 4.8

Comparison 4: RH versus LH, Outcome 8: Febrile episodes or unspecified infections

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Operation time (descriptive data)

Study

comment

Deimling 2016

Mean operation time 73.9 minutes

Median 67.0 minutes

(IQR 59.0 to 83.0 minutes)

Mean operation time 74.9 minutes

Median 65.5 minutes

(IQR 57.0 to 90.5 minutes)

The nonparametric, one‐sided, bootstrapped bias‐corrected and accelerated 95% CI of the difference in mean operative time was 6.6 minutes (P < 0.001)

The upper bound of this 95% CI was smaller than the specified non‐inferiority margin of 15 minutes, indicating non‐inferiority

Analysis 4.9

Comparison 4: RH versus LH, Outcome 9: Operation time (descriptive data)

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Return to normal activities (descriptive data)

Study

Description

Comment

Paraiso 2013

Percentage to return to normal baseline activities

At 1, 2, 3, 4, 5 and 6 weeks postoperatively

1 week (n = 17): 22%

2 weeks (n = 17): 46%

3 weeks (n = 17): 54%

4 weeks (n = 17): 60%

5 weeks (n = 17): 66%

6 weeks (n = 16): 72%

1 week (n = 19): 29%

2 weeks (n = 19): 46%

3 weeks (n = 18): 58%

4 weeks (n = 18): 64%

5 weeks (n = 17): 73%

6 weeks (n = 17): 82%

P value (overall) = 0.25

Analysis 4.10

Comparison 4: RH versus LH, Outcome 10: Return to normal activities (descriptive data)

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Analysis 5.1

Comparison 5: SP‐LH versus LH, Outcome 1: Bladder injury

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Analysis 5.2

Comparison 5: SP‐LH versus LH, Outcome 2: Ureter injury

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Analysis 5.3

Comparison 5: SP‐LH versus LH, Outcome 3: Conversion or aditional port placement

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Analysis 5.4

Comparison 5: SP‐LH versus LH, Outcome 4: Transfusion

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Analysis 5.5

Comparison 5: SP‐LH versus LH, Outcome 5: Pelvic haematoma

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Analysis 5.6

Comparison 5: SP‐LH versus LH, Outcome 6: Wound/abdominal wall infection

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Analysis 5.7

Comparison 5: SP‐LH versus LH, Outcome 7: Febrile episodes or unspecified infection

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Analysis 5.8

Comparison 5: SP‐LH versus LH, Outcome 8: Vaginal cuff dehiscence

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Analysis 5.9

Comparison 5: SP‐LH versus LH, Outcome 9: Postoperative ileus

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Analysis 5.10

Comparison 5: SP‐LH versus LH, Outcome 10: Operation time (mins)

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Analysis 5.11

Comparison 5: SP‐LH versus LH, Outcome 11: Length of hospital stay (days)

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Operation time (descriptive data)

Study

SP‐LH

Conventional LH

Comments

Kim 2015

n = 125 Sp‐LHa

Median operative time, min

Range 80 (30 to 250)

n = 126

Median operative time 69.5

Range (25 to 240)

P = 0.22

Song 2013

n = 20 SP‐LAVH

Mean = 92 min

Range 57 to 220 min

n = 19 LAVH

Mean = 95 min

Range 70 to 154 min

P = 0.47

Analysis 5.12

Comparison 5: SP‐LH versus LH, Outcome 12: Operation time (descriptive data)

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Study	SP‐LH	LH	Comments
Length of hospital stay (descriptive data)
Jung 2011	n = 30 SP‐TLH Median postoperative hospital stay = 3.4 days Range 3.0 to 4.3 days	n = 34 TLH Median postoperative hospital stay = 3.0 days Range 3.0 to 3.0 days	P value = 0.075
Kim 2015	n = 125 SP‐NC LH Median postoperative hospital stay 3 days Range (2 to 7)	n = 125 NC LH Median postoperative hospital stay 3 days Range (2 to 13)	P value = 0.45
Song 2013	n = 20 SP‐LAVH Mean = 3 days Range 2 to 4 days	n = 19 LAVH Mean = 3 days Range 2 to 4 days	P value = 0.95

Analysis 5.13

Comparison 5: SP‐LH versus LH, Outcome 13: Length of hospital stay (descriptive data)

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Cost (descriptive data)

Study

Description

SP‐LH

MP‐LH

Chung 2015

Cost of trocars used for SP‐LH and MP‐LH. No description of reported measure (mean or median). Units of currency = US dollars (USD)

n = 29

257 USD

n = 29

265 USD

Analysis 5.14

Comparison 5: SP‐LH versus LH, Outcome 14: Cost (descriptive data)

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Analysis 6.1

Comparison 6: TLH versus LAVH, Outcome 1: Intraoperative visceral injury (dichotomous)

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Analysis 6.2

Comparison 6: TLH versus LAVH, Outcome 2: Long‐term complications (dichotomous)

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Analysis 6.3

Comparison 6: TLH versus LAVH, Outcome 3: Operation time (mins)

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Analysis 6.4

Comparison 6: TLH versus LAVH, Outcome 4: Unintended laparotomy

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Analysis 6.5

Comparison 6: TLH versus LAVH, Outcome 5: Short‐term outcomes (dichotomous)

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Analysis 6.6

Comparison 6: TLH versus LAVH, Outcome 6: Length of hospital stay (days)

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Analysis 7.1

Comparison 7: V‐NOTES versus LH, Outcome 1: Conversion or additional port placement

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Analysis 7.2

Comparison 7: V‐NOTES versus LH, Outcome 2: Operation time

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Analysis 7.3

Comparison 7: V‐NOTES versus LH, Outcome 3: Bladder injury

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Analysis 7.4

Comparison 7: V‐NOTES versus LH, Outcome 4: Febrile episodes or unspecified infection

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Analysis 7.5

Comparison 7: V‐NOTES versus LH, Outcome 5: Length of hospital stay (days)

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Analysis 7.6

Comparison 7: V‐NOTES versus LH, Outcome 6: Substantial bleeding

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Analysis 7.7

Comparison 7: V‐NOTES versus LH, Outcome 7: Wound/abdominal wall infection

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Study	vNOTES	LH	Comments
Operation time (descriptive data)
Park 2021	n = 13 Median = 55 mins Range (25 to 105)	n = 13 Median = 75 mins Range (50 to 110)	LH group regards laparo‐endoscopic single site surgery (LESS)

Analysis 7.8

Comparison 7: V‐NOTES versus LH, Outcome 8: Operation time (descriptive data)

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Study	vNOTES	LH	Comments
Length of hospital stay (descriptive data)
Park 2021	n = 13 Median = 4 days Range (4 to 4)	n = 13 Median = 4 days Range (4 to 5)	P value = 0.762

Analysis 7.9

Comparison 7: V‐NOTES versus LH, Outcome 9: Length of hospital stay (descriptive data)

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Summary of findings 1. Vaginal hysterectomy versus abdominal hysterectomy for benign gynaecological disease

Outcomes		Anticipated absolute effects^* (95% CI)		Relative effect (95% CI)	No of participants (studies)	Certainty of the evidence (GRADE)	Comments
Vaginal hysterectomy versus abdominal hysterectomy for benign gynaecological disease
Patient or population: patients with benign gynaecological disease Settings: hospital Intervention: vaginal versus abdominal hysterectomy
Outcomes		Risk with abdominal hysterectomy	Risk with vaginal hysterectomy	Relative effect (95% CI)	No of participants (studies)	Certainty of the evidence (GRADE)	Comments
Return to normal activities (days)		The mean return to normal activities (days) in the AH group was 42.1days	The mean return to normal activities (days) in the VH group was 10.91 lower (17.95 to 3.87 lower)	—	274 (4 RCTs)	⊕⊕⊕◯ Moderate¹	—
Long‐term outcomes	Satisfaction (dichotomous)	915 per 1000	967 per 1000 (844 to 994)	OR 2.69 (0.50 to 14.42)	119 (1 RCT)	⊕◯◯◯ Very low^2,3,4	—
Long‐term outcomes	Quality of life (descriptive data)	No study in this comparison reported on quality of life
Long‐term complications (dichotomous)	Urinary dysfunction	11 per 1000	35 per 1000 (4 to 266)	OR 3.20 (0.32 to 31.90)	177 (2 RCTs)	⊕⊕◯◯ Low^5,6	—
Intra‐operative visceral injury (dichotomous)	Bladder injury	6 per 1000	9 per 1000 (3 to 28)	OR 1.62 (0.52 to 4.99)	697 (7 RCTs)	⊕⊕◯◯ Low^5,6	—
Intra‐operative visceral injury (dichotomous)	Ureter injury	0 per 1000	0 per 1000 (0 to 0)	OR 3.10 (0.12 to 79.23)	277 (3 RCTs)	⊕◯◯◯ Very low^7,8	—
Major short‐term complications (dichotomous)	Vaginal cuff infection	9 per 1000	29 per 1000 (4 to 161)	OR 3.14 (0.48 to 20.55)	216 (3 RCTs)	⊕⊕◯◯ Low^9,10	—
	Wound/abdominal wall infection	61 per 1000	11 per 1000 (4 to 33)	OR 0.18 (0.06 to 0.53)	628 (6 RCTs)	⊕⊕⊕◯ Moderate⁹	—
	Febrile episodes or unspecified infection	132 per 1000	82 per 1000 (50 to 133)	OR 0.59 (0.35 to 1.01)	593 (6 RCTs)	⊕⊕⊕◯ Moderate¹¹	—
*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). AH: abdominal hysterectomy; CI: confidence interval; MD: mean difference; OR: odds ratio; RCT: randomised controlled trial; VH: vaginal hysterectomy
GRADE Working Group grades of evidence High certainty: Further research is very unlikely to change our confidence in the estimate of effect. Moderate certainty: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. Low certainty: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. Very low certainty: We are very uncertain about the estimate.
¹Downgraded one level for inconsistency: the I² statistic is high (67%), with minimal overlap in confidence intervals, however most studies favour the vaginal approach. ²Downgraded one level for risk of bias: the study involved had unclear allocation concealment, no blinding and unclear selective reporting bias. ³Downgraded two levels for indirectness: a single study cannot be held to represent all possible populations having this surgery. ⁴Downgraded one level for imprecision: the result comes from a single study (Benassi 2002, n = 119) and has a wide confidence interval that crosses the line of no effect. ⁵Downgraded one level for risk of bias: sources of bias included unclear randomisation, allocation concealment, reporting bias etc. ⁶Downgraded one level for imprecision: the studies included are small and the outcome is rare; the total number of events is insufficient. ⁷Downgraded one level for risk of bias: one study had unclear allocation concealment; others lacked details on surgeon experience or methods. ⁸Downgraded two levels for imprecision: only three studies reported on this outcome and only one contributed data to the meta‐analysis, thus the optimal information size for a rare outcome like this one was not reached. ⁹Downgraded one level for risk of bias: some studies lacked clear randomisation and allocation processes. ¹⁰Downgraded one level for imprecision: only three studies reported on this rare outcome. ¹¹Downgraded one level for risk of bias: one study had unclear randomisation, another had unclear allocation concealment, multiple others had poorly described surgical methods.

Summary of findings 1. Vaginal hysterectomy versus abdominal hysterectomy for benign gynaecological disease

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Summary of findings 2. Laparoscopic hysterectomy versus abdominal hysterectomy for benign gynaecological disease

Outcomes		Anticipated absolute effects^* (95% CI)		Relative effect (95% CI)	No of participants (studies)	Certainty of the evidence (GRADE)	Comments
Laparoscopic hysterectomy versus abdominal hysterectomy for benign gynaecological disease
Patient or population: patients with benign gynaecological disease Settings: hospital Intervention: laparoscopic versus abdominal hysterectomy
Outcomes		Risk with abdominal hysterectomy	Risk with laparoscopic hysterectomy	Relative effect (95% CI)	No of participants (studies)	Certainty of the evidence (GRADE)	Comments
Return to normal activities (days)		The mean return to normal activities (days) in the AH group was 36.9 days	The mean return to normal activities (days) in the LH group was 13.01 lower (16.47 to 9.56 lower)	—	618 (7 RCTs)	⨁⨁◯◯ Low^1,2	—
Long‐term outcomes	Satisfaction (dichotomous)	778 per 1000	695 per 1000 (528 to 820)	OR 0.65 (0.32 to 1.30)	166 (1 RCT)	⨁◯◯◯ Very low^3,4,5	Based on 1 study comparing LH (method unspecified) versus AH
Long‐term outcomes	Quality of life (descriptive data)	Five studies in this comparison reported on quality of life. Data was obtained from several questionnaires. Three of five studies found that quality of life improved postoperatively independent of route of surgery but was overall higher in the LH group than in the AH group. Two studies found no significant differences in postoperative quality of life between the LH and AH groups.
Long‐term complications (dichotomous)	Urinary dysfunction	135 per 1000	128 per 1000 (71 to 222)	OR 0.94 (0.49 to 1.82)	343 (3 RCTs)	⨁⨁◯◯ Low^7,9	—
Intra‐operative visceral injury (dichotomous)	Bladder injury	10 per 1000	17 per 1000 (9 to 31)	OR 1.68 (0.88 to 3.22)	2298 (15 RCTs)	⨁⨁◯◯ Low^6,7	—
Intra‐operative visceral injury (dichotomous)	Ureter injury	1 per 1000	5 per 1000 (2 to 16)	OR 3.62 (1.18 to 11.11)	1675 (10 RCTs)	⨁⨁⨁◯ Moderate⁸	—
Major short‐term complications (dichotomous)	Vaginal cuff infection	24 per 1000	34 per 1000 (16 to 69)	OR 1.43 (0.67 to 3.04)	852 (9 RCTs)	⨁⨁◯◯ Low^7,9	—
	Wound/abdominal wall infection	81 per 1000	18 per 1000 (9 to 38)	OR 0.21 (0.10 to 0.45)	824 (9 RCTs)	⨁⨁⨁◯ Moderate¹⁰	—
	Febrile episodes or unspecified infection	124 per 1000	84 per 1000 (65 to 107)	OR 0.65 (0.49 to 0.85)	2386 (18 RCTs)	⨁⨁⨁◯ Moderate¹¹	—
*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). AH: abdominal hysterectomy; CI: confidence interval; LH: laparoscopic hysterectomy; MD: mean difference; OR: odds ratio; RCT: randomised controlled trial
GRADE Working Group grades of evidence High certainty: Further research is very unlikely to change our confidence in the estimate of effect. Moderate certainty: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. Low certainty: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. Very low certainty: We are very uncertain about the estimate.
¹Downgraded one level for risk of bias: multiple studies had unclear risk of bias in other important areas such as randomisation, allocation concealment, attrition bias and selective reporting bias. Other sources of bias included poor reporting on surgical methods or surgeon experience (Ekanayake 2020), and lack of power calculation (Summitt 1992). ²Downgraded one level for inconsistency: heterogeneity as measured by the I² statistic is high (68%), however all but one study consistently favoured LH. ³Downgraded one level for risk of bias: the study involved had no blinding, high risk of attrition bias and unclear reporting bias. ⁴Downgraded two levels for indirectness: a single study cannot be held to represent all possible populations having this surgery. ⁵Downgraded one level for imprecision: the study involved was small, with a wide confidence interval. ⁶Downgraded one level for risk of bias: while it was felt unlikely lack of blinding would affect this outcome, most studies had other important sources of potential bias. These included unclear randomisation and allocation concealment, high risk of attrition bias (Garry 2004; Kluivers 2007; Lumsden 2000; Wakhloo 2015), selective reporting bias (Wakhloo 2015), and other sources of bias such as poor reporting of surgical methods. ⁷Downgraded one level for imprecision: few events and CI includes appreciable benefit and harm. ⁸Downgraded one level for risk of bias: we felt it was unlikely that lack of blinding would affect this outcome, and rated it down due to other risks of bias. For example Wakhloo 2015 and Perino 1999 both had unclear randomisation and allocation concealment. Multiple studies had poorly reported surgical methods. While it is less clear if it would specifically alter this outcome, Kluivers 2007, Garry 2004 and Lumsden 2000 had high risk of attrition bias. ⁹Downgraded one level for risk of bias: there were significant sources of bias in the included studies that we felt lowered the certainty of evidence for this outcome. These included multiple studies with unclear allocation concealment, attrition bias, lack of intention‐to‐treat analysis, unclear length of follow‐up etc. ¹⁰Downgraded one level for risk of bias: some of the studies that contributed most to the meta‐analysis (for example, Wakhloo 2015 and Panda 2015) were very poorly reported with high risk of randomisation, allocation concealment and attrition bias. ¹¹Downgraded one level for risk of bias: multiple studies had unclear randomisation and allocation concealment. There were multiple concerns about attrition bias, reporting bias, lack of intention‐to‐treat analysis and poorly reported surgical methods.

Summary of findings 2. Laparoscopic hysterectomy versus abdominal hysterectomy for benign gynaecological disease

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Summary of findings 3. Laparoscopic hysterectomy versus vaginal hysterectomy for benign gynaecological disease

Outcomes		Anticipated absolute effects^* (95% CI)		Relative effect (95% CI)	No of participants (studies)	Certainty of the evidence (GRADE)	Comments
Laparoscopic hysterectomy versus vaginal hysterectomy for benign gynaecological disease
Patient or population: patients with benign gynaecological disease Settings: hospital Intervention: laparoscopic versus vaginal hysterectomy
Outcomes		Risk with vaginal hysterectomy	Risk with laparoscopic hysterectomy	Relative effect (95% CI)	No of participants (studies)	Certainty of the evidence (GRADE)	Comments
Return to normal activities (days)		The mean return to normal activities (days) in the VH group was 30.7 days	The mean return to normal activities (days) in the LH group was 1.06 lower (4.18 lower to 2.05 higher)	—	238 (3 RCTs)	⨁⨁◯◯ Low¹	—
Long‐term outcomes	Satisfaction (dichotomous)	No study in this comparison reported on satisfaction.
Long‐term outcomes	Quality of life (descriptive data)	One study in this comparison reported on quality of life. Data was obtained using a quality of life questionnaire. No significant difference was found between the LH and VH group. The quality of life scores were higher for both the TLH and NDVH groups than for the LAVH group.
Long‐term complications (dichotomous)	Urinary dysfunction	24 per 1000	24 per 1000 (6 to 92)	OR 1.00 (0.25 to 4.07)	248 (3 RCTs)	⨁⨁◯◯ Low^1,3	—
Intra‐operative visceral injury (dichotomous)	Bladder injury	13 per 1000	13 per 1000 (5 to 31)	OR 0.93 (0.37 to 2.33)	1237 (10 RCTs)	⨁⨁◯◯ Low^1,3	—
Intra‐operative visceral injury (dichotomous)	Ureter injury	3 per 1000	2 per 1000 (0 to 16)	OR 0.69 (0.09 to 5.43)	846 (4 RCTs)	⨁⨁◯◯ Low^1,2	—
Major short‐term complications (dichotomous)	Vaginal cuff infection	22 per 1000	21 per 1000 (5 to 89)	OR 0.98 (0.22 to 4.39)	276 (4 RCTs)	⨁⨁◯◯ Low^1,4	—
	Wound/abdominal wall infection	6 per 1000	8 per 1000 (2 to 40)	OR 1.41 (0.28 to 7.03)	363 (4 RCTs)	⨁◯◯◯ Very low^1,5	—
	Febrile episodes or unspecified infection	60 per 1000	49 per 1000 (32 to 73)	OR 0.81 (0.53 to 1.24)	1508 (12 RCTs)	⨁⨁◯◯ Low^3,6	—
*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: confidence interval; LH: laparoscopic hysterectomy; LAVH: laparoscopically‐assisted vaginal hysterectomy; MD: mean difference; NDVH: non‐descent vaginal hysterectomy; OR: odds ratio; RCT: randomised controlled trial; TLH: total laparoscopic hysterectomy; VH: vaginal hysterectomy
GRADE Working Group grades of evidence High certainty: Further research is very unlikely to change our confidence in the estimate of effect. Moderate certainty: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. Low certainty: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. Very low certainty: We are very uncertain about the estimate.
¹Downgraded two levels for imprecision: the studies involved were small. The confidence interval is wide and includes the possibility of treatment benefit or harm. ²Downgraded one level for risk of bias: Allam 2015 and Garry 2004 were the main studies contributing to the meta‐analysis. We did not feel the risk of bias in Allam would impact this outcome. However, in Garry 2004 the number of patients who dropped out prior to surgery was high (n = 17). In the LH arm the loss to follow‐up was high (> 15%). Surgeon experience varied and surgical methods were not reported. ³Downgraded one level for risk of bias: while the lack of blinding across studies was felt unlikely to contribute bias to this outcome, multiple studies had unclear randomisation, allocation concealment, risk of attrition bias and poorly reported surgical methods. ⁴Downgraded one level for risk of bias: two studies had unclear allocation concealment (Darai 2001; Summitt 1992). Additionally, Summitt 1992 contributed the most to the meta‐analysis and had two different groups of surgeons performing the procedures. ⁵Downgraded one level for risk of bias: multiple studies involved had poorly reported methods with unclear randomisation, allocation concealment and attrition bias. ⁶Downgraded one level for imprecision: the studies involved are small; the confidence interval includes the possibility of treatment benefit or harm.

Summary of findings 3. Laparoscopic hysterectomy versus vaginal hysterectomy for benign gynaecological disease

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Summary of findings 4. Robotic hysterectomy compared to laparoscopic hysterectomy for benign gynaecological disease

Outcomes		Anticipated absolute effects^* (95% CI)		Relative effect (95% CI)	No of participants (studies)	Certainty of the evidence (GRADE)	Comments
Robotic hysterectomy versus laparoscopic hysterectomy for benign gynaecological disease
Patient or population: patients with benign gynaecological disease Settings: hospital Intervention: robotic versus laparoscopic hysterectomy
Outcomes		Risk with laparoscopic hysterectomy	Risk with robotic hysterectomy	Relative effect (95% CI)	No of participants (studies)	Certainty of the evidence (GRADE)	Comments
Return to normal activities (days)		The mean return to normal activities (days) in the LH group was 31.2 days	The mean return to normal activities (days) in the RH group was 2.4 lower (8.54 lower to 3.74 higher)	—	100 (1 RCT)	⨁◯◯◯ Very low^1,2,3	Based on 1 study
Long‐term outcomes	Satisfaction (dichotomous)	No study in this comparison reported on satisfaction.
Long‐term outcomes	Quality of life (descriptive data)	No study in this comparison reported on quality of life.
Long‐term complications (dichotomous)	Urinary dysfunction	No study in this comparison reported on urinary dysfunction.
Intra‐operative visceral injury (dichotomous)	Bladder injury	No study in this comparison reported on bladder injury.
Intra‐operative visceral injury (dichotomous)	Ureter injury	20 per 1000	7 per 1000 (0 to 144)	OR 0.33 (0.01 to 8.21)	100 (1 RCT)	⨁◯◯◯ Very low^2,4	—
Major short‐term complications (dichotomous)	Vaginal cuff infection	No study in this comparison reported on vaginal cuff infection.
	Wound/abdominal wall infection	16 per 1000	10 per 1000 (1 to 71)	OR 0.60 (0.08 to 4.57)	244 (2 RCTs)	⨁⨁◯◯ Low⁵	—
	Febrile episodes or unspecified infection	No study in this comparison reported on febrile episodes or unspecified infection.
*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: confidence interval; LH: laparoscopic hysterectomy; MD: mean difference; OR: odds ratio; RCT: randomised controlled trial; RH: robotic hysterectomy
GRADE Working Group grades of evidence High certainty: we are very confident that the true effect lies close to that of the estimate of the effect. Moderate certainty: we are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. Low certainty: our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect. Very low certainty: we have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect.
¹Downgraded one level for risk of bias: in the one study reporting on this outcome, allocation concealment was not described, blinding was not performed and follow‐up was not described (Sarlos 2012). ²Downgraded two levels for indirectness: a single study cannot be held to represent all possible populations having this surgery. ³Downgraded one level for imprecision: this was a small study (50 participants per arm) and the confidence interval includes the possibility of treatment benefit or harm. ⁴Downgraded two levels for imprecision: this was a small study (50 participants per arm) and the confidence interval includes the possibility of treatment benefit or harm. ⁵Downgraded two levels for imprecision: the studies involved were small, the outcomes rare, and the confidence interval includes the possibility of treatment benefit or harm.

Summary of findings 4. Robotic hysterectomy compared to laparoscopic hysterectomy for benign gynaecological disease

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Summary of findings 5. Single‐port laparoscopic hysterectomy compared to laparoscopic hysterectomy for benign gynaecological disease

Outcomes		Anticipated absolute effects^* (95% CI)		Relative effect (95% CI)	No of participants (studies)	Certainty of the evidence (GRADE)	Comments
Single‐port laparoscopic hysterectomy compared to laparoscopic hysterectomy for benign gynaecological disease
Patient or population: patients with benign gynaecological disease Settings: hospital Intervention: single‐port laparoscopic versus laparoscopic hysterectomy
Outcomes		Risk with laparoscopic hysterectomy	Risk with single‐port laparoscopic hysterectomy	Relative effect (95% CI)	No of participants (studies)	Certainty of the evidence (GRADE)	Comments
Return to normal activities (days)		No study in this comparison reported on return to normal activities.
Long‐term outcomes	Satisfaction (dichotomous)	No study in this comparison reported on satisfaction.
Long‐term outcomes	Quality of life (descriptive data)	No study in this comparison reported on quality of life.
Long‐term complications (dichotomous)	Urinary dysfunction	No study in this comparison reported on urinary dysfunction.
Intra‐operative visceral injury (dichotomous)	Bladder injury	0 per 1000	0 per 1000 (0 to 0)	OR 3.51 (0.14 to 89.42)	64 (1 RCT)	⨁◯◯◯ Very low^1,2,3	Based on 1 study comparing SP‐LH to TLH
Intra‐operative visceral injury (dichotomous)	Ureter injury	8 per 1000	3 per 1000 (0 to 62)	OR 0.33 (0.01 to 8.26)	251 (1 RCT)	⨁◯◯◯ Very low^2,3,4	—
Major short‐term complications (dichotomous)	Vaginal cuff infection	No study in this comparison reported on vaginal cuff infection.
	Wound/abdominal wall infection	10 per 1000	10 per 1000 (2 to 48)	OR 1.03 (0.20 to 5.15)	411 (3 RCTs)	⨁⨁◯◯ Low^5,6	Based on studies comparing SP‐LAVH versus LAVH
	Febrile episodes or unspecified infection	19 per 1000	47 per 1000 (13 to 153)	OR 2.56 (0.70 to 9.44)	315 (2 RCTs)	⨁◯◯◯ Very low^1,4,6,7	Based on studies comparing SP‐TLH versus TLH
*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: confidence interval; LAVH: laparoscopically‐assisted vaginal hysterectomy; LH: laparoscopic hysterectomy; MD: mean difference; OR: odds ratio; RCT: randomised controlled trial; SP‐LH: single‐port laparoscopic hysterectomy; TLH: total laparoscopic hysterectomy
GRADE Working Group grades of evidence High certainty: we are very confident that the true effect lies close to that of the estimate of the effect. Moderate certainty: we are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. Low certainty: our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect. Very low certainty: we have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect.
¹Downgraded one level for risk of bias: in Jung 2011 the allocation concealment was not described and four procedures that were converted from SP‐TLH to TLH were excluded from the analysis. ²Downgraded two levels for indirectness: a single study cannot be held to represent all possible populations having this surgery. ³Downgraded one level for imprecision: this was a small study, with few events, and a confidence interval that includes the possibility of treatment benefit or harm. ⁴Downgraded one level for risk of bias: in Kim 2015 multiple patients withdrew from the study before surgery but after randomisation. Additionally, many different surgeons were involved with varying levels of experience, the majority of whom had greater experience with conventional laparoscopy. Finally, they did not use a standardised LH technique. ⁵Downgraded one level for risk of bias: studies involved had various potential sources of bias including unclear randomisation, allocation concealment, attrition bias, variation in surgical methods and surgeon experience. ⁶Downgraded one level for imprecision: these were small studies, with few events, and the confidence interval includes the possibility of treatment benefit or harm. ⁷Downgraded one level for inconsistency: heterogeneity was high (I² statistic = 53%).

Summary of findings 5. Single‐port laparoscopic hysterectomy compared to laparoscopic hysterectomy for benign gynaecological disease

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Summary of findings 6. Total laparoscopic hysterectomy compared to laparoscopic‐assisted vaginal hysterectomy for benign gynaecological disease

Outcomes		Anticipated absolute effects^* (95% CI)		Relative effect (95% CI)	No of participants (studies)	Certainty of the evidence (GRADE)	Comments
Laparoscopic‐assisted vaginal hysterectomy versus total laparoscopic hysterectomy for benign gynaecological disease
Patient or population: patients with benign gynaecological disease Settings: hospital Intervention: laparoscopic‐assisted vaginal versus total laparoscopic hysterectomy
Outcomes		Risk with laparoscopic‐assisted vaginal hysterectomy	Risk with total laparoscopic hysterectomy	Relative effect (95% CI)	No of participants (studies)	Certainty of the evidence (GRADE)	Comments
Return to normal activities (days)		No study in this comparison reported on return to normal activities.
Long‐term outcomes	Satisfaction (dichotomous)	No study in this comparison reported on satisfaction.
Long‐term outcomes	Quality of life (descriptive data)	No study in this comparison reported on quality of life.
Long‐term complications (dichotomous)	Urinary dysfunction	No study in this comparison reported on urinary dysfunction.
Intra‐operative visceral injury (dichotomous)	Bladder injury	22 per 1000	16 per 1000 (1 to 158)	OR 0.72 (0.06 to 8.27)	161 (2 RCTs)	⨁⨁◯◯ Low^1,2	—
Intra‐operative visceral injury (dichotomous)	Ureter injury	11 per 1000	33 per 1000 (3 to 279)	OR 3.03 (0.27 to 34.52)	161 (2 RCTs)	⨁⨁◯◯ Low^1,2	—
Major short‐term complications (dichotomous)	Vaginal cuff infection	83 per 1000	25 per 1000 (3 to 182)	OR 0.28 (0.03 to 2.45)	101 (1 RCT)	⨁◯◯◯ Very low^3,4,5	—
	Abdominal wall/wound infection	67 per 1000	13 per 1000 (1 to 225)	OR 0.19 (0.01 to 4.06)	60 (1 RCT)	⨁◯◯◯ Very low^4,5	—
	Febrile episodes or unspecified infection	50 per 1000	73 per 1000 (15 to 292)	OR 0.61 (0.15 to 2.45)	233 (3 RCTs)	⨁⨁◯◯ Low^1,2	—
*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: confidence interval; LAVH: laparoscopic‐assisted vaginal hysterectomy; MD: mean difference; OR: odds ratio; RCT: randomised controlled trial; TLH: total laparoscopic hysterectomy
GRADE Working Group grades of evidence High certainty: we are very confident that the true effect lies close to that of the estimate of the effect. Moderate certainty: we are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. Low certainty: our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect. Very low certainty: we have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect.
¹Downgraded one level for risk of bias: both studies were found to have unclear randomisation, unclear allocation concealment and high risk of attrition bias (Long 2002; Roy 2011). ²Downgraded one level for imprecision: these were small studies with few events and the confidence interval includes the possibility of treatment benefit or harm. ³Downgraded two levels for risk of bias: the one study involved had serious risks of bias, including unclear randomisation, allocation concealment, significant dropouts after randomisation but prior to surgery, lack of intention‐to‐treat analysis and different surgeons for different procedures (Long 2002). Combined these factors were felt by authors to merit downgrading the certainty of evidence by two levels. ⁴Downgraded two levels for indirectness: a single study cannot be held to represent all possible populations having this surgery. ⁵Downgraded one level for imprecision: this was a small study with few events and the confidence interval includes the possibility of treatment benefit or harm. ⁶Downgraded one level for risk of bias: Roy 2011 had unclear randomisation and allocation concealment bias as well as high risk of attrition bias.

Summary of findings 6. Total laparoscopic hysterectomy compared to laparoscopic‐assisted vaginal hysterectomy for benign gynaecological disease

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Summary of findings 7. V‐NOTES compared to laparoscopic hysterectomy for benign gynaecological disease

Outcomes		Anticipated absolute effects^* (95% CI)		Relative effect (95% CI)	No of participants (studies)	Certainty of the evidence (GRADE)	Comments
V‐NOTES versus laparoscopic hysterectomy for benign gynaecological disease
Patient or population: patients with benign gynaecological disease Settings: hospital Intervention: V‐NOTES versus laparoscopic hysterectomy
Outcomes		Risk with V‐NOTES	Risk with laparoscopic hysterectomy	Relative effect (95% CI)	No of participants (studies)	Certainty of the evidence (GRADE)	Comments
Return to normal activities (days)		No study in this comparison reported on return to normal activities.
Long‐term outcomes	Satisfaction (dichotomous)	No study in this comparison reported on satisfaction.
Long‐term outcomes	Quality of life (descriptive data)	No study in this comparison reported on quality of life.
Long‐term complications (dichotomous)	Urinary dysfunction	No study in this comparison reported on urinary dysfunction.
Intra‐operative visceral injury (dichotomous)	Bladder injury	0 per 1000	0 per 1000 (0 to 0)	OR 3.09 (0.12 to 78.41)	96 (2 RCTs)	⨁⨁◯◯ Low¹	—
Intra‐operative visceral injury (dichotomous)	Ureter injury	No study in this comparison reported on ureter injury.
Major short‐term complications (dichotomous)	Vaginal cuff infection	No study in this comparison reported on vaginal cuff infection.
	Wound/abdominal wall infection	0 per 1000	0 per 1000 (0 to 0)	OR 3.24 (0.12 to 87.13)	26 (1 RCT)	⨁◯◯◯ Very low^1,2	Based on 1 study comparing V‐NOTES to single‐port LH
	Febrile episodes or unspecified infection	42 per 1000	42 per 1000 (7 to 207)	OR 1.00 (0.17 to 6.01)	96 (2 RCTs)	⨁⨁◯◯ Low³	—
*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: confidence interval; LH: laparoscopic hysterectomy; MD: mean difference; OR: odds ratio; RCT: randomised controlled trial; V‐NOTES: vaginal natural orifice transluminal endoscopic surgery
GRADE Working Group grades of evidence High certainty: we are very confident that the true effect lies close to that of the estimate of the effect. Moderate certainty: we are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. Low certainty: our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect. Very low certainty: we have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect.
¹Downgraded three levels for imprecision: this is from a single very small study (13 participants per arm) with few events and the confidence interval includes the possibility of treatment benefit or harm. ²Downgraded two levels for indirectness: a single study cannot be held to represent all possible populations having this surgery. ³Downgraded two levels for imprecision: these were very small studies with few events and the confidence includes the possibility of treatment benefit or harm.

Summary of findings 7. V‐NOTES compared to laparoscopic hysterectomy for benign gynaecological disease

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Table 1. Staging of laparoscopic hysterectomy ‐ Richardson 1995

Stage	Laparoscopic content
0	Laparoscopy done but no laparoscopic procedure before vaginal hysterectomy
1	Procedure includes laparoscopic adhesiolysis and/or excision of endometriosis
2	Either or both adnexa freed laparoscopically
3	Bladder dissected from the uterus laparoscopically
4	Uterine artery transected laparoscopically
5	Anterior and/or posterior colpotomy or entire uterus freed laparoscopically

Table 1. Staging of laparoscopic hysterectomy ‐ Richardson 1995

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Table 2. AAGL Classification System for Laparoscopic Hysterectomy

Type O	Laparoscopic‐directed preparation for vaginal hysterectomy
Type I	Dissection up to but not including the uterine arteries
Type II	Type I + uterine artery occlusion and division, unilateral or bilateral
Type III	Type II + portion of cardinal‐uterosacral ligament complex only, unilateral or bilateral
Type IV	Type II + total cardinal‐uterosacral ligament complex, unilateral or bilateral

Table 2. AAGL Classification System for Laparoscopic Hysterectomy

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Table 3. Sub‐categorisation of laparoscopic hysterectomy

Type of LH	LH versus AH RCTs	LH versus VH RCTs	LAVH versus TLH RCTs	LH versus SP‐LH RCTs	LH versus RH RCTs	LH versus V‐NOTES RCTs
LAVH	Ellstrom 1998 (IV)	Agostini 2006 (II)	Long 2002 (III)	Chen 2011 (III)
	Ferrari 2000 (III)	Darai 2001 (IV)	Roy 2011 (III)	Song 2013 (III)
	Kunz 1996 (II)	Eggemann 2018 (III)	Sesti 2014b (II)
	Marana 1999 (II)	Mohammed 2017 (IV)
	Muzii 2007 (III)	Ottosen 2000 (0)
	Olsson 1996 (IV)	Panda 2015*
	Ottosen 2000 (0)	Roy 2011 (III)
	Panda 2015*	Roy 2012 (III)
	Persson 2006 (IV)	Sesti 2008a (III)
	Raju 1994 (II)	Sesti 2008b (III)
	Schütz 2002 (IV)	Soriano 2001 (IV)
	Sesti 2008a (III)	Summitt 1992 (IV)
	Summitt 1998 (IV)	Zhu 2009 (IV)
	Tsai 2003 (III)
	Yuen 1998 (IV)
	Zhu 2009 (IV)

TLH	Allam 2015 (V)	Allam 2015 (V)	Ghezzi 2011	Chung 2015 (V)	Deimling 2016 (V)	Baekelandt 2019 (V)
	Ekanayake 2020 (V)	Candiani 2009 (V)	Long 2002 (V)	Jung 2011 (V)	Paraiso 2013 (V)	Park 2021 (V)
	Falcone 1999 (V)	Ekanayake 2020 (V)	Roy 2011 (V)	Mustea 2019 (V)	Sarlos 2012 (V)
	Harkki‐Siren 2000 (V)	Ghezzi 2010 (V)	Sesti 2014b (V)	Tormena 2017 (V)
	Hwang 2002 (V)	Hwang 2002 (V)
	Kluivers 2007 (V)	Nanavati 2016 (V)*
	Langebrekke 1996 (V)	Ribeiro 2003 (V)
	Nanavati 2016 (V)*	Roy 2011 (V)
	Perino 1999 (V)	Sesti 2014b (V)
	Ribeiro 2003 (V)
	Seracchioli 2002 (V)

Non‐categorisable LH	Garry 2004	Garry 2004		Kim 2015 (I‐IV)
	Kongwattanakul 2012	Richardson 1995
	Lumsden 2000
	Wakhloo 2015
AH: abdominal hysterectomy LAVH: laparoscopic‐assisted vaginal hysterectomy LH: laparoscopic hysterectomy RCT: randomised controlled trial TLH: total laparoscopic hysterectomy VH: vaginal hysterectomy

Table 3. Sub‐categorisation of laparoscopic hysterectomy

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Table 4. Studies reporting dropouts

Trial	No. dropouts	Details
Chen 2011	2	Excluded from analysis postoperatively, because they underwent accessory adnexal surgery
Chung 2015	2 (1 TLH, 1 SP‐TLH)	One person in each of the groups was excluded from the analysis because they did not use the postop PCA for pain control (one due to NV, one due to error)
Deimling 2016	1 (TLH)	One patient assigned to the TLH group had severe adhesions and hysterectomy was aborted
Falcone 1999	4 (1 LH; 3 AH)	Withdrew pre‐operatively
Kim 2015	5 (3 SP‐LH; 2 LH)	Withdrew pre‐operatively
Garry 2004	34 (23 LH (11 aLH; 12 vLH); 6 AH; 5 VH)	Withdrew pre‐operatively
Long 2002	13	3 laparotomy conversions were excluded from analysis; 7 incomplete records; 3 combined procedures that were excluded post‐randomisation
Lumsden 2000	10	10 dropouts were not analysed. 7 women did not attend surgery and 3 records were not available
Kluivers 2007	1	Refused assignment procedure
Lumsden 2000	10	7 withdrew pre‐operatively; 3 case records not available
Mustea 2019	4	Unclear/not reported
Paraiso 2013	6	6 withdrew after randomisation but before the intervention was performed
Persson 2006	6	5 allocated to AH and 1 to LH withdrew after informed consent prior to the operation or withdrew in the postoperative period before the 5‐week follow‐up
Roy 2011	9	5 excluded because they needed adenectomy during surgery and 4 excluded from all analyses because they did not show up for follow‐up after intervention
Roy 2012	1	1 LH patient excluded from analysis due to conversion
Sarlos 2012	5	After randomisation 5 did not complete the study and were excluded from the analysis
Song 2013	1	1 lost to follow‐up because of dissatisfaction with hospital care
Summitt 1998	2	Refused assignment procedure
Tormena 2017	2 (1 SP‐LH, 1 LH)	One was converted to multi‐port laparoscopy for extensive adhesions, another no‐showed their follow‐up appointment. Both were excluded from analysis
Yuen 1998	6	4 declined operation; 2 refused to participate postoperatively
AH: abdominal hysterectomy aLH: laparoscopic cases in the abdominal arm of the eVALuate trial LH: laparoscopic hysterectomy VH: vaginal hysterectomy vLH: laparoscopic cases in the vaginal arm of the eVALuate trial

Table 4. Studies reporting dropouts

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Comparison 1. VH versus AH

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1.1 Return to normal activities (days) Show forest plot	4	274	Mean Difference (IV, Random, 95% CI)	‐10.91 [‐17.95, ‐3.87]

1.2 Long‐term outcomes: satisfaction (dichotomous) Show forest plot	1		Odds Ratio (M‐H, Fixed, 95% CI)	Subtotals only

1.3 Intraoperative visceral injury (dichotomous) Show forest plot	9		Odds Ratio (M‐H, Fixed, 95% CI)	Subtotals only

1.3.1 Bladder injury	7	697	Odds Ratio (M‐H, Fixed, 95% CI)	1.62 [0.52, 4.99]
1.3.2 Ureter injury	3	277	Odds Ratio (M‐H, Fixed, 95% CI)	3.10 [0.12, 79.23]
1.3.3 Urinary tract (bladder or ureter) injury	9	901	Odds Ratio (M‐H, Fixed, 95% CI)	1.73 [0.65, 4.63]
1.3.4 Bowel injury	4	0	Odds Ratio (M‐H, Fixed, 95% CI)	Not estimable
1.3.5 Vascular injury	2	219	Odds Ratio (M‐H, Fixed, 95% CI)	0.33 [0.01, 8.21]
1.4 Long‐term complications (dichotomous) Show forest plot	2		Odds Ratio (M‐H, Fixed, 95% CI)	Subtotals only

1.4.1 Urinary dysfunction	2	177	Odds Ratio (M‐H, Fixed, 95% CI)	3.20 [0.32, 31.90]
1.5 Operation time (mins) Show forest plot	7		Mean Difference (IV, Random, 95% CI)	Subtotals only

1.5.1 VH versus AH	7	594	Mean Difference (IV, Random, 95% CI)	‐19.02 [‐46.80, 8.75]
1.6 Short‐term outcomes (dichotomous) Show forest plot	11		Odds Ratio (M‐H, Fixed, 95% CI)	Subtotals only

1.6.1 Transfusion	9	852	Odds Ratio (M‐H, Fixed, 95% CI)	0.78 [0.44, 1.38]
1.6.2 Pelvic haematoma	7	694	Odds Ratio (M‐H, Fixed, 95% CI)	1.11 [0.45, 2.78]
1.6.3 Vaginal cuff infection	3	216	Odds Ratio (M‐H, Fixed, 95% CI)	3.14 [0.48, 20.55]
1.6.4 Wound/abdominal wall infection	6	628	Odds Ratio (M‐H, Fixed, 95% CI)	0.18 [0.06, 0.53]
1.6.5 UTI	5	350	Odds Ratio (M‐H, Fixed, 95% CI)	0.52 [0.14, 1.97]
1.6.6 Chest infection	1	60	Odds Ratio (M‐H, Fixed, 95% CI)	1.00 [0.13, 7.60]
1.6.7 Febrile episodes or unspecified infection	6	593	Odds Ratio (M‐H, Fixed, 95% CI)	0.59 [0.35, 1.01]
1.6.8 Thromboembolism	2	0	Odds Ratio (M‐H, Fixed, 95% CI)	Not estimable
1.7 Length of hospital stay (days) Show forest plot	7	570	Mean Difference (IV, Random, 95% CI)	‐1.57 [‐2.11, ‐1.03]

1.8 All outcomes, descriptive data Show forest plot	9		Other data	No numeric data

1.8.1 Quality of life (descriptive data)	1		Other data	No numeric data
1.8.2 Operation time (descriptive data)	5		Other data	No numeric data
1.8.3 Length of hospital stay (descriptive data)	5		Other data	No numeric data
1.8.4 Urinary and sexual dysfunction (descriptive data)	1		Other data	No numeric data
1.8.5 Cost (descriptive data)	2		Other data	No numeric data

Comparison 1. VH versus AH

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Comparison 2. LH versus AH

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
2.1 Return to normal activities (days) Show forest plot	7	618	Mean Difference (IV, Random, 95% CI)	‐13.01 [‐16.47, ‐9.56]

2.1.1 LAVH vs AH	3	288	Mean Difference (IV, Random, 95% CI)	‐12.20 [‐18.55, ‐5.86]
2.1.2 TLH vs AH	4	330	Mean Difference (IV, Random, 95% CI)	‐14.33 [‐17.92, ‐10.75]
2.2 Satisfaction Show forest plot	1		Odds Ratio (M‐H, Fixed, 95% CI)	Totals not selected

2.2.1 LH (method unspecified) versus AH	1		Odds Ratio (M‐H, Fixed, 95% CI)	Totals not selected
2.3 Bladder injury Show forest plot	15	2298	Odds Ratio (M‐H, Fixed, 95% CI)	1.68 [0.88, 3.22]

2.3.1 LAVH versus AH	6	723	Odds Ratio (M‐H, Fixed, 95% CI)	1.70 [0.49, 5.88]
2.3.2 TLH versus AH	5	359	Odds Ratio (M‐H, Fixed, 95% CI)	0.54 [0.13, 2.19]
2.3.3 LH (method unspecified) versus AH	4	1216	Odds Ratio (M‐H, Fixed, 95% CI)	2.87 [1.02, 8.07]
2.4 Ureter injury Show forest plot	10	1675	Odds Ratio (M‐H, Fixed, 95% CI)	3.62 [1.18, 11.11]

2.4.1 TLH versus AH	6	459	Odds Ratio (M‐H, Fixed, 95% CI)	3.93 [0.81, 19.15]
2.4.2 LH (method unspecified) versus AH	4	1216	Odds Ratio (M‐H, Fixed, 95% CI)	3.36 [0.69, 16.31]
2.5 Urinary tract (bladder or ureter) injury Show forest plot	18	2594	Odds Ratio (M‐H, Fixed, 95% CI)	2.16 [1.19, 3.93]

2.5.1 LAVH versus AH	7	819	Odds Ratio (M‐H, Fixed, 95% CI)	1.34 [0.44, 4.10]
2.5.2 TLH versus AH	7	559	Odds Ratio (M‐H, Fixed, 95% CI)	1.73 [0.58, 5.15]
2.5.3 LH (method unspecified) versus AH	4	1216	Odds Ratio (M‐H, Fixed, 95% CI)	3.30 [1.24, 8.77]
2.6 Bowel injury Show forest plot	7	1431	Odds Ratio (M‐H, Fixed, 95% CI)	0.23 [0.05, 1.14]

2.6.1 LAVH versus AH	1	96	Odds Ratio (M‐H, Fixed, 95% CI)	0.30 [0.01, 7.56]
2.6.2 TLH versus AH	3	0	Odds Ratio (M‐H, Fixed, 95% CI)	Not estimable
2.6.3 LH (method unspecified) versus AH	3	1116	Odds Ratio (M‐H, Fixed, 95% CI)	0.21 [0.03, 1.33]
2.7 Vascular injury Show forest plot	3	1056	Odds Ratio (M‐H, Fixed, 95% CI)	1.40 [0.48, 4.09]

2.7.1 LAVH versus AH	1	80	Odds Ratio (M‐H, Fixed, 95% CI)	5.26 [0.24, 113.11]
2.7.2 LH (method unspecified) versus AH	2	976	Odds Ratio (M‐H, Fixed, 95% CI)	1.06 [0.33, 3.44]
2.8 Fistula Show forest plot	2	245	Odds Ratio (M‐H, Fixed, 95% CI)	3.07 [0.32, 29.96]

2.8.1 LAVH versus AH	1	143	Odds Ratio (M‐H, Fixed, 95% CI)	3.09 [0.12, 77.01]
2.8.2 TLH versus AH	1	102	Odds Ratio (M‐H, Fixed, 95% CI)	3.06 [0.12, 76.88]
2.9 Urinary dysfunction Show forest plot	3	343	Odds Ratio (M‐H, Fixed, 95% CI)	0.94 [0.49, 1.82]

2.9.1 LAVH versus AH	1	80	Odds Ratio (M‐H, Fixed, 95% CI)	3.08 [0.12, 77.80]
2.9.2 LH (method unspecified) versus AH	1	166	Odds Ratio (M‐H, Fixed, 95% CI)	0.88 [0.44, 1.76]
2.9.3 TLH versus AH	1	97	Odds Ratio (M‐H, Fixed, 95% CI)	1.02 [0.06, 16.81]
2.10 Operation time (mins) Show forest plot	15		Mean Difference (IV, Random, 95% CI)	Subtotals only

2.10.1 LAVH versus AH	9	910	Mean Difference (IV, Random, 95% CI)	23.16 [‐4.04, 50.35]
2.10.2 TLH versus AH	5	393	Mean Difference (IV, Random, 95% CI)	19.75 [7.94, 31.55]
2.10.3 LH (method unspecified) versus AH	1	100	Mean Difference (IV, Random, 95% CI)	14.80 [7.36, 22.24]
2.11 Bleeding Show forest plot	6	1366	Odds Ratio (M‐H, Fixed, 95% CI)	0.46 [0.19, 1.10]

2.11.1 LAVH versus AH	3	340	Odds Ratio (M‐H, Fixed, 95% CI)	0.33 [0.07, 1.66]
2.11.2 TLH versus AH	1	50	Odds Ratio (M‐H, Fixed, 95% CI)	0.18 [0.01, 4.04]
2.11.3 LH (method unspecified) versus AH	2	976	Odds Ratio (M‐H, Fixed, 95% CI)	0.67 [0.21, 2.12]
2.12 Transfusion Show forest plot	23	2911	Odds Ratio (M‐H, Random, 95% CI)	0.58 [0.34, 0.99]

2.12.1 LAVH versus AH	13	1194	Odds Ratio (M‐H, Random, 95% CI)	0.41 [0.22, 0.77]
2.12.2 TLH versus AH	7	601	Odds Ratio (M‐H, Random, 95% CI)	0.61 [0.24, 1.53]
2.12.3 LH (method unspecified) versus AH	3	1116	Odds Ratio (M‐H, Random, 95% CI)	0.91 [0.08, 9.85]
2.13 Pelvic haematoma Show forest plot	10	938	Odds Ratio (M‐H, Fixed, 95% CI)	0.69 [0.36, 1.33]

2.13.1 LAVH versus AH	8	778	Odds Ratio (M‐H, Fixed, 95% CI)	0.73 [0.36, 1.52]
2.13.2 TLH versus AH	2	160	Odds Ratio (M‐H, Fixed, 95% CI)	0.56 [0.13, 2.37]
2.14 Length of hospital stay (days) Show forest plot	13		Mean Difference (IV, Random, 95% CI)	Subtotals only

2.14.1 LAVH versus AH	8	870	Mean Difference (IV, Random, 95% CI)	‐2.39 [‐3.20, ‐1.59]
2.14.2 TLH versus AH	4	333	Mean Difference (IV, Random, 95% CI)	‐2.07 [‐3.29, ‐0.84]
2.14.3 LH (method unspecified) versus AH	1	100	Mean Difference (IV, Random, 95% CI)	‐43.04 [‐44.39, ‐41.69]
2.15 Vaginal cuff infection Show forest plot	9	852	Odds Ratio (M‐H, Fixed, 95% CI)	1.43 [0.67, 3.04]

2.15.1 LAVH versus AH	6	698	Odds Ratio (M‐H, Fixed, 95% CI)	1.00 [0.42, 2.38]
2.15.2 TLH versus AH	3	154	Odds Ratio (M‐H, Fixed, 95% CI)	4.81 [0.77, 29.89]
2.16 Wound/abdominal wall infection Show forest plot	9	824	Odds Ratio (M‐H, Fixed, 95% CI)	0.21 [0.10, 0.45]

2.16.1 LAVH versus AH	4	286	Odds Ratio (M‐H, Fixed, 95% CI)	0.20 [0.06, 0.65]
2.16.2 TLH versus AH	3	248	Odds Ratio (M‐H, Fixed, 95% CI)	0.39 [0.09, 1.68]
2.16.3 LH (method unspecified) versus AH	2	290	Odds Ratio (M‐H, Fixed, 95% CI)	0.13 [0.03, 0.57]
2.17 Urinary tract infection Show forest plot	9	757	Odds Ratio (M‐H, Fixed, 95% CI)	1.15 [0.61, 2.16]

2.17.1 LAVH versus AH	4	315	Odds Ratio (M‐H, Fixed, 95% CI)	0.98 [0.39, 2.50]
2.17.2 TLH versus AH	3	202	Odds Ratio (M‐H, Fixed, 95% CI)	2.36 [0.58, 9.58]
2.17.3 LH (method unspecified) versus AH	2	240	Odds Ratio (M‐H, Fixed, 95% CI)	0.84 [0.26, 2.69]
2.18 Chest infection Show forest plot	3	294	Odds Ratio (M‐H, Fixed, 95% CI)	0.31 [0.07, 1.35]

2.18.1 TLH versus AH	2	104	Odds Ratio (M‐H, Fixed, 95% CI)	0.63 [0.10, 3.93]
2.18.2 LH (method not specified) versus AH	1	190	Odds Ratio (M‐H, Fixed, 95% CI)	0.11 [0.01, 2.01]
2.19 Febrile episodes or unspecified infection Show forest plot	18	2386	Odds Ratio (M‐H, Fixed, 95% CI)	0.65 [0.49, 0.85]

2.19.1 LAVH versus AH	8	685	Odds Ratio (M‐H, Fixed, 95% CI)	0.49 [0.28, 0.86]
2.19.2 TLH versus AH	6	485	Odds Ratio (M‐H, Fixed, 95% CI)	0.39 [0.21, 0.72]
2.19.3 LH (method unspecified) versus AH	4	1216	Odds Ratio (M‐H, Fixed, 95% CI)	0.88 [0.61, 1.27]
2.20 Thromboembolism Show forest plot	4	1225	Odds Ratio (M‐H, Fixed, 95% CI)	1.10 [0.33, 3.71]

2.20.1 TLH versus AH	2	159	Odds Ratio (M‐H, Fixed, 95% CI)	1.09 [0.15, 8.06]
2.20.2 LH (method unspecified) versus AH	2	1066	Odds Ratio (M‐H, Fixed, 95% CI)	1.11 [0.24, 5.13]
2.21 Wound dehiscence Show forest plot	2		Odds Ratio (M‐H, Fixed, 95% CI)	Subtotals only

2.21.1 LAVH versus AH	2	181	Odds Ratio (M‐H, Fixed, 95% CI)	0.33 [0.07, 1.63]
2.22 Return to normal activities (descriptive data) Show forest plot	0		Other data	No numeric data

2.23 Long‐term outcomes: quality of life (descriptive data) Show forest plot	0		Other data	No numeric data

2.24 Operation time (descriptive data) Show forest plot	0		Other data	No numeric data

2.25 Length of hospital stay (descriptive data) Show forest plot	0		Other data	No numeric data

2.26 Cost (descriptive data) Show forest plot	0		Other data	No numeric data

2.27 Urinary and sexual dysfunction (descriptive data) Show forest plot	0		Other data	No numeric data

Comparison 2. LH versus AH

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Comparison 3. LH versus VH

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
3.1 Return to normal activities (days) Show forest plot	3	238	Mean Difference (IV, Fixed, 95% CI)	‐1.06 [‐4.18, 2.05]

3.1.1 LAVH versus VH	1	80	Mean Difference (IV, Fixed, 95% CI)	‐1.60 [‐5.11, 1.91]
3.1.2 TLH versus VH	2	158	Mean Difference (IV, Fixed, 95% CI)	0.88 [‐5.82, 7.59]
3.2 Ureter injury Show forest plot	4	846	Odds Ratio (M‐H, Fixed, 95% CI)	0.69 [0.09, 5.43]

3.2.1 LAVH versus VH	2	0	Odds Ratio (M‐H, Fixed, 95% CI)	Not estimable
3.2.2 TLH versus VH	2	105	Odds Ratio (M‐H, Fixed, 95% CI)	0.32 [0.01, 8.24]
3.2.3 LH (method unspecified) versus VH	1	504	Odds Ratio (M‐H, Fixed, 95% CI)	1.51 [0.06, 37.18]
3.3 Bladder injury Show forest plot	10	1237	Odds Ratio (M‐H, Fixed, 95% CI)	0.93 [0.37, 2.33]

3.3.1 LAVH versus VH	6	503	Odds Ratio (M‐H, Fixed, 95% CI)	1.22 [0.34, 4.30]
3.3.2 TLH versus VH	3	185	Odds Ratio (M‐H, Fixed, 95% CI)	0.32 [0.01, 8.26]
3.3.3 LH (method unspecified) versus VH	2	549	Odds Ratio (M‐H, Fixed, 95% CI)	0.83 [0.18, 3.79]
3.4 Urinary tract (bladder or ureter) injury Show forest plot	13	1536	Odds Ratio (M‐H, Fixed, 95% CI)	0.92 [0.40, 2.09]

3.4.1 LAVH versus VH	8	670	Odds Ratio (M‐H, Fixed, 95% CI)	1.00 [0.32, 3.16]
3.4.2 TLH versus VH	5	317	Odds Ratio (M‐H, Fixed, 95% CI)	0.59 [0.08, 4.61]
3.4.3 LH (method unspecified) versus VH	2	549	Odds Ratio (M‐H, Fixed, 95% CI)	1.01 [0.23, 4.38]
3.5 Bowel injury Show forest plot	5	986	Odds Ratio (M‐H, Fixed, 95% CI)	3.26 [0.13, 82.16]

3.5.1 LAVH versus VH	3	332	Odds Ratio (M‐H, Fixed, 95% CI)	3.26 [0.13, 82.16]
3.5.2 TLH versus VH	2	0	Odds Ratio (M‐H, Fixed, 95% CI)	Not estimable
3.5.3 LH (method unspecified) versus VH	1	0	Odds Ratio (M‐H, Fixed, 95% CI)	Not estimable
3.6 Vascular injury Show forest plot	5	785	Odds Ratio (M‐H, Fixed, 95% CI)	1.58 [0.48, 5.27]

3.6.1 LAVH versus VH	2	136	Odds Ratio (M‐H, Fixed, 95% CI)	2.89 [0.11, 74.15]
3.6.2 TLH versus VH	1	0	Odds Ratio (M‐H, Fixed, 95% CI)	Not estimable
3.6.3 LH (method unspecified) versus VH	2	549	Odds Ratio (M‐H, Fixed, 95% CI)	1.42 [0.39, 5.22]
3.7 Fistula Show forest plot	1		Odds Ratio (M‐H, Fixed, 95% CI)	Totals not selected

3.7.1 LAVH versus VH	1		Odds Ratio (M‐H, Fixed, 95% CI)	Totals not selected
3.8 Urinary dysfunction Show forest plot	3	248	Odds Ratio (M‐H, Fixed, 95% CI)	1.00 [0.25, 4.07]

3.8.1 LAVH versus VH	1	80	Odds Ratio (M‐H, Fixed, 95% CI)	3.08 [0.12, 77.80]
3.8.2 TLH versus VH	2	168	Odds Ratio (M‐H, Fixed, 95% CI)	0.71 [0.14, 3.66]
3.9 Operation time (mins) Show forest plot	14		Mean Difference (IV, Random, 95% CI)	Subtotals only

3.9.1 LAVH versus VH	12	905	Mean Difference (IV, Random, 95% CI)	41.32 [32.70, 49.94]
3.9.2 TLH versus VH	3	192	Mean Difference (IV, Random, 95% CI)	41.89 [‐5.52, 89.31]
3.10 Bleeding Show forest plot	4	806	Odds Ratio (M‐H, Fixed, 95% CI)	1.37 [0.29, 6.39]

3.10.1 LAVH versus VH	3	257	Odds Ratio (M‐H, Fixed, 95% CI)	1.24 [0.15, 10.03]
3.10.2 TLH versus VH	1	45	Odds Ratio (M‐H, Fixed, 95% CI)	1.58 [0.06, 41.03]
3.10.3 LH (method unspecified) versus VH	1	504	Odds Ratio (M‐H, Fixed, 95% CI)	1.51 [0.06, 37.18]
3.11 Transfusion Show forest plot	14	1586	Odds Ratio (M‐H, Fixed, 95% CI)	1.25 [0.76, 2.06]

3.11.1 LAVH versus VH	9	647	Odds Ratio (M‐H, Fixed, 95% CI)	1.50 [0.63, 3.58]
3.11.2 TLH versus VH	6	435	Odds Ratio (M‐H, Fixed, 95% CI)	0.88 [0.41, 1.91]
3.11.3 LH (method unspecified) versus VH	1	504	Odds Ratio (M‐H, Fixed, 95% CI)	1.74 [0.63, 4.79]
3.12 Pelvic haematoma Show forest plot	6	463	Odds Ratio (M‐H, Fixed, 95% CI)	0.86 [0.30, 2.51]

3.12.1 LAVH versus VH	5	403	Odds Ratio (M‐H, Fixed, 95% CI)	1.21 [0.36, 4.03]
3.12.2 TLH versus VH	1	60	Odds Ratio (M‐H, Fixed, 95% CI)	0.19 [0.01, 4.06]
3.13 Unintended laparotomy Show forest plot	13	1414	Odds Ratio (M‐H, Fixed, 95% CI)	1.40 [0.72, 2.71]

3.13.1 LAVH versus VH	10	688	Odds Ratio (M‐H, Fixed, 95% CI)	4.11 [1.25, 13.52]
3.13.2 TLH versus VH	3	177	Odds Ratio (M‐H, Fixed, 95% CI)	0.70 [0.09, 5.58]
3.13.3 LH (method unspecified) versus VH	2	549	Odds Ratio (M‐H, Fixed, 95% CI)	0.67 [0.26, 1.74]
3.14 Vaginal cuff infection Show forest plot	4	276	Odds Ratio (M‐H, Fixed, 95% CI)	0.98 [0.22, 4.39]

3.14.1 LAVH versus VH	3	216	Odds Ratio (M‐H, Fixed, 95% CI)	0.98 [0.22, 4.39]
3.14.2 TLH versus VH	1	0	Odds Ratio (M‐H, Fixed, 95% CI)	Not estimable
3.15 Wound/abdominal wall infection Show forest plot	4	363	Odds Ratio (M‐H, Fixed, 95% CI)	1.41 [0.28, 7.03]

3.15.1 LAVH versus VH	3	220	Odds Ratio (M‐H, Fixed, 95% CI)	2.88 [0.31, 27.06]
3.15.2 TLH versus VH	2	143	Odds Ratio (M‐H, Fixed, 95% CI)	0.33 [0.01, 8.22]
3.16 Urinary tract infection Show forest plot	4	328	Odds Ratio (M‐H, Fixed, 95% CI)	2.12 [0.60, 7.50]

3.16.1 LAVH versus VH	2	125	Odds Ratio (M‐H, Fixed, 95% CI)	1.02 [0.15, 6.89]
3.16.2 TLH versus VH	3	203	Odds Ratio (M‐H, Fixed, 95% CI)	3.60 [0.59, 21.83]
3.17 Chest infection Show forest plot	1		Odds Ratio (M‐H, Fixed, 95% CI)	Totals not selected

3.17.1 TLH versus VH	1		Odds Ratio (M‐H, Fixed, 95% CI)	Totals not selected
3.18 Febrile episodes or unspecified infection Show forest plot	12	1508	Odds Ratio (M‐H, Fixed, 95% CI)	0.81 [0.53, 1.24]

3.18.1 LAVH versus VH	8	653	Odds Ratio (M‐H, Fixed, 95% CI)	1.50 [0.65, 3.47]
3.18.2 TLH versus VH	5	351	Odds Ratio (M‐H, Fixed, 95% CI)	0.36 [0.10, 1.29]
3.18.3 LH (method unspecified) versus VH	1	504	Odds Ratio (M‐H, Fixed, 95% CI)	0.72 [0.41, 1.25]
3.19 Thromboembolism Show forest plot	3	664	Odds Ratio (M‐H, Fixed, 95% CI)	1.38 [0.28, 6.88]

3.19.1 TLH versus VH	2	160	Odds Ratio (M‐H, Fixed, 95% CI)	1.00 [0.14, 7.24]
3.19.2 LH (method unspecified) versus VH	1	504	Odds Ratio (M‐H, Fixed, 95% CI)	2.52 [0.12, 52.76]
3.20 Length of hospital stay (days) Show forest plot	11	912	Mean Difference (IV, Random, 95% CI)	0.65 [0.45, 0.85]

3.20.1 LAVH versus VH	10	780	Mean Difference (IV, Random, 95% CI)	0.62 [0.40, 0.83]
3.20.2 TLH versus VH	2	132	Mean Difference (IV, Random, 95% CI)	0.58 [‐0.90, 2.06]
3.21 Return to normal activities (descriptive data) Show forest plot	0		Other data	No numeric data

3.22 Long‐term outcomes: quality of life (descriptive data) Show forest plot	0		Other data	No numeric data

3.23 Operation time (descriptive data) Show forest plot	0		Other data	No numeric data

3.24 Length of hospital stay (descriptive data) Show forest plot	0		Other data	No numeric data

3.25 Cost (descriptive data) Show forest plot	0		Other data	No numeric data

3.26 Urinary and sexual dysfunction (descriptive data) Show forest plot	0		Other data	No numeric data

Comparison 3. LH versus VH

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Comparison 4. RH versus LH

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
4.1 Return to normal activities (days) Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Subtotals only

4.2 Intraoperative visceral injury (dichotomous) Show forest plot	1		Odds Ratio (M‐H, Fixed, 95% CI)	Subtotals only

4.2.1 Ureter injury	1	100	Odds Ratio (M‐H, Fixed, 95% CI)	0.33 [0.01, 8.21]
4.2.2 Vascular injury	1	100	Odds Ratio (M‐H, Fixed, 95% CI)	1.00 [0.06, 16.44]
4.3 Operation time Show forest plot	2	152	Mean Difference (IV, Random, 95% CI)	44.09 [5.31, 82.88]

4.4 Bleeding Show forest plot	1		Odds Ratio (M‐H, Fixed, 95% CI)	Subtotals only

4.4.1 Bleeding	1	144	Odds Ratio (M‐H, Fixed, 95% CI)	0.08 [0.00, 1.56]
4.5 Wound dehiscence Show forest plot	2		Odds Ratio (M‐H, Fixed, 95% CI)	Subtotals only

4.5.1 Wound dehiscence	2	244	Odds Ratio (M‐H, Fixed, 95% CI)	1.00 [0.17, 5.86]
4.6 Transfusion Show forest plot	1		Odds Ratio (M‐H, Fixed, 95% CI)	Subtotals only

4.7 Wound/abdominal wall infection Show forest plot	2		Odds Ratio (M‐H, Fixed, 95% CI)	Subtotals only

4.7.1 Wound/abdominal wall infection	2	244	Odds Ratio (M‐H, Fixed, 95% CI)	0.60 [0.08, 4.57]
4.8 Febrile episodes or unspecified infections Show forest plot	1		Odds Ratio (M‐H, Fixed, 95% CI)	Subtotals only

4.9 Operation time (descriptive data) Show forest plot	0		Other data	No numeric data

4.10 Return to normal activities (descriptive data) Show forest plot	0		Other data	No numeric data

Comparison 4. RH versus LH

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Comparison 5. SP‐LH versus LH

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
5.1 Bladder injury Show forest plot	1		Odds Ratio (M‐H, Fixed, 95% CI)	Totals not selected

5.1.1 SP‐TLH versus TLH	1		Odds Ratio (M‐H, Fixed, 95% CI)	Totals not selected
5.2 Ureter injury Show forest plot	1		Odds Ratio (M‐H, Fixed, 95% CI)	Subtotals only

5.3 Conversion or aditional port placement Show forest plot	1		Odds Ratio (M‐H, Fixed, 95% CI)	Subtotals only

5.4 Transfusion Show forest plot	6	552	Odds Ratio (M‐H, Fixed, 95% CI)	0.78 [0.34, 1.77]

5.4.1 SP‐LAVH versus LAVH	3	390	Odds Ratio (M‐H, Fixed, 95% CI)	0.58 [0.23, 1.47]
5.4.2 SP‐TLH versus TLH	3	162	Odds Ratio (M‐H, Fixed, 95% CI)	3.30 [0.33, 32.63]
5.5 Pelvic haematoma Show forest plot	1		Odds Ratio (M‐H, Fixed, 95% CI)	Totals not selected

5.5.1 SP‐LAVH versus LAVH	1		Odds Ratio (M‐H, Fixed, 95% CI)	Totals not selected
5.6 Wound/abdominal wall infection Show forest plot	3		Odds Ratio (M‐H, Fixed, 95% CI)	Subtotals only

5.6.1 SP‐LAVH versus LAVH	3	411	Odds Ratio (M‐H, Fixed, 95% CI)	1.03 [0.20, 5.15]
5.7 Febrile episodes or unspecified infection Show forest plot	2		Odds Ratio (M‐H, Fixed, 95% CI)	Subtotals only

5.7.1 SP‐LH versus LH	2	315	Odds Ratio (M‐H, Fixed, 95% CI)	2.56 [0.70, 9.44]
5.8 Vaginal cuff dehiscence Show forest plot	1		Odds Ratio (M‐H, Fixed, 95% CI)	Subtotals only

5.9 Postoperative ileus Show forest plot	1		Odds Ratio (M‐H, Fixed, 95% CI)	Subtotals only

5.9.1 SP‐TLH versus TLH	1	64	Odds Ratio (M‐H, Fixed, 95% CI)	2.36 [0.20, 27.39]
5.10 Operation time (mins) Show forest plot	4	262	Mean Difference (IV, Fixed, 95% CI)	14.95 [7.53, 22.38]

5.10.1 SP‐LAVH versus LAVH	1	100	Mean Difference (IV, Fixed, 95% CI)	‐5.00 [‐17.65, 7.65]
5.10.2 SP‐TLH versus TLH	3	162	Mean Difference (IV, Fixed, 95% CI)	25.43 [16.26, 34.59]
5.11 Length of hospital stay (days) Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Subtotals only

5.11.1 SP‐LAVH versus LAVH	1	100	Mean Difference (IV, Fixed, 95% CI)	‐0.20 [‐0.49, 0.09]
5.12 Operation time (descriptive data) Show forest plot	0		Other data	No numeric data

5.13 Length of hospital stay (descriptive data) Show forest plot	0		Other data	No numeric data

5.14 Cost (descriptive data) Show forest plot	0		Other data	No numeric data

Comparison 5. SP‐LH versus LH

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Comparison 6. TLH versus LAVH

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
6.1 Intraoperative visceral injury (dichotomous) Show forest plot	3		Odds Ratio (M‐H, Fixed, 95% CI)	Subtotals only

6.1.1 Bladder injury	2	161	Odds Ratio (M‐H, Fixed, 95% CI)	0.72 [0.06, 8.27]
6.1.2 Ureter injury	2	161	Odds Ratio (M‐H, Fixed, 95% CI)	3.03 [0.27, 34.52]
6.1.3 Urinary tract (bladder or ureter) injury	3	233	Odds Ratio (M‐H, Fixed, 95% CI)	1.50 [0.29, 7.83]
6.1.4 Bowel injury	2	0	Odds Ratio (M‐H, Fixed, 95% CI)	Not estimable
6.1.5 Vascular injury	1	101	Odds Ratio (M‐H, Fixed, 95% CI)	1.48 [0.09, 24.27]
6.2 Long‐term complications (dichotomous) Show forest plot	1		Odds Ratio (M‐H, Fixed, 95% CI)	Subtotals only

6.2.1 Dyspareunia	1	101	Odds Ratio (M‐H, Fixed, 95% CI)	2.64 [0.59, 11.72]
6.2.2 Orgasm (< 1 of 3)	1	101	Odds Ratio (M‐H, Fixed, 95% CI)	0.84 [0.38, 1.86]
6.3 Operation time (mins) Show forest plot	2	173	Mean Difference (IV, Fixed, 95% CI)	23.36 [12.50, 34.22]

6.4 Unintended laparotomy Show forest plot	3		Odds Ratio (M‐H, Fixed, 95% CI)	Subtotals only

6.4.1 Conversion to laparotomy	3	236	Odds Ratio (M‐H, Fixed, 95% CI)	1.28 [0.21, 7.85]
6.5 Short‐term outcomes (dichotomous) Show forest plot	3	687	Odds Ratio (M‐H, Random, 95% CI)	0.58 [0.28, 1.18]

6.5.1 Transfusion	3	233	Odds Ratio (M‐H, Random, 95% CI)	0.72 [0.18, 2.83]
6.5.2 Vaginal cuff infection	1	101	Odds Ratio (M‐H, Random, 95% CI)	0.28 [0.03, 2.45]
6.5.3 Abdominal wall/wound infection	1	60	Odds Ratio (M‐H, Random, 95% CI)	0.19 [0.01, 4.06]
6.5.4 UTI	1	60	Odds Ratio (M‐H, Random, 95% CI)	1.00 [0.13, 7.60]
6.5.5 Febrile episodes or unspecified infection	3	233	Odds Ratio (M‐H, Random, 95% CI)	0.61 [0.15, 2.45]
6.6 Length of hospital stay (days) Show forest plot	2	173	Mean Difference (IV, Fixed, 95% CI)	0.01 [‐0.35, 0.37]

Comparison 6. TLH versus LAVH

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Comparison 7. V‐NOTES versus LH

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
7.1 Conversion or additional port placement Show forest plot	2	0	Odds Ratio (M‐H, Fixed, 95% CI)	Not estimable

7.1.1 V‐NOTES vs TLH	1	0	Odds Ratio (M‐H, Fixed, 95% CI)	Not estimable
7.1.2 V‐NOTES vs SP‐LH	1	0	Odds Ratio (M‐H, Fixed, 95% CI)	Not estimable
7.2 Operation time Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Subtotals only

7.3 Bladder injury Show forest plot	2	96	Odds Ratio (M‐H, Fixed, 95% CI)	3.09 [0.12, 78.41]

7.3.1 V‐NOTES vs TLH	1	70	Odds Ratio (M‐H, Fixed, 95% CI)	3.09 [0.12, 78.41]
7.3.2 V‐NOTES vs SP‐LH	1	0	Odds Ratio (M‐H, Fixed, 95% CI)	Not estimable
7.4 Febrile episodes or unspecified infection Show forest plot	2	96	Odds Ratio (M‐H, Fixed, 95% CI)	1.00 [0.17, 6.01]

7.4.1 V‐NOTES vs TLH	1	70	Odds Ratio (M‐H, Fixed, 95% CI)	0.49 [0.04, 5.61]
7.4.2 V‐NOTES vs SP‐LH	1	26	Odds Ratio (M‐H, Fixed, 95% CI)	3.24 [0.12, 87.13]
7.5 Length of hospital stay (days) Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Subtotals only

7.6 Substantial bleeding Show forest plot	1		Odds Ratio (M‐H, Fixed, 95% CI)	Subtotals only

7.7 Wound/abdominal wall infection Show forest plot	1		Odds Ratio (M‐H, Fixed, 95% CI)	Subtotals only

7.8 Operation time (descriptive data) Show forest plot	0		Other data	No numeric data

7.9 Length of hospital stay (descriptive data) Show forest plot	0		Other data	No numeric data

Comparison 7. V‐NOTES versus LH

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