Hysterectomy is the most frequently performed gynecological surgery worldwide andremains the definitive treatment for multiple benign and malignant uterine pathologies, including abnormal uterine bleeding (AUB), fibroids, adenomyosis, and early-stagemalignancies. With the rise of minimally invasive techniques, total laparoscopic hysterectomy (TLH) has gained prominence due to advantages such as reducedpostoperative pain, shorter hospital stay, faster recovery, and decreased blood loss. Despite these benefits, controversies remain regarding specific intraoperative steps, particularly the management of the vaginal vault. Traditionally, vault closure has been recommended to maintain pelvic anatomy, minimize risk of prolapse, and support primary healing. However, closure is associated with increasedoperative time, postoperative pain, hematoma, granulation tissue, and infection. In contrast, leaving the vault open facilitates drainage, reduces hematoma formation, and may improve recovery, though concerns persist regarding long-term risks of prolapse or dehiscence. Anatomically, vagina is anteroposteriorly closed organ, vault closes by secondary intention within 48hours. Evidence from previous studies is inconclusive, with some favoring closure while others highlight the advantages of non-closure. This study aimed to evaluate and compare the outcomes and complications of vault closure (VC) versus vault non-closure (VNC) in TLH performed for benign gynecologic conditions, primarily AUB.

This randomized prospective comparative study was conducted at the Department of Obstetrics and Gynecology, Krishna Institute of Medical Sciences (KIMS), Hyderabad, between October 2023 and December 2024. Ethical approval was obtained, and informed consent was collected from all participants. Study Population A total of 68 women undergoing TLH for benign gynecologic conditions were included. They were randomized into two groups: • Group VC: Vault closure performed (n = 34) • Group VNC: Vault left open (n = 34) Inclusion Criteria: • Age 30–65 years • Indications: AUB, fibroids, adenomyosis, endometrial hyperplasia, benign adnexal mass, cervical dysplasia, or chronic pelvic pain • Willingness for follow-up up to 6 weeks Exclusion Criteria: • Malignancies (uterine/cervical) • Severe cardiopulmonary comorbidities • Immunocompromised states or active pelvic infections Preoperative and intraoperative Assessment All patients underwent baseline hematological, biochemical, and radiological investigations, including complete blood count, renal function tests, coagulation profile, pelvic ultrasound, and ECG. Standardized anesthesia and surgical protocols were followed. Vault closure was performed using either laparoscopic barbed sutures (2-0 V-Loc) or vaginal Vicryl sutures, while in the non-closure group, hemostasis was secured and vault edges coagulated without suturing. Outcome Measures Primary outcomes: • Operative time • Blood loss • Postoperative complications (hematoma, infection, discharge, vault dehiscence, prolapse) • Vault healing at 6 weeks Secondary outcomes: • Postoperative pain (measured by Visual Analogue Scale, VAS) at 1 week and 6 weeks • Duration of hospital stay Statistical Analysis Data were analyzed using SPSS version 26. Continuous variables were expressed as mean ± SD, while categorical variables were analyzed using Chi-square test. A p-value <0.05 was considered statistically significant.

Demographics The demographic profile was comparable across both groups. The mean age was 48.1 ± 6.9 years, and mean BMI was 26.7 ± 2.9 kg/m². Multiparity was predominant (88.2%). Most women (63.2%) belonged to the 40–49 year age group. Operative Time The mean operative time was significantly higher in the VC group (125.2 ± 19.8 minutes) compared to the VNC group (109.7 ± 26.9 minutes, p=0.009). Blood Loss and Transfusion No statistically significant difference was found in intraoperative blood loss (VC: 75.9 ± 11.2 ml vs VNC: 73.9 ± 13.1 ml, p=0.502) or transfusion requirement. Hospital Stay Contrary to expectations, hospital stay was shorter in the VC group (2.0 ± 0.3 days) compared to VNC group (2.9 ± 0.28 days, p=0.001). Postoperative Pain At 1 week, mild pain was reported by 97.1% of VC patients versus 79.4% of VNC patients (p=0.024). At 6 weeks, only 20.6% of VC and 8.8% of VNC patients reported mild pain, with no significant difference (p=0.171). Vault Healing and Complications All patients achieved complete vault healing by 6 weeks. Vault hematoma occurred in 3 patients (8.8%) in VC, while none were reported in VNC. Vault discharge was more frequent in VC (5.8%). No cases of vault dehiscence, prolapse, or pelvic abscess were observed in either group.

This randomized study contributes valuable evidence to the debate on vault closure versus non-closure during TLH. The findings indicate that vault non-closure is associated with shorter operative time, less postoperative pain, and lower incidence of hematoma and discharge compared to closure, without compromising healing. Previous studies have demonstrated similar findings. Lodhi et al. (2020) reported lower operative time and fewer infections in non-closure cases [11]. Saha et al. (2020) also documented reduced hematoma and improved drainage with non-closure [15]. Malla et al. (2022) confirmed that both closure and non-closure yield comparable outcomes in abdominal hysterectomy, though hematoma incidence was slightly higher in closure cases [16]. Vault closure has traditionally been justified for its presumed benefits in maintaining pelvic support and reducing long-term prolapse. However, these advantages remain unproven in the laparoscopic era with increasing surgeon expertise. In our study, no prolapse or dehiscence occurred in either group at 6 Weeks. This aligns with Smith et al. (2017), who emphasized that closure techniques do not significantly reduce dehiscence rates [12]. Pain outcomes are noteworthy. The VNC group consistently reported lower pain at 1 week, contributing to faster ambulation and earlier return to daily activities. Reduced pain and fewer discharges likely improve patient satisfaction. Although hospital stay was shorter in VC patients in this study, this discrepancy could be influenced by institutional discharge protocols rather than clinical outcomes. The strengths of this study include its randomized design and uniform surgical protocol. However, limitations must be acknowledged: the modest sample size and short follow-up (6 weeks) restrict conclusions on rare or long-term outcomes such as vault prolapse, chronic granulation, or sexual function. Larger multicenter studies with extended follow-up are required to confirm these findings.

Vault non-closure in total laparoscopic hysterectomy offers advantages of reduced operative time, less postoperative pain, and fewer complications such as hematoma and discharge, without compromising healing. While vault closure remains common practice, these findings support selective use of non-closure, especially in uncomplicated cases with good hemostasis. Future multicentric studies with larger sample size should evaluate long-term outcomes to establish definitive guidelines.

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