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Medical Journal of Obstetrics and Gynecology

Role of Vasopressin in Total Laparoscopic Hysterectomy-A Randomized Controlled Tria

Research Article | Open Access | Volume 10 | Issue 1

  • 1. Department of Endoscopy, Paul’s Hospital, Centre for Advanced Endoscopy &Infertility, India
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Corresponding Authors
Paul PG, Department of Endoscopy, Paul’s Hospital, Centre for Advanced Endoscopy &Infertility, Kochi, Kerala, India,Tel: 919747551797; Email: drpaulpg@gmail.com
ABSTRACT

Objective: To evaluate the use of intramyometrial vasopressin for reducing blood loss in total laparoscopic hysterectomy (TLH) in cases where the uterus is ≥ 12 weeks size.

Design: A randomized controlled trial was conducted at a tertiary care center over 2.5 years. A total of 110 participants were randomized into Group A (vasopressin), and group B (normal saline), with equal arms.

Materials and Methods: Group A and group B received intramyometrial injection of dilute vasopressin and normal saline, respectively. Estimated blood loss (EBL), and change in the postoperative hemoglobin were evaluated as primary outcomes. Bleeding from the pedicles and myoma spiral site were used to assess the role of vasopressin to maintain a clear surgical field.

Results: The median EBL was 200 mL in group A and 250 mL in group B, the difference not being statistically significant. The mean postoperative Hb was 10.7 g/dL in group A and 10.8g/dL in group B. The occurrence of bleeding at the pedicles was comparable in both groups. There was no bleeding at the myoma spiral site in 89% of patients in the vasopressin group compared to 45% in the control group, and this difference is significant.

Conclusion: There was no significant difference in the blood loss with the use of vasopressin in TLH for a uterine size of > 12 weeks compared to normal saline. Vasopressin helps reduce bleeding from the myoma spiral site used for uterine manipulation.

KEYWORDS
  • Vasopressin
  • Blood loss in laparoscopic hysterectomy
  • Myoma spiral
  • Large uteri

 

CITATION

Paul PG, Shilotri M, Chowdary AK, Degapudi M, Paul G, et al. (2022) Role of Vasopressin in Total Laparoscopic Hysterectomy - A Randomized Controlled Trial. Med J Obstet Gynecol 10(1): 1156.

DISCUSSION

Laparoscopic hysterectomy is the preferred method where an abdominal route is indicated for hysterectomy [15]. Blood loss during laparoscopic hysterectomy is on an average < 230 mL in large uteri [16]. But the blood loss further increases with the duration and the complexity of hysterectomy, especially when the uterus is enlarged [2].There are a few studies on the use of intramyometrial vasopressin during hysterectomy. However, there are no studies on its use in TLH. To our knowledge, this is the first RCT on the use of intramyometrial vasopressin during TLH to reduce bleeding with normal saline as the control group. This study found no difference in the blood loss during TLH for uteri > 12 weeks size between the intramyometrial vasopressin and normal saline groups. Myoma spiral site bleeding, which was used to manipulate the uterus, was significantly lesser in the vasopressin group.

Vasopressin has been shown to reduce blood loss in many gynecological surgeries and is used very commonly [7-10]. It is secreted by the posterior pituitary and mediated via 3 distinct receptors. The V1 receptor is located throughout the vascular tree, but primarily on the capillaries, small arterioles and venules, and smooth muscle throughout the body, including the myometrium [5].The vasoconstrictive effect and increased myometrial contractility may contribute to the effectiveness of  vasopressin as a hemostatic agent in gynecologic surgery. 1 study has shown blood flow to the uterine artery is markedly reduced for 20 minutes [17].

We selected 100 mL of diluted vasopressin (20 U in 200 mL saline), equivalent to 10 U, a safe quantity used in many studies [5]. We preferred to use a larger volume as there is a lesser chance of an accidental intravascular large bolus that can precipitate side effects. A larger volume also allows for some loss of the medication during intramyometrial injection without reducing its effect. We used a similar volume of normal saline as a control so that the tourniquet effect of the fluid would be balanced in both groups.

The site and timing of vasopressin administration also vary in different studies. In the study on LSH by Ghomi et al., vasopressin (20 U in 50 mL saline) was injected into the myometrium after coagulating the uterine pedicles and just before amputating the uterine corpus from the cervix [12]. In the study by Chan et al. vasopressin (5 U in 40 mL saline) was injected in the submucosa circumferentially around the cervix before commencing the vaginal part of the LAVH [11]. In the study describing the use of vasopressin in total abdominal hysterectomy (TAH) by Okin et al., 10 U of vasopressin was injected bilaterally, 1 cm medial to the uterine vessels at the most distal area of the lower uterine segment [9]. In our study, 10 U of vasopressin was injected at the fundus and before beginning the hysterectomy, with the aim of preventing bleeding from the myoma spiral site, pedicles, and during adhesiolysis.

Several methods are used to estimate blood loss during laparoscopic surgery, and all of them are far from perfect. In our study, we estimated blood loss by measuring the suctioned blood and subtracting the fluid volume irrigated. The mean blood loss was 200 mL in the vasopressin group and 250 mL in the control group; however, this difference was not statistically significant. The change in Hb after surgery was also used as an additional parameter. The postoperative Hb was not significantly different between both the groups (10.7 vs. 10.8 g%). This observation is comparable to the studies on LAVH and LSH [11,12]. In contrast, in the studies on the use of vasopressin in TAH and VH, there was a definite reduction in the blood loss [9,10]. In the study on vasopressin in TAH, the reduction in blood loss averaged 280 mL, which was 40 % lesser than that in the placebo group [9]. However, there was no significant difference in the postoperative Hb, which they have not explained. Ascher-Walsh et al. also demonstrated a significant reduction in blood loss of 121 mL with the use of vasopressin in VH, while the change in Hb was not assessed [10].

In this study, we additionally tried to determine whether the use of vasopressin during TLH maintains a clean surgical field and reduces the additional use of suction and coagulation of the surgical site bleeding during dissection. We found that moderate and severe bleeding from the myoma spiral site was significantly lesser in the vasopressin group. The myoma spiral is a beneficial instrument for manipulating an enlarged and distorted uterus and aids optimal visualization of pedicles. The uterine manipulator alone is not effective in such a situation. The myoma spiral site can bleed profusely and obscure the surgical field when changing from 1 port to another. Thus, the use of vasopressin can definitely help to reduce this bleeding. We could not find this observation in any other studies. There was no difference in the bleeding during adhesiolysis in both the groups; however, the number of cases requiring adhesiolysis was less to draw a conclusion.

The total duration of surgery was significantly longer in the vasopressin group compared to the control group (141.1 vs. 123.9 minutes). In comparison, the total operating time did not differ between the vasopressin and control groups in the studies on TAH, VH, LAVH, and LSH [9-12].This discrepancy can be explained by the larger uterus size in the vasopressin group (580 g vs. 480 g), although this difference is not statistically significant. Since the time to reach the uterine pedicles was similar in both the groups, the total operating time was more in the vasopressin group due to the longer time taken for specimen retrieval. However, we did not objectively note the time taken for specimen retrieval as the study was not so planned.

There was a transient rise in systolic BP after the injection of vasopressin. A similar effect was noted in the studies where vasopressin was used in TAH and VH [9,10]. The main concern about the use of vasopressin is the serious cardiac complications. The potential complications are cardiac arrest, myocardial infarction, cardiogenic shock, arrhythmias, pulmonary edema, and life-threatening hypotension.5 There were no such complications in our group. The absence of complications in our study may be explained by the limited number of participants and a low quoted incidence of these complications in other studies. We also used a safe dose of 10 U of vasopressin diluted in a large volume which may have provided a margin of safety.

There were no cases of postoperative infections, cuff cellulitis, or readmissions in our study. An older study showed higher rates of cuff cellulitis with the use of epinephrine in vaginal hysterectomy and attributed it to its vasoconstricting action [18]. But an RCT conducted later did not substantiate this finding [19].

The limitation of our study is the estimation of intraoperative blood loss. In laparoscopic surgery, blood gets collected in the subdiaphragmatic space and the paracolic gutters where it is not possible to suction satisfactorily. The use of irrigation fluid for achieving hemostasis also makes the measurement inaccurate. Postoperative Hb measurement done after 18 hours can be inconsistent as the Hb tends to vary with time and the amount of fluid infusion given during and after surgery.

The strength of our study is that it is an RCT, and the surgeries were performed by a single experienced surgeon in the same institution using a standard technique.

As vasopressin has proven useful in reducing blood loss during TAH and VH, further studies may be needed with a larger sample population to demonstrate its utility in TLH. Alternate methods for reducing blood loss in TLH, especially in cases with large uteri, endometriosis or adhesions, are worth exploring.

ABBREVIATIONS

SD: Standard Deviation; LSCS: Lower-Segment Caesarean Section; TLH: Total Laparoscopic Hysterectomy; RCT: Randomized Controlled Trial; VH: Vaginal Hysterectomy; Hb: Haemoglobin; LAVH: Laparoscopic Assisted Vaginal Hysterectomy; LSH: Laparoscopic Supracervical Hysterectomy; TAH: Total Abdominal Hysterectomy; EBL: Estimated Blood Loss; IQR: Interquartile Range; SNOSE: Serially Numbered Opaque Sealed Envelope

RESULTS

During the study period, the total number of patients who were advised TLH was 738, as shown in Figure 1. Of this, 515 patients were excluded due to a uterine size of < 12 weeks, while 97 patients were excluded due to concomitant medical disorders as described in the exclusion criteria. 16 patients declined to participate in the study. 110 patients who satisfied both the inclusion and exclusion criteria were randomized into 2 groups: group A (vasopressin) and group B (normal saline), containing 55 patients each.

Figure 1 CONSORT Diagram showing the flow of patients in the study.

Figure 1 CONSORT Diagram showing the flow of patients in the study.

Sociodemographic and preoperative characteristics of the study groups (Table 1)

Table 1: Sociodemographic and preoperative characteristics (N=110).

 

 

Vasopressin

Normal saline

 

 

 

N = 55

N = 55

 

p value

 

n

%

n

%

A

Sociodemographic Characteristics

1

Mean (SD) Age, in years

45.2 (4.7)

 

46.3

(4.5)

 

0.208

2

Previous Surgery

 

No

20

36.4

23

41.8

 

0.558

Yes

35

63.6

32

58.2

3

Previous LSCS

 

No

36

65.4

34

61.8

 

0.887

Yes

19

34.6

21

38.2

B

Details of surgery

1

Indication of TLH

 

Myomas

47

85.4

44

80

 

 

0.199

Adenomyosis

3

5.5

8

14.6

Endometriosis

5

9.1

2

3.6

Others (ovarian cysts, endometrial hyperplasia)

0

0

1

1.8

2

Additional procedure

 

No

22

40

25

45.4

 

0.563

Yes

33

60

30

54.5

3

Endometriosis

 

Absent

44

80

47

85.4

 

0.449

Present

11

20

8

14.5

4

Severity of Endometriosis

 

Minimal/Mild

1

9.1

2

25

 

0.302

Moderate

2

18.2

3

37.5

Severe

8

72.7

3

37.5

5

Uterus Size (SD), in weeks

15 (2.6)

 

14.5 (2.4)

 

0.288

6

Preoperative haemoglobin, in g/dL

11.9 (1.3)

 

11.7 (1.1)

1.1

0.379

SD: Standard deviation. LSCS: Lower-segment caesarean section. TLH: Total laparoscopic hysterectomy.

The mean (SD) age of the participants in group A and group B was 45.2 (4.7) years and 46.3 (4.5) years, respectively, and is comparable in both groups. The number of patients who previously underwent any abdominal surgeries was 35 (64%) in group A vs. 32 (58%) in group B. The number of women who underwent cesarean sections was similar in both the study groups (group A: 19 (35%) vs. group B: 21 (38%). All the participants underwent TLH for benign conditions such as myoma uterus, adenomyosis, endometriosis, or additional pathologies like ovarian cysts and endometrial hyperplasia. The distribution of indications for hysterectomy in both groups was comparable. A similarly proportionate number of women underwent additional surgical procedures in both the groups, i.e. 33 in group A (60%) vs. 30 in group B (54. 5%). The overall number of patients who underwent hysterectomy with endometriosis was equivalent in both groups. Both the study groups were similar in terms of the size of the uterus in weeks. The mean preoperative Hb level in group A is 11.9 (1.3) g/dL and 11.7 (1.1) g/dL in group B and was comparable in both the study groups.

Operative and postoperative characteristics of the study groups (Table 2)

Table 2: Operative and postoperative characteristics.

 

 

Vasopressin

Normal saline

 

 

 

Mean

SD

Mean

SD

p value

1

Change in blood pressure (BP), in mm Hg

 

a

Preoperative systolic BP

128.4

14.4

128.9

15.5

0.848

b

Preoperative diastolic BP

86

10.5

84

11.5

0.342

c

Postoperative systolic BP

138

19.1

130.2

16

0.022

d

Postoperative diastolic BP

90

15

86.2

12.2

0.147

2

Suctioned blood, in mL

200

150-400

250

150-400

0.729

3

Postoperative hemoglobin, in g/dL

10.7

1.2

10.8

1

0.731

4

Duration of surgery, in minutes

141.1

48.80

123.9

31.9

0.031

5

Time to reach uterine pedicles in minutes

33

12.3

33.9

12.1

0.708

6

Number of intraoperative complications

0

 

0

 

 

7

Number of Postoperative complications

1

 

2

 

0.558

8

Duration of hospital stay

1

0.10

1

0.2

0.5625

9

Weight of specimen, in grams

580

350 -750

480

300 -800

0.471

SD:Standard deviation.

.The mean (SD) systolic BP before injecting the drug was 128.4 (14.4) mmHg in group A and 128.9 (15.5) mmHg in group B. After the injection of the drug, we observed a rise in the systolic BP in group A with a mean value of 138 (19.1) mm Hg and this is significantly higher when compared to that in group B 130.2 (16) mm Hg. The diastolic BP was equivalent in both the groups before and after injecting the medication.

The median (IQR) EBL was 200 (150-400) mL in group A and 250 (150-400) mL in group B. Though the blood loss is more in the normal saline group, the difference is not statistically significant. The mean (SD) postoperative Hb was 10.7 (1.2) g/dL in group A and 10.8 (1) g/dL in group B, and there is no significant difference between the study groups. The mean total operative time in group A is 141 (48.8), minutes and 123.9 (31.9) in group B, this difference being statistically significant. The time to reach the uterine pedicle is 33.1 minutes in the vasopressin group (group A) and 33.9 minutes in the control group (group B). The uterine specimen weighed 580 g in the vasopressin group and 480 g in the normal saline group, the difference not being statistically significant. The mean duration of hospital stay was 1 day in both groups. 1 of the patients in the vasopressin group was transfused 1 unit of packed red cells preoperatively in view of anemia. None of the patients required intraoperative or postoperative blood transfusion. There were no intraoperative complications in either of the study groups. 1 patient in each group developed fever in the immediate postoperative period, which resolved with antibiotics. There was 1 case of urinary tract infection in the normal saline group. 

The assessment of severity of bleeding at various steps during the TLH is described in Table 3. There was no bleeding at the myoma spiral site in 89% (49) patients in the vasopressin group compared to 45% (25) in the control group, and this difference was significant. The occurrence of bleeding and its severity at the pedicles was comparable in both groups; 25 (45.4%) in group A and 31 (56.3 %) in group B. There was no significant difference in bleeding during adhesiolysis in both groups.

Table 3: Assessment of severity of bleeding during TLH.

 

 

n

%

n

%

p value

1

Myoma spiral site bleeding

 

No

49

89.1

25

45.4

 

Moderate bleeding

5

9.1

23

41.8

<0.001

Severe bleeding

1

1.8

7

12.7

0.06

2

Pedicle Bleeding

 

No

30

54.5

24

43.6

 

0.421

Moderate bleeding

19

34.6

25

45.5

Severe bleeding

6

10.9

6

10.9

3

Adhesiolysis

 

No

7

77.80

3

60

 

0.58

Yes

2

22.20

2

40

Moderate bleeding

1

50.00

2

100

 

Severe Bleeding

1

50.00

0

0

 

 

INTRODUCTION

Hysterectomy is the most common major gynecological surgery performed worldwide [1]. Common indications for total laparoscopic hysterectomy (TLH), are leiomyoma, adenomyosis, endometrial hyperplasia, endometriosis, and abnormal uterine bleeding refractory to medical management. Conditions like large uteri, pelvic adhesions, and endometriosis are associated with increased blood loss during TLH [2]. Some of the patients may already be anemic due to heavy menstrual bleeding. It has always been a challenge for gynecologists to reduce blood loss in these situations, and several interventions have been suggested. They include ligation of the uterine artery at the origin before proceeding with the hysterectomy and intraoperative use of vessel-sealing bipolar instruments or ultrasonic devices. Perioperative use of misoprostol, oxytocin, and vasopressin has also been studied [3-5].

Vasopressin has been used in gynecologic surgery for reducing blood loss since the1950s [6].There are many studies supporting the intraoperative administration of vasopressin to minimize blood loss in abdominal and laparoscopic myomectomy as well as in abdominal and vaginal hysterectomy (VH) [7-10]. The studies on laparoscopy-assisted vaginal hysterectomy (LAVH) and laparoscopic supracervical hysterectomy (LSH), using vasopressin for reducing blood loss concluded that the routine use of intramyometrial vasopressin does not reduce blood loss [11,12]. But, to our knowledge, there are no studies on its use in TLH. We thus planned to undertake a randomized controlled trial (RCT), to assess the role of vasopressin in TLH.

The primary aim of our study was to compare the blood loss during TLH with the use of dilute vasopressin versus normal saline in cases where the uterus is ≥ 12 weeks size, with or without endometriosis or adhesions. Intramyometrial vasopressin gives blanching of the uterus, and there is less likelihood of bleeding during dissection. If the surgical field is clear without bleeding, there are fewer instrument changes for suction and coagulation, which can reduce the strain on the surgeon. Lesser the additional steps required to achieve hemostasis, faster is the progress to the uterine pedicles. Thus, the secondary aims were to determine the role of vasopressin in maintaining a clear surgical field, the time taken to reach the uterine pedicles, and the intraoperative/ postoperative complications associated with its use.

MATERIALS AND METHODS

This RCT was conducted at Paul’s Hospital, a tertiary care center, over 2.5 years from October 2017 to April 2020. The study was approved by the institutional review board (Institutional Ethics Committee, Paul’s Hospital, Kochi, Kerala, India approval number IEC-PH-2017-GYN-002 dated 30th September 2017). All women scheduled for elective TLH with or without salpingo- oophorectomy were identified as possible participants for this study.

As there were no RCTs in estimating the mean blood loss in TLH, the sample size for the study was determined using total blood loss as the primary outcome variable as in a study conducted by Asher-Walsh et al., in VH [10]. The mean blood loss in a VH with and without the use of vasopressin was 144 mL and 266 mL, respectively, as observed in this study. With a confidence level of 95% and power of 80%, a sample size of 41 participants in each arm was derived. We recruited 55 participants in each arm to compensate for any dropouts during the study.

Women above 35 years of age with benign gynecological conditions and the uterus enlarged to > 12 weeks size were included in the study. Women with a history of cardiovascular diseases like coronary artery disease, myocardial infarction, cardiomyopathy, uncontrolled hypertension and other conditions like neurological disorders, migraine, asthma, chronic obstructive pulmonary disease, abnormal renal and liver function, any suspected bleeding or coagulation disorders, and history of allergy to vasopressin were excluded from the study. Informed consent was obtained from all the patients who satisfied the inclusion and exclusion criteria. Preoperative assessment was done on an outpatient basis within 7 days of the surgery. Demographic data and clinical history of the patients were recorded. The patients were divided into 2 groups; Group A constituted women who received dilute vasopressin, while Group B constituted women who received normal saline. Serially Numbered Opaque Sealed Envelopes (SNOSE) were created using random number table in Microsoft Excel. Randomization was done at the participant level by the circulating nurse. The nurse would open the envelope in the pre-operative room and would allocate the patient to the right arm. The surgeon and operative staff could not be blinded due to the difficulty in concealing the blanching effect of vasopressin on the uterus.

Operative procedure

General anesthesia was administered in all cases. No other drugs that would affect the circulatory system were administered during surgery. All patients received a prophylactic dose of an antibiotic before surgery. Intermittent pneumatic compression was used as prophylaxis for deep vein thrombosis.

The TLH was performed by a standard 4-port technique described earlier and was uniformly followed in all the cases [13,14].The patient was in Trendelenburg position at an incline of 20 degrees, and intra-abdominal pressure was set at 15 mmHg. Pneumoperitoneum was created by inserting a Veress needle at the umbilicus or Palmer’s point. A 10 mm primary camera port was inserted 3-4 cm above the upper margin of the enlarged uterus. A visual entry technique for primary entry was performed if the patient had any previous laparotomies or if bowel adhesions were suspected. 3 working ports of 5 mm each (1 suprapubic and 2 lateral), were placed 3-4 cm above the line joining the anterior superior iliac spines. A 30-degree telescope was used for the surgery. After the initial inspection of the abdomen, a single intramyometrial injection of 100 mL of either dilute vasopressin solution (20 IU in 200 mL normal saline) or normal saline, using a laparoscopic injection needle, was administered. A myoma spiral was used midline near the fundus along with a manipulator for uterine manipulation in all the cases. Vessel-sealing devices or bipolar diathermy with an ultrasonic device were used for coagulation and division of the pedicles. Opportunistic salpingectomy was performed in all cases when the ovaries were preserved. The specimen was removed vaginally after morcellation with a cold knife. The vaginal cuff was closed vaginally with conventional delayed absorbable or laparoscopically with barbed sutures. Additional procedures, if any, such as cystectomy, pelvic floor repair, appendicectomy, or hernia repair were performed at this stage.

In addition to the routine intraoperative monitoring, the patient’s blood pressure (BP), was recorded at the time of injection and 10 minutes after injection to calculate the change in these parameters. The total suction canister fluid was measured, and estimated blood loss (EBL), during surgery was calculated as EBL = total suction canister fluid volume - irrigated fluid volume. Postoperative hemoglobin (Hb) was measured before discharging the patient (approximately 12-16 hours after surgery). Other parameters such as total operative time, intraoperative and postoperative complications were noted.

We assessed the severity of bleeding at the myoma spiral site, lateral pedicles, during bladder dissection, and adhesiolysis. The severity of bleeding was graded as moderate (controlled by coagulation), and severe bleeding (needs suctioning and coagulation). The time to reach the uterine pedicles was also noted. We did not assess bleeding from the tackling of uterine vessels onwards as the action of vasopressin is not expected to be effective after 20 minutes. This assessment was done by watching all the surgical videos by assistant gynecologists, who were not part of the operative procedures.

Patients were followed up 2-4 weeks after surgery. The data collected from the medical records included information such as age, history of any previous surgeries, indication for the present surgery, any additional procedures done with hysterectomy, the uterine size, uterine weight, presence of endometriosis, the intraoperative change in BP on injection of the drug, change in the postoperative Hb, perioperative blood transfusion, the length of hospital stay and complications such as postoperative fever, if any.

Statistical analysis

The data retrieved from the records was entered in Microsoft Excel. Continuous variables like age, BP, and Hb levels were summarized as mean with standard deviation (SD). Other independent variables such as clinical details of the participants like any history of previous surgery, indication of surgery, any 

additional procedures undertaken, etc. were summarized as frequency with proportions. The independent variables were compared across the 2 study groups using unpaired t-test or Mann-Whitney U test (for continuous data) and Chi-square or Fisher’s exact test (for proportions).

EBL followed a non-normal distribution and hence was summarized as median with its interquartile range (IQR) and compared using Mann-Whitney U Test between the study groups. The duration of surgery and time to reach the uterine pedicles were summarized as mean with SD and compared using the unpaired t-test. Presence of bleeding from the pedicles and myoma spiral site was summarized as proportions and compared between the 2 groups using the Chi-square test. Analysis was performed using Stata version 14.0 developed by StataCorp, 2015. A p-value less than 0.05 was considered significant throughout the study.

ACKNOWLEDGEMENTS

We thank Dr. Sharan Murali, Consultant (Medical), India EIS Training Programme, NIE - ICMR, Chennai for his invaluable help with the statistical analysis.

CONCLUSION

Our RCT on the use of vasopressin in TLH for a uterine size of >12 weeks did not find any significant difference in the blood loss compared to normal saline. There were no untoward events with the use of dilute vasopressin in this study. Vasopressin helps reduce bleeding from the myoma spiral site used for uterine manipulation during TLH.

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Paul PG, Shilotri M, Chowdary AK, Degapudi M, Paul G, et al. (2022) Role of Vasopressin in Total Laparoscopic Hysterectomy - A Randomized Controlled Trial. Med J Obstet Gynecol 10(1): 1156.

Received : 23 Jan 2022
Accepted : 10 Feb 2022
Published : 13 Feb 2022
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JSM Schizophrenia
Launched : 2016
Journal of Nausea
Launched : 2020
JSM Internal Medicine
Launched : 2016
JSM Hepatitis
Launched : 2016
JSM Oro Facial Surgeries
ISSN : 2578-3211
Launched : 2016
Journal of Human Nutrition and Food Science
ISSN : 2333-6706
Launched : 2013
JSM Regenerative Medicine and Bioengineering
ISSN : 2379-0490
Launched : 2013
JSM Spine
ISSN : 2578-3181
Launched : 2016
Archives of Palliative Care
ISSN : 2573-1165
Launched : 2016
JSM Nutritional Disorders
ISSN : 2578-3203
Launched : 2017
Annals of Neurodegenerative Disorders
ISSN : 2476-2032
Launched : 2016
Journal of Fever
ISSN : 2641-7782
Launched : 2017
JSM Bone Marrow Research
ISSN : 2578-3351
Launched : 2016
JSM Mathematics and Statistics
ISSN : 2578-3173
Launched : 2014
Journal of Autoimmunity and Research
ISSN : 2573-1173
Launched : 2014
JSM Arthritis
ISSN : 2475-9155
Launched : 2016
JSM Head and Neck Cancer-Cases and Reviews
ISSN : 2573-1610
Launched : 2016
JSM General Surgery Cases and Images
ISSN : 2573-1564
Launched : 2016
JSM Anatomy and Physiology
ISSN : 2573-1262
Launched : 2016
JSM Dental Surgery
ISSN : 2573-1548
Launched : 2016
Annals of Emergency Surgery
ISSN : 2573-1017
Launched : 2016
Annals of Mens Health and Wellness
ISSN : 2641-7707
Launched : 2017
Journal of Preventive Medicine and Health Care
ISSN : 2576-0084
Launched : 2018
Journal of Chronic Diseases and Management
ISSN : 2573-1300
Launched : 2016
Annals of Vaccines and Immunization
ISSN : 2378-9379
Launched : 2014
JSM Heart Surgery Cases and Images
ISSN : 2578-3157
Launched : 2016
Annals of Reproductive Medicine and Treatment
ISSN : 2573-1092
Launched : 2016
JSM Brain Science
ISSN : 2573-1289
Launched : 2016
JSM Biomarkers
ISSN : 2578-3815
Launched : 2014
JSM Biology
ISSN : 2475-9392
Launched : 2016
Archives of Stem Cell and Research
ISSN : 2578-3580
Launched : 2014
Annals of Clinical and Medical Microbiology
ISSN : 2578-3629
Launched : 2014
JSM Pediatric Surgery
ISSN : 2578-3149
Launched : 2017
Journal of Memory Disorder and Rehabilitation
ISSN : 2578-319X
Launched : 2016
JSM Tropical Medicine and Research
ISSN : 2578-3165
Launched : 2016
JSM Head and Face Medicine
ISSN : 2578-3793
Launched : 2016
JSM Cardiothoracic Surgery
ISSN : 2573-1297
Launched : 2016
JSM Bone and Joint Diseases
ISSN : 2578-3351
Launched : 2017
JSM Bioavailability and Bioequivalence
ISSN : 2641-7812
Launched : 2017
JSM Atherosclerosis
ISSN : 2573-1270
Launched : 2016
Journal of Genitourinary Disorders
ISSN : 2641-7790
Launched : 2017
Journal of Fractures and Sprains
ISSN : 2578-3831
Launched : 2016
Journal of Autism and Epilepsy
ISSN : 2641-7774
Launched : 2016
Annals of Marine Biology and Research
ISSN : 2573-105X
Launched : 2014
JSM Health Education & Primary Health Care
ISSN : 2578-3777
Launched : 2016
JSM Communication Disorders
ISSN : 2578-3807
Launched : 2016
Annals of Musculoskeletal Disorders
ISSN : 2578-3599
Launched : 2016
Annals of Virology and Research
ISSN : 2573-1122
Launched : 2014
JSM Renal Medicine
ISSN : 2573-1637
Launched : 2016
Journal of Muscle Health
ISSN : 2578-3823
Launched : 2016
JSM Genetics and Genomics
ISSN : 2334-1823
Launched : 2013
JSM Anxiety and Depression
ISSN : 2475-9139
Launched : 2016
Clinical Journal of Heart Diseases
ISSN : 2641-7766
Launched : 2016
Annals of Medicinal Chemistry and Research
ISSN : 2378-9336
Launched : 2014
JSM Pain and Management
ISSN : 2578-3378
Launched : 2016
JSM Women's Health
ISSN : 2578-3696
Launched : 2016
Clinical Research in HIV or AIDS
ISSN : 2374-0094
Launched : 2013
Journal of Endocrinology, Diabetes and Obesity
ISSN : 2333-6692
Launched : 2013
Journal of Substance Abuse and Alcoholism
ISSN : 2373-9363
Launched : 2013
JSM Neurosurgery and Spine
ISSN : 2373-9479
Launched : 2013
Journal of Liver and Clinical Research
ISSN : 2379-0830
Launched : 2014
Journal of Drug Design and Research
ISSN : 2379-089X
Launched : 2014
JSM Clinical Oncology and Research
ISSN : 2373-938X
Launched : 2013
JSM Bioinformatics, Genomics and Proteomics
ISSN : 2576-1102
Launched : 2014
JSM Chemistry
ISSN : 2334-1831
Launched : 2013
Journal of Trauma and Care
ISSN : 2573-1246
Launched : 2014
JSM Surgical Oncology and Research
ISSN : 2578-3688
Launched : 2016
Annals of Food Processing and Preservation
ISSN : 2573-1033
Launched : 2016
Journal of Radiology and Radiation Therapy
ISSN : 2333-7095
Launched : 2013
JSM Physical Medicine and Rehabilitation
ISSN : 2578-3572
Launched : 2016
Annals of Clinical Pathology
ISSN : 2373-9282
Launched : 2013
Annals of Cardiovascular Diseases
ISSN : 2641-7731
Launched : 2016
Journal of Behavior
ISSN : 2576-0076
Launched : 2016
Annals of Clinical and Experimental Metabolism
ISSN : 2572-2492
Launched : 2016
Clinical Research in Infectious Diseases
ISSN : 2379-0636
Launched : 2013
JSM Microbiology
ISSN : 2333-6455
Launched : 2013
Journal of Urology and Research
ISSN : 2379-951X
Launched : 2014
Journal of Family Medicine and Community Health
ISSN : 2379-0547
Launched : 2013
Annals of Pregnancy and Care
ISSN : 2578-336X
Launched : 2017
JSM Cell and Developmental Biology
ISSN : 2379-061X
Launched : 2013
Annals of Aquaculture and Research
ISSN : 2379-0881
Launched : 2014
Clinical Research in Pulmonology
ISSN : 2333-6625
Launched : 2013
Journal of Immunology and Clinical Research
ISSN : 2333-6714
Launched : 2013
Annals of Forensic Research and Analysis
ISSN : 2378-9476
Launched : 2014
JSM Biochemistry and Molecular Biology
ISSN : 2333-7109
Launched : 2013
Annals of Breast Cancer Research
ISSN : 2641-7685
Launched : 2016
Annals of Gerontology and Geriatric Research
ISSN : 2378-9409
Launched : 2014
Journal of Sleep Medicine and Disorders
ISSN : 2379-0822
Launched : 2014
JSM Burns and Trauma
ISSN : 2475-9406
Launched : 2016
Chemical Engineering and Process Techniques
ISSN : 2333-6633
Launched : 2013
Annals of Clinical Cytology and Pathology
ISSN : 2475-9430
Launched : 2014
JSM Allergy and Asthma
ISSN : 2573-1254
Launched : 2016
Journal of Neurological Disorders and Stroke
ISSN : 2334-2307
Launched : 2013
Annals of Sports Medicine and Research
ISSN : 2379-0571
Launched : 2014
JSM Sexual Medicine
ISSN : 2578-3718
Launched : 2016
Annals of Vascular Medicine and Research
ISSN : 2378-9344
Launched : 2014
JSM Biotechnology and Biomedical Engineering
ISSN : 2333-7117
Launched : 2013
Journal of Hematology and Transfusion
ISSN : 2333-6684
Launched : 2013
JSM Environmental Science and Ecology
ISSN : 2333-7141
Launched : 2013
Journal of Cardiology and Clinical Research
ISSN : 2333-6676
Launched : 2013
JSM Nanotechnology and Nanomedicine
ISSN : 2334-1815
Launched : 2013
Journal of Ear, Nose and Throat Disorders
ISSN : 2475-9473
Launched : 2016
JSM Ophthalmology
ISSN : 2333-6447
Launched : 2013
Journal of Pharmacology and Clinical Toxicology
ISSN : 2333-7079
Launched : 2013
Annals of Psychiatry and Mental Health
ISSN : 2374-0124
Launched : 2013
Annals of Pediatrics and Child Health
ISSN : 2373-9312
Launched : 2013
JSM Clinical Pharmaceutics
ISSN : 2379-9498
Launched : 2014
JSM Foot and Ankle
ISSN : 2475-9112
Launched : 2016
JSM Alzheimer's Disease and Related Dementia
ISSN : 2378-9565
Launched : 2014
Journal of Addiction Medicine and Therapy
ISSN : 2333-665X
Launched : 2013
Journal of Veterinary Medicine and Research
ISSN : 2378-931X
Launched : 2013
Annals of Public Health and Research
ISSN : 2378-9328
Launched : 2014
Annals of Orthopedics and Rheumatology
ISSN : 2373-9290
Launched : 2013
Journal of Clinical Nephrology and Research
ISSN : 2379-0652
Launched : 2014
Annals of Community Medicine and Practice
ISSN : 2475-9465
Launched : 2014
Annals of Biometrics and Biostatistics
ISSN : 2374-0116
Launched : 2013
JSM Clinical Case Reports
ISSN : 2373-9819
Launched : 2013
Journal of Cancer Biology and Research
ISSN : 2373-9436
Launched : 2013
Journal of Surgery and Transplantation Science
ISSN : 2379-0911
Launched : 2013
Journal of Dermatology and Clinical Research
ISSN : 2373-9371
Launched : 2013
JSM Gastroenterology and Hepatology
ISSN : 2373-9487
Launched : 2013
Annals of Nursing and Practice
ISSN : 2379-9501
Launched : 2014
JSM Dentistry
ISSN : 2333-7133
Launched : 2013
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