J Clin Gynecol Obstet

Journal of Clinical Gynecology and Obstetrics, ISSN 1927-1271 print, 1927-128X online, Open Access

Article copyright, the authors; Journal compilation copyright, J Clin Gynecol Obstet and Elmer Press Inc

Journal website https://jcgo.elmerpub.com

Original Article

Volume 14, Number 4, December 2025, pages 130-148

Advanced Electrosurgical Bipolar Vessel Sealing to Control Intraoperative Bleeding in Hysterectomy: A Rapid Review and Meta-Analysis

Figure 1. Vaginal hysterectomy comparison of ABVS to conventional sutures: (a) blood loss (ml), (b) operative time (min), (c) length of hospital stay (days). ABVS: advanced electrosurgical bipolar vessel sealing; CI: confidence interval; HK: Hartung-Knapp adjustment; MD: mean difference.

Figure 2. Vaginal hysterectomy comparison of ABVS to conventional sutures: patient-reported pain. CI: confidence interval; HK: Hartung-Knapp adjustment; MD: mean difference.

Figure 3. Laparoscopic hysterectomy comparison of ABVS to conventional EBVS: (a) blood loss (mL), (b) operative time (min), (c) length of hospital stay (days). CI: confidence interval; LAVH: laparoscopically-assisted vaginal hysterectomy; MD: mean difference; SLH: subtotal laparoscopic hysterectomy; TLH: total laparoscopic hysterectomy.

Figure 4. Abdominal hysterectomy comparison of ABVS to conventional suturing: (a) blood loss (mL), (b) operative time (min), (c) length of hospital stay (days), (d) blood transfusion required. For length of hospital stay reported by Dubey, only means for each group and a P value of 0.000 were reported; the MD and standard error were estimated by taking a conservative exact P value of 0.00049. ABVS: advanced electrosurgical bipolar vessel sealing; CI: confidence interval; HK: Hartung-Knapp adjustment; MD: mean difference; RR: risk ratio.

Figure 5. Abdominal hysterectomy comparison of ABVS to conventional suturing: patient-reported pain. CI: confidence interval; SMD: standardized mean difference.

**Table 1.** Inclusion and Exclusion Criteria for Evidence Included in the Review
	Inclusion criteria	Exclusion criteria
Population	People undergoing abdominal, laparoscopic, or vaginal hysterectomy for any indication	People undergoing other gynecological surgery without concurrent hysterectomy
Intervention	Advanced electrosurgical bipolar vessel sealing
Comparison/comparators	Conventional sutures; monopolar electrosurgery; conventional EBVS; other advanced energy systems.
Outcome measures	Blood loss; operative time; complications; length of hospital stay; patient reported pain; required blood transfusion; health-related QoL; resource use; economic outcomes.
Study design	We will prioritize the following study types, in the order listed: 1) Systematic reviews of randomized controlled trials. 2) Randomized controlled trials. 3) Non-randomized comparative trials. 4) Single-arm (no control group) trials that report any relevant outcome. We will only include evidence from “lower priority” sources where this is not reported by a “higher priority” source. This could be because higher priority evidence: 1) Does not cover all relevant populations; 2) Does not compare the technology of interest to all relevant comparators; 3) Does not cover all outcomes of interest; 4) Reports over short-term follow up periods, and longer follow up data is required to facilitate decision making. Where relevant and well-conducted systematic reviews exist, we will use these by: 1) Reporting or adapting their reported outcome measures where these are fully relevant to the scope of our review, and appropriate synthesis methods have been used; 2) Using these reviews as a source of potentially relevant studies where the review cannot be used as a source of outcome data.
Search limits	No date limits. English language only.

Table 1. Inclusion and Exclusion Criteria for Evidence Included in the Review

Inclusion criteria

Exclusion criteria

Population

People undergoing abdominal, laparoscopic, or vaginal hysterectomy for any indication

People undergoing other gynecological surgery without concurrent hysterectomy

Intervention

Advanced electrosurgical bipolar vessel sealing

Comparison/comparators

Conventional sutures; monopolar electrosurgery; conventional EBVS; other advanced energy systems.

Outcome measures

Blood loss; operative time; complications; length of hospital stay; patient reported pain; required blood transfusion; health-related QoL; resource use; economic outcomes.

Study design

We will prioritize the following study types, in the order listed: 1) Systematic reviews of randomized controlled trials.
2) Randomized controlled trials. 3) Non-randomized comparative trials. 4) Single-arm (no control group) trials that report any relevant outcome.
We will only include evidence from “lower priority” sources where this is not reported by a “higher priority” source. This could be because higher priority evidence: 1) Does not cover all relevant populations; 2) Does not compare the technology of interest to all relevant comparators; 3) Does not cover all outcomes of interest; 4) Reports over short-term follow up periods, and longer follow up data is required to facilitate decision making.
Where relevant and well-conducted systematic reviews exist, we will use these by: 1) Reporting or adapting their reported outcome measures where these are fully relevant to the scope of our review, and appropriate synthesis methods have been used; 2) Using these reviews as a source of potentially relevant studies where the review cannot be used as a source of outcome data.

Search limits

No date limits. English language only.

**Table 2.** Outcomes Reported in Included RCTs
Study	Intervention/comparator	Blood loss	Operative time	Length of hospital stay	Patient-reported pain	Blood transfusion (n)
^aP > 0.05; ^bP < 0.05; ^cP < 0.01; ^dP value not reported. ABVS: advanced electrosurgical bipolar vessel sealing; EBVS: electrosurgical bipolar vessel sealing; LAVH: laparoscopically-assisted vaginal hysterectomy; LH: laparoscopic hysterectomy; NR: not reported; OT: operative time; SD: standard deviation; SE: standard error; SLH: subtotal laparoscopic hysterectomy; TLH: total laparoscopic hysterectomy; VAS: visual analogue scale.
Vaginal hysterectomy
Ahmed et al [9] Mean ± SD	Intervention: LigaSure (n = 20) Control: Sutures (n = 20)	Intervention: 315 ± 191.3 mL Control: 592.5 ± 296.2 mL^c	Intervention: 53.95 ± 6.94 min Control: 62.90 ± 7.28 min^c	NR	Evening after surgery: Intervention: 54.50 ± 4.47; Control: 67.20 ± 3.55^c 1 day: Intervention: 46.70 ± 5.68; Control: 59.95 ± 4.52^c 2 days: Intervention: 35.50 ± 6.82; Control: 53.50 ± 5.08^c 6 weeks: Intervention: 11.20 ± 2.12; Control: 10.10 ± 1.48^a	Intervention: 0 Control: 1^a
Ray et al [10] Median (interquartile range)	Intervention: LigaSure (n = 48) Control: Sutures (n = 47)	Intervention: 100 (50 to 200) mL Control: 100 (50 to 150) mL^a	Intervention: 40.5 (29.75 to 52) min Control: 38 (33 to 46) min^a	“4 vs 4.83 h”^d It is not entirely clear within the article which value is for which group. It is assumed the first value is for the intervention group.	0 day: Intervention, n = 45: 49 (25 to 75); Control, n = 46: 50.5 (32.25 to 66.5)^a 1 day: Intervention, n = 42: 40.5 (21.2 to 56.75); Control, n = 44: 42 (20.5 to 64)^a 3 days: Intervention, n = 42: 30.5 (13.75 to 48); Control, n = 44: 40 (13.75 to 67)^a 5 days: Intervention, n = 42: 16.5 (5.25 to 33.75); Control, n = 44: 23 (4 to 40.75)^a 2 weeks: Intervention, n = 35: 2 (0 to 13.5); Control, n = 38: 4 (1 to 10)^a	Intervention: 0 Control: 0^d
Laparoscopic hysterectomy
Ashraf et al [24] Mean ± SD	Intervention: LigaSure (n = 20) Control: UltraCision harmonic shears (n = 20)	NR	Intervention: 64.15 ± 12.02 min Control: 138.25 ± 23.41 min^c	Intervention: 1.65 ± 0.58 days Control: 2.00 ± 1.52 days^a	NR	NR
Batra et al [8] Mean ± SD	Intervention: LigaSure (n = 60) Control: Conventional EBVS (n = 60)	Intervention: 141.67 ± 101.75 mL Control: 145 ± 84.7 mL^a	Primary OT: Intervention: 74.388 ± 11.84 min; Control: 97.0319 ± 13.425 min^c Total OT: Intervention: 136.37 ± 14.35 min; Control: 142.50 (SD not reported) min^c	Intervention: 2.32 ± 0.56 days Control: 2.54 ± 0.988 days^a	NR	NR
Hasabe et al [25] Average	Intervention: LigaSure (n = 30) Controls: harmonic scalpel (n = 30), bipolar shears (n = 30)	NR	Intervention: 54.36 min Harmonic scalpel: 68.25 min Bipolar shears: 59.34 min^d	Intervention: 1.35 days Harmonic scalpel: 1.84 days Bipolar shears: 1.60 days^d	NR	NR
Janssen et al [22] Mean ± SD	Intervention: Ligasure (n = 66) Control: conventional EBVS (n = 65)	All LH: Intervention: 234.1 ± 263 mL; Control: 273.1 ± 329 mL^a TLH: Intervention: 232.6 ± 286 mL; Control: 305.9 ± 375 mL^d LAVH: Intervention: 212.2 ± 133 mL; Control: 220.0 ± 212 mL^d SLH: Intervention: 255.8 ± 257 mL; Control: 202.5 ± 233 mL^d	OT to detachment of uterus All LH: Intervention: 97.6 ± 31.4 min; Control: 91.8 ± 35.4 min^a TLH: Intervention: 92.1 ± 33.8 min; Control: 98.1 ± 38.5 min^d LAVH: Intervention: 105.5 ± 25.3 min; Control: 82.71 ± 28.7 min^d SLH: Intervention: 111.5 ± 21.1 min; Control: 76.4 ± 22.8 min^d Total OT All LH: Intervention: 148.2 ± 43.6 min; Control: 142.1 ± 46.1 min^a TLH: Intervention: 140.3 ± 39.0 min; Control: 147.2 ± 48.7 min^d LAVH: Intervention: 130.9 ± 35.5 min; Control: 120.0 ± 42.9 min^d SLH: Intervention: 190.8 ± 42.5 min; Control: 141.0 ± 29.2 min^d	All LH: Intervention: 2.9 ± 1.3 days; Control: 2.9 ± 1.0 days^a TLH: Intervention: 2.9 ± 1.1 days; Control: 2.8 ± 0.9 days^d LAVH: Intervention: 3.8 ± 2.0 days; Control: 2.8 ± 0.8 days^d SLH: Intervention: 2.1 ± 0.8 days; Control: 3.6 ± 1.8 days^d	NR	NR
Rothmund et al [26]	Intervention: EnSeal (n = 80) Control: conventional EBVS (n = 80)	Less than 50 mL blood loss (n): Intervention: 72; Control: 62^b 50 to 100 mL blood loss (n): Intervention: 8; Control: 18^c	Total OT (mean ± SD): Intervention: 78.18 ± 33.96 min; Control: 86.31 ± 35.35 min^b T1: Intervention: 15.10 ± 5.51 min; Control: 16.21 ± 5.53 min^a T2: Intervention: 24.90 ± 14.80 min; Control: 36.23 ± 25.44 min^c T3: Intervention: 38.00 ± 22.25 min; Control: 33.86 ± 14.12 min^a	Intervention: 2.01 ± 0.44 days Control: 2.17 ± 0.47 days^b	Day 1: Intervention: 3.44 ± 1.62; Control: 3.18 ± 1.71^a Day 2: (n = 154) Intervention (77): 2.03 ± 1.49; Control (77): 1.96 ± 1.38^a Day 3: (n = 25) Intervention (8): 2.13 ± 1.26; Control (17): 1.59 ± 1.58^a	Intervention: 0 Control: 0^d
Rothmund et al [27] Mean ± SD	Intervention: BiCision Control: UltraCision harmonic scalpel n = 30 (self-controlled trial)	Overall intraoperative blood loss score: Intervention: 1.07 ± 0.25; Control: 1.63 ± 0.49^c	Intervention: 8.8 ± 1.8 min Control: 8.3 ± 1.9 min^a	NR	NR	Intervention: 0 Control: 0^d
Taşkin et al [23] Mean ± SD	Intervention: LigaSure (n = 34) Control: conventional EBVS (n = 34)	Intervention: 176.1 ± 78.2 mL Control: 182.3 ± 104.3 mL^a	Intervention: 134.2 ± 29.7 min Control: 163.5 ± 27.7 min^c	Intervention: 1.9 ± 0.9 days Control: 2.1 ± 1.1 days^a	8 h: Intervention: 3.3 ± 1.1; Control: 3.6 ± 0.9^a 24 h: Intervention: 2.1 ± 0.8; Control: 2.1 ± 0.9^a	Intervention: 2 Control: 4^a
Abdominal hysterectomy
Aydin et al [28] Mean ± SD	Intervention: LigaSure (n = 44) Control: Sutures (n = 44)	NR	Intervention: 109.91 ± 26.55 min Control: 124.77 ± 35.51 min^b	Intervention: 5.92 ± 2.63 days Control: 5.95 ± 1.82 days^a	0 h: Intervention: 6.02 ± 1.17; Control: 6.25 ± 1.01^a 24 h: Intervention: 1.07 ± 0.66; Control: 1.93 ± 0.58^a	Intervention: 0 Control: 1^d
Dubey et al [29] Mean ± SD	Intervention: LigaSure (n = 30) Control: Sutures (n = 30)	Intervention: 111 ± 53.31 mL Control: 320 ± 193.90 mL^c	Intervention: 26.97 ± 9.08 min Control: 33.67 ± 8.77 min^c	Intervention: 3.57 days Control: 5.43 days^c (SD NR)	1 day: Intervention: mode 6; Control: mode 8^d 2 days: Intervention: mode 3; Control: mode 6^d 3 days: Intervention: mode 2; Control: mode 3^d	Intervention: 2 Control: 5^d
Hagen et al [30] Mean	Intervention: LigaSure (n = 15) Control: Sutures (n = 15)	Intervention: 303 mL Control: 298 mL^d	Intervention: 61.7 min Control: 54.5 min^d	Intervention: 10 days Control: 6 days^d	NR	NR
Lakeman et al [31] Median (range)	Intervention: LigaSure (n = 28) Control: Sutures (n = 29)	Intervention: 200 (33 to 1,500) mL Control: 335 (70 to 1,750) mL^a	Intervention: 69 (29 to 130) min Control: 63 (38 to 124) min^a	Intervention: 4 (2 to 32) days Control: 5 (3 to 11) days^a	Evening after surgery (mean (SE)): Intervention: 52 (5); Control: 69 (4)^c 1 day (mean (SE)): Intervention: 47 (5); Control: 63 (3)^d 2 days (mean (SE)): Intervention: 36 (4); Control: 49 (4)^d 3 days (mean (SE)): Intervention: 27 (4); Control: 41 (4)^d 4 days (mean (SE)): Intervention: 28 (4); Control: 33 (4)^a 5 days (mean (SE)): Intervention: 20 (3); Control: 31 (4)^d 6 days (mean (SE)): Intervention: 24 (4); Control: 27 (4)^d 7 days (mean (SE)): Intervention: 18 (3); Control: 21 (4)^d 2 weeks (mean (SE)): Intervention: 14 (4); Control: 16 (3)^a 6 weeks (mean (SE)): Intervention: 11 (3); Control: 10 (3)^d	Intervention: 0 Control: 1^d
Mohamed et al [32] Mean ± SD	Intervention: LigaSure (n = 35) Control: Sutures (n = 35)	Intervention: 142.7 ± 23.1 mL Control: 285.7 ± 28.4 mL^c	Intervention: 54.9 ± 6.7 min Control: 63.1 ± 6.6 min^c	Intervention: 0.80 ± 0.93 days Control: 1.0 ± 1.0 days^a	Evening after surgery: Intervention: 54.3 ± 4.8; Control: 68.3 ± 4.0^c 1 day: Intervention: 46.1 ± 4.7; Control: 60.3 ± 5.7^c 2 days: Intervention: 34.1 ± 5.7; Control: 43.0 ± 5.0^c 6 weeks: Intervention: 10.6 ± 2.1; Control: 11.1 ± 1.8^a	NR
Shady et al [33] Mean ± SD	Intervention: LigaSure (n = 45) Control: Sutures (n = 45)	Intraoperative: Intervention: 270.44 ± 51.39 mL; Control: 471.33 ± 54.13 mL^c Postoperative: Intervention: 69.78 ± 14.998 mL; Control: 108.00 ± 26.68 mL^c Total: Intervention: 340.22 ± 56.67 mL; Control: 579.11 ± 70.61 mL^c	Intervention: 61.78 ± 15.71 min Control: 96.29 ± 9.51 min^c	Intervention: 2 (1 to 7) days Control: 3 (2 to 8) days^c Median (range)	4 h: Intervention: 8.49 ± 1.06; Control: 8.76 ± 1.00^a 6 h: Intervention: 6.62 ± 0.96; Control: 8.49 ± 1.06^c 8 h: Intervention: 4.80 ± 0.87; Control: 7.33 ± 0.95^c 12 h: Intervention: 3.71 ± 0.76; Control: 7.02 ± 0.92^c 24 h: Intervention: 1.67 ± 0.798; Control: 5.73 ± 0.94^c	Intervention: 1 Control: 4^a

Table 2. Outcomes Reported in Included RCTs

Study

Intervention/comparator

Blood loss

Operative time

Length of hospital stay

Patient-reported pain

Blood transfusion (n)

^aP > 0.05; ^bP < 0.05; ^cP < 0.01; ^dP value not reported. ABVS: advanced electrosurgical bipolar vessel sealing; EBVS: electrosurgical bipolar vessel sealing; LAVH: laparoscopically-assisted vaginal hysterectomy; LH: laparoscopic hysterectomy; NR: not reported; OT: operative time; SD: standard deviation; SE: standard error; SLH: subtotal laparoscopic hysterectomy; TLH: total laparoscopic hysterectomy; VAS: visual analogue scale.

Vaginal hysterectomy

Ahmed et al [9]
Mean ± SD

Intervention: LigaSure (n = 20)
Control: Sutures (n = 20)

Intervention: 315 ± 191.3 mL
Control: 592.5 ± 296.2 mL^c

Intervention:
53.95 ± 6.94 min
Control:
62.90 ± 7.28 min^c

Evening after surgery:
Intervention: 54.50 ± 4.47;
Control: 67.20 ± 3.55^c
1 day:
Intervention: 46.70 ± 5.68;
Control: 59.95 ± 4.52^c
2 days:
Intervention: 35.50 ± 6.82;
Control: 53.50 ± 5.08^c
6 weeks:
Intervention: 11.20 ± 2.12;
Control: 10.10 ± 1.48^a

Intervention: 0
Control: 1^a

Ray et al [10]
Median (interquartile range)

Intervention: LigaSure (n = 48)
Control: Sutures (n = 47)

Intervention: 100 (50 to 200) mL
Control: 100 (50 to 150) mL^a

Intervention:
40.5 (29.75 to 52) min
Control:
38 (33 to 46) min^a

“4 vs 4.83 h”^d
It is not entirely clear within the article which value is for which group. It is assumed the first value is for the intervention group.

0 day:
Intervention, n = 45: 49 (25 to 75);
Control, n = 46: 50.5 (32.25 to 66.5)^a
1 day:
Intervention, n = 42: 40.5 (21.2 to 56.75);
Control, n = 44: 42 (20.5 to 64)^a
3 days:
Intervention, n = 42: 30.5 (13.75 to 48);
Control, n = 44: 40 (13.75 to 67)^a
5 days:
Intervention, n = 42: 16.5 (5.25 to 33.75);
Control, n = 44: 23 (4 to 40.75)^a
2 weeks:
Intervention, n = 35: 2 (0 to 13.5);
Control, n = 38: 4 (1 to 10)^a

Intervention: 0
Control: 0^d

Laparoscopic hysterectomy

Ashraf et al [24]
Mean ± SD

Intervention: LigaSure (n = 20)
Control: UltraCision harmonic shears (n = 20)

Intervention:
64.15 ± 12.02 min
Control:
138.25 ± 23.41 min^c

Intervention: 1.65 ± 0.58 days
Control: 2.00 ± 1.52 days^a

Batra et al [8]
Mean ± SD

Intervention: LigaSure (n = 60)
Control: Conventional EBVS (n = 60)

Intervention: 141.67 ± 101.75 mL
Control: 145 ± 84.7 mL^a

Primary OT:
Intervention:
74.388 ± 11.84 min;
Control:
97.0319 ± 13.425 min^c
Total OT:
Intervention:
136.37 ± 14.35 min;
Control:
142.50 (SD not reported) min^c

Intervention: 2.32 ± 0.56 days
Control: 2.54 ± 0.988 days^a

Hasabe et al [25]
Average

Intervention: LigaSure (n = 30)
Controls: harmonic scalpel (n = 30), bipolar shears (n = 30)

Intervention: 54.36 min
Harmonic scalpel: 68.25 min
Bipolar shears: 59.34 min^d

Intervention: 1.35 days
Harmonic scalpel: 1.84 days
Bipolar shears: 1.60 days^d

Janssen et al [22]
Mean ± SD

Intervention: Ligasure (n = 66)
Control: conventional EBVS (n = 65)

All LH:
Intervention: 234.1 ± 263 mL;
Control: 273.1 ± 329 mL^a
TLH:
Intervention: 232.6 ± 286 mL;
Control: 305.9 ± 375 mL^d
LAVH:
Intervention: 212.2 ± 133 mL;
Control: 220.0 ± 212 mL^d
SLH:
Intervention: 255.8 ± 257 mL;
Control: 202.5 ± 233 mL^d

OT to detachment of uterus
All LH:
Intervention: 97.6 ± 31.4 min; Control: 91.8 ± 35.4 min^a
TLH:
Intervention: 92.1 ± 33.8 min; Control: 98.1 ± 38.5 min^d
LAVH:
Intervention: 105.5 ± 25.3 min; Control: 82.71 ± 28.7 min^d
SLH:
Intervention: 111.5 ± 21.1 min; Control: 76.4 ± 22.8 min^d
Total OT
All LH:
Intervention: 148.2 ± 43.6 min; Control: 142.1 ± 46.1 min^a
TLH:
Intervention: 140.3 ± 39.0 min; Control: 147.2 ± 48.7 min^d
LAVH:
Intervention: 130.9 ± 35.5 min; Control: 120.0 ± 42.9 min^d
SLH:
Intervention: 190.8 ± 42.5 min; Control: 141.0 ± 29.2 min^d

All LH:
Intervention: 2.9 ± 1.3 days;
Control: 2.9 ± 1.0 days^a
TLH:
Intervention: 2.9 ± 1.1 days;
Control: 2.8 ± 0.9 days^d
LAVH:
Intervention: 3.8 ± 2.0 days;
Control: 2.8 ± 0.8 days^d
SLH:
Intervention: 2.1 ± 0.8 days;
Control: 3.6 ± 1.8 days^d

Rothmund et al [26]

Intervention: EnSeal (n = 80)
Control: conventional EBVS (n = 80)

Less than 50 mL blood loss (n):
Intervention: 72; Control: 62^b
50 to 100 mL blood loss (n):
Intervention: 8; Control: 18^c

Total OT (mean ± SD):
Intervention: 78.18 ± 33.96 min; Control: 86.31 ± 35.35 min^b
T1:
Intervention: 15.10 ± 5.51 min; Control: 16.21 ± 5.53 min^a
T2:
Intervention: 24.90 ± 14.80 min; Control: 36.23 ± 25.44 min^c
T3:
Intervention: 38.00 ± 22.25 min; Control: 33.86 ± 14.12 min^a

Intervention: 2.01 ± 0.44 days
Control: 2.17 ± 0.47 days^b

Day 1:
Intervention: 3.44 ± 1.62; Control: 3.18 ± 1.71^a
Day 2: (n = 154)
Intervention (77): 2.03 ± 1.49; Control (77): 1.96 ± 1.38^a
Day 3: (n = 25)
Intervention (8): 2.13 ± 1.26; Control (17): 1.59 ± 1.58^a

Intervention: 0
Control: 0^d

Rothmund et al [27]
Mean ± SD

Intervention: BiCision
Control: UltraCision harmonic scalpel
n = 30 (self-controlled trial)

Overall intraoperative blood loss score:
Intervention: 1.07 ± 0.25;
Control: 1.63 ± 0.49^c

Intervention: 8.8 ± 1.8 min
Control: 8.3 ± 1.9 min^a

Intervention: 0
Control: 0^d

Taşkin et al [23]
Mean ± SD

Intervention: LigaSure (n = 34)
Control: conventional EBVS (n = 34)

Intervention: 176.1 ± 78.2 mL
Control: 182.3 ± 104.3 mL^a

Intervention: 134.2 ± 29.7 min
Control: 163.5 ± 27.7 min^c

Intervention: 1.9 ± 0.9 days
Control: 2.1 ± 1.1 days^a

8 h:
Intervention: 3.3 ± 1.1;
Control: 3.6 ± 0.9^a
24 h:
Intervention: 2.1 ± 0.8;
Control: 2.1 ± 0.9^a

Intervention: 2
Control: 4^a

Abdominal hysterectomy

Aydin et al [28]
Mean ± SD

Intervention: LigaSure (n = 44)
Control: Sutures (n = 44)

Intervention: 109.91 ± 26.55 min
Control: 124.77 ± 35.51 min^b

Intervention: 5.92 ± 2.63 days
Control: 5.95 ± 1.82 days^a

0 h:
Intervention: 6.02 ± 1.17;
Control: 6.25 ± 1.01^a
24 h:
Intervention: 1.07 ± 0.66;
Control: 1.93 ± 0.58^a

Intervention: 0
Control: 1^d

Dubey et al [29]
Mean ± SD

Intervention: LigaSure (n = 30)
Control: Sutures (n = 30)

Intervention: 111 ± 53.31 mL
Control: 320 ± 193.90 mL^c

Intervention: 26.97 ± 9.08 min
Control: 33.67 ± 8.77 min^c

Intervention: 3.57 days
Control: 5.43 days^c
(SD NR)

1 day:
Intervention: mode 6;
Control: mode 8^d
2 days:
Intervention: mode 3;
Control: mode 6^d
3 days:
Intervention: mode 2;
Control: mode 3^d

Intervention: 2
Control: 5^d

Hagen et al [30]
Mean

Intervention: LigaSure (n = 15)
Control: Sutures (n = 15)

Intervention: 303 mL
Control: 298 mL^d

Intervention: 61.7 min
Control: 54.5 min^d

Intervention: 10 days
Control: 6 days^d

Lakeman et al [31]
Median (range)

Intervention: LigaSure (n = 28)
Control: Sutures (n = 29)

Intervention: 200 (33 to 1,500) mL
Control: 335 (70 to 1,750) mL^a

Intervention: 69 (29 to 130) min
Control: 63 (38 to 124) min^a

Intervention: 4 (2 to 32) days
Control: 5 (3 to 11) days^a

Evening after surgery (mean (SE)):
Intervention: 52 (5); Control: 69 (4)^c
1 day (mean (SE)):
Intervention: 47 (5); Control: 63 (3)^d
2 days (mean (SE)):
Intervention: 36 (4); Control: 49 (4)^d
3 days (mean (SE)):
Intervention: 27 (4); Control: 41 (4)^d
4 days (mean (SE)):
Intervention: 28 (4); Control: 33 (4)^a
5 days (mean (SE)):
Intervention: 20 (3); Control: 31 (4)^d
6 days (mean (SE)):
Intervention: 24 (4); Control: 27 (4)^d
7 days (mean (SE)):
Intervention: 18 (3); Control: 21 (4)^d
2 weeks (mean (SE)):
Intervention: 14 (4); Control: 16 (3)^a
6 weeks (mean (SE)):
Intervention: 11 (3); Control: 10 (3)^d

Intervention: 0
Control: 1^d

Mohamed et al [32]
Mean ± SD

Intervention: LigaSure (n = 35)
Control: Sutures (n = 35)

Intervention: 142.7 ± 23.1 mL
Control: 285.7 ± 28.4 mL^c

Intervention: 54.9 ± 6.7 min
Control: 63.1 ± 6.6 min^c

Intervention: 0.80 ± 0.93 days
Control: 1.0 ± 1.0 days^a

Evening after surgery:
Intervention: 54.3 ± 4.8; Control: 68.3 ± 4.0^c
1 day:
Intervention: 46.1 ± 4.7; Control: 60.3 ± 5.7^c
2 days:
Intervention: 34.1 ± 5.7; Control: 43.0 ± 5.0^c
6 weeks:
Intervention: 10.6 ± 2.1; Control: 11.1 ± 1.8^a

Shady et al [33]
Mean ± SD

Intervention: LigaSure (n = 45)
Control: Sutures (n = 45)

Intraoperative:
Intervention: 270.44 ± 51.39 mL;
Control: 471.33 ± 54.13 mL^c
Postoperative:
Intervention: 69.78 ± 14.998 mL;
Control: 108.00 ± 26.68 mL^c
Total:
Intervention: 340.22 ± 56.67 mL;
Control: 579.11 ± 70.61 mL^c

Intervention: 61.78 ± 15.71 min
Control: 96.29 ± 9.51 min^c

Intervention: 2 (1 to 7) days
Control: 3 (2 to 8) days^c
Median (range)

4 h:
Intervention: 8.49 ± 1.06; Control: 8.76 ± 1.00^a
6 h:
Intervention: 6.62 ± 0.96; Control: 8.49 ± 1.06^c
8 h:
Intervention: 4.80 ± 0.87; Control: 7.33 ± 0.95^c
12 h:
Intervention: 3.71 ± 0.76; Control: 7.02 ± 0.92^c
24 h:
Intervention: 1.67 ± 0.798; Control: 5.73 ± 0.94^c

Intervention: 1
Control: 4^a

**Table 3.** Summary of the Included Economic Study
Study details	Study population and design	Data sources	Results	Quality assessment
ABVS: advanced electrosurgical bipolar vessel sealing; PSSRU: Personal Social Services Research Unit; PASA: Purchasing and Supply Agency.
Author and year: Peirce 2007 [21] Country: UK Type of economic analysis: cost-consequence analysis Perspective: NHS perspective Currency: £ GBP Price year: 2007 Time horizon: immediate surgical period only Discounting: NA Potential conflict of interest: none reported	Population: people undergoing removal of the uterus and ovaries (hysterectomy) for benign conditions carried out vaginally. Intervention: ABVS Comparator: traditional suturing Study design: study collects costs data on ABVS systems and compares this to potential savings in costs associated with hospital stay and sutures, based on expert opinion.	Source of resource use and cost data: costs of the ABVS systems based on costs provided by five manufacturers. Costs per hospital bed per day sourced from PSSRU. Costs of sutures sourced from Cardiff and Vale NHS Trust. Costs of decontamination of ABVS instruments from NHS PASA. Expert opinion (three UK experts) used for estimated length of hospital stay per intervention. Reduction in sutures based on outcomes reported by Cronjé [11].	Base case cost results compared to traditional suturing: BOWA, Arc350L Generator cost: £11,163 Forceps cost per case: £88 ERBE VIO Generator cost: £14,635 Forceps cost per case: £14 Gyrus, PK Generator cost: £9,307 Forceps cost per case: £241 Gyrus, PK SuperPulse Generator cost: £15,884 Forceps cost per case: £241 Gyrus, PK (loan generator) Generator cost: - Forceps cost per case: £241 Valleylab, LigaSure Generator cost: £16,679 Forceps cost per case: £159 Valleylab, LigaSure (loan) Generator cost: - Forceps cost per case: £159 Valleylab, Triad Generator cost: £28,131 Forceps cost per case: £159 Matin, maXium Generator cost: £14,727 Forceps cost per case: £23 Savings in suture costs per case: £10.58 Savings per case if patient stay reduced by: 1 day: £243 2 days: £486 3 days: £729	Applicability: directly applicable Limitations This study has potentially serious limitations: 1) Clinical evidence found large variations in reduced hospital stay with ABVS, ranging from 0 to 5 days; however, statistical significance is not reported. Expert opinion suggested a difference of around 1 - 1.5 days. The cost analysis only evaluated savings associated with between 1 and 3 reduced hospital days. 2) Savings associated with operating times was not included within analysis due to theater schedules being fixed in duration. 3) It is not reported whether the reduced number of sutures in the analysis is based off statistically significant outcomes. 4) Cost per case has not been calculated for the ABVS systems and so it is difficult to quantify if the intervention will be overall cost saving or cost incurring based on the assumptions. 5) No sensitivity or scenario analyses have been undertaken in the analysis.

Table 3. Summary of the Included Economic Study

Study details

Study population and design

Data sources

Results

Quality assessment

ABVS: advanced electrosurgical bipolar vessel sealing; PSSRU: Personal Social Services Research Unit; PASA: Purchasing and Supply Agency.

Author and year: Peirce 2007 [21]
Country: UK
Type of economic analysis: cost-consequence analysis
Perspective: NHS perspective
Currency: £ GBP
Price year: 2007
Time horizon: immediate surgical period only
Discounting: NA
Potential conflict of interest: none reported

Population: people undergoing removal of the uterus and ovaries (hysterectomy) for benign conditions carried out vaginally.
Intervention: ABVS
Comparator: traditional suturing
Study design: study collects costs data on ABVS systems and compares this to potential savings in costs associated with hospital stay and sutures, based on expert opinion.

Source of resource use and cost data: costs of the ABVS systems based on costs provided by five manufacturers.
Costs per hospital bed per day sourced from PSSRU.
Costs of sutures sourced from Cardiff and Vale NHS Trust.
Costs of decontamination of ABVS instruments from NHS PASA.
Expert opinion (three UK experts) used for estimated length of hospital stay per intervention.
Reduction in sutures based on outcomes reported by Cronjé [11].

Base case cost results compared to traditional suturing:
BOWA, Arc350L
Generator cost: £11,163
Forceps cost per case: £88
ERBE VIO
Generator cost: £14,635
Forceps cost per case: £14
Gyrus, PK
Generator cost: £9,307
Forceps cost per case: £241
Gyrus, PK SuperPulse
Generator cost: £15,884
Forceps cost per case: £241
Gyrus, PK (loan generator)
Generator cost: -
Forceps cost per case: £241
Valleylab, LigaSure
Generator cost: £16,679
Forceps cost per case: £159
Valleylab, LigaSure (loan)
Generator cost: -
Forceps cost per case: £159
Valleylab, Triad
Generator cost: £28,131
Forceps cost per case: £159
Matin, maXium
Generator cost: £14,727
Forceps cost per case: £23
Savings in suture costs per case: £10.58
Savings per case if patient stay reduced by:
1 day: £243
2 days: £486
3 days: £729

Applicability: directly applicable
Limitations
This study has potentially serious limitations:
1) Clinical evidence found large variations in reduced hospital stay with ABVS, ranging from 0 to 5 days; however, statistical significance is not reported. Expert opinion suggested a difference of around 1 - 1.5 days. The cost analysis only evaluated savings associated with between 1 and 3 reduced hospital days.
2) Savings associated with operating times was not included within analysis due to theater schedules being fixed in duration.
3) It is not reported whether the reduced number of sutures in the analysis is based off statistically significant outcomes.
4) Cost per case has not been calculated for the ABVS systems and so it is difficult to quantify if the intervention will be overall cost saving or cost incurring based on the assumptions.
5) No sensitivity or scenario analyses have been undertaken in the analysis.