Laparoscopic hysterectomy using various energy sources in swine: a histopathologic assessment

Vaginal Cuff Dehiscence: Two Case Reports and a Review of the Literature

Vaginal cuff dehiscence (VCD) is a rare but serious condition associated with high morbidity, especially in the presence of an evisceration. It usually occurs as a complication of hysterectomy, but has also been reported after other pelvic surgeries. In this article, we will present two cases of vaginal cuff dehiscence with evisceration in post-menopausal patients. Both cases occurred post-operatively, the first after a laparoscopic radical hysterectomy and the other after a trachelectomy performed by robotic-assisted laparoscopy (with a prior history of subtotal hysterectomy). Both cases were treated surgically, the first by a combined laparoscopic and vaginal approach, and the second case only by laparoscopic approach. The main risk and protective factors are discussed in a narrative literature review which summarizes the available evidence on this rare condition, discussed by type of study designs and thus evidence level. A laparoscopic vaginal cuff closure is the most protective factor in preventing VCD, compared to a vaginal closure. Clinicians should be aware of this condition and of its risk factors and precipitating events in order to identify high-risk patients. Knowledge of these allows prompt recognition, which is crucial for adequate management, for which multiple approaches have been described.

Comparison of the Thermal Spread of Three Different Electrosurgical Generators on Rat Uterus: A Preliminary Experimental Study

BACKGROUND/AIMS

The objective of this study was to compare the depth and width of thermal spread caused on rat uterine tissue after application of 3 different electrosurgical generators.

METHODS

Alsa Excell 350 MCDSe (Unit A), Meditom DT-400P (Unit M), and ERBE Erbotom VIO 300 D (Unit E) electrosurgical units (ESUs) were used. The number of Wistar Hannover rats required to obtain valid results was 10. The primary objective of the study was to compare the 3 ESUs using the same instrument and the same waveform. The secondary objective of the study was to compare the differences between monopolar and bipolar systems of each ESU separately using the same waveform.

RESULTS

The thermal spread caused by each ESU using monopolar instruments with continuous and interrupted waveforms was significantly different. Among the 3 devices, Unit A caused the largest thermal uterine tissue spread. On the other hand, Unit E caused the most superficial thermal tissue spread, and the smallest thermal spread among all ESUs.

CONCLUSIONS

Surgeons should note that different ESUs used with the same power output might create different thermal effects especially in the monopolar configuration within the same waveform, for the same duration, and with the same instrument.

Comparing two Uterine Manipulators During Total Laparoscopic Hysterectomy: A Randomized Controlled Trial

STUDY OBJECTIVE

To compare 2 different types of uterine manipulators (i.e., tight fitting vs loose fitting) used for total laparoscopic hysterectomy (TLH).

DESIGN

A randomized controlled trial. The primary end points were time for colpotomy, time from skin incision to detachment of the uterus, and histologic assessment of thermal damage to the vagina (Canadian Task Force classification I).

SETTING

A university teaching hospital.

PATIENTS

All consecutive women scheduled for TLH from May 2014 to December 2015. Patients were excluded if pregnancy or malignancy was suspected or uterine size exceeded 20 weeks' gestation.

INTERVENTIONS

Patients were randomized to undergo TLH with 1 of the following uterine manipulators: (1) Colpo-Probe Vaginal Fornix Delineator (Cooper Surgical, Inc, Trumbull, CT) or (2) Hohl manipulator (KARL STORZ AG, Tuttlingen, Germany).

MEASUREMENTS AND MAIN RESULTS

A total of 91 patients, 49 in the Hohl manipulator group and 42 in the Colpo-Probe group, were included in the final analysis. There was no difference in patient characteristics, uterine weight, or estimated blood loss. The median time for insertion of the manipulator (2 minutes [interquartile range (IQR), 2-5 minutes] vs 6 minutes [IQR, 5-7], p < .001), the median time from skin incision to detachment of the uterus (55 minutes [IQR, 41-70] vs 65 minutes [IQR, 58-79], p = .004), and the median time for colpotomy (7 minutes [IQR, 5-10] vs 12 [IQR, 8-17], p < .001) were shorter with the Hohl manipulator. Thermal damage to the vagina varied greatly and ranged from 32 μm to 5232 μm but was not significantly different between groups (median maximum thermal damage = 1043 μm [IQR, 682-1934] vs 1522 μm [IQR, 884-2144], p = .211).

CONCLUSION

Use of the Hohl manipulator results in a shorter operative time from skin incision to detachment of the uterus during TLH. Although the colpotomy time is shorter using the Hohl manipulator, this did not translate to less thermal damage to the vaginal cuff. Further studies comparing uterine manipulators are warranted to find the optimal instrument for ease of surgery and decreased thermal spread.

Retrospective Cohort Study Comparing Redo Operations Using Ferromagnetic Dissection and Conventional Monopolar Dissection

Purpose To evaluate effectiveness of a novel hemostatic dissection tool in patients with congenital heart disease undergoing redo pericardiac dissections. Description This dissection tool employs ferromagnetic energy to cut and coagulate. The unit passes no electric current through the patient, thus eliminating cautery-induced dysrhythmias and electrical interference. Ferromagnetic dissection is precise and reduces thermal injury spread by as much as 90%. Evaluation We case matched 22 patients undergoing reoperation for congenital heart surgery by weight/operation. Group 1 used the ferromagnetic tool, and Group 2 used conventional monopolar cautery for pericardiac dissection. For groups 1 and 2, the mean weight was 27.7 and 28.4, respectively (P = .87). Time (minutes) from skin incision to cardiopulmonary bypass was 71 versus 72 (P = .44), cardiopulmonary bypass (minutes) was 75.6 versus 73.6 (P = .42), total operative time (minutes) was 193 versus 201 (P = .34). Chest tube output/kilogram in first 6 and first 24 hours was 0.4 versus 1.3 (P = .02) and 0.8 versus 2.4 (P = .01) for groups 1 and 2, respectively. Re-exploration for bleeding was 0% versus 9% (P = .07). There was no mortality. Conclusion The ferromagnetic dissection system appears safe and efficacious. Bleeding was significantly decreased and the need for re-exploration reduced.

Clinical utility of a novel ultrasonic vessel sealing device in transecting and sealing large vessels during laparoscopic hysterectomy using advanced hemostasis mode

OBJECTIVE(S)

The ultrasonic advanced energy study device (AH device) is the first surgical device indicated to seal vessels up to and including 7mm using ultrasonic technology alone. This study assesses clinical experience during total laparoscopic hysterectomy (TLH) using advanced hemostasis mode (AHM).

STUDY DESIGN

This was a prospective, non-randomized, single arm, multicenter, observational study which did not modify or influence current surgeon technique for elective TLH for benign disease. Each surgeon assessed hemostasis, defined as the hemostatic transection of the uterine vasculature (left/right) with at least one use of the AH device in AHM without the use of additional hemostatic measures other than the AH device. Patients were followed for 4-6 weeks after surgery. Vessel sealing performance was quantitatively assessed for transection and sealing of the uterine artery (UA), the uterine pedicle (UP; defined as cases where the UA could not be 'isolated') and the ovarian pedicle (OP) (when indicated). Adverse events (AEs) related to the AH device or procedures were collected.

RESULTS

Forty patients underwent the procedure. Mean age was 49 years and mean body mass index was 28kg/m(2). Mean surgical duration was 88min. None required conversion to open procedure. Using only the AH device, hemostasis was achieved and maintained in 119 (94.4%) transections (both left and right sides of the UA/UP and OP). Additional hemostasis was achieved in 5 patients using conventional bipolar (4) or monopolar (1) energy. No patient required a blood transfusion postoperatively. Only one adverse event of pain was considered to be related to the use of the ultrasonic AH device during this study.

CONCLUSION

These results support that the AH device with its AHM has clinical utility in sealing named vessels in TLH. The new algorithm to deliver energy in the AHM has the potential to reduce the need for additional hemostatic devices or products as well as the potential to reduce the need for multiple instrument changes during surgery.

The effect of increased experience on complications in robotic hysterectomy for malignant and benign gynecological disease

The study objective was to assess the effect of increased experience on complications in robotic hysterectomy for malignant and benign gynecological disease. This is a retrospective cohort study. It is a Canadian Task Force classification II-2 study conducted at the University Hospital, Sweden. The patients were 949 women planned for robotic hysterectomy for malignant (75 %) and benign (25 %) gynecological disease between October 2005 and December 2013. They were continuously evaluated for the rate of intraoperative and postoperative complications up to 1-year post-surgery, the latter according to Clavien-Dindo classification following the introduction of robotic surgery with special awareness of complications possibly related to robot-specific risk factors, the description of refinement of practice and assessment of the effect of these measures. The rate of intraoperative complications, the overall rate of complications and the rate of ≥grade 3 complications decreased from the first to the last time period (4.8 vs 2.6 %, p = 0.037, 34 vs 19 %, p = 0.003 and 13.5 vs 3.2 %, p = 0.0003, respectively). The rate of intraoperative complications and the rate of postoperative complications possibly related to robot-specific risk factors was reduced from the first to the last time period (3.8 vs 0.6 %, p = 0.028 and 7.7 vs 1.5 %, p = 0.003, respectively). In patients undergoing robotic hysterectomy for malignant and benign gynecological disease intraoperative and postoperative complications and complications possibly related to the robotic approach diminish with training, experience and refinement of practice.

Ultrasonic thermal damage during robotic hysterectomy

Application of energy in minimally invasive hysterectomy creates thermal injury which may increase vaginal cuff dehiscence. The purpose of this study was to compare vaginal tissue damage in a swine model between the two power settings of ultrasonic energy. This was an IACUC-approved, prospective, single-blinded study analyzing energy-induced damage to the swine vagina during robotic hysterectomy. Multiple colpotomy transections were performed on 18 animals using robotic ultrasonic energy, the exact same platform used in human surgery. Specimens (n = 72) were analyzed by a veterinary pathologist blinded to the energy source. Thermal injury was microscopically measured. Mean thermal injury (µm) was not statistically different between Max-Setting 5 and Min-Setting 3 (1243 ± 544 vs. 1293 ± 554; 95 % CI -310 to 210, p = 0.66). Time (s) to complete transection was significantly shorter when using Setting 5 (13.00 ± 7.75 vs. 17.92 ± 9.03; 95 % CI -4.92 to -8.88, p = 0.001). The rate of injury (µm/s) for Setting 5 also trended toward being higher (118.98 ± 72.81 vs. 93.03 ± 62.34; 95 % CI -5.91 to 57.81, p = 0.053). In these swine vaginal specimens, energy-induced tissue damage was not statistically different for the two ultrasonic power settings. Max-Setting 5 was faster and trended toward a higher rate of damage; this was balanced by equivalent distance of tissue injury compared with Min-Setting 3. In larger human specimens, the use of Max-Setting 5 may be recommended to decrease surgical time as it is faster and causes an equivalent amount of injury to Min-Setting 3.

Pilot laparoscopic ileal cannulation in pigs

Zhang, S. X., Wang, H. B., Zhang, H., Liu, H. F., Zhou, Z. F., Zhang, J. T. and Gao, L. 2014. Pilot laparoscopic ileal cannulation in pigs. Can. J. Anim. Sci. 94: 371–377. Pilot laparoscopic ileal cannulation was performed in eight anesthetized pigs (40.5±1.9 kg) positioned in dorsal recumbency using three portals in the abdomen. The T-shaped ileal cannulation site was located 15 cm anterior to the ileocecal valve on the antimesenteric section of the ileum. A transabdominal suspension suture was placed approximately 3 cm caudal to the ileal cannulation site. A purse-string suture was placed first around the insertion site, and a stab incision was made in the middle of the purse-string suture. The T-shaped cannula was inserted into the ileal lumen through the stab incision, and the purse-string suture was tightened. The T-shaped ileal cannula was pulled out of the abdominal cavity through the exit wound located 3–5 cm lateral and 10–12 cm caudal to the right or left side of the umbilicus. The transabdominal suspension suture was then removed. The T-shaped cannula was secured to the skin with a finger-trap suture. Surgical time and complications were recorded. Repeat laparoscopy was performed 35 d later. No major intraoperative or postoperative complications were encountered. The ileal contents were collected easily. On repeat laparoscopy, firm adhesion between the ileum and the abdominal wall was observed in all pigs, and there was no evidence of digesta leakage or consequential peritonitis.

Unidirectional barbed suture versus interrupted vicryl suture in vaginal cuff healing during robotic-assisted laparoscopic hysterectomy

This study examined the performance of unidirectional barbed suture versus polyglactin 910 with respect to vaginal cuff healing in robotic-assisted total laparoscopic hysterectomy (RATLH). This was a retrospective cohort study of 93 patients who underwent RATLH in a teaching hospital from July 2008 to June 2012. In the first 44 patients, the vaginal cuff was closed by interrupted polyglactin (Vicryl) 2-0 suture. In the following 49 patients, unidirectional barbed suture (V-loc) in a running fashion was used for cuff closure. Patients were seen 2 and 6 weeks postoperatively to evaluate cuff healing. Age, tobacco use, hemoglobin, deliveries, uterine weight, menopause, steroid use, underlying health problems, and concomitant procedures were found not to be significantly different between the two groups. There was one cuff dehiscence in the unidirectional barbed suture group and none in the interrupted polyglactin group (P > 0.05). The mean cuff healing time (8.5 vs. 7.7 weeks), incidence of cuff cellulitis (4.6 vs. 4.1 %), and postoperative bleeding (22.7 vs. 14.3 %) were not statistically significantly different between polyglactin and barbed suture closures, respectively (P > 0.05). However, polyglactin suture was associated with greater presence of granulation tissue than barbed suture (27.3 vs. 8.2 %, odds ratio = 3.34, P < 0.05). Unidirectional barbed suture cases were associated with shorter total operative times (220.2 vs. 272.8 min) and less estimated blood loss (164.8 vs. 274.9 ml); however, cuff closure times were not specifically measured. In our study, unidirectional barbed suture was identified as possibly superior to polyglactin cuff closure because of less observed granulation tissue, shorter operative duration, and lower estimated blood loss. However, there was no statistical difference in cuff healing time, cuff dehiscence, cellulitis, or postoperative bleeding between the two groups. A prospective randomized trial would be necessary to confirm these findings.

Comparative studies of energy sources in gynecologic laparoscopy

Energy sources incorporating "vessel sealing" capabilities are being increasingly used in gynecologic laparoscopic surgery although conventional monopolar and bipolar electrosurgery remain popular. The preference for one device over another is based on a combination of factors, including the surgeon's subjective experience, availability, and cost. Although comparative clinical studies and meta-analyses of laparoscopic energy sources have reported small but statistically significant differences in volumes of blood loss, the clinical significance of such small volumes is questionable. The overall usefulness of the various energy sources available will depend on a number of factors including vessel burst pressure and seal time, lateral thermal spread, and smoke production. Animal studies and laboratory-based trials are useful in providing a controlled environment to investigate such parameters. At present, there is insufficient evidence to support the use of one energy source over another.

Vaginal cuff dehiscence in laparoscopic hysterectomy: influence of various suturing methods of the vaginal vault

Vaginal cuff dehiscence (VCD) is a severe adverse event and occurs more frequently after total laparoscopic hysterectomy (TLH) compared with abdominal and vaginal hysterectomy. The aim of this study is to compare the incidence of VCD after various suturing methods to close the vaginal vault. We conducted a retrospective cohort study. Patients who underwent TLH between January 2004 and May 2011 were enrolled. We compared the incidence of VCD after closure with transvaginal interrupted sutures versus laparoscopic interrupted sutures versus a laparoscopic single-layer running suture. The latter was either bidirectional barbed or a running vicryl suture with clips placed at each end commonly used in transanal endoscopic microsurgery. Three hundred thirty-one TLHs were included. In 75 (22.7 %), the vaginal vault was closed by transvaginal approach; in 90 (27.2 %), by laparoscopic interrupted sutures; and in 166 (50.2 %), by a laparoscopic running suture. Eight VCDs occurred: one (1.3 %) after transvaginal interrupted closure, three (3.3 %) after laparoscopic interrupted suturing and four (2.4 %) after a laparoscopic running suture was used (p = .707). With regard to the incidence of VCD, based on our data, neither a superiority of single-layer laparoscopic closure of the vaginal cuff with an unknotted running suture nor of the transvaginal and the laparoscopic interrupted suturing techniques could be demonstrated. We hypothesise that besides the suturing technique, other causes, such as the type and amount of coagulation used for colpotomy, may play a role in the increased risk of VCD after TLH.