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Porcari I, Zorzato PC, Bosco M, Garzon S, Magni F, Salvatore S, Franchi MP, Uccella S. Clinician perspectives on hysterectomy versus uterine preservation in pelvic organ prolapse surgery: A systematic review and meta-analysis. Int J Gynaecol Obstet 2024; 166:173-189. [PMID: 38269852 DOI: 10.1002/ijgo.15343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2023] [Revised: 12/13/2023] [Accepted: 12/17/2023] [Indexed: 01/26/2024]
Abstract
BACKGROUND Previous reviews on hysterectomy versus uterine-sparing surgery in pelvic organ prolapse (POP) repair did not consider that the open abdominal approach or transvaginal mesh use have been largely abandoned. OBJECTIVES To provide up-to-date evidence by examining only studies investigating techniques currently in use for POP repair. SEARCH STRATEGY MEDLINE and Embase databases were searched from inception to January 2023. SELECTION CRITERIA We included randomized and non-randomized studies comparing surgical procedures for POP with or without concomitant hysterectomy. Studies describing open abdominal approaches or transvaginal mesh implantation were excluded. DATA COLLECTION AND ANALYSIS A random effect meta-analysis was conducted on extracted data reporting pooled mean differences and odds ratios (OR) between groups with 95% confidence intervals (CI). MAIN RESULTS Thirty-eight studies were included. Hysterectomy and uterine-sparing procedures did not differ in reoperation rate (OR 0.93; 95% CI 0.74-1.17), intraoperative major (OR 1.34; 95% CI 0.79-2.26) and minor (OR 1.38; 95% CI 0.79-2.4) complications, postoperative major (OR 1.42; 95% CI 0.85-2.37) and minor (OR 1.18; 95% CI 0.9-1.53) complications, and objective (OR 1.38; 95% CI 0.92-2.07) or subjective (OR 1.23; 95% CI 0.8-1.88) success. Uterine preservation was associated with a shorter operative time (-22.7 min; 95% CI -16.92 to -28.51 min), shorter hospital stay (-0.35 days, 95% CI -0.04 to -0.65 days), and less blood loss (-61.7 mL; 95% CI -31.3 to -92.1 mL). When only studies using a laparoscopic approach for both arms were considered, no differences were observed in investigated outcomes between the two groups. CONCLUSIONS No major differences were observed in POP outcomes between procedures with and without concomitant hysterectomy. The decision to preserve or remove the uterus should be tailored on individual factors.
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Affiliation(s)
- Irene Porcari
- Department of Obstetrics and Gynecology, AOUI Verona, University of Verona, Verona, Italy
| | - Pier Carlo Zorzato
- Department of Obstetrics and Gynecology, AOUI Verona, University of Verona, Verona, Italy
| | - Mariachiara Bosco
- Department of Obstetrics and Gynecology, AOUI Verona, University of Verona, Verona, Italy
| | - Simone Garzon
- Department of Obstetrics and Gynecology, AOUI Verona, University of Verona, Verona, Italy
| | - Francesca Magni
- Department of Obstetrics and Gynecology, AOUI Verona, University of Verona, Verona, Italy
| | - Stefano Salvatore
- Department of Obstetrics and Gynecology, IRCCS San Raffaele Scientific Institute, University Vita and Salute, Milan, Italy
| | - Massimo P Franchi
- Department of Obstetrics and Gynecology, AOUI Verona, University of Verona, Verona, Italy
| | - Stefano Uccella
- Department of Obstetrics and Gynecology, AOUI Verona, University of Verona, Verona, Italy
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Pavone M, Lecointre L, Seeliger B, Oliva R, Akladios C, Querleu D, Scambia G, Marescaux J, Forgione A. The vaginal route for minimally invasive surgery: a practical guide for general surgeons. MINIM INVASIV THER 2024:1-10. [PMID: 38850263 DOI: 10.1080/13645706.2024.2359707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2024] [Accepted: 04/21/2024] [Indexed: 06/10/2024]
Abstract
INTRODUCTION Vaginal approaches have become routine in the field of gynecologic surgery, whereas in general surgery vaginal wall transection is an infrequent practice typically reserved for extensive tumor resections. Approximately two decades ago, natural orifice transluminal endoscopic surgery (NOTES) revolutionized conventional boundaries by accessing the peritoneal cavity transorally, transrectally, or transvaginally, enabling general surgery without visible scars. Although transvaginal approaches have been successfully used for various abdominal procedures by general surgeons, a gap remains in comprehensive training to fully exploit the potential of this route. MATERIAL AND METHODS PubMed, Google Scholar, and Scopus databases were searched to retrieve relevant articles illustrating how general surgeons can adeptly manage vaginal approaches. RESULTS The article presents a practical framework for general surgeons to execute a complete vaginal approach, addressing the management of vaginal specimen extraction and vaginal cuff closure, even in the absence of an experienced gynecologist. CONCLUSION The evolution of abdominal surgery is moving towards less invasive techniques, emphasizing the importance of understanding the nuances and challenges associated with the vaginal route. This approach is linked to minimal oncological, sexual, and infective complications, and to the absence of pregnancy-related complications. Such knowledge becomes increasingly crucial, particularly with the renewed demand for transvaginal access in robot-assisted NOTES procedures.
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Affiliation(s)
- Matteo Pavone
- IRCAD, Research Institute Against Digestive Cancer, Strasbourg, France
- IHU Strasbourg, Institute of Image-Guided Surgery, Strasbourg, France
- Dipartimento di Scienze per la salute della Donna e del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli, IRCCS, UOC Ginecologia Oncologica, Rome, Italy
| | - Lise Lecointre
- IHU Strasbourg, Institute of Image-Guided Surgery, Strasbourg, France
- Department of Gynecologic Surgery, University Hospital of Strasbourg, Strasbourg, France
- ICube, UMR 7357 CNRS, University of Strasbourg, Strasbourg, France
| | - Barbara Seeliger
- IRCAD, Research Institute Against Digestive Cancer, Strasbourg, France
- IHU Strasbourg, Institute of Image-Guided Surgery, Strasbourg, France
- ICube, UMR 7357 CNRS, University of Strasbourg, Strasbourg, France
- Department of Digestive and Endocrine Surgery, University Hospitals of Strasbourg, Strasbourg, France
| | - Riccardo Oliva
- IRCAD, Research Institute Against Digestive Cancer, Strasbourg, France
- Dipartimento di Scienze per la salute della Donna e del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli, IRCCS, UOC Ginecologia Oncologica, Rome, Italy
| | - Cherif Akladios
- Department of Gynecologic Surgery, University Hospital of Strasbourg, Strasbourg, France
| | - Denis Querleu
- IHU Strasbourg, Institute of Image-Guided Surgery, Strasbourg, France
- Dipartimento di Scienze per la salute della Donna e del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli, IRCCS, UOC Ginecologia Oncologica, Rome, Italy
- ICube, UMR 7357 CNRS, University of Strasbourg, Strasbourg, France
| | - Giovanni Scambia
- Dipartimento di Scienze per la salute della Donna e del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli, IRCCS, UOC Ginecologia Oncologica, Rome, Italy
| | - Jacques Marescaux
- IRCAD, Research Institute Against Digestive Cancer, Strasbourg, France
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Uccella S, Casprini C, Bertoli F, Zorzato PC, Garzon S, Galli L. Regarding "Utility of Routine Postoperative Examination for Detecting Vaginal Cuff Dehiscence After Total Laparoscopic Hysterectomy". J Minim Invasive Gynecol 2024; 31:464. [PMID: 38342227 DOI: 10.1016/j.jmig.2024.01.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Accepted: 01/12/2024] [Indexed: 02/13/2024]
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Zorzato PC, Ferrari FA, Garzon S, Franchi M, Cianci S, Laganà AS, Chiantera V, Casarin J, Ghezzi F, Uccella S. Advanced bipolar vessel sealing devices vs conventional bipolar energy in minimally invasive hysterectomy: a systematic review and meta-analysis. Arch Gynecol Obstet 2024; 309:1165-1174. [PMID: 37955717 PMCID: PMC10894136 DOI: 10.1007/s00404-023-07270-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 10/16/2023] [Indexed: 11/14/2023]
Abstract
PURPOSE To compare conventional bipolar electrosurgery with advanced bipolar vessel sealing (ABVS) devices for total laparoscopic hysterectomy (TLH). METHODS A systematic review was conducted by searching Scopus, PubMed/MEDLINE, ScienceDirect, and Cochrane Library from January 1989 to November 2021. We identified all studies comparing ABVS devices with conventional bipolar electrosurgery in TLH and reporting at least one of the following outcomes: total blood loss, total operative time, hospital stay, perioperative complications, or costs. Meta-analysis was conducted with a random effect model reporting pooled mean differences and odds ratios (ORs) with related 95% confidence intervals (CIs). RESULTS Two randomized controlled trials and two retrospective studies encompassing 314 patients were included out of 615 manuscripts. The pooled estimated total blood loss in the ABVS devices group was lower than conventional bipolar electrosurgery of 39 mL (95% CI - 65.8 to - 12.6 mL; p = .004). The use of ABVS devices significantly reduced the total operative time by 8 min (95% CI - 16.7 to - 0.8 min; p = .033). Hospital stay length did not differ between the two groups, and a comparable overall surgical complication rate was observed [OR of 0.9 (95% CI 0.256 - 3.200; p = .878]. CONCLUSIONS High-quality evidence comparing ABVS devices with conventional bipolar electrosurgery for TLH is lacking. ABVS devices were associated with reduced total blood loss and operative time; however, observed differences seem clinically irrelevant. Further research is required to clarify the advantages of ABVS devices over conventional bipolar electrosurgery and to identify cases that may benefit more from their use.
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Affiliation(s)
- Pier Carlo Zorzato
- Unit of Obstetrics and Gynecology, Department of Surgery, Dentistry, Pediatrics, and Gynecology, University of Verona, AOUI Verona, Verona, Italy
| | - Filippo Alberto Ferrari
- Unit of Obstetrics and Gynecology, Department of Surgery, Dentistry, Pediatrics, and Gynecology, University of Verona, AOUI Verona, Verona, Italy
| | - Simone Garzon
- Unit of Obstetrics and Gynecology, Department of Surgery, Dentistry, Pediatrics, and Gynecology, University of Verona, AOUI Verona, Verona, Italy.
| | - Massimo Franchi
- Unit of Obstetrics and Gynecology, Department of Surgery, Dentistry, Pediatrics, and Gynecology, University of Verona, AOUI Verona, Verona, Italy
| | - Stefano Cianci
- Department of Obstetrics and Gynecology, University of Messina, Messina, Italy
| | - Antonio Simone Laganà
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, Palermo, Italy
- Unit of Obstetrics and Gynecology, Paolo Giaccone Hospital, Palermo, Italy
| | - Vito Chiantera
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, Palermo, Italy
- Unit of Gynecologic Oncology, National Cancer Institute - IRCCS - Fondazione "G. Pascale", Naples, Italy
| | - Jvan Casarin
- Department of Obstetrics and Gynecology, Filippo Del Ponte Hospital, University of Insubria, Varese, Italy
| | - Fabio Ghezzi
- Department of Obstetrics and Gynecology, Filippo Del Ponte Hospital, University of Insubria, Varese, Italy
| | - Stefano Uccella
- Unit of Obstetrics and Gynecology, Department of Surgery, Dentistry, Pediatrics, and Gynecology, University of Verona, AOUI Verona, Verona, Italy
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Lim ET, Stylianides N, Craciunas L, Tsampras N. Vaginal vault dehiscence with small bowel evisceration, bowel necrosis, and intra-abdominal haemorrhage: a case report. J Surg Case Rep 2024; 2024:rjae191. [PMID: 38572288 PMCID: PMC10987206 DOI: 10.1093/jscr/rjae191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Accepted: 03/06/2024] [Indexed: 04/05/2024] Open
Abstract
Vaginal vault dehiscence with evisceration is a rare but a potentially life-threatening complication of total hysterectomy that requires prompt recognition, diagnosis, and management. The overall incidence of vaginal vault dehiscence is 0.53%. The mortality rate increases to 5.6% when bowel evisceration is present. We report a case of vaginal vault dehiscence with small bowel evisceration complicated by bowel necrosis and intra-abdominal haemorrhage in a 48-year-old woman following her first sexual intercourse 4 months after her total abdominal hysterectomy.
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Affiliation(s)
- Ee Thong Lim
- Department of Gynaecology, Manchester University NHS Foundation Trust, Oxford Rd, Manchester M13 9WL, United Kingdom
| | - Nicholas Stylianides
- Department of General Surgery, Manchester University NHS Foundation Trust, Oxford Rd, Manchester M13 9WL, United Kingdom
| | - Laurentiu Craciunas
- Centre for Life, Newcastle Fertility Centre, Biomedicine West Wing, International Centre for Life, Times Square, Newcastle upon Tyne NE1 4EP, United Kingdom
| | - Nikolaos Tsampras
- Developmental Biology and Medicine, School of Medical Sciences, The University of Manchester, Oxford Road, Manchester M13 9PL, United Kingdom
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Agarwal M, Sinha S, Singh S, Haripriya H, Simran S. Vaginal Vault Closure Following Total Laparoscopic Hysterectomy: Laparoscopic versus Conventional Technique - A Comparative Study. Gynecol Minim Invasive Ther 2024; 13:90-94. [PMID: 38911314 PMCID: PMC11192275 DOI: 10.4103/gmit.gmit_8_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2023] [Revised: 05/16/2023] [Accepted: 06/01/2023] [Indexed: 06/25/2024] Open
Abstract
Objectives Vault closure is the final step to hysterectomy, protecting the abdominal cavity from the exterior environment. Thus, closure becomes crucial in preventing ascend of infection to the peritoneal cavity. Our study aims to compare vault closure between laparoscopic and vaginal routes, their operating time, and postoperative complications. Materials and Methods The ambispective comparative study was done in a tertiary care teaching center from June 2016 to December 2022. Three hundred and forty-four patients were included in the study that underwent a total laparoscopic hysterectomy. Interventions - Patients who had laparoscopic vault closure were in Group 1 (N = 198) and those who had vaginal closure were in Group 2 (N = 146). The results were compared. It included age, body mass index of the patient, the indication of surgery, intraoperative blood loss, size of the uterus, time taken during vault closure, and postoperative complications. Results The time taken by laparoscopic vault repair was significantly less than vaginal repair (19.7 ± 13.3 min vs. 30.1 ± 6.6 min, P < 0.001). There was postoperative vault infection (2.7%), vault hematoma (1.3%), and no vault prolapse seen in vaginal repair. The organisms isolated were mainly Pseudomonas aeruginosa, Escherichia coli, and Klebsiella. Conclusion Laparoscopic vault closure has shown significantly improved results compared to vaginal route repair.
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Affiliation(s)
- Mukta Agarwal
- Department of Obstetrics and Gynecology, AIIMS, Patna, Bihar, India
| | - Shivangni Sinha
- Department of Obstetrics and Gynecology, AIIMS, Patna, Bihar, India
| | - Smita Singh
- Department of Obstetrics and Gynecology, AIIMS, Patna, Bihar, India
| | - H. Haripriya
- Department of Community and Family Medicine, AIIMS, Patna, Bihar, India
| | - S Simran
- Department of Obstetrics and Gynecology, AIIMS, Patna, Bihar, India
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Radtke S, Arms R, Son MA, Sanchez S, Singh V, Bencomo M, Mccall E, Rodriguez S, Olivas-Cardiel K. Reducing patient's perception of postoperative vaginal bleeding after laparoscopic hysterectomy via independent closure of the vaginal cuff angles (RCT). Eur J Obstet Gynecol Reprod Biol 2024; 294:111-116. [PMID: 38237308 DOI: 10.1016/j.ejogrb.2024.01.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Revised: 01/06/2024] [Accepted: 01/12/2024] [Indexed: 02/21/2024]
Abstract
STUDY OBJECTIVE Determine if independently suturing the vaginal cuff angles in addition to running barbed suture has an effect on patients' perception of postoperative bleeding after laparoscopic hysterectomy. DESIGN Randomized controlled trial. SETTING University-based medical center. PATIENTS Females ages 18-60 undergoing laparoscopic hysterectomy. INTERVENTIONS Patients were randomly assigned to either cuff closure via single layer of barbed suture (control) vs adding figure-of-eight stitches at each angle (intervention). A survey was given between 10 and 25 days after surgery inquiring about bleeding and dyspareunia. A second survey was given between postoperative days 90-114. Chart review was performed to record emergency room visits, complications, infections, and reoperations during the first 90 postoperative days. RESULTS n = 117 patients were analyzed. 62 (control) and 55 (intervention). Groups were similar in terms of age (42.92 v 44.29p =.35), BMI (33.79 v 34.06p =.85), diabetes (5.26 % (3/55) v 15.09 % (8/53) p =.08) p =.97). Bleeding was decreased in intervention arm (24.19 % (15/62) v 9.09 % (5/55) p =.03). Median (IQR) pelvic pain score was similar (2.0 (0-5.0) v 2.0 (0-4.0) p =.26). Median total operative time (IQR) (129 min (102, 166) v 139 min (120, 163) p =.39) and median EBL (IQR) (50 mL (30-75) vs 50 mL (20-75) p =.43) were similar. Cuff closure in seconds (IQR) was higher in intervention group (373 sec (323, 518) v 571 sec (520, 715) p <.01). 8/60 control patients visited the ED (13.33 %) v 7/54 (12.96 %) p =.95. Readmissions (1.67 % (1/60) v 1.85 % (1/55) p = 1), re-operations (0 % (0/60) v 1.85 % (1/55) p =.47) and postoperative infections (5.0 % (3/60) v 1.85 % (1/54) p =.62) were similar. Secondary survey showed no significant difference in bleeding (15.38 % (4/26) v 4.35 % (1/23) p =.35) and SF-36 results were similar. CONCLUSION Independently suturing the vaginal cuff angles reduces patients' perception of vaginal bleeding in the early postoperative period. Incidence of complications, reoperations, and long-term quality of life are similar.
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Affiliation(s)
- Steven Radtke
- Texas Tech University Health Sciences Center El Paso, USA.
| | - Richard Arms
- Texas Tech University Health Sciences Center El Paso, USA
| | - Mary Ann Son
- Texas Tech University Health Sciences Center El Paso, USA
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Uccella S, Magni F, Zorzato PC, Ricci A, Favilli A, Garzon S. Hysterectomy Trends and Risk of Vaginal Cuff Dehiscence: An Update by Mode of Surgery. J Minim Invasive Gynecol 2023; 30:932-933. [PMID: 37586478 DOI: 10.1016/j.jmig.2023.06.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 06/27/2023] [Indexed: 08/18/2023]
Affiliation(s)
- Stefano Uccella
- Department of Obstetrics and Gynecology, AOUI Verona, University of Verona, 37126 Verona, Italy
| | - Francesca Magni
- Department of Obstetrics and Gynecology, AOUI Verona, University of Verona, 37126 Verona, Italy.
| | - Pier Carlo Zorzato
- Department of Obstetrics and Gynecology, AOUI Verona, University of Verona, 37126 Verona, Italy
| | - Alberta Ricci
- Department of Obstetrics and Gynecology, AOUI Verona, University of Verona, 37126 Verona, Italy
| | - Alessandro Favilli
- Section of Obstetrics and Gynecology, Department of Medicine and Surgery, University of Perugia, 06123 Perugia, Italy
| | - Simone Garzon
- Department of Obstetrics and Gynecology, AOUI Verona, University of Verona, 37126 Verona, Italy
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Pickett CM, Seeratan DD, Mol BWJ, Nieboer TE, Johnson N, Bonestroo T, Aarts JW. Surgical approach to hysterectomy for benign gynaecological disease. Cochrane Database Syst Rev 2023; 8:CD003677. [PMID: 37642285 PMCID: PMC10464658 DOI: 10.1002/14651858.cd003677.pub6] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/31/2023]
Abstract
BACKGROUND Currently, there are five major approaches to hysterectomy for benign gynaecological disease: abdominal hysterectomy (AH), vaginal hysterectomy (VH), laparoscopic hysterectomy (LH), robotic-assisted hysterectomy (RH) and vaginal natural orifice hysterectomy (V-NOTES). Within the LH category we further differentiate the laparoscopic-assisted vaginal hysterectomy (LAVH) from the total laparoscopic hysterectomy (TLH) and single-port laparoscopic hysterectomy (SP-LH). OBJECTIVES To assess the effectiveness and safety of different surgical approaches to hysterectomy for women with benign gynaecological conditions. SEARCH METHODS We searched the following databases (from their inception to December 2022): the Cochrane Gynaecology and Fertility Specialised Register of Controlled Trials, CENTRAL, MEDLINE, Embase, CINAHL and PsycINFO. We also searched the trial registries and relevant reference lists, and communicated with experts in the field for any additional trials. SELECTION CRITERIA We included randomised controlled trials (RCTs) in which clinical outcomes were compared between one surgical approach to hysterectomy and another. DATA COLLECTION AND ANALYSIS At least two review authors independently selected trials, assessed risk of bias and performed data extraction. Our primary outcomes were return to normal activities, satisfaction and quality of life, intraoperative visceral injury and major long-term complications (i.e. fistula, pelvic-abdominal pain, urinary dysfunction, bowel dysfunction, pelvic floor condition and sexual dysfunction). MAIN RESULTS We included 63 studies with 6811 women. The evidence for most comparisons was of low or moderate certainty. The main limitations were poor reporting and imprecision. Vaginal hysterectomy (VH) versus abdominal hysterectomy (AH) (12 RCTs, 1046 women) Return to normal activities was probably faster in the VH group (mean difference (MD) -10.91 days, 95% confidence interval (CI) -17.95 to -3.87; 4 RCTs, 274 women; I2 = 67%; moderate-certainty evidence). This suggests that if the return to normal activities after AH is assumed to be 42 days, then after VH it would be between 24 and 38 days. We are uncertain whether there is a difference between the groups for the other primary outcomes. Laparoscopic hysterectomy (LH) versus AH (28 RCTs, 3431 women) Return to normal activities may be sooner in the LH group (MD -13.01 days, 95% CI -16.47 to -9.56; 7 RCTs, 618 women; I2 = 68%, low-certainty evidence), but there may be more urinary tract injuries in the LH group (odds ratio (OR) 2.16, 95% CI 1.19 to 3.93; 18 RCTs, 2594 women; I2 = 0%; moderate-certainty evidence). This suggests that if the return to normal activities after abdominal hysterectomy is assumed to be 37 days, then after laparoscopic hysterectomy it would be between 22 and 25 days. It also suggests that if the rate of ureter injury during abdominal hysterectomy is assumed to be 0.2%, then during laparoscopic hysterectomy it would be between 0.2% and 2%. We are uncertain whether there is a difference between the groups for the other primary outcomes. LH versus VH (22 RCTs, 2135 women) We are uncertain whether there is a difference between the groups for any of our primary outcomes. Both short- and long-term complications were rare in both groups. Robotic-assisted hysterectomy (RH) versus LH (three RCTs, 296 women) None of the studies reported satisfaction rates or quality of life. We are uncertain whether there is a difference between the groups for our other primary outcomes. Single-port laparoscopic hysterectomy (SP-LH) versus LH (seven RCTs, 621 women) None of the studies reported satisfaction rates, quality of life or major long-term complications. We are uncertain whether there is a difference between the groups for rates of intraoperative visceral injury. Total laparoscopic hysterectomy (TLH) versus laparoscopic-assisted vaginal hysterectomy (LAVH) (three RCTs, 233 women) None of the studies reported satisfaction rates or quality of life. We are uncertain whether there is a difference between the groups for rates of intraoperative visceral injury or major long-term complications. Transvaginal natural orifice transluminal endoscopic surgery (V-NOTES) versus LH (two RCTs, 96 women) We are uncertain whether there is a difference between the groups for rates of bladder injury. Our other primary outcomes were not reported. Overall, adverse events were rare in the included studies. AUTHORS' CONCLUSIONS Among women undergoing hysterectomy for benign disease, VH appears to be superior to AH. When technically feasible, VH should be performed in preference to AH because it is associated with faster return to normal activities, fewer wound/abdominal wall infections and shorter hospital stay. Where VH is not possible, LH has advantages over AH including faster return to normal activities, shorter hospital stay, and decreased risk of wound/abdominal wall infection, febrile episodes or unspecified infection, and transfusion. These advantages must be balanced against the increased risk of ureteric injury and longer operative time. When compared to LH, VH was associated with no difference in time to return to normal activities but shorter operative time and shorter hospital stay. RH and V-NOTES require further evaluation since there is a lack of evidence of any patient benefit over conventional LH. Overall, the evidence in this review has to be interpreted with caution as adverse event rates were low, resulting in low power for these comparisons. The surgical approach to hysterectomy should be discussed with the patient and decided in the light of the relative benefits and hazards. Surgical expertise is difficult to quantify and poorly reported in the available studies and this may influence outcomes in ways that cannot be accounted for in this review. In conclusion, when VH is not feasible, LH has multiple advantages over AH, but at the cost of more ureteric injuries. Evidence is limited for RH and V-NOTES.
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Affiliation(s)
- Charlotte M Pickett
- Department of Obstetrics and Gynecology, University of California San Diego, La Jolla, California, USA
| | - Dachel D Seeratan
- Department of Obstetrics and Gynaecology, Amsterdam University Medical Centers, Amsterdam, Netherlands
| | - Ben Willem J Mol
- Department of Obstetrics and Gynaecology, Monash University, Clayton, Australia
| | | | - Neil Johnson
- Obstetrics & Gynaecology, College of Medicine and Public Health, Flinders University, Adelaide, Australia
| | - Tijmen Bonestroo
- Department of Obstetrics and Gynecology, Rijnstate Hospital, Arnhem, Netherlands
| | - Johanna Wm Aarts
- Obstetrics and Gynaecology, Amsterdam University Medical Centers, Amsterdam, Netherlands
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Polin M, Boone R, Lim F, Advincula AP, May B, Hur C, Hur HC. Hysterectomy Trends and Risk of Vaginal Cuff Dehiscence: An Update by Mode of Surgery. J Minim Invasive Gynecol 2023; 30:562-568. [PMID: 36921892 DOI: 10.1016/j.jmig.2023.03.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 03/07/2023] [Accepted: 03/09/2023] [Indexed: 03/15/2023]
Abstract
STUDY OBJECTIVE To analyze hysterectomy trends and vaginal cuff dehiscence (VCD) rates by mode of surgery at a tertiary care medical center and to describe characteristics of VCD cases. DESIGN Observational retrospective cohort study. SETTING Large academic hospital and affiliated community hospital. PATIENTS 4722 patients who underwent hysterectomy at Columbia University Irving Medical Center between January 2010 and August 2021. INTERVENTIONS Current Procedural Terminology and International Classification of Diseases codes identified hysterectomies and VCD cases. Hysterectomy trends and VCD rates were calculated by mode of surgery. Relative risks of VCD for each mode were compared with total abdominal hysterectomy (TAH). Clinical characteristics of VCDs were reviewed. MEASUREMENTS AND MAIN RESULTS There were 4059 total hysterectomies. Laparoscopic hysterectomies, including total laparoscopic hysterectomies (TLHs), laparoscopic-assisted vaginal hysterectomies, and robot-assisted TLHs (RA-TLHs), increased from 41.9% in 2010 to 65.9% in 2021 (p <.001). RA-TLH increased from 5.7% in 2010 to 40.2% in 2021. Supracervical hysterectomies followed similar trends and were excluded from VCD analysis. There were 15 VCDs (overall rate 0.37%). VCD was highest after RA-TLH (0.66%), followed by TLH (0.32%) and TAH (0.27%), with no VCDs after laparoscopic-assisted vaginal hysterectomy or total vaginal hysterectomy. Compared with TAH, the relative risk for VCD after RA-TLH was 2.44 (95% confidence interval 0.66-9.00) and after TLH was 1.18 (95% confidence interval 0.24-5.83), which were not statistically significant. The mean time to dehiscence was 39 days (range 8-145 days). The most common trigger event was coitus (41%). CONCLUSION VCD rates were low (<1%) for all modes of hysterectomy, and rates after robotic and laparoscopic hysterectomy were much lower than previously reported. Although VCD rates trended higher after robotic and laparoscopic hysterectomy compared with abdominal hysterectomy, the difference was not significant. It is difficult to determine whether this finding represents true lack of difference vs a lack of power to detect a significant difference given the rarity of VCD.
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Affiliation(s)
- Melanie Polin
- Department of Obstetrics and Gynecology, Division of Gynecologic Specialty Surgery (Drs. Polin, Boone, Advincula, and H. Hur), Columbia University Irving Medical Center, New York, New York
| | - Ryan Boone
- Department of Obstetrics and Gynecology, Division of Gynecologic Specialty Surgery (Drs. Polin, Boone, Advincula, and H. Hur), Columbia University Irving Medical Center, New York, New York
| | - Francesca Lim
- Department of Medicine, Columbia University Irving Medical Center (Ms. Lim and Dr. C. Hur), New York, New York
| | - Arnold P Advincula
- Department of Obstetrics and Gynecology, Division of Gynecologic Specialty Surgery (Drs. Polin, Boone, Advincula, and H. Hur), Columbia University Irving Medical Center, New York, New York
| | - Benjamin May
- Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center (Mr. May and Dr. C. Hur), New York, New York
| | - Chin Hur
- Department of Medicine, Columbia University Irving Medical Center (Ms. Lim and Dr. C. Hur), New York, New York; Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center (Mr. May and Dr. C. Hur), New York, New York
| | - Hye-Chun Hur
- Department of Obstetrics and Gynecology, Division of Gynecologic Specialty Surgery (Drs. Polin, Boone, Advincula, and H. Hur), Columbia University Irving Medical Center, New York, New York.
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11
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Jaime Moens B, Buonomo A, De Sutter P. Vaginal Cuff Dehiscence: Two Case Reports and a Review of the Literature. J Clin Med 2023; 12:4187. [PMID: 37445221 DOI: 10.3390/jcm12134187] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Revised: 06/07/2023] [Accepted: 06/18/2023] [Indexed: 07/15/2023] Open
Abstract
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.
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Affiliation(s)
- Babette Jaime Moens
- Department of Gynaecology, Universitair Ziekenhuis Brussel, Laarbeeklaan 101, 1090 Jette, Belgium
| | - Antonino Buonomo
- Department of Gynaecology, Centre Hospitalier Universitaire Tivoli, Avenue Max Buset 34, 7100 La Louviere, Belgium
| | - Philippe De Sutter
- Department of Gynaecology, Universitair Ziekenhuis Brussel, Laarbeeklaan 101, 1090 Jette, Belgium
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12
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Eoh KJ, Lee YJ, Nam EJ, Jung HI, Kim YT. Vaginal Cuff Dehiscence and a Guideline to Determine Treatment Strategy. J Pers Med 2023; 13:890. [PMID: 37373878 DOI: 10.3390/jpm13060890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 05/18/2023] [Accepted: 05/18/2023] [Indexed: 06/29/2023] Open
Abstract
In this retrospective study, our aim was to investigate a novel treatment strategy guideline for vaginal cuff dehiscence after hysterectomy based on the mode of operation and time of occurrence in patients who underwent hysterectomy at Severance Hospital between July 2013 and February 2019. We analyzed the characteristics of 53 cases of vaginal cuff dehiscence according to the mode of hysterectomy and time of occurrence. Out of a total of 6530 hysterectomy cases, 53 were identified as vaginal cuff dehiscence (0.81%; 95% confidence interval: 0.4-1.6%). The incidence of dehiscence after minimally invasive hysterectomy was significantly higher in patients with benign diseases, while malignant disease was associated with a higher risk of dehiscence after transabdominal hysterectomy (p = 0.011). The time of occurrence varied significantly based on menopausal status, with dehiscence occurring relatively earlier in pre-menopausal women compared to post-menopausal women (93.1% vs. 33.3%, respectively; p = 0.031). Surgical repair was more frequently required in cases of late-onset vaginal cuff dehiscence (≥8 weeks) compared to those with early-onset dehiscence (95.8% vs. 51.7%, respectively; p < 0.001). Patient-specific factors, such as age, menopausal status, and cause of operation, may influence the timing and severity of vaginal cuff dehiscence and evisceration. Therefore, a guideline may be indicated for the treatment of potentially emergent complications after hysterectomy.
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Affiliation(s)
- Kyung Jin Eoh
- Department of Obstetrics and Gynecology, Yongin Severance Hospital, Yonsei University College of Medicine, Yongin 16995, Republic of Korea
| | - Young Joo Lee
- Department of Obstetrics and Gynecology, Institute of Women's Medical Life Science, Yonsei Cancer Center, Severance Hospital, Yonsei University College of Medicine, Seoul 03722, Republic of Korea
| | - Eun Ji Nam
- Department of Obstetrics and Gynecology, Institute of Women's Medical Life Science, Yonsei Cancer Center, Severance Hospital, Yonsei University College of Medicine, Seoul 03722, Republic of Korea
| | - Hye In Jung
- Department of Obstetrics and Gynecology, Institute of Women's Medical Life Science, Yonsei Cancer Center, Severance Hospital, Yonsei University College of Medicine, Seoul 03722, Republic of Korea
| | - Young Tae Kim
- Department of Obstetrics and Gynecology, Institute of Women's Medical Life Science, Yonsei Cancer Center, Severance Hospital, Yonsei University College of Medicine, Seoul 03722, Republic of Korea
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13
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Bruno M, Legge F, Gentile C, Carone V, Stabile G, Di Leo F, Ludovisi M, Di Florio C, Guido M. Risk Assessment Model for Complications in Minimally Invasive Hysterectomy: A Pilot Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 20:ijerph20010234. [PMID: 36612556 PMCID: PMC9819802 DOI: 10.3390/ijerph20010234] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Revised: 12/14/2022] [Accepted: 12/16/2022] [Indexed: 06/01/2023]
Abstract
Objective: To estimate the rate of intra-operative and postoperative complications, and to define the risk of 30-day major postoperative complications (Clavien-Dindo > 2) according to the presence of one of 10 different variables of minimally invasive (MI) hysterectomy; and then to create a risk assessment model easily applicable in clinical practice. Methods: A single center single arm retrolective study. Data of consecutive patients who have undergone MI hysterectomy for gynaecologic disorders between May 2018 and April 2021 were analyzed. Perioperative surgical outcomes, occurrence of intra- and postoperative complications, and readmissions within 30 days from surgery were registered. Univariate and multivariable analyses were performed to determine the factors associated with major postoperative complications. Results: Over the study period, 445 patients were included in the study. The majority of patients developed a minor event, while major complications (grade III) were required in 14 patients. None of the patients showed a grade IV or V complication. Univariate analysis was performed on patients who had developed intra- or postoperative complications from those who did not experience complications. Body mass index (BMI) (p-value 0.045) and surgeon’s experience (p-value 0.015) were found to be associated with a different surgery time. Regarding major postoperative complications, a statistically significant association was found for the variables: BMI (p-value 0.006), previous abdominal surgery (p-value 0.015), and surgeon’s experience (p-value 0.035) in the univariate analysis. Also in the multivariate analysis, the risk of major postoperative complications was higher in these three different variables. BMI, previous surgery, and surgeon’s experience were inserted in a reproducible risk assessment model in order to stratify the risk of major postoperative complications. Conclusions: We proposed a risk assessment model including factors not previously considered in the literature: the standardization of the surgical technique, the surgeon’s experience, the best MI approach (laparoscopy or robot-assisted), and previous abdominal surgery are crucial tools to consider. Further prospective studies with a larger population sample are needed to validate these preliminary evaluations for patients undergoing MI hysterectomy.
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Affiliation(s)
- Matteo Bruno
- Obstetrics and Gynaecology Unit, San Salvatore Hospital, 67100 L’Aquila, Italy
| | - Francesco Legge
- Gynecologic Oncology Unit, Department of Obstetrics and Gynecology “F. Miulli” General Regional Hospital, Acquaviva delle Fonti, 70021 Bari, Italy
| | - Cosimo Gentile
- Gynecologic Oncology Unit, Department of Obstetrics and Gynecology “F. Miulli” General Regional Hospital, Acquaviva delle Fonti, 70021 Bari, Italy
| | - Vito Carone
- Gynecologic Oncology Unit, Department of Obstetrics and Gynecology “F. Miulli” General Regional Hospital, Acquaviva delle Fonti, 70021 Bari, Italy
| | - Guglielmo Stabile
- Institute for Maternal and Child Health-IRCCS “Burlo Garofolo”, Department of Obstetrics and Gynaecology, 34137 Trieste, Italy
| | - Federico Di Leo
- Obstetrics and Gynaecology Unit, San Salvatore Hospital, 67100 L’Aquila, Italy
| | - Manuela Ludovisi
- Department of Life, Health and Environmental Sciences, University of L’Aquila, 67100 L’Aquila, Italy
| | - Christian Di Florio
- Obstetrics and Gynaecology Unit, San Salvatore Hospital, 67100 L’Aquila, Italy
| | - Maurizio Guido
- Department of Life, Health and Environmental Sciences, University of L’Aquila, 67100 L’Aquila, Italy
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Prevention and management of vaginal cuff dehiscence: an updated review. Curr Opin Obstet Gynecol 2022; 34:250-255. [PMID: 35895968 DOI: 10.1097/gco.0000000000000791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Minimally invasive hysterectomy has gained popularity because of its many benefits. However, laparoscopic and robotic assisted hysterectomy have been associated with increased risk of vaginal cuff dehiscence. This review is meant to address risk management and prevention of vaginal cuff dehiscence in patients undergoing minimally invasive hysterectomy. RECENT FINDINGS Recent findings in the literature focus on addressing modifiable risk factors in patients and on using good surgical technique to help minimize the risk of vaginal cuff dehiscence. SUMMARY The focus of this review is to help surgeons identify patient risk factors and address them preoperatively and to review surgical techniques that can minimize the risk of vaginal cuff dehiscence.
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15
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Evaluation and Management of Common Intraoperative and Postoperative Complications in Gynecologic Endoscopy. Obstet Gynecol Clin North Am 2022; 49:355-368. [DOI: 10.1016/j.ogc.2022.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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16
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Watrowski R, Kostov S, Alkatout I. Complications in laparoscopic and robotic-assisted surgery: definitions, classifications, incidence and risk factors - an up-to-date review. Wideochir Inne Tech Maloinwazyjne 2021; 16:501-525. [PMID: 34691301 PMCID: PMC8512506 DOI: 10.5114/wiitm.2021.108800] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Accepted: 06/30/2021] [Indexed: 11/26/2022] Open
Abstract
Almost all gynecological and general-surgical operations are - or can be - performed laparoscopically. In comparison to an abdominal approach, the minimally invasive access offers several advantages; however, laparoscopy (both conventional and robotic-assisted) can be associated with a number of approach-specific complications. Although the majority of them are related to the laparoscopic entry, adverse events may also occur due to the presence of pneumoperitoneum or the use of laparoscopic instruments. Unfortunately, a high proportion of complications (especially affecting the bowel and ureter) remain unrecognized during surgery. This narrative review provides comprehensive up-to-date information about definitions, classifications, risk factors and incidence of surgical complications in conventional and robotic-assisted laparoscopy, with a special focus on gynecology. The topic is discussed from various perspectives, e.g. in the context of stage of surgery, injured organs, involved instruments, and in relation to malpractice claims.
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Affiliation(s)
- Rafał Watrowski
- St. Josefskrankenhaus, Teaching Hospital of the University of Freiburg, Freiburg, Germany
| | - Stoyan Kostov
- Department of Gynecology, Medical University Varna, Varna, Bulgaria
| | - Ibrahim Alkatout
- Department of Gynecology and Obstetrics, Kiel School of Gynecological Endoscopy, University Hospitals Schleswig-Holstein, Kiel, Germany
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17
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Uccella S, Garzon S, Lanzo G, Gallina D, Bosco M, Porcari I, Gueli-Alletti S, Cianci S, Franchi M, Zorzato PC. Uterine artery closure at the origin versus at the uterus level in total laparoscopic hysterectomy: A randomized controlled trial. Acta Obstet Gynecol Scand 2021; 100:1840-1848. [PMID: 34396512 DOI: 10.1111/aogs.14238] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Revised: 07/19/2021] [Accepted: 08/01/2021] [Indexed: 11/28/2022]
Abstract
INTRODUCTION The transfusion rate in hysterectomies for benign pathology is almost 3%. However, despite the strong interest in reducing intraoperative bleeding, limited evidence is available regarding the technical aspects concerning uterine vessel management during a total laparoscopic hysterectomy (TLH). Uterine artery (UA) closure in TLH can be performed at the origin from the internal iliac artery or at the uterus level (UL). However, low-quality evidence is available regarding the superiority of one method over the other. MATERIAL AND METHODS We performed a single-blind randomized (1:1) controlled trial (NCT04156932) between December 2019 and August 2020. One hundred and eighty women undergoing TLH for benign gynecological diseases were randomized to TLH with UA closure at the origin from the internal iliac artery (n = 90), performed at the beginning of the procedure by putting two clips per side at the origin, versus closure at the UL (n = 90). Intraoperative blood loss estimated from suction devices was the primary outcome. Secondary end points were perioperative outcomes, the conversion rate from one technique to the other, and complication rates with 4 months of follow up. RESULTS Uterine artery closure at the origin was completed in all 90 patients (0%), whereas closure at the UL was converted to closure at the origin in 11 cases (12.2%; p < 0.001); failures were mainly associated with the presence of endometriosis (81.8% [9/11] versus 10.1% [8/79]; p < 0.001). In the intention-to-treat analysis, the intraoperative blood loss was higher in the group assigned to the closure at the UL (108.5 mL) than in the group with closure at the origin (69.3 mL); the mean difference was 39.2 mL (95% CI 13.47-64.93 mL; p = 0.003). Other perioperative outcomes and complications rates did not differ. CONCLUSIONS Uterine artery closure at the origin reduces intraoperative blood loss during a TLH and appears to be more reproducible than closure at the UL without higher complication rates. However, the absent translation in clinical benefits impedes the support of a clinical superiority in all women. Closure at the origin may provide clinical advantages in the presence of severe preoperative anemia or pelvic anatomic distortion.
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Affiliation(s)
- Stefano Uccella
- Division of Obstetrics and Gynecology, Department of Maternal, Neonatal and Infant Health, ASL Biella, Biella, Italy.,Department of Obstetrics and Gynecology, AOUI Verona, University of Verona, Verona, Italy
| | - Simone Garzon
- Department of Obstetrics and Gynecology, AOUI Verona, University of Verona, Verona, Italy
| | - Gabriele Lanzo
- Division of Obstetrics and Gynecology, Department of Maternal, Neonatal and Infant Health, ASL Biella, Biella, Italy
| | - Davide Gallina
- Division of Obstetrics and Gynecology, Department of Maternal, Neonatal and Infant Health, ASL Biella, Biella, Italy
| | - Mariachiara Bosco
- Department of Obstetrics and Gynecology, AOUI Verona, University of Verona, Verona, Italy
| | - Irene Porcari
- Department of Obstetrics and Gynecology, AOUI Verona, University of Verona, Verona, Italy
| | - Salvatore Gueli-Alletti
- Division of Gynecologic Oncology, Department of Women and Children's Health, A. Gemelli University Hospital and Institute for Research and Care, Rome, Italy
| | - Stefano Cianci
- Unit of Gynecology, Department of Human Pathology of Adult and Childhood "G. Barresi", University of Messina, Messina, Italy
| | - Massimo Franchi
- Department of Obstetrics and Gynecology, AOUI Verona, University of Verona, Verona, Italy
| | - Pier Carlo Zorzato
- Division of Obstetrics and Gynecology, Department of Maternal, Neonatal and Infant Health, ASL Biella, Biella, Italy.,Department of Obstetrics and Gynecology, AOUI Verona, University of Verona, Verona, Italy
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Cost-effective minimally invasive gynecologic surgery: emphasizing surgical efficiency. Curr Opin Obstet Gynecol 2021; 32:243-247. [PMID: 32371608 DOI: 10.1097/gco.0000000000000636] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW The United States has the highest healthcare costs among developed countries. This review evaluates surgical practices and equipment choices during endoscopic hysterectomy, highlighting opportunities for the gynecologic surgeon to reduce costs and maximize surgical efficiency. RECENT FINDINGS There are opportunities to economize at every step of the endoscopic hysterectomy. When surgeons are provided education about instrumentation costs, the cost of hysterectomy has been shown to decrease. Colpotomy has been found to be the rate-limiting step in laparoscopic hysterectomy; use of a uterine manipulator likely saves time and money. When evaluating the economic impact of route of surgery, the cost differential between laparoscopic and robotic-assisted hysterectomy has decreased. Robotic-assisted hysterectomy may be more cost-effective in some cases, such as for larger uteri. From a systems-level perspective, dedicating a specific operating room team to the gynecology service can decrease operative time. SUMMARY The gynecologic surgeon is best equipped to control surgery-related costs by making choices that improve surgical efficiency and decrease operating room time. If a costlier piece of equipment leads to a more efficient case, the choice may be more cost-effective. There are multiple systems-level changes that can be implemented to decrease surgery-related costs.
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Putman JG, Meister MR, Lenger SM, Lowder JL. Regional Performance of Apical Support Procedures at Time of Hysterectomy for Benign Indications: What Is the Role of Surgeon Training? Female Pelvic Med Reconstr Surg 2021; 27:421-426. [PMID: 32701766 PMCID: PMC8130707 DOI: 10.1097/spv.0000000000000904] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The objective of this study was to determine factors associated with performance of concomitant apical support procedures (ASPs) with benign hysterectomy at a regional medical system. METHODS Benign hysterectomies performed within 1 regional medical system from January 2011 to November 2017 were identified using International Classification of Diseases, Ninth and 10th Revision, and Current Procedural Terminology codes. Primary outcome was performance of concomitant ASP. χ2 Tests compared categorical variables. Multivariable logistic regression analysis was performed to determine factors associated with performance of concomitant ASP. RESULTS A total of 12,345 benign hysterectomies were performed during the study period. Uterovaginal prolapse was the primary diagnosis in 924 (7.48%) hysterectomies and an associated diagnosis in 1180 (9.56%) hysterectomies. A total of 686 patients (5.56%) had concurrent ASPs: 119 (17.3%) in patients without a diagnosis of prolapse and 567 (82.7%) with prolapse. Using multivariable logistic regression, controlling for age, race, insurance type, hospital type, procedure year, hysterectomy route, and surgeon training in patients with a diagnosis of prolapse, older age, supracervical hysterectomy, and surgeon training were associated with performance of ASPs. CONCLUSIONS Even in patients with a preoperative diagnosis of uterovaginal prolapse, ASPs are not routinely performed at time of hysterectomy. Fellowship-trained surgeons were more likely to perform ASPs. Ongoing educational efforts during training and postgraduate at the national and regional level on the importance of reestablishing apical vaginal support at time of hysterectomy is needed to prevent incident and recurrent post-hysterectomy vaginal vault prolapse.
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Affiliation(s)
- Jessica G Putman
- From the Department of Obstetrics and Gynecology, Barnes-Jewish Hospital, Washington University in St. Louis, Saint Louis, MO
| | - Melanie R Meister
- Department of Obstetrics and Gynecology, University of Kansas, Kansas City, KS
| | - Stacy M Lenger
- Department of Obstetrics and Gynecology, Washington University in St. Louis, Saint Louis, MO
| | - Jerry L Lowder
- Department of Obstetrics and Gynecology, Washington University in St. Louis, Saint Louis, MO
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Casarin J, Cromi A, Bogani G, Multinu F, Uccella S, Ghezzi F. Surgical morbidity of total laparoscopic hysterectomy for benign disease: Predictors of major postoperative complications. Eur J Obstet Gynecol Reprod Biol 2021; 263:210-215. [PMID: 34229185 DOI: 10.1016/j.ejogrb.2021.06.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Revised: 05/24/2021] [Accepted: 06/18/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVE To estimate rate of perioperative complications and to define risk factors of 30-day major (Clavien-Dindo ≥ 2) postoperative complications of total laparoscopic hysterectomy (TLH) for benign disease. STUDY DESIGN An uncontrolled single-center single-arm retrospective study. Data of consecutive patients who have undergone TLH for pathologically confirmed benign disease between January 2000 and December 2019 have been analyzed. Perioperative surgical outcomes, occurrence of postoperative complications, readmissions, and reoperations within 30 days from surgery were registered. Univariate and multivariable analyses were performed to determine the factors associated with major (Clavien-Dindo ≥ 2) postoperative complications. RESULTS Over the study period 3090 patients were included in the study. Conversion to open surgery occurred in 54 (1.7%) cases. Mean operative time for TLH was 87.7 (±1.7) minutes while mean estimated blood loss was 119.5 (+7.4) mL. Overall, postoperative complications were registered in 430 (13.9%) patients, and major events were observed in 208 (6.7%) of the cases. Same-hospital readmissions and reoperations within 30-day from surgery occurred in 78 (2.5%) and 28 (0.9%) patients, respectively. At multivariable analysis, endometriosis (odds ratio: 3.51, 95%CI:1.54-8.30, p = 0.02), the need for conversion to open surgery (odds ratio: 1.26, 98%CI:1.03-12.64, p < 0.001), and the occurrence of any intraoperative complication (odds ratio: 3.10, 95%CI: 1.45-21.61, p < 0.001) were found as independent risk factors for major postoperative complications. CONCLUSIONS Total hysterectomy performed via laparoscopy is associated with acceptable major postoperative complications rate. A huge effort should be made to minimize the occurrence of intraoperative complications and the need for conversion to open surgery. Patients undergoing TLH for endometriosis should be counselled about the increased risk of major postoperative events.
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Affiliation(s)
- J Casarin
- Obstetrics and Gynecology Department of the University of Insubria, Varese, Italy.
| | - A Cromi
- Obstetrics and Gynecology Department of the University of Insubria, Varese, Italy
| | - G Bogani
- Fondazione IRCCS Istituto Nazionale dei Tumori di Milano, Milano, Italy
| | - F Multinu
- Division of Gynecologic Surgery, IEO, European Institute of Oncology IRCSS, Milan, Italy
| | - S Uccella
- Obstetrics and Gynecology Department, University of Verona, Italy
| | - F Ghezzi
- Obstetrics and Gynecology Department of the University of Insubria, Varese, Italy
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Two-Layer Compared With One-Layer Vaginal Cuff Closure at the Time of Total Laparoscopic Hysterectomy to Reduce Complications. Obstet Gynecol 2021; 138:59-65. [PMID: 34259464 DOI: 10.1097/aog.0000000000004428] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Accepted: 03/25/2021] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To explore whether two-layer laparoscopic vaginal cuff closure at the time of laparoscopic hysterectomy is associated with a lower rate of postoperative complications compared with a standard one-layer cuff closure. METHODS A retrospective cohort study of total laparoscopic hysterectomies performed by fellowship-trained minimally invasive gynecologic surgeons between 2011 and 2017 was performed. Surgeons sutured the vaginal cuff laparoscopically, either in a two- or one-layer closure. The primary outcome was a composite of total postoperative complications, including all medical and surgical complications within 30 days and vaginal cuff complications within 180 days. Factors known to influence laparoscopic vaginal cuff complications including age, postmenopausal status, body mass index, tobacco use, and immunosuppressant medications were examined and controlled for, while surgeon skill, colpotomy technique, and suture material remained standardized. We conducted statistical analyses including χ2, Fisher exact test, logistic regression, and post hoc power calculations. RESULTS Of the 2,973 women who underwent total laparoscopic hysterectomies, 40.8% (n=1,213) of vaginal cuffs were closed with a two-layer closure and 59.2% (n=1,760) with a one-layer technique. Two-layer vaginal cuff closure was associated with decreased numbers of total postoperative complications (3.5% vs 5.7%; P<.01). The primary difference stemmed from lower vaginal cuff complications within 180 days (0.9% vs 2.6%; P<.01); no differences in 30-day medical and surgical postoperative complications were observed between the two groups (2.6% vs 3.1%; P=.77). No patients in the two-layer vaginal cuff closure cohort experienced a vaginal cuff dehiscence or mucosal separation compared with 1.0% in the one-layer group (P<.01). Compared with a one-layer closure, a two-layer closure was protective from postoperative complications (adjusted odds ratio 0.38, 95% CI 0.19-0.74). CONCLUSION Although postoperative complications with laparoscopic hysterectomies are rare, two-layer laparoscopic vaginal cuff closure is associated with lower total postoperative complications compared with a one-layer closure. The difference was primary driven by cuff complications.
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22
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Uccella S, Kho RM, Garzon S, Casarin J, Zorzato PC, Ghezzi F. The Large Uterus Classification System: a prospective observational study. BJOG 2021; 128:1526-1533. [PMID: 33988895 PMCID: PMC8362220 DOI: 10.1111/1471-0528.16753] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/26/2021] [Indexed: 12/22/2022]
Abstract
Objective To investigate the Large Uterus Classification System (LUCS) ability to predict surgical outcomes and complications in total laparoscopic hysterectomies (TLHs) for large uteri. Design Prospective observational study. Setting Two referral centres. Population or sample Three hundred and ninety‐two women who underwent TLH for a large uterus (uterine fundus at or over the transverse umbilical line). Methods Between 2004 and 2019, the intraoperative LUCS was estimated in all patients. The LUCS considers the uterine and adnexal vascular pedicles displacement. Type 1 is without vascular pedicles displacement. Type 2 has the cephalad displacement of adnexal vascular pedicles. The uterine vessels displacement regardless of adnexal pedicles defines Type 3. Main outcome measures Patients’ characteristics with perioperative outcomes were prospectively collected and compared between the three types of large uteri. Results Two hundred and fifty‐one (64%), 82 (20.9%) and 59 (15.1%) women had Type 1, Type 2 and Type 3 uteri, respectively. Women with Type 1 uteri had a lower uterine weight, shorter operative time, less blood loss and lower complication rates than women with Types 2 and 3. The conversion rate to laparotomy in Type 1 was similar to that in Type 2 (odds ratio [OR] 0.98; 95% CI 0.32–3.56) but lower than Type 3 (OR 0.35; 95% CI 0.14–0.97); in Type 2 it was lower than Type 3, although without the conventional statistical significance (OR 0.36; 95% CI 0.13–1.13; P = 0.07). Multivariable analysis showed that the uterine Type (1 versus 2–3) was independently associated with the total complications rate (OR 2.00; 95% CI 1.09–3.68; P = 0.02). Conclusions The LUCS appears associated with surgical outcomes and complications, potentially stratifying the surgical risk and guiding the surgical technique in TLHs for large uteri. Tweetable abstract The Large Uterus Classification System may predict outcomes in total laparoscopic hysterectomy of large uteri. The Large Uterus Classification System may predict outcomes in total laparoscopic hysterectomy of large uteri.
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Affiliation(s)
- S Uccella
- Division of Obstetrics and Gynaecology, Department of Maternal, Neonatal and Infant Health, ASL Biella, Biella, Italy.,Department of Obstetrics and Gynaecology, AOUI Verona, University of Verona, Verona, Italy
| | - R M Kho
- Department Obstetrics and Gynecology, Women's Health Institute, Cleveland Clinic, Cleveland, OH, USA
| | - S Garzon
- Department of Obstetrics and Gynaecology, AOUI Verona, University of Verona, Verona, Italy
| | - J Casarin
- Department of Obstetrics and Gynaecology, F. Del Ponte Hospital, University of Insubria, Varese, Italy
| | - P C Zorzato
- Division of Obstetrics and Gynaecology, Department of Maternal, Neonatal and Infant Health, ASL Biella, Biella, Italy.,Department of Obstetrics and Gynaecology, AOUI Verona, University of Verona, Verona, Italy
| | - F Ghezzi
- Department of Obstetrics and Gynaecology, F. Del Ponte Hospital, University of Insubria, Varese, Italy
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23
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Radosa JC, Radosa MP, Zimmermann JSM, Braun EM, Findeklee S, Wieczorek A, Stotz L, Hamza A, Takacs FZ, Risius UM, Gerlinger C, Radosa CG, Wagenpfeil S, Solomayer EF. Incidence of and risk factors for vaginal cuff dehiscence following total laparoscopic hysterectomy: a monocentric hospital analysis. Arch Gynecol Obstet 2021; 304:447-454. [PMID: 33938997 PMCID: PMC8277650 DOI: 10.1007/s00404-021-06064-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Accepted: 04/09/2021] [Indexed: 11/27/2022]
Abstract
PURPOSE Vaginal cuff dehiscence (VCD) is one of the major surgical complications following hysterectomy with data on incidence rates varying largely and studies assessing risk factors being sparse with contradictive results. The aim of this study was to assess the incidence rate of and risk factors for VCD in a homogenous cohort of women treated for benign uterine pathologies via total laparoscopic hysterectomy (TLH) with standardized follow-up. METHODS All patients undergoing TLH at the Department of Gynecology and Obstetrics, Saarland University Hospital between November 2010 and February 2019 were retrospectively identified from a prospectively maintained service database. RESULTS VCD occurred in 18 (2.9%) of 617 patients included. In univariate and multivariate analyses, a lower level of surgeon laparoscopic expertise (odds ratio 3.19, 95% confidence interval (CI) 1.0-9.38; p = 0.03) and lower weight of removed uterus (odds ratio 0.99, 95% CI 0.98-0.99; p = 0.02) were associated positively with the risk of VCD. CONCLUSION In this homogenous cohort undergoing TLH, laparoscopic expertise and uterine weight influenced the risk of postoperative VCD. These findings might help to further reduce the rate of this complication.
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Affiliation(s)
- Julia Caroline Radosa
- Department of Gynecology and Obstetrics, Saarland University Hospital, Kirrbergerstraße 100, 66421, Homburg, Saar, Germany.
| | - Marc Philipp Radosa
- Department of Gynecology and Obstetrics, Klinikum Bremen-Nord, Bremen, Germany
| | - Julia Sarah Maria Zimmermann
- Department of Gynecology and Obstetrics, Saarland University Hospital, Kirrbergerstraße 100, 66421, Homburg, Saar, Germany
| | - Eva-Marie Braun
- Department of Gynecology and Obstetrics, Saarland University Hospital, Kirrbergerstraße 100, 66421, Homburg, Saar, Germany
| | - Sebastian Findeklee
- Department of Gynecology and Obstetrics, Saarland University Hospital, Kirrbergerstraße 100, 66421, Homburg, Saar, Germany
| | - Annette Wieczorek
- Department of Gynecology and Obstetrics, Saarland University Hospital, Kirrbergerstraße 100, 66421, Homburg, Saar, Germany
| | - Lisa Stotz
- Department of Gynecology and Obstetrics, Saarland University Hospital, Kirrbergerstraße 100, 66421, Homburg, Saar, Germany
| | - Amr Hamza
- Department of Gynecology and Obstetrics, Saarland University Hospital, Kirrbergerstraße 100, 66421, Homburg, Saar, Germany
| | - Ferenc Zoltan Takacs
- Department of Gynecology and Obstetrics, Saarland University Hospital, Kirrbergerstraße 100, 66421, Homburg, Saar, Germany
| | - Uda Mareke Risius
- Department of Business and Psychology, University of Applied Sciences Europe, Berlin, Germany
| | - Christoph Gerlinger
- Department of Gynecology and Obstetrics, Saarland University Hospital, Kirrbergerstraße 100, 66421, Homburg, Saar, Germany
| | | | - Stefan Wagenpfeil
- Institute of Medical Biometry, Epidemiology and Medical Informatics, Saarland University Hospital, Homburg, Saar, Germany
| | - Erich-Franz Solomayer
- Department of Gynecology and Obstetrics, Saarland University Hospital, Kirrbergerstraße 100, 66421, Homburg, Saar, Germany
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Stabile G, Romano F, De Santo D, Sorrentino F, Nappi L, Cracco F, Ricci G. Case Report: Bowel Occlusion Following the Use of Barbed Sutures in Abdominal Surgery. A Single-Center Experience and Literature Review. Front Surg 2021; 8:626505. [PMID: 33959630 PMCID: PMC8093862 DOI: 10.3389/fsurg.2021.626505] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Accepted: 03/11/2021] [Indexed: 12/20/2022] Open
Abstract
Introduction: A high level of surgical ability is required to perform endoscopic knot tying. Barbed sutures help in avoiding this procedure, thus reducing intraoperative time and lowering blood loss and hospitalization time when compared to traditional sutures. Some cases of bowel occlusion following the use of barbed sutures have been described in literature. All of them are characterized by the entanglement of an intestinal loop in wire barbs with bowel occlusion symptoms. Case Presentation: We report two more cases which occurred in our Institute in 2020 and review those which have been reported in the literature by searching on Pubmed, Scopus, and Embase. We used the search terms: “Barbed,” ”Suture,” “Bowel,” and ”Obstruction.” We examined in the literature the surgical procedures, the type of complications, the time to onset of the complications, and the type of barbed suture. Discussion: Twenty-two cases in total were reported in the literature from 2011 to 2020, and bowel complications were largely subsequent to interventions such as hernia surgical repair and myomectomy. In order to take advantage of barbed sutures while minimizing the risk of adverse events, such as intestinal occlusion, some precautions may be considered, such as the shortening of thread tails and use of antiadhesive barriers. Moreover, performing a few stitches backwards when ending the suture might be a useful suggestion. Further studies in this field may be useful in order to assess whether it might be better avoiding barbed suture application on serosal tissues to prevent bowel damage.
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Affiliation(s)
- Guglielmo Stabile
- Institute for Maternal and Child Health, Istituto di Ricovero e Cura a Carattere Scientifico "Burlo Garofolo", Trieste, Italy
| | - Federico Romano
- Institute for Maternal and Child Health, Istituto di Ricovero e Cura a Carattere Scientifico "Burlo Garofolo", Trieste, Italy
| | - Davide De Santo
- Institute for Maternal and Child Health, Istituto di Ricovero e Cura a Carattere Scientifico "Burlo Garofolo", Trieste, Italy
| | - Felice Sorrentino
- Department of Medical and Surgical Sciences, Institute of Obstetrics and Gynecology, University of Foggia, Foggia, Italy
| | - Luigi Nappi
- Department of Medical and Surgical Sciences, Institute of Obstetrics and Gynecology, University of Foggia, Foggia, Italy
| | - Francesco Cracco
- University Clinical Department of Medical, Surgical and Health Sciences, University of Trieste, Trieste, Italy
| | - Giuseppe Ricci
- Institute for Maternal and Child Health, Istituto di Ricovero e Cura a Carattere Scientifico "Burlo Garofolo", Trieste, Italy.,University Clinical Department of Medical, Surgical and Health Sciences, University of Trieste, Trieste, Italy
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25
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Carrubba AR, McKee DC, Wasson MN. Route of Hysterectomy: “Straight-Stick” Laparoscopy. J Gynecol Surg 2021. [DOI: 10.1089/gyn.2020.0223] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Aakriti R. Carrubba
- Department of Medical and Surgical Gynecology, Mayo Clinic, Jacksonville, Florida, USA
| | - Dana C. McKee
- Department of Medical and Surgical Gynecology, Mayo Clinic, Phoenix, Arizona, USA
| | - Megan N. Wasson
- Department of Medical and Surgical Gynecology, Mayo Clinic, Phoenix, Arizona, USA
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Frank GP, Rhemrev J, Westerterp M, English J. Recurrent vaginal cuff dehiscence after surgery for endometriosis: a technique for laparoscopic repair with an omental flap. BMJ Case Rep 2021; 14:14/3/e239540. [PMID: 33737278 PMCID: PMC7978248 DOI: 10.1136/bcr-2020-239540] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Vaginal evisceration is a rare but severe complication after hysterectomy or colpotomy and is generally successfully repaired by reapproximating healthy tissue edges of the vagina. Recurrent vaginal cuff dehiscence is problematic especially in sexually active women. We describe two cases of recurrent vaginal cuff dehiscence. The first patient had a hysterectomy for endometriosis. The second patient underwent laparoscopic excision of an endometriotic nodule at the vaginal vault. The vaginal cuff dehiscence was repaired by a laparoscopic approach employing an omental flap to enhance tissue healing. This closure technique turned out to be successful at follow-up in both cases. In case of recurrent vaginal cuff dehiscence, management options are limited. Our case report offers a laparoscopic treatment option by using an omental flap. This procedure can be used when conventional repair fails.
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Affiliation(s)
- Gerard-Peter Frank
- Obstetrics and Gynaecology, Medisch Centrum Haaglanden, The Hague, Zuid-Holland, The Netherlands
| | - Johann Rhemrev
- Obstetrics and Gynaecology, Medisch Centrum Haaglanden, The Hague, Zuid-Holland, The Netherlands.,Endometriose in Balans (referral centre), Medisch Centrum Haaglanden, The Hague, Zuid-Holland, The Netherlands
| | - Marinke Westerterp
- Surgery, Medisch Centrum Haaglanden, The Hague, Zuid-Holland, The Netherlands
| | - Jim English
- Endometriose in Balans (referral centre), Medisch Centrum Haaglanden, The Hague, Zuid-Holland, The Netherlands
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27
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Uccella S, Zorzato PC, Favilli A, Bosco M, Franchi MP, Garzon S. Regarding "Trends and Risk Factors for Vaginal Cuff Dehiscence after Laparoscopic Hysterectomy". J Minim Invasive Gynecol 2021; 28:913. [PMID: 33434697 DOI: 10.1016/j.jmig.2020.12.036] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Accepted: 12/02/2020] [Indexed: 02/06/2023]
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28
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Das D, Sinha A, Yao M, Michener CM. Author's Reply. J Minim Invasive Gynecol 2021; 28:913-914. [PMID: 33434696 DOI: 10.1016/j.jmig.2021.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Accepted: 01/07/2021] [Indexed: 11/29/2022]
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29
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Incidence and Prevention of Vaginal Cuff Dehiscence after Laparoscopic and Robotic Hysterectomy: A Systematic Review and Meta-analysis. J Minim Invasive Gynecol 2021; 28:710-720. [PMID: 33348012 DOI: 10.1016/j.jmig.2020.12.016] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Revised: 12/08/2020] [Accepted: 12/11/2020] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Vaginal cuff dehiscence, a severe and potentially detrimental complication, has significantly increased after the introduction of endoscopic hysterectomy. The aim of this systematic review and meta-analysis of the available literature was to identify the incidence of, and possible strategies to prevent, this complication after total laparoscopic hysterectomy and total robotic hysterectomy. DATA SOURCES PubMed, ClinicalTrials.gov, Scopus, and Web of Science databases were systematically queried to identify all articles reporting either laparoscopic or robot-assisted hysterectomies for benign indications in which vaginal dehiscence was reported as an outcome. Reference lists of the identified studies were manually searched. Only papers written in English were considered. METHODS OF STUDY SELECTION The Population, Intervention, Comparison, and Outcome framework for the review included (1) population of interest: women who underwent conventional and robot-assisted laparoscopic hysterectomy; (2) interventions: possible methods to prevent vaginal dehiscence; (3) comparison: experimental strategies vs standard treatment or alternative strategy for each item of intervention; and (4) outcome: rate of vaginal dehiscence. Series of subtotal hysterectomies and radical hysterectomies in addition to reports that combined both benign and malignant cases were excluded. The meta-analysis was performed using RevMan version 5.4.1 (Cochrane Training, London, United Kingdom). Two independent reviewers identified all reports comparing 2 or more possible strategies to prevent vaginal dehiscence. TABULATION, INTEGRATION, AND RESULTS A total of 460 articles were identified. Of these, 20 (6 randomized, 2 prospective, and 12 retrospective) studies were included in this review for a total of 19 392 patients. The incidence of vaginal dehiscence after total laparoscopic hysterectomy ranged between 0.64% and 1.35%. Robotic hysterectomy was associated with a risk of vaginal dehiscence of approximately 1.64%. No study compared early vs delayed resumption of coital activity nor analyzed the role of training in laparoscopic suturing. No study specifically assessed the impact of electrosurgery on the risk of vaginal dehiscence in endoscopic hysterectomies for benign indications. Double-layer and reinforced sutures did not decrease the risk of dehiscence. Barbed sutures reduced the risk of separation compared with nonbarbed closure (0.4% [4/1108] vs 2% [22/1097]; odds ratio [OR] 0.25; 95% confidence interval [CI], 0.11-0.57). However, these data came mainly from retrospective series. Excluding studies on the use of self-anchoring sutures during robotic hysterectomy, there was no significant difference in the risk of dehiscence between barbed and nonbarbed sutures (0.5% [4/890] vs 1.4% [181/776]; OR 0.38; 95% CI, 0.13-1.10). Transvaginal suture of the vault at the end of an endoscopic hysterectomy seemed to increase the risk of dehiscence when compared with laparoscopic closure (2.3% [23/1002] vs 1.16% [11/944]; OR 1.97; 95% CI, 1.00-3.88). CONCLUSION There is a paucity of high-quality papers evaluating vaginal dehiscence and possible prevention strategies in the current literature. Only 2 effective strategies have been identified in reducing the risk for this complication: the use of barbed sutures and the adoption of a laparoscopic approach to close the vaginal cuff. When restricting the analysis only to laparoscopic cases, the use of barbed sutures does not protect against vaginal cuff separation.
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Balafoutas D, Wöckel A, Wulff C, Joukhadar R. Implementation of robotic gynecological surgery in a German University Hospital: patient safety after 110 procedures. Arch Gynecol Obstet 2020; 302:1381-1388. [PMID: 32844240 PMCID: PMC7584536 DOI: 10.1007/s00404-020-05751-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2020] [Accepted: 08/13/2020] [Indexed: 11/30/2022]
Abstract
PURPOSE Robotic surgery represents the latest development in the field of minimally invasive surgery and offers many technical advantages. Despite the higher costs, this novel approach has been applied increasingly in gynecological surgery. Regarding the implementation of a new operative method; however, the most important factor to be aware of is patient safety. In this study, we describe our experience in implementing robotic surgery in a German University Hospital focusing on patient safety after 110 procedures. METHODS We performed a retrospective analysis of 110 consecutive robotic procedures performed in the University Hospital of Würzburg between June 2017 and September 2019. During this time, 37 patients were treated for benign general gynecological conditions, 27 patients for gynecological malignancies, and 46 patients for urogynecological conditions. We evaluated patient safety through standardized assessment of intra- and postoperative complications, which were categorized according to the Clavien-Dindo classification. RESULTS No complications were recorded in 90 (81.8%) operations. We observed Clavien-Dindo grade I complications in 8 (7.3%) cases, grade II complications in 5 (4.5%) cases, grade IIIa complications in 1 case (0.9%), and grade IIIb complications in 6 (5.5%) cases. No conversion to laparotomy or blood transfusion was needed. CONCLUSION Robotic surgery could be implemented for complex gynecological operations without relevant problems and was accompanied by low complication rates.
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Affiliation(s)
- Dimitrios Balafoutas
- Department of Obstetrics and Gynecology, University Hospital of Würzburg, Josef-Schneider-Str. 4, 97080, Würzburg, Germany.
| | - Achim Wöckel
- Department of Obstetrics and Gynecology, University Hospital of Würzburg, Josef-Schneider-Str. 4, 97080, Würzburg, Germany
| | - Christine Wulff
- Department of Obstetrics and Gynecology, University Hospital of Würzburg, Josef-Schneider-Str. 4, 97080, Würzburg, Germany
| | - Ralf Joukhadar
- Department of Obstetrics and Gynecology, University Hospital of Würzburg, Josef-Schneider-Str. 4, 97080, Würzburg, Germany
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Colombo PE, Nguyen VH, Taoum C, Mourregot A, Neron M, Kerr C, Rouanet P, Carrier G. Robotic Radical Hysterectomy for Cervical Adenocarcinoma after Preoperative Brachytherapy in 10 Steps. J Minim Invasive Gynecol 2020; 28:1138-1139. [PMID: 33031927 DOI: 10.1016/j.jmig.2020.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 09/27/2020] [Accepted: 10/01/2020] [Indexed: 11/19/2022]
Abstract
STUDY OBJECTIVE Minimally invasive surgery decreases postoperative morbidity after radical hysterectomy (RH) for early-stage cervical cancer. However, a randomized trial and large retrospective data question its safety after observing lower rates of survival than open surgery [1,2]. The causes of this higher recurrence rate are not definitely established but may result from cancer exposure to the peritoneum during vaginal section and cancerous cells' spillage enhanced by pneumoperitoneum or a uterine manipulator. The aim of this surgical video was to present a standardized step-by-step approach for robotic RH according to the recent recommendations from the ARCAGY -Group of National Investigators for the Study of Ovarian and Breast Cancers surgeon's group [3]. DESIGN Step-by-step video demonstration of the technique. SETTING Tertiary center specialized in gynecologic oncology and minimally invasive surgery. INTERVENTIONS A 48-year-old woman was diagnosed with a stage IB2 endocervical adenocarcinoma (International Federation of Gynecology and Obstetrics 2018) with a tumor size of 27 mm. Surgery was planned after preoperative pulsed dose rate uterovaginal brachytherapy. Surgery was performed following 10 reproducible steps: • Pelvic sentinel node identification according to the SENTICOL-III trial • Right infundibulopelvic and round ligaments transection • Right uterine vessels transection • Parametrectomy • Right uterosacral ligament transection • Bladder mobilization • Identical left dissection • Rectovaginal space development • Colpectomy by vaginal route after complete pneumoperitoneum exsufflation • Robotic vaginal cuff closure and pelvic inspection Thorough robotically assisted vaginal cuff closure was carried out as a comparative study suggesting that abdominal closure may decrease vaginal complications and dehiscence [3]. CONCLUSION No international recommendations for the RH approach have yet been endorsed. Patients must be clearly informed about the benefit-risk ratio of the surgical route. If a minimally invasive RH is still decided, the patient should be referred to experienced centers, and precautionary measures must be implemented [4]. Colpotomy by vaginal route without pneumoperitoneum is recommended. Uterine manipulators have to be strictly avoided. Preoperative brachytherapy has been reported in experienced centers in France with favorable histologic response with high rates of pathologic complete response (near 70%) and seems particularly worthwhile for tumor sizes ranging from 2 to 4 cm or presenting with lymphovascular invasion [5].
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Affiliation(s)
- Pierre-Emmanuel Colombo
- Departments of Surgical Oncology (Drs. Colombo, Nguyen, Taoum, Mourregot, Neron, Rouanet, and Carrier).
| | - Van-Ha Nguyen
- Departments of Surgical Oncology (Drs. Colombo, Nguyen, Taoum, Mourregot, Neron, Rouanet, and Carrier)
| | - Christophe Taoum
- Departments of Surgical Oncology (Drs. Colombo, Nguyen, Taoum, Mourregot, Neron, Rouanet, and Carrier)
| | - Anne Mourregot
- Departments of Surgical Oncology (Drs. Colombo, Nguyen, Taoum, Mourregot, Neron, Rouanet, and Carrier)
| | - Mathias Neron
- Departments of Surgical Oncology (Drs. Colombo, Nguyen, Taoum, Mourregot, Neron, Rouanet, and Carrier)
| | - Christine Kerr
- Radiotherapy (Dr. Kerr), Montpellier Cancer Institute - Val d'Aurelle, Montpellier, France
| | - Philippe Rouanet
- Departments of Surgical Oncology (Drs. Colombo, Nguyen, Taoum, Mourregot, Neron, Rouanet, and Carrier)
| | - Guillaume Carrier
- Departments of Surgical Oncology (Drs. Colombo, Nguyen, Taoum, Mourregot, Neron, Rouanet, and Carrier)
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A Laparoscopic Approach to Postcoital Vaginal Perforation in an Adolescent with Peritonitis and Hypovolemic Shock. J Pediatr Adolesc Gynecol 2020; 33:594-598. [PMID: 32416268 DOI: 10.1016/j.jpag.2020.05.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 04/25/2020] [Accepted: 05/01/2020] [Indexed: 11/24/2022]
Abstract
BACKGROUND Vaginal laceration during coitus is not a rare occurrence; however, vaginal perforation from coitus is uncommon and occurs in less than 1% of nonobstetric genital tract injuries. Limited case reports exist discussing the recognition and management of vaginal perforation. Previously described management is commonly performed with laparotomy. CASE We report a case of postcoital vaginal laceration and posterior fornix perforation in an adolescent with hemoperitoneum, pneumoperitoneum, and subsequent hypovolemic shock, and describe a laparoscopic approach for repair. SUMMARY AND CONCLUSION Vaginal perforation with subsequent peritonitis and hemodynamic instability is a rare outcome in an adolescent who presents to the emergency department with pain or bleeding in the setting of recent penile intercourse. Delays in recognition can lead to further patient compromise, with potential morbidity or mortality. In this patient cohort, we suggest maintaining a high clinical suspicion for this sequela, and a low threshold for surgery with perforations greater than 1 cm. In the event that surgical management is warranted, we recommend a laparoscopic approach to increase visibility and to improve postoperative outcomes.
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33
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Das D, Sinha A, Yao M, Michener CM. Trends and Risk Factors for Vaginal Cuff Dehiscence after Laparoscopic Hysterectomy. J Minim Invasive Gynecol 2020; 28:991-999.e1. [PMID: 32920145 DOI: 10.1016/j.jmig.2020.09.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 08/15/2020] [Accepted: 09/08/2020] [Indexed: 12/16/2022]
Abstract
STUDY OBJECTIVE The primary objective was to assess the effect of the route of closure of the vaginal cuff on the incidence of vaginal cuff dehiscence (VCD) in laparoscopic hysterectomy (LH). The secondary objective was to assess patient- and surgical-risk factors associated with VCD, rate of perioperative complications by route of closure, and impact of surgeon volume on complications. DESIGN Retrospective chart review with case-control component. SETTING Tertiary care center (main hospital and regional hospitals). PATIENTS A total of 1278 women underwent LH or robot-assisted hysterectomy in 2016, and met the inclusion criteria. Independently, 26 cases of VCD were identified from 2009 through 2016. INTERVENTIONS A retrospective comparison of patients with vaginal cuff closure and laparoscopic cuff closure (LCC) undergoing LH or robot-assisted hysterectomy in 2016. Patients with VCD from 2009 through 2016 (n = 26) were matched by route of cuff closure to the next 7 patients who underwent hysterectomies (n = 182), who became controls. MEASUREMENTS AND MAIN RESULTS In 2016, there were 9 cases of VCD (0.70%). There was no significant difference in VCD between LCC (8/989; 0.81%) and vaginal cuff closure (1/289; 0.35%; p = .41). Seven VCD cases were performed by high-volume surgeons (>30 hysterectomies per year) who were more likely to perform LCC and use barbed suture. There were no significant differences in the rates of perioperative complications or surgeon volume between routes of cuff closure. The case-control patients differed in smoking status (p = .010) and history of prior laparotomy (p = .017). Logistic regression showed that increasing age (odds ratio 0.95; 95% confidence interval, 0.91-0.99) and increasing body mass index (odds ratio 0.98; 95% confidence interval, 0.83-0.97) were protective for VCD. CONCLUSION VCD is a rare but serious complication of LH. Despite previous studies, we did not find a significant difference in VCD or intra- and perioperative complications by route of cuff closure or surgeon volume. Given the lack of evidence favoring one route of cuff closure, we recommend that, to optimize patient outcomes, surgeons employ the closure technique that they are best accustomed to.
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Affiliation(s)
- Deepanjana Das
- Department of Obstetrics and Gynecology, Women's Health Institute (Drs. Das, Sinha, and Michener).
| | - Annika Sinha
- Department of Obstetrics and Gynecology, Women's Health Institute (Drs. Das, Sinha, and Michener)
| | - Meng Yao
- Department of Quantitative Health Sciences (Mr. Yao), Cleveland Clinic, Cleveland, Ohio
| | - Chad M Michener
- Department of Obstetrics and Gynecology, Women's Health Institute (Drs. Das, Sinha, and Michener)
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Barreras González JE, Díaz Ortega I, Castillo Sánchez Y, Pereira Fraga JG, López Milhet AB. Laparoscopic Hysterectomy for 2780 Patients: In Havana's National Center for Minimally Invasive Surgery. J Gynecol Surg 2020. [DOI: 10.1089/gyn.2019.0069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Javier Ernesto Barreras González
- Department of Laparoscopic and Endoscopic Surgery, National Center for Minimally Invasive Surgery, Havana Medical University, Havana, Cuba
| | - Israel Díaz Ortega
- Department of Laparoscopic and Endoscopic Surgery, National Center for Minimally Invasive Surgery, Havana Medical University, Havana, Cuba
| | - Yuderkis Castillo Sánchez
- Department of Laparoscopic and Endoscopic Surgery, National Center for Minimally Invasive Surgery, Havana Medical University, Havana, Cuba
| | - Jorge Gerardo Pereira Fraga
- Department of Laparoscopic and Endoscopic Surgery, National Center for Minimally Invasive Surgery, Havana Medical University, Havana, Cuba
| | - Ana Bertha López Milhet
- Department of Laparoscopic and Endoscopic Surgery, National Center for Minimally Invasive Surgery, Havana Medical University, Havana, Cuba
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Neron M, Lambaudie E, Thezenas S, Leaha C, Kerr C, Gonzague L, Provansal M, Colombo PE, Fabbro M. Impact of time to radiation therapy in adjuvant settings in endometrial carcinoma: A multicentric retrospective study. Eur J Obstet Gynecol Reprod Biol 2020; 247:121-126. [PMID: 32088529 DOI: 10.1016/j.ejogrb.2020.02.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2019] [Revised: 02/09/2020] [Accepted: 02/11/2020] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Time to adjuvant treatment could have an impact on cancer prognosis. It is possible that robotic surgery lengthens the healing time of vaginal cuff after minimally invasive hysterectomy. The objective of this study was to state the impact of time to RT (TTR) on prognosis in endometrial carcinoma (EC) patients and to assess variables associated with TTR. STUDY DESIGN We conducted a multicentric retrospective study in two cancer centers. We included EC patients, between January 1996 and January 2016. We searched variables associated with TTR and impact of TTR on end-points: local recurrence-free survival, metastatic-free survival, event-free survival and overall survival. RESULTS 329 patients were included and 279 were analyzed for TTR impact. Robotic surgery was associated with shorter TTR (8 weeks, 8.9 w for laparotomy, 9.2 w for laparoscopy). Pelvic lymphadenectomy, para-aortic lymphadenectomy, discussion in multidisciplinary meeting and treatment center was independently associated with TTR. No impact of TTR was shown on metastatic-free survival, event-free survival and overall survival but there was a trend of a decreased local recurrence rate in case of prolonged TTR (HRcontinuous variable = 1.08; CI95 %: 0.97-1.2). CONCLUSION Our study did not show any impact of treatment delay on survival end-points although prolonged TTR could moderate the benefit of radiotherapy on local control rate. Surgical route was not associated with TTR, particularly robot-associated laparoscopy did not lengthen treatment delay. TTR seems dependent of health-care organization and could represent a quality criterion of EC care for institutions.
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Affiliation(s)
- Mathias Neron
- Department of Surgical Oncology, Institut du Cancer de Montpellier, Univ Montpellier, 34000 Montpellier, France.
| | - Eric Lambaudie
- Department of Surgical Oncology, Aix-Marseille Univ, Inserm, CNRS, Institut Paoli-Calmettes, CRCM, 13000 Marseille, France
| | - Simon Thezenas
- Department of Biostatistics, Institut du Cancer de Montpellier, 34000 Montpellier, France
| | - Cristina Leaha
- Department of Pathology, Institut du Cancer de Montpellier, 34000 Montpellier, France
| | - Christine Kerr
- Department of Radiation Oncology, Institut du Cancer de Montpellier, 34000 Montpellier, France
| | - Laurence Gonzague
- Department of Radiation Oncology, Aix-Marseille Univ, Institut Paoli-Calmettes, 13000 Marseille, France
| | - Magali Provansal
- Department of Medical Oncology, Aix-Marseille Univ, Institut Paoli-Calmettes, 13000 Marseille, France
| | - Pierre-Emmanuel Colombo
- Department of Surgical Oncology, Institut du Cancer de Montpellier, Univ Montpellier, 34000 Montpellier, France
| | - Michel Fabbro
- Department of Medical Oncology, Institut du Cancer de Montpellier, 34000 Montpellier, France
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Gueli Alletti S, Perrone E, Cretì A, Cianci S, Uccella S, Fedele C, Fanfani F, Palmieri S, Fagotti A, Scambia G, Rossitto C. Feasibility and perioperative outcomes of percutaneous-assisted laparoscopic hysterectomy: A multicentric Italian experience. Eur J Obstet Gynecol Reprod Biol 2020; 245:181-185. [DOI: 10.1016/j.ejogrb.2019.12.020] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Revised: 12/16/2019] [Accepted: 12/23/2019] [Indexed: 01/25/2023]
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Uccella S, Capozzi VA, Ricco’ M, Perrone E, Zanello M, Ferrari S, Zorzato PC, Seracchioli R, Cromi A, Serati M, Ergasti R, Fanfani F, Berretta R, Malzoni M, Cianci S, Vizza E, Guido M, Legge F, Ciravolo G, Gueli Alletti S, Ghezzi F, Candiani M, Scambia G. Sexual Function following Laparoscopic versus Transvaginal Closure of the Vaginal Vault after Laparoscopic Hysterectomy: Secondary Analysis of a Randomized Trial by the Italian Society of Gynecological Endoscopy Using a Validated Questionnaire. J Minim Invasive Gynecol 2020; 27:186-194. [PMID: 30951920 DOI: 10.1016/j.jmig.2019.03.018] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Revised: 03/25/2019] [Accepted: 03/26/2019] [Indexed: 11/27/2022]
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Demirayak G, Özdemir İA, Comba C, Aslan Çetin B, Aydogan Mathyk B, Yıldız M, Mihmanlı V, Karaca İ, Öztürk M, Güralp O. Comparison of laparoendoscopic single-site (LESS) surgery and conventional multiport laparoscopic (CMPL) surgery for hysterectomy: long-term outcomes of abdominal incisional scar. J OBSTET GYNAECOL 2019; 40:217-221. [DOI: 10.1080/01443615.2019.1606183] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Gökhan Demirayak
- Department of Gynecologic Oncology, Health Sciences University, Bakırköy Dr Sadi Konuk Education and Research Hospital, Istanbul, Turkey
| | - İsa Aykut Özdemir
- Department of Gynecologic Oncology, Health Sciences University, Bakırköy Dr Sadi Konuk Education and Research Hospital, Istanbul, Turkey
| | - Cihan Comba
- Department of Gynecologic Oncology, Health Sciences University, Bakırköy Dr Sadi Konuk Education and Research Hospital, Istanbul, Turkey
| | - Berna Aslan Çetin
- Department of Obstetrics and Gynecology, Health Sciences University, Kanuni Sultan Suleyman Education and Research Hospital, Istanbul, Turkey
| | - Begüm Aydogan Mathyk
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University of North Carolina, Chapel Hill, NC, USA
| | - Mustafa Yıldız
- Department of Obstetrics and Gynecology, Health Sciences University, Okmeydanı Education and Research Hospital, Istanbul, Turkey
| | - Veli Mihmanlı
- Department of Obstetrics and Gynecology, Health Sciences University, Okmeydanı Education and Research Hospital, Istanbul, Turkey
| | - İbrahim Karaca
- Department of Obstetrics and Gynecology, Health Sciences University, Bakırköy Dr Sadi Konuk Education and Research Hospital, Istanbul, Turkey
| | - Mustafa Öztürk
- Department of Obstetrics and Gynecology, Health Sciences University, Gulhane Education and Research Hospital, Ankara, Turkey
| | - Onur Güralp
- Department of Obstetrics and Gynecology, Oldenburg University, Oldenburg, Germany
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Gencdal S, Demirel E, Soyman Z, Kelekci S. Prophylactic McCall Culdoplasty by a Vaginal Approach during Mini-Laparoscopic Hysterectomy. BIOMED RESEARCH INTERNATIONAL 2019; 2019:8047924. [PMID: 31236413 PMCID: PMC6545777 DOI: 10.1155/2019/8047924] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/22/2018] [Revised: 04/14/2019] [Accepted: 05/02/2019] [Indexed: 12/31/2022]
Abstract
BACKGROUND In gynecological surgery, one particular area of concern after hysterectomy is the risk of developing an enterocele or vaginal apical prolapse. The aims of this study were to evaluate the safety and efficacy of prophylactic McCall culdoplasty (MC) performed during mini-total laparoscopic hysterectomy (mini-TLH), as well as to compare the differences in apical support, total vaginal length (TVL), and sexual function at one and two years postoperatively. METHODS Data were retrospectively reviewed for all women who underwent mini-TLH and mini-TLH + MC at a tertiary care center between August 2012 and January 2016 were from the hospital database. There were 18 women who underwent mini-TLH + MC and were considered as the study group, while 20 women who were treated with mini-TLH were considered as the control group. The primary outcome measures were the differences in apical support and TVL and impact on sexual function. RESULTS After mini-TLH + MC, the apical vaginal support difference was improved by 2.2 cm. The mean difference in C point was 1.03 cm in the mini-TLH group, which was not significant at two years after the operation. The vaginal vault descent at two years after operation was more prominent in the mini-TLH group than the mini-TLH + MC groups. Apical support changes at two years after the operation were more prominent in the mini-TLH group (0.5 ± 0.6 cm) than the mini-TLH + MC group (1.9 ± 1.2 cm). CONCLUSION Prophylactic MC by a vaginal approach during mini-TLH is safe, satisfactory, and efficient for apical support without severe morbidity.
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Affiliation(s)
- Servet Gencdal
- Izmir Katip Celebi University, Atatürk Education and Research Hospital, Department of Obstetrics and Gynecology, Izmir, Turkey
| | - Emine Demirel
- Izmir Katip Celebi University, Atatürk Education and Research Hospital, Department of Obstetrics and Gynecology, Izmir, Turkey
| | - Zeynep Soyman
- Istanbul Education and Research Hospital, Department of Obstetrics and Gynecology, Istanbul, Turkey
| | - Sefa Kelekci
- Izmir Katip Celebi University, Atatürk Education and Research Hospital, Department of Obstetrics and Gynecology, Izmir, Turkey
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Thurston J, Murji A, Scattolon S, Wolfman W, Kives S, Sanders A, Leyland N. No 377- Indications gynécologiques bénignes de l'hystérectomie. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2019; 41:558-574. [DOI: 10.1016/j.jogc.2019.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Thurston J, Murji A, Scattolon S, Wolfman W, Kives S, Sanders A, Leyland N. No. 377-Hysterectomy for Benign Gynaecologic Indications. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2019; 41:543-557. [DOI: 10.1016/j.jogc.2018.12.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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MacKoul P, Danilyants N, Sarfoh V, van der Does L, Kazi N. A Retrospective Review of Vaginal Cuff Dehiscence: Comparing Absorbable and Nonabsorbable Sutures. J Minim Invasive Gynecol 2019; 27:122-128. [PMID: 30853572 DOI: 10.1016/j.jmig.2019.03.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Revised: 02/28/2019] [Accepted: 03/01/2019] [Indexed: 11/26/2022]
Abstract
STUDY OBJECTIVE To compare the rate of spontaneous and complete vaginal cuff dehiscence (VCD) using absorbable versus nonabsorbable sutures for vaginal cuff closure. DESIGN Retrospective comparative cohort design. SETTING Freestanding ambulatory surgery center in suburban Maryland. PATIENTS Women age >18 years old who underwent hysterectomy for benign conditions between October 2013 and April 2018. INTERVENTION Laparoscopic retroperitoneal hysterectomy was performed by 2 gynecologic surgical specialists. Transvaginal cuff closure was performed using either absorbable Vicryl (polyglactin 910) sutures (n = 881) or nonabsorbable Ethibond (polyester) sutures (n = 574). The nonabsorbable sutures were surgically removed after 90 days. MEASUREMENTS AND MAIN RESULTS No statistically significant differences in age, race, weight, body mass index, parity, uterine weight, or number of comorbidities were noted between the nonabsorbable and absorbable suture groups. Spontaneous vaginal cuff dehiscence (VCD) occurred in 3 patients (0.52%) in the nonabsorbable group and in 12 patients (1.4%) in the absorbable group (p = .183). Eleven of the 12 cases of VCD in the absorbable group were precipitated by intercourse and occurred within 90 days of surgery. CONCLUSION Our data suggest that use of a nonabsorbable suture may be an effective approach to prevent spontaneous VCD, but the benefits should be weighed against the inherent risk associated with a second procedure to remove sutures.
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Suzuki Y, Imai Y, Ruiz‐Yokota N, Miyagi E. Laparoscopic repair of the vaginal cuff dehiscence: Dehiscence occurring after the first sexual intercourse after the laparoscopic modified radical hysterectomy. Clin Case Rep 2018; 6:2495-2497. [PMID: 30564356 PMCID: PMC6293150 DOI: 10.1002/ccr3.1906] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Revised: 09/26/2018] [Accepted: 10/18/2018] [Indexed: 11/11/2022] Open
Abstract
Total vaginal cuff dehiscence (VCD) is an important adverse event after hysterectomy. Here, we showed two cases in whom laparoscopic repair of VCD was successful. This procedure is effective, safe, and thus minimally invasive for patients after hysterectomy.
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Affiliation(s)
- Yukio Suzuki
- The Department of Obstetrics and GynecologyYokohama City University Graduate School of MedicineYokohamaJapan
| | - Yuichi Imai
- The Department of Obstetrics and GynecologyYokohama City University Graduate School of MedicineYokohamaJapan
| | - Naho Ruiz‐Yokota
- The Department of Obstetrics and GynecologyYokohama City University Graduate School of MedicineYokohamaJapan
| | - Etsuko Miyagi
- The Department of Obstetrics and GynecologyYokohama City University Graduate School of MedicineYokohamaJapan
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López CC, Ríos JFDL, González Y, Vásquez-Trespalacios EM, Serna D, Arango A, Cifuentes C, Vásquez R, Castañeda JD, Almanza LA, Jiménez LA. Barbed Suture versus Conventional Suture for Vaginal Cuff Closure in Total Laparoscopic Hysterectomy: Randomized Controlled Clinical Trial. J Minim Invasive Gynecol 2018; 26:1104-1109. [PMID: 30414998 DOI: 10.1016/j.jmig.2018.08.030] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Revised: 08/15/2018] [Accepted: 08/20/2018] [Indexed: 02/08/2023]
Abstract
STUDY OBJECTIVE To determine the surgical time, suture time, presence of postoperative dyspareunia, and complications that occur after closing the vaginal cuff with a barbed suture compared with conventional suture. DESIGN A randomized, controlled clinical trial (Canadian Task Force classification I). SETTING Private gynecologic clinic in Medellin, Colombia. PATIENTS One hundred fifty women who underwent total laparoscopic hysterectomy for benign pathology. INTERVENTIONS The patients underwent total laparoscopic hysterectomy with intracorporeal closure of the vaginal cuff and were randomized to 2 groups, 1 using a barbed suture (V-Loc 90; Medtronic/Covidien, New Haven, CT) and 1 using polyglactin 910 (coated Vicryl suture; Ethicon/Johnson & Johnson, New Brunswick, NJ). MEASUREMENTS AND MAIN RESULTS The total operative time, closing time of the vaginal vault, presence of complications in the cuff, and incidence of postoperative dyspareunia were recorded. The patients were evaluated at a postoperative office visit 2 weeks after the procedure and by telephone interview at 24 weeks. Seventy-five patients were included in the barbed suture group and 75 patients in the polyglactin 910 group. The average time to complete the suture of the vaginal cuff was 12.01 minutes (± 5.37 standard deviation) for the barbed suture group versus 13.49 minutes (± 6.48) in the polyglactin 910 group (95% confidence interval, -.44 to 3.4; p = .130). Blood loss was 31.56 ± 22.93 mL in the barbed suture group versus 30.82 ± 21.75 mL in the polyglactin 910 group (95% confidence interval, -7.95 to 6.47; p = .840). The frequency of postoperative events such as hematoma, cellulitis, cuff dehiscence, fever, emergency consultation, and hospitalization was not statistically significant between groups. No statistically significant difference was found regarding deep dyspareunia at 24 postoperative weeks. CONCLUSION No differences were found in surgical time or frequency of adverse events when comparing patients after vaginal cuff closure with barbed suture versus polyglactin 910.
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Affiliation(s)
- Claudia C López
- Clinica del Prado (Drs. López, De Los Ríos, Arango, Cifuentes, Vásquez, Castañeda, Almanza, and Jiménez), Medellín, Colombia, and the School of Medicine (Drs. González, Vásquez-Trespalacios, and Serna), CES University, Medellín, Colombia
| | - José F De Los Ríos
- Clinica del Prado (Drs. López, De Los Ríos, Arango, Cifuentes, Vásquez, Castañeda, Almanza, and Jiménez), Medellín, Colombia, and the School of Medicine (Drs. González, Vásquez-Trespalacios, and Serna), CES University, Medellín, Colombia
| | - Yenyffer González
- Clinica del Prado (Drs. López, De Los Ríos, Arango, Cifuentes, Vásquez, Castañeda, Almanza, and Jiménez), Medellín, Colombia, and the School of Medicine (Drs. González, Vásquez-Trespalacios, and Serna), CES University, Medellín, Colombia
| | - Elsa María Vásquez-Trespalacios
- Clinica del Prado (Drs. López, De Los Ríos, Arango, Cifuentes, Vásquez, Castañeda, Almanza, and Jiménez), Medellín, Colombia, and the School of Medicine (Drs. González, Vásquez-Trespalacios, and Serna), CES University, Medellín, Colombia..
| | - Daniel Serna
- Clinica del Prado (Drs. López, De Los Ríos, Arango, Cifuentes, Vásquez, Castañeda, Almanza, and Jiménez), Medellín, Colombia, and the School of Medicine (Drs. González, Vásquez-Trespalacios, and Serna), CES University, Medellín, Colombia
| | - Adriana Arango
- Clinica del Prado (Drs. López, De Los Ríos, Arango, Cifuentes, Vásquez, Castañeda, Almanza, and Jiménez), Medellín, Colombia, and the School of Medicine (Drs. González, Vásquez-Trespalacios, and Serna), CES University, Medellín, Colombia
| | - Carolina Cifuentes
- Clinica del Prado (Drs. López, De Los Ríos, Arango, Cifuentes, Vásquez, Castañeda, Almanza, and Jiménez), Medellín, Colombia, and the School of Medicine (Drs. González, Vásquez-Trespalacios, and Serna), CES University, Medellín, Colombia
| | - Ricardo Vásquez
- Clinica del Prado (Drs. López, De Los Ríos, Arango, Cifuentes, Vásquez, Castañeda, Almanza, and Jiménez), Medellín, Colombia, and the School of Medicine (Drs. González, Vásquez-Trespalacios, and Serna), CES University, Medellín, Colombia
| | - Juan D Castañeda
- Clinica del Prado (Drs. López, De Los Ríos, Arango, Cifuentes, Vásquez, Castañeda, Almanza, and Jiménez), Medellín, Colombia, and the School of Medicine (Drs. González, Vásquez-Trespalacios, and Serna), CES University, Medellín, Colombia
| | - Luis A Almanza
- Clinica del Prado (Drs. López, De Los Ríos, Arango, Cifuentes, Vásquez, Castañeda, Almanza, and Jiménez), Medellín, Colombia, and the School of Medicine (Drs. González, Vásquez-Trespalacios, and Serna), CES University, Medellín, Colombia
| | - Luis A Jiménez
- Clinica del Prado (Drs. López, De Los Ríos, Arango, Cifuentes, Vásquez, Castañeda, Almanza, and Jiménez), Medellín, Colombia, and the School of Medicine (Drs. González, Vásquez-Trespalacios, and Serna), CES University, Medellín, Colombia
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Uccella S, Federico A, Scambia G. Reducing the Rate of Minimally Invasive Hysterectomy for Fibroids in Favor of Abdominal Surgery-There Is Always Something Evil in Good Intentions. JAMA Surg 2018; 153:1063. [PMID: 30140907 DOI: 10.1001/jamasurg.2018.2732] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Stefano Uccella
- Department of Woman and Child Health, Fondazione Policlinico Universitario A. Gemelli, Università Cattolica del Sacro Cuore, IRCCS, Rome, Italy
| | - Alex Federico
- Department of Woman and Child Health, Fondazione Policlinico Universitario A. Gemelli, Università Cattolica del Sacro Cuore, IRCCS, Rome, Italy
| | - Giovanni Scambia
- Department of Woman and Child Health, Fondazione Policlinico Universitario A. Gemelli, Università Cattolica del Sacro Cuore, IRCCS, Rome, Italy
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Ala‐Nissilä S, Laurikainen E, Mäkinen J, Jokimaa V. Vaginal cuff dehiscence is observed in a higher rate after total laparoscopic hysterectomy compared with other types of hysterectomy. Acta Obstet Gynecol Scand 2018; 98:44-50. [DOI: 10.1111/aogs.13459] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2018] [Revised: 08/28/2018] [Accepted: 09/05/2018] [Indexed: 11/29/2022]
Affiliation(s)
- Seija Ala‐Nissilä
- Department of Obstetrics and Gynecology Turku University Hospital Turku Finland
| | - Eija Laurikainen
- Department of Obstetrics and Gynecology Turku University Hospital Turku Finland
| | - Juha Mäkinen
- Department of Obstetrics and Gynecology Turku University Hospital Turku Finland
| | - Varpu Jokimaa
- Department of Obstetrics and Gynecology Turku University Hospital Turku Finland
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