A simplified method to decrease operative blood loss in laparoscopic-assisted vaginal hysterectomy for the large uterus

A double-blind randomized trial on subendometrial injection of vasopressin to control bleeding in postpartum hysterectomy due to abnormally invasive placenta

OBJECTIVE

To investigate the effect of subendometrial vasopressin injection in patients with abnormally invasive placenta (AIP), who underwent cesarean section and hysterectomy.

METHODS

This randomized double-blinded clinical trial was conducted on pregnant women diagnosed with AIP grade 4 and 5 by ultrasonography during cesarean section. Women were randomly divided into two equal groups including group 1 (vasopressin) and group 2 (control) who underwent 20 units of vasopressin and 20 cc normal saline injection, respectively. Vasopressin and placebo were injected subendometrially 1 cm medial to the uterine vessels into the lower uterine segment. The exclusion criteria include presence of myocardial infarction, cardiomyopathy, congestive heart failure, uncontrolled hypertension, chronic obstructive pulmonary disease, pelvic malignancy. The outcome of the study was total quantitative blood loss during the cesarean section. We estimated blood loss by measuring the blood volume in one of the suction bottles with addition for weight changes of mops, pads, and soaked linen savers.

RESULTS

Sixty patients were recruited into the study, 30 as the vasopressin group and 30 as the controls; with no excluded case. The amount of bleeding in the vasopressin group was significantly lower compared with that in the control group (P < 0.001). In the vasopressin group, 83.4% of patients had bleeding of less than 1.5 L, while only 3.3% of the control women had bleeding of less than 1.5 L (relative risk = 5). In addition, the number of injected packed cells was lower in the vasopressin group (P < 0.001).

CONCLUSION

It was shown that vasopressin injection can help prevent excess hemorrhage and the subsequent risks of anemia or blood transfusions during abdominal hysterectomy in women with AIP.

Evaluating efficacy of intravenous carbetocin in reducing blood loss during abdominal myomectomy: a randomized controlled trial

OBJECTIVE

To evaluate the efficacy of carbetocin versus placebo in decreasing intraoperative blood loss and the need for blood transfusion during abdominal myomectomy.

DESIGN

Randomized, double-blind, placebo-controlled trial.

SETTING

Tertiary university hospital from September 2019 to February 2020.

PATIENT(S)

A total of 138 women with symptomatic leiomyoma who were candidates for abdominal myomectomy (n = 69 in each group).

INTERVENTION(S)

We randomized the study participants in a 1:1 ratio to carbetocin and placebo groups. Intravenous 100 μg carbetocin or placebo was administered slowly after induction of anesthesia.

MAIN OUTCOME MEASURE(S)

Intraoperative blood loss, need for blood transfusion, postoperative hemoglobin, operative time, length of hospitalization, and drug side-effects.

RESULT(S)

The baseline characteristics were similar among all groups. Carbetocin had significantly lower intraoperative blood loss compared with placebo (mean difference 184 mL). Hemoglobin level 24 hours after surgery was significantly lower in the placebo group than in the carbetocin group (9.1 ± 0.8 vs. 10.3 ± 0.6 g/dL). Eight women in the carbetocin group needed blood transfusion compared with 17 in placebo group. Operative time, length of hospitalization, and side-effects were similar in both groups.

CONCLUSION(S)

A single preoperative intravenous dose of 100 μg carbetocin is a simple, practical, and effective method of decreasing intraoperative blood loss and the need for blood transfusion during abdominal myomectomy, with tolerable, few, nonsignificant side-effects.

CLINICAL TRIAL REGISTRATION NUMBER

NCT04083625.

Perioperative Interventions to Minimize Blood Loss at the Time of Hysterectomy for Uterine Leiomyomas: A Systematic Review and Meta-analysis

STUDY OBJECTIVE

Hysterectomy for uterine leiomyoma(s) is associated with significant morbidity including blood loss. A systematic review and meta-analysis was conducted to identify nonhormonal interventions, perioperative surgical interventions, and devices to minimize blood loss at the time of hysterectomy for leiomyoma.

DATA SOURCES

Librarian-led search of Embase, MEDLINE, Web of Science, Scopus, Cumulative Index to Nursing and Allied Health Literature, and Cochrane databases from 1946 to 2018 with hand-guided updates.

METHODS OF STUDY SELECTION

Included studies reported on keywords of hysterectomy, leiomyoma, and operative blood loss/postoperative hemorrhage/uterine bleeding/metrorrhagia/hematoma. The review excluded a comparison of route of hysterectomy, morcellation, vaginal cuff closure, hormonal medications, vessel sealing devices for vaginal hysterectomy, and case series with <10 patients.

TABULATION, INTEGRATION, AND RESULTS

Surgical blood loss, postoperative hemoglobin (Hb) drop, hemorrhage, transfusion, and major and minor complications were analyzed and aggregated in meta-analyses for comparable studies in each category. A total of 2016 unique studies were identified, 33 of which met the inclusion criteria, and 22 were used for quantitative synthesis. The perioperative use of misoprostol in abdominal hysterectomy (AH) was associated with a lower postoperative Hb drop (0.59 g/dL; 95% confidence interval [CI], 0.39-0.79; p < .01) and blood loss (-96.43 mL; 95% CI, -153.52 to -39.34; p < .01) compared with placebo. Securing the uterine vessels at their origin in laparoscopic hysterectomy (LH) was associated with decreased intraoperative blood loss (-69.07 mL; 95% CI, -135.20 to -2.95; p = .04) but no significant change in postoperative Hb (0.24 g/dL; 95% CI, -0.31 to 0.78; p = .39) compared with securing them by the uterine isthmus. Uterine artery ligation in LH before dissecting the ovarian/utero-ovarian vessels was associated with lower surgical blood loss compared with standard ligation (-27.72 mL; 95% CI, -35.07 to -20.38; p < .01). The postoperative Hb drop was not significantly different with a bipolar electrosurgical device versus suturing in AH (0.26 g/dL; 95% CI, -0.19 to 0.71; p = .26). There was no significant difference between an electrosurgical bipolar vessel sealer (EBVS) and conventional bipolar electrosurgical devices in the Hb drop (0.02 g/dL; 95% CI, -0.15 to 0.20; p = .79) or blood loss (-50.88 mL; 95% CI, -106.44 to 4.68; p = .07) in LH. Blood loss in LH was not decreased with the LigaSure (Medtronic, Minneapolis, MN) impedance monitoring EBVS compared with competing EBVS systems monitoring impedance or temperature (2.00 mL; 95% CI, -8.09 to 12.09; p = .70). No significant differences in hemorrhage, transfusion, or major complications were noted for all interventions.

CONCLUSION

Perioperative misoprostol in AH led to a reduction in surgical blood loss and postoperative Hb drop (moderate level of evidence by Grading of Recommendations, Assessment, Development and Evaluation guidelines) although the clinical benefit is likely limited. Remaining interventions, although promising, had at best low-quality evidence to support their use at this time. Larger and rigorously designed randomized trials are needed to establish the optimal set of perioperative interventions for use in hysterectomy for leiomyomas.

Oxytocin infusion reduces bleeding during abdominal myomectomies: a randomized controlled trial

PURPOSE

To evaluate the effectiveness of oxytocin infusion to reduce intraoperative bleeding during abdominal myomectomies.

METHODS

This randomized, parallel group, blinded study was conducted between October 2017 and May 2018. Patients undergoing abdominal myomectomies were randomized 1:1 either to the oxytocin group or to the control group (saline). In the oxytocin group, 10 IU oxytocin in 500 ml of saline at a rate of 120 ml/h was given during the course of the operation. The primary outcome of this study was to measure intraoperative blood loss between the study groups. Correlation and multiple regression analysis were performed to illustrate factors associated with intraoperative blood loss during the myomectomy.

RESULTS

The mean intraoperative blood loss during the surgery was 489.20 ± 239.72 ml in the oxytocin group and was 641.40 ± 288.21 ml in the control group. The hemoglobin decline was more evident in the control group than in the oxytocin group. Positive correlations were also observed between the intraoperative blood loss and number of fibroids removed during the surgery, largest fibroid removed and weight of fibroids removed. The use of oxytocin infusion during the myomectomy resulted in a reduction of bleeding in the regression model.

CONCLUSION

Intravenous oxytocin infusion is a safe and practical method to reduce intraoperative blood loss during the abdominal myomectomy.

Effect of oxytocin infusion on reducing the blood loss during abdominal myomectomy: a double-blind randomised controlled trial

OBJECTIVE

To assess the effectiveness and safety of oxytocin to reduce blood loss during abdominal myomectomy.

DESIGN

Double-blind randomised controlled trial.

SETTING

Obstetrics and Gynecologic University Medical Centre.

POPULATION

Eighty healthy women candidates for abdominal myomectomy.

METHODS

Women were randomly assigned to two groups. In the study group (n = 40) oxytocin 30 IU in 500 ml normal saline; and in the placebo group (n = 40) pure normal saline was administered during myomectomy. The main outcome measures were peri-operative blood loss and rates of blood transfusion.

MAIN OUTCOME MEASURE

Estimated intra-operative blood loss.

RESULTS

Estimated intra-operative blood loss in the study group (189.5 ± 16.72 ml) was significantly lower than the placebo group (692.25 ± 89.93 ml) (95% CI 672.54-711.96; P < 0.0001).The need for blood transfusion was significantly lower in the study group. Blood transfusions were required for three (7.5%) women in the study group and 10 (25%) women in the placebo group (95% CI 15.5-34.5; P < 0.001).

CONCLUSIONS

Intra-operative oxytocin infusion appears to be safe and effective in decreasing blood loss during abdominal myomectomy.

TWEETABLE ABSTRACT

Intra-operative oxytocin is effective in decreasing blood loss during abdominal myomectomy.

A network meta-analysis of updated haemostatic strategies for hysterectomy

OBJECTIVE

To determine the best haemostatic strategy for hysterectomy through a network meta-analysis.

METHODS

We conducted a systematic literature search of the PubMed, Embase, and Cochrane Library databases and extracted data from randomized controlled trials comparing haemostatic strategies for hysterectomy. Direct comparisons and network meta-analyses were conducted in RevMan and ADDIS. Consistency models were established to identify the differences among different haemostatic strategies, and cumulative probability was used to rank the included strategies. Inconsistencies were also tested using node-splitting models.

RESULTS

Twenty studies from 16 articles (2 articles contained 3 studies each) comprising 1392 patients were included. Direct meta-analysis showed that the LigaSure (SMD = -1.42 [-2.39, -0.44], P = 0.004), bipolar vessel sealing systems (BVSS) (SMD = -0.35 [-0.66, -0.03], P = 0.03), and pituitrin (SMD = -2.13 [-4.14, -0.13], P = 0.04) applications were effective haemostatic strategies. Based on the network meta-analysis and related subgroup analysis of different surgical procedures, the results showed that the application of pituitrin seemed to be the best haemostatic method for hysterectomy (Rank P = 0.64), especially for vaginal hysterectomy (Rank P = 0.72). The application of LigaSure was the best strategy for abdominal hysterectomy (Rank P = 0.54) but was not effective for laparoscopic hysterectomy (direct comparison with BVSS, MD = -31.39 [-146.61, 83.83], P = 0.59). The node-splitting models test revealed that no significant inconsistencies existed in this research.

CONCLUSIONS

Pituitrin application seemed to be the most effective haemostatic strategy for hysterectomy and was especially suitable for vaginal hysterectomy. The best method for reducing blood loss in abdominal hysterectomy was the application of LigaSure.

Hemostatic Techniques for Myomectomy: An Evidence-Based Approach

Uterine leiomyomas are the most common benign gynecologic tumor. They are also a significant cause of morbidity, necessitating treatments ranging from hormonal suppression to surgical intervention. Myomectomy, the removal of these highly vascular tumors, offers significant quality of life and fertility-sparing benefit for patients affected by uterine leiomyomas but with a risk of substantial intraoperative blood loss. This risk of hemorrhage leads not only an increased transfusion rate but also he need for hysterectomy and other potential operative complications. Numerous medical and surgical techniques have been developed to minimize potentially significant blood loss during abdominal, laparoscopic, and robotic-assisted myomectomies. Combined with judicious preoperative assessment, these techniques substantially enhance patient safety during a myomectomy and outcomes during recovery.

Laparoscopic hysterectomies for large uteri

Laparoscopic hysterectomies increase recently due to several advantages of minimally invasive surgery. Controversy exists for laparoscopic hysterectomies for large uteri weighing >500g because some reports show increased complications and morbidities and high laparoconversion rate in the past. With familiarity of laparoscopic procedures and progress in surgical techniques, the issue should be discussed and reviewed by evidence again. Hence, we conducted a systematic review of laparoscopic hysterectomies for large uteri.

Urinary tract injury in laparoscopic-assisted vaginal hysterectomy

STUDY OBJECTIVE

To evaluate the incidence and characteristics of urinary tract injury after laparoscopic-assisted vaginal hysterectomy (LAVH).

DESIGN

A retrospective study that evaluated all cases of urinary tract injury at the time of LAVH in an 11-year period. Parameters including surgical indication, site of injury, time of diagnosis, method of treatment, and long-term follow-up were analyzed. (Canadian Task Force classification II-2).

SETTING

Tertiary care university hospital.

PATIENTS

A total of 38 urinary tract injuries were found in 7725 LAVH.

INTERVENTION

LAVH and repair of urinary tract injuries with transvaginal or transabdominal approach.

MEASUREMENTS AND MAIN RESULTS

The incidence of urinary tract injury after LAVH was 4.9/1000 procedures: 3.9/1000 for urinary bladder injury and 1.0/1000 for ureteral injury. Prior cesarean section was the most common risk factor for bladder injuries. Ninety-six percent (29/30) of urinary bladder injuries were detected and treated during surgery. Half (4/8, 50%) of the ureteral injuries were identified during surgery. Of the 38 complications, 28 (75.7%) occurred in surgery.

CONCLUSION

Most urinary tract injuries in LAVH were identified during surgery and are associated with the surgeon's experience. Bladder injury can be repaired either transvaginally or abdominally; ureteral injury can be repaired abdominally.

Oxytocin infusion in laparoscopic myomectomy may decrease operative blood loss

STUDY OBJECTIVE

To evaluate the influence of oxytocin on operative blood loss during laparoscopic myomectomy (LM).

DESIGN

Prospective clinical study (Canadian Task Force classification I).

SETTING

Tertiary care university hospital.

PATIENTS

Sixty women scheduled for myomectomy because of symptomatic uterine myomas.

INTERVENTION

Two ampules of oxytocin (10 u/mL/amp) were added to 1000 mL of saline solution running at the rate of 40 mU/min during the course of LM.

MEASUREMENTS AND MAIN RESULTS

Blood loss and blood transfusion rate were significantly greater in the group without oxytocin infusion (group B) than in the group with oxytocin infusion (group A), with 445.0 +/- 268.6 mL (95% CI 344.7-545.3) versus 269.5 +/- 225.8 mL (95% CI 185.2-353.8)/(p <.05), and 36.7% versus 6.7% (p <.05), respectively. There was no significant difference in average age, body weight, or numbers of vaginal delivery and cesarean sections between the 2 groups. There was no significant difference in mean total myoma weight, main myoma size, postoperative stay, and complications between the 2 groups.

CONCLUSION

Oxytocin infusion combined with skillful surgical techniques may decrease operative blood loss and blood transfusion during LM.

Laparoscopic myomectomy for large uterine fibroids. A comparative study

BACKGROUND

The goal of this study was to examine the safety and feasibility of laparoscopic myomectomy (LM) for the management of symptomatic intramural uterine fibroids with weight greater than 80 g as compared to those less than 80 g.

METHODS

In a prospective comparative study, 176 women with symptomatic uterine fibroids were scheduled for LM. They were divided into two groups, one with main uterine fibroid (intramural type) weight greater than 80 g and the other with fibroid weight less than 80 g. Outcome measures for the two groups were studied in terms of operation time, amount of blood loss, requirement of blood transfusion, and length of hospital stay.

RESULT

Operation time and amount of blood loss were significantly greater in the group with fibroid > or = 80 g than in the group < 80 g (121.5 +/- 58.9 min versus 79.1 +/- 28.6 min, p < 0.001; and 346.3 +/- 299.6 ml versus 123.0 +/- 89.7 ml, p < 0.001, respectively). However, there was no difference in the length of hospital stay and overall incidence of operative complications between these two groups. None of the women had any major complications. Nevertheless, 11 minor complications were noted, including two pelvic abscesses requiring a second laparoscopic treatment. There was no incidence of switching to laparatomy during the operation. Extreme intraoperative hemorrhage of more than 1000 ml occurred in 8 patients; however, all progressed to full recovery after blood transfusion. Rate of blood transfusion was significantly lower in the group with fibroid < 80 g (3.2% versus 22.1%, p < 0.001).

CONCLUSIONS

Despite the increased operation time and blood loss, LM can be safely performed in the treatment of large uterine fibroid. However, high risk of blood transfusion in these patients has to be kept in mind.

Use of laparoscopic cytoreductive surgery to treat infertile women with localized adenomyosis

OBJECTIVE

We report on two infertile women with localized adenomyosis who had successful pregnancies after treatment with laparoscopic cytoreductive surgery.

DESIGN

Case report.

SETTING

Tertiary care university hospital.

PATIENT(S)

Two infertile women with localized adenomyosis.

INTERVENTION(S)

Laparoscopic excision of adenomyotic lesion with/without subsequent hypoestrogenic agent was performed.

MAIN OUTCOME MEASURE(S)

Pregnancy.

RESULT(S)

Hypoestrogenic agent with danazol was administered 3 months immediately after surgery in one woman. Both women conceived spontaneously at 30 and 21 months after surgery, respectively. The pregnancies were uneventful, and healthy infants were delivered via cesarean section at term.

CONCLUSION(S)

Laparoscopic cytoreductive surgery can be an alternative treatment to the use of hypoestrogenic agents or hysterectomy in women with localized adenomyosis, especially for those who want to maintain their fertility and achieve successful pregnancies. Patients may wait up to 21 months after surgery until a pregnancy occurs.

The four-trocar method for performing laparoscopically-assisted vaginal hysterectomy on large uteri

STUDY OBJECTIVE

To assess the feasibility and efficacy of laparoscopically-assisted-vaginal hysterectomy (LAVH) for a large uterus with the new trocar technique.

DESIGN

Retrospective clinical study (Canadian Task Force classification III).

SETTING

University teaching hospital.

PATIENTS

Thirty-four women with a large uterus (>500 g).

INTERVENTION

LAVH with Choi's 4-trocar method.

MEASUREMENTS AND MAIN RESULTS

We reviewed the medical records of 34 patients for age, parity, history of previous abdominal surgery, operative indications, histopathologic diagnosis, mean operative time, weight of the removed uterus, change in the hemoglobin level, hospital stay, and occurrence of any complications. The patient's median age was 45 years (range 36-51 years), median parity was 2 (range 0-3), and 18 patients (52.9%) had a previous operative history. The most common operative indication was a palpable abdominal mass, and the most common histopathologic diagnosis was leiomyoma. The median operative time was 62.5 minutes (range 35-245 minutes), and the median weight of the removed uterus was 615.0 g (range 500-1200 g). The median change in hemoglobin level was 1.4 g/dL (range 0-5 g/dL). The median hospital stay was 4.0 days (range 2-6 days). The only complication was superficial port site bleeding (1 patient). None of the operations were switched to total abdominal hysterectomy.

CONCLUSION

Choi's 4-trocar method provided an excellent operative field during LAVH for a large uterus.