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Aziz A, Khan RS. Circumferential Vaginal Tear During the Cesarean Section: A Complication of Vaginal Hand Assistance in a Deeply Impacted Fetal Head. Cureus 2024; 16:e61869. [PMID: 38975524 PMCID: PMC11227650 DOI: 10.7759/cureus.61869] [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] [Accepted: 06/06/2024] [Indexed: 07/09/2024] Open
Abstract
We present the case of a 29-year-old, G2P1+0 pregnant woman who was unbooked and presented to the emergency room at 36+5 weeks gestation with complaints of leaking liquor, labour pains, vaginal bleeding and raised blood pressure. Her history revealed previous vaginal delivery and index pregnancy complicated with obstetric cholestasis, pre-eclampsia, and fetal growth restriction. During her hospital course, the patient underwent an emergency cesarean section due to uncontrolled blood pressure and pathological cardiotocograph (CTG) revealing a deeply impacted fetal head intraoperatively and necessitating an inverted T incision on the uterus. Although the newborn was delivered successfully, a full-thickness circumferential tear in the vaginal vault was discovered, requiring immediate surgical repair with the involvement of a urologist. The patient experienced postoperative complications related to pre-eclampsia and sepsis but was eventually discharged in stable condition. This case highlights the importance of prompt diagnosis and management of obstetric emergencies especially in the case of deeply impacted fetal head, and the need for a multidisciplinary approach to address complications such as vaginal tears during cesarean sections due to vaginal assistance in delivering the baby.
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Affiliation(s)
- Anum Aziz
- Obstetrics and Gynaecology, Aga Khan University, Karachi, PAK
| | - Rozilla S Khan
- Obstetrics and Gynaecology, Aga Khan University, Karachi, PAK
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2
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Dabiri SR, Mehri A, Mollanorouzi F, Alavi D, Abdollahi A, Rajabi Mashhadi MT. Small bowel evisceration after abdominal hysterectomy with open vaginal cuff technique: A case report. Clin Case Rep 2024; 12:e8910. [PMID: 38827941 PMCID: PMC11142900 DOI: 10.1002/ccr3.8910] [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: 03/14/2024] [Revised: 04/18/2024] [Accepted: 04/27/2024] [Indexed: 06/05/2024] Open
Abstract
Key Clinical Message Vaginal cuff dehiscence post-hysterectomy is rare yet significant. Early recognition and prompt surgical intervention are crucial to prevent complications like bowel infarction. Consider second-look laparotomy in cases of uncertain bowel viability. Abstract Vaginal cuff dehiscence (VCD) is a rare but potentially life-threatening complication following a hysterectomy characterized by the separation of the vaginal vault. This condition, which may result in vaginal evisceration (VE), presents a significant risk of pelvic contents, particularly the small bowel, protruding into the vagina. Early diagnosis and prompt surgical intervention are paramount to prevent severe complications, including bowel infarction, obstruction, and peritonitis. Although VCD and VE are rare, they require urgent surgical management to avoid adverse outcomes. We reported a case of small bowel evisceration in a woman with a history of total abdominal hysterectomy 6 months ago. VCD and VE are very rare but life-threatening complications of hysterectomy. Discussing the symptoms with patients who have multiple risk factors is crucial to avoid severe sequels following hysterectomy. Based on our experience, performing a second-look laparotomy is a reliable approach to ensure the viability of the intestinal loop. However, it will likely increase the risk of infection.
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Affiliation(s)
- Seyed Ramin Dabiri
- Department of Surgery, Faculty of MedicineMashhad University of Medical SciencesMashhadIran
| | - Ali Mehri
- Endoscopic and Minimally Invasive Surgery Research CenterMashhad University of Medical SciencesMashhadIran
| | - Farzaneh Mollanorouzi
- Department of Surgery, Faculty of MedicineMashhad University of Medical SciencesMashhadIran
| | - Davod Alavi
- Department of Surgery, Faculty of MedicineMashhad University of Medical SciencesMashhadIran
| | - Abbas Abdollahi
- Endoscopic and Minimally Invasive Surgery Research CenterMashhad University of Medical SciencesMashhadIran
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3
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Li Q, Zhang L, Fang F, Xu P, Zhang C. Research progress of indocyanine green fluorescence technology in gynecological applications. Int J Gynaecol Obstet 2024; 165:936-942. [PMID: 37953657 DOI: 10.1002/ijgo.15249] [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: 05/05/2023] [Revised: 08/22/2023] [Accepted: 10/30/2023] [Indexed: 11/14/2023]
Abstract
Indocyanine green is a near-infrared fluorescent dye which is widely used in various fields of surgery and gynecology. It is currently mainly used to detect various malignant tumors, sentinel lymph nodes, endometriosis lesions, ureter or intestinal occlusion, vaginal perfusion, uterine arterial blood perfusion, pelvic nerve, uterine niche, lymphatic edema, metastatic lesion shadow, and so on, providing new methods for decision-making during surgery. This article elaborates the application progress of indocyanine green fluorescence technology in gynecology.
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Affiliation(s)
- Qing Li
- Department of Gynecology, Huaian Maternity and Child Clinical College of Xuzhou Medical University, Huaian, Jiangsu, China
| | - Li Zhang
- Department of Gynecology, Huaian Maternity and Child Clinical College of Xuzhou Medical University, Huaian, Jiangsu, China
| | - Fang Fang
- Department of Gynecology, Huaian Maternity and Child Clinical College of Xuzhou Medical University, Huaian, Jiangsu, China
| | - Ping Xu
- Department of Gynecology, Huaian Maternity and Child Clinical College of Xuzhou Medical University, Huaian, Jiangsu, China
| | - Chunhua Zhang
- Department of Gynecology, Huaian Maternity and Child Clinical College of Xuzhou Medical University, Huaian, Jiangsu, China
- Macau University of Science and Technology, Macau, China
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4
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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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5
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Sa SW, Ma QH, Guo T. Vaginal cuff dehiscence after radical hysterectomy. Asian J Surg 2024; 47:1055-1056. [PMID: 38042658 DOI: 10.1016/j.asjsur.2023.10.106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 10/27/2023] [Indexed: 12/04/2023] Open
Affiliation(s)
- Sha-Wei Sa
- Department of Obstetrics and Gynecology, West China Second University Hospital, Sichuan University, China; Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, Sichuan, China
| | - Qian-Hong Ma
- Department of Obstetrics and Gynecology, West China Second University Hospital, Sichuan University, China; Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, Sichuan, China
| | - Tao Guo
- Department of Obstetrics and Gynecology, West China Second University Hospital, Sichuan University, China; Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, Sichuan, China.
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6
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O'Connor RM, Scott ME, Rimel BJ. Vaginal Cuff Dehiscence in Transgender Patients After Minimally Invasive Hysterectomy. J Minim Invasive Gynecol 2024; 31:138-146. [PMID: 37925016 PMCID: PMC11129707 DOI: 10.1016/j.jmig.2023.10.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Revised: 09/21/2023] [Accepted: 10/26/2023] [Indexed: 11/06/2023]
Abstract
STUDY OBJECTIVE To compare rates of vaginal cuff dehiscence (VCD) in transgender patients with cisgender patients after minimally invasive hysterectomy (MIH). DESIGN We performed a single-surgeon, retrospective cohort analysis comparing the rates of VCD in patients undergoing MIH for gender affirmation with other indications (benign, malignant, prophylactic) with our study surgeon between January, 2015, and December, 2021. SETTING Major, urban, academic tertiary care hospital in the United States. PATIENTS 166 patients met inclusion criteria with 49 of those patients undergoing MIH (29.5%) for gender affirmation. Of the remaining 117 patients, 92 (78.6%) underwent MIH for cancer, 15 (12.8%) for prophylaxis, and 10 (8.5%) for benign indications. INTERVENTIONS Not applicable. MEASUREMENTS We assessed included patients for baseline demographics, presence of risk factors for VCD, details of index hysterectomy, and details of cuff dehiscence events. MAIN RESULTS Transgender patients tended to be younger at the time of surgery, but demographics were otherwise similar between both groups. Most transgender patients (n = 36, 73.5%) had both ovaries removed at the time of hysterectomy, 100% were on testosterone therapy pre- and postoperatively, and none used supplementary estrogen. Three of the 49 transgender patients (6.1%) experienced postoperative dehiscence of the vaginal cuff compared with 2 of the 117 cisgender patients (1.7%). This failed to reach statistical significance; however, our descriptive analysis showed that all cases of dehiscence in the cisgender group had identifiable precipitating factors (i.e., trauma). By comparison, all cases of dehiscence in the transgender group were spontaneous with few identifiable risk factors. CONCLUSION Transgender patients undergoing MIH may be at increased risk of VCD, although the rarity of this surgical complication precluded determination of statistical significance in our data set. We propose testosterone exposure as a possible risk factor for VCD, although we cannot exclude other factors, such as young age, as drivers of VCD in this population. Future studies of biospecimens are needed to evaluate for cellular differences in these patients.
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Affiliation(s)
- Reed M O'Connor
- Department of Obstetrics and Gynecology (Dr. O'Connor), Cedars-Sinai Medical Center, Los Angeles, CA
| | - Marla E Scott
- Division of Gynecologic Oncology (Drs. Scott and Rimel)
| | - B J Rimel
- Division of Gynecologic Oncology (Drs. Scott and Rimel).
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Caskey R, Niino C, Meyer R, Schneyer R, Hamilton K, Truong MD, Wright K, Siedhoff M. Utility of Routine Postoperative Examination for Detecting Vaginal Cuff Dehiscence After Total Laparoscopic Hysterectomy. J Minim Invasive Gynecol 2024; 31:147-154. [PMID: 38061491 DOI: 10.1016/j.jmig.2023.12.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Revised: 10/30/2023] [Accepted: 12/01/2023] [Indexed: 02/09/2024]
Abstract
STUDY OBJECTIVE To determine the utility of routine postoperative vaginal cuff examination for detection of vaginal cuff dehiscence (VCD) after total laparoscopic hysterectomy (TLH). DESIGN Retrospective cohort study. SETTING Quaternary care academic hospital in the United States. PATIENTS All patients who underwent TLH with a minimally invasive gynecologic surgeon at our institution from 2016 to 2022. INTERVENTIONS Laparoscopic hysterectomy with routine vaginal cuff check 6 to 8 weeks postoperatively and laparoscopic hysterectomy without routine vaginal cuff check. MEASUREMENTS AND MAIN RESULTS We identified 703 patients who underwent TLH, 216 (30.7%) with routine cuff checks and 487 (69.3%) without. Within the no cuff check group, 287 (58.9%) had entirely virtual follow-up. There was no difference in VCD between the routine cuff check (1.28%, n = 2) and no cuff check groups (0.93%, n = 7, p = .73). Median time to VCD was 70.0 days (27.5-114.0). No VCDs were identified in asymptomatic patients on routine examination, and both patients in the cuff check group with VCD had appropriately healing cuffs on routine examination. In the cuff check group, 7 patients (3.2%) had findings of incomplete healing requiring intervention (silver nitrate, extended pelvic rest), all of whom were asymptomatic at the time of examination. Eight patients (3.7%) in the routine cuff check group and 21 (4.3%) in the no examination group required a nonroutine cuff check owing to symptoms. There was no difference in points of contact for postoperative symptoms between the groups (median 0 [0-1.0] for both groups, p = .778). CONCLUSION Routine postoperative vaginal cuff examination does not seem to affect or negate the risk of future VCD. Virtual follow-up for asymptomatic patients may be appropriate after TLH.
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Affiliation(s)
- Rachel Caskey
- Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center, Los Angeles, California..
| | - Clarissa Niino
- Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center, Los Angeles, California
| | - Raanan Meyer
- Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center, Los Angeles, California
| | - Rebecca Schneyer
- Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center, Los Angeles, California
| | - Kacey Hamilton
- Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center, Los Angeles, California
| | - Mireille D Truong
- Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center, Los Angeles, California
| | - Kelly Wright
- Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center, Los Angeles, California
| | - Matthew Siedhoff
- Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center, Los Angeles, California
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Cannone FG, Cormaci L, Ettore C, Gulino FA, Incognito GG, Benvenuto D, Ettore G. Rate of Vaginal Cuff Dehiscence When Using Vicryl (Poliglactyn 910) Compared to PDS (Polydioxanone) for Vaginal Cuff Closure in Laparoscopic Hysterectomy. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:90. [PMID: 38256351 PMCID: PMC10821056 DOI: 10.3390/medicina60010090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Revised: 12/19/2023] [Accepted: 12/29/2023] [Indexed: 01/24/2024]
Abstract
Objective: To compare the vaginal cuff dehiscence (VCD) rates using Vicryl (Poliglactyn 910) and Polydioxanone (PDS) in patients who underwent laparoscopic hysterectomy. Materials and methods: A retrospective, monocentric study was conducted, including all patients undergoing laparoscopic hysterectomy at the Department of Obstetrics and Gynaecology, Azienda di Rilievo Nazionale e di Alta Specializzazione (ARNAS) Garibaldi Nesima, Catania, between January 2014 and December 2021. Patients underwent hysterectomy for benign gynecologic pathologies (endometriosis, leiomyomas, or benign pelvic pathologies) or malignant gynecologic pathologies (endometrium cancer, complex endometrial hyperplasia, ovarian cancer, cervix cancer, or uterine carcinosarcoma). The Z-score calculation was performed to find eventual statistically significant differences between the two populations regarding VCD rates. Results: Laparoscopic vaginal cuff closure was performed, with Vicryl sutures in 202 patients and PDS sutures in 184 women. Demographic and baseline characteristics were not significantly different in the two groups. VCD occurred in three patients in the Vicryl group and did not occur in the PDS group. The three cases of VCD were precipitated by intercourses that occurred within 90 days of surgery. However, there was not a significant statistical difference between the two groups regarding VCD (p = 0.09). Conclusions: Vicryl and PDS sutures seem to be similar for vaginal cuff closure in laparoscopic hysterectomy. The VCD rate was low, and the observed differences between the Vicryl and PDS groups did not reach statistical significance. Further research through prospective studies is essential.
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Affiliation(s)
- Francesco Giuseppe Cannone
- Department of Obstetrics and Gynaecology, Azienda di Rilievo Nazionale e di Alta Specializzazione (ARNAS) Garibaldi Nesima, 95122 Catania, Italy; (F.G.C.); (L.C.); (C.E.); (G.G.I.); (G.E.)
| | - Livia Cormaci
- Department of Obstetrics and Gynaecology, Azienda di Rilievo Nazionale e di Alta Specializzazione (ARNAS) Garibaldi Nesima, 95122 Catania, Italy; (F.G.C.); (L.C.); (C.E.); (G.G.I.); (G.E.)
| | - Carla Ettore
- Department of Obstetrics and Gynaecology, Azienda di Rilievo Nazionale e di Alta Specializzazione (ARNAS) Garibaldi Nesima, 95122 Catania, Italy; (F.G.C.); (L.C.); (C.E.); (G.G.I.); (G.E.)
| | - Ferdinando Antonio Gulino
- Department of Obstetrics and Gynaecology, Azienda di Rilievo Nazionale e di Alta Specializzazione (ARNAS) Garibaldi Nesima, 95122 Catania, Italy; (F.G.C.); (L.C.); (C.E.); (G.G.I.); (G.E.)
| | - Giosuè Giordano Incognito
- Department of Obstetrics and Gynaecology, Azienda di Rilievo Nazionale e di Alta Specializzazione (ARNAS) Garibaldi Nesima, 95122 Catania, Italy; (F.G.C.); (L.C.); (C.E.); (G.G.I.); (G.E.)
| | - Domenico Benvenuto
- Unit of Medical Statistics and Molecular Epidemiology, University Campus Bio-Medico of Rome, 00128 Rome, Italy;
| | - Giuseppe Ettore
- Department of Obstetrics and Gynaecology, Azienda di Rilievo Nazionale e di Alta Specializzazione (ARNAS) Garibaldi Nesima, 95122 Catania, Italy; (F.G.C.); (L.C.); (C.E.); (G.G.I.); (G.E.)
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9
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Ribeiro R, Baiocchi G, Moretti-Marques R, Linhares JC, Costa CN, Pareja R. Uterine transposition for fertility and ovarian function preservation after radiotherapy. Int J Gynecol Cancer 2023; 33:1837-1842. [PMID: 37898483 DOI: 10.1136/ijgc-2023-004723] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/30/2023] Open
Abstract
OBJECTIVE To evaluate the feasibility of uterine transposition as a method of preserving fertility and ovarian function after pelvic radiation. METHODS This prospective multicenter observational study included patients with non-gynecologic pelvic cancers who underwent pelvic radiation as part of their cancer treatment between June 2017 and June 2019. For inclusion in the study, patients were required to have normal menstrual cycles and hormone levels (follicle-stimulating hormone, luteinizing hormone, and estrogen) before treatment. Uterine transposition to the upper abdomen was performed prior to irradiation. Clinical examinations and Doppler ultrasonography were used to evaluate the gonadal vasculature post-surgery. The uterus was repositioned into the pelvis 2-4 weeks after radiation therapy or at the time of rectosigmoid resection in patients with rectal cancer who had undergone neoadjuvant treatment. Cancer treatment and follow-up were performed according to standard guidelines. RESULTS Eight patients (seven with rectal cancer and one with pelvic liposarcoma) underwent uterine transposition at a median age of 30.5 years (range 19-37). The uterus was successfully preserved in six patients, accompanied by normal menses, hormonal levels, and vaginal intercourse after treatment. One patient with rectal cancer died of carcinomatosis 4 months after uterine transposition. One patient presented with uterine necrosis 4 days after uterine transposition, and the uterus was removed; however, one ovary was preserved. Cervical ischemia was the most common post-surgical complication in three (37.5%) patients. Three patients attempted to conceive, and two (66%) were spontaneously successful and delivered healthy babies at 36 and 38 weeks by cesarean section without complications. CONCLUSIONS Uterine transposition is a feasible procedure for preserving gonadal and uterine function in patients requiring pelvic radiotherapy for non-gynecological cancer, with the potential for achieving spontaneous pregnancy and successful delivery.
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Affiliation(s)
- Reitan Ribeiro
- Department of Gynecologic Oncology, Erasto Gaertner Hospital, Curitiba, Paraná, Brazil
| | - Glauco Baiocchi
- Department of Gynecologic Oncology, ACCamargo Cancer Center, Sao Paulo, Brazil
| | | | | | | | - Rene Pareja
- Department of Gynecology Oncology, Clinica ASTORGA, Medellin, and Instituto Nacional de Cancerología, Bogotá, Colombia, Medellin, Colombia
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10
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Jiang L, Jia P, Duan B, Yang Z, Zhang Y. Spontaneous vaginal cuff dehiscence with evisceration in a woman with vaginal vault prolapse long after hysterectomy: a case report. J OBSTET GYNAECOL 2023; 43:2141619. [PMID: 36411720 DOI: 10.1080/01443615.2022.2141619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Lu Jiang
- Department of Ostetrics and Gynecology, Peking University First Hospital, Beijing, China
| | - Peng Jia
- Department of Ostetrics and Gynecology, Peking University First Hospital, Beijing, China
| | - Baofeng Duan
- Department of Ostetrics and Gynecology, Peking University First Hospital, Beijing, China
| | - Zixuan Yang
- Peking University Health Science Center, Beijing, China
| | - Yan Zhang
- Department of Ostetrics and Gynecology, Peking University First Hospital, Beijing, China
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11
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Ingraham C, Makai G. Perioperative visits in minimally invasive gynecologic surgery. Curr Opin Obstet Gynecol 2023; 35:316-320. [PMID: 37266572 DOI: 10.1097/gco.0000000000000883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
PURPOSE OF REVIEW Perioperative visits for gynecologic surgery patients have traditionally included in-person examinations and counseling, but the advent of telemedicine has prompted clinicians to consider varying approaches to perioperative care. We aim to educate readers on the optimal setting and context of perioperative visits and provide insight from our experience to optimize care. RECENT FINDINGS The widespread adoption of telemedicine and a focus on equity and access has prompted gynecologic surgeons to reconsider traditional preoperative and postoperative visits. SUMMARY This review summarizes evidence for new approaches to perioperative care for minimally invasive gynecologic surgery, including transition to telemedicine for preoperative and postoperative care, adjuvant tools for perioperative counseling, and the value of in-person visits for preoperative planning.
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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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13
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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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14
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Eoh KJ, Lee YJ, Nam EJ, Jung HI, Kim YT. Clinical Relevance of Vaginal Cuff Dehiscence after Minimally Invasive versus Open Hysterectomy. J Clin Med 2023; 12:3001. [PMID: 37109333 PMCID: PMC10142584 DOI: 10.3390/jcm12083001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 04/10/2023] [Accepted: 04/19/2023] [Indexed: 04/29/2023] Open
Abstract
This study aimed to evaluate the clinical relevance of vaginal cuff dehiscence following a hysterectomy. Data were prospectively collected from all patients who underwent hysterectomies at a tertiary academic medical center between 2014 and 2018. The incidence and clinical factors of vaginal cuff dehiscence after minimally invasive versus open hysterectomy were compared. Vaginal cuff dehiscence occurred in 1.0% (95% confidence interval [95% CI], 0.7-1.3%) of women who underwent either form of hysterectomy. Among those who underwent open (n = 1458), laparoscopic (n = 3191), and robot-assisted (n = 423) hysterectomies, vaginal cuff dehiscence occurred in 15 (1.0%), 33 (1.0%), and 3 (0.7%) cases, respectively. No significant differences in cuff dehiscence occurrence were identified in patients who underwent various modes of hysterectomies. A multivariate logistic regression model was created using the variables indication for surgery and body mass index. Both variables were identified as independent risk factors for vaginal cuff dehiscence (odds ratio [OR]: 2.74; 95% CI, 1.51-4.98 and OR: 2.20; 95% CI, 1.09-4.41, respectively). The incidence of vaginal cuff dehiscence was exceedingly low in patients who underwent various modes of hysterectomies. The risk of cuff dehiscence was predominantly influenced by surgical indications and obesity. Thus, the different modes of hysterectomy do not influence the risk of vaginal cuff dehiscence.
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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; (Y.J.L.); (E.J.N.)
| | - 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; (Y.J.L.); (E.J.N.)
| | - 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; (Y.J.L.); (E.J.N.)
| | - 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; (Y.J.L.); (E.J.N.)
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15
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Fermin O, Delgado A, Sarkar P, Chern JY, Wenham R, Hoffman MS. Vaginal Evisceration Subsequent to Hysterectomy at a Major Cancer Center. J Gynecol Surg 2022. [DOI: 10.1089/gyn.2022.0081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
- Oriana Fermin
- University of Central Florida College of Medicine, Orlando, Florida, USA
| | - Arlin Delgado
- Department of Obstetrics and Gynecology, University of South Florida, Tampa, Florida, USA
| | - Papri Sarkar
- Department of Obstetrics and Gynecology, University of South Florida, Tampa, Florida, USA
| | - Jing-Yi Chern
- Department of Obstetrics and Gynecology, University of South Florida, Tampa, Florida, USA
- Department of Gynecology/Oncology, Moffitt Cancer Center, Tampa, Florida, USA
| | - Robert Wenham
- Department of Obstetrics and Gynecology, University of South Florida, Tampa, Florida, USA
- Department of Gynecology/Oncology, Moffitt Cancer Center, Tampa, Florida, USA
| | - Mitchel S. Hoffman
- Department of Obstetrics and Gynecology, University of South Florida, Tampa, Florida, USA
- Department of Gynecology/Oncology, Moffitt Cancer Center, Tampa, Florida, USA
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16
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Rathigashini R, Wanniarachchi WADP, De Silva A, Herath RP. Recurrent vaginal vault dehiscence and evisceration following total laparoscopic hysterectomy, successfully repaired with polypropylene mesh and sacrocolpopexy. J Surg Case Rep 2022; 2022:rjac453. [PMID: 36196124 PMCID: PMC9526542 DOI: 10.1093/jscr/rjac453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Accepted: 09/07/2022] [Indexed: 11/17/2022] Open
Abstract
Recurrent vault dehiscence is a rare and potentially serious complication following hysterectomy. We report a rare case of recurrent vault dehiscence and evisceration following a total laparoscopic hysterectomy (TLH) which was successfully repaired with polypropylene mesh and sacro-colpopexy. A 47-year-old multiparous woman underwent TLH for adenomyosis. During the surgery, vaginal wall was incised with monopolar diathermy and sutured with synthetic absorbable barbed suture in a single layer. She presented 12 weeks later with vault dehiscence and evisceration of omentum. Laparoscopically, eviscerated omental part was removed and the vaginal cuff was repaired vaginally with absorbable synthetic suture. She came with a recurrence in 3 months with vault dehiscence and a vault prolapse without any evisceration. She underwent laparoscopic mesh repair of the vault combined with laparoscopic Sacro-colpopexy with complete recovery. Incidence of vault dehiscence is found to be higher in TLH than abdominal or vaginal hysterectomy. Treatment options for recurrent vault dehiscence involve strengthening the vault with tissues, or with a prosthesis.
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Affiliation(s)
- R Rathigashini
- Correspondence address. Faculty of Medicine, Department of Obstetrics & Gynecology, University of Kelaniya, Thalgolla Road, Ragama, Sri Lanka. Tel: +94 11 2961000; E-mail:
| | - W A D P Wanniarachchi
- Faculty of Medicine, Department of Obstetrics & Gynecology, University of Kelaniya, Sri Lanka
| | - A De Silva
- Faculty of Medicine, Department of Obstetrics & Gynecology, University of Kelaniya, Sri Lanka
| | - R P Herath
- Faculty of Medicine, Department of Obstetrics & Gynecology, University of Kelaniya, Sri Lanka
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17
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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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Ortega-Checa D, Vojvodic-Hernández I, Benavides-Morales D. Evisceración intestinal transvaginal incarcerada con perforación intestinal después de una colporrafia con malla. Reporte de un caso. REVISTA COLOMBIANA DE CIRUGÍA 2022. [DOI: 10.30944/20117582.982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Introducción. La evisceración intestinal transvaginal es consecuencia, en la gran mayoría de casos, de dehiscencia del muñón vaginal posterior a histerectomía en pacientes postmenopáusicas. A través de la dehiscencia vaginal se produce la salida del contenido abdominopélvico, que puede presentarse como una evisceración simple, incarceración, obstrucción, estrangulamiento y perforación de un asa intestinal.
Caso clínico. Mujer de 78 años, con antecedente inmediato de colpocleisis y colporrafia con malla de polipropileno por prolapso vaginal, que presentó dehiscencia del muñón vaginal debido a rechazo de la malla, que condicionó la solución de continuidad de la pared vaginal, con prolapso, incarceración, obstrucción y perforación de íleon. Con el diagnóstico de evisceración intestinal transvaginal incarcerada con perforación intestinal se llevó a tratamiento quirúrgico, con abordaje inicial por vía vaginal para liberar el asa intestinal, luego por laparotomía se realizó resección y anastomosis de íleon, sacrocolpopexia con malla y plastia de Douglas. Presentó buena evolución postoperatoria.
Conclusión. La evisceración intestinal transvaginal con perforación intestinal es una entidad de muy rara presentación. El órgano más frecuentemente comprometido es el intestino delgado, especialmente el íleon. Puede complicarse con incarceración, obstrucción intestinal, isquemia y perforación. El manejo quirúrgico involucra resección intestinal, cuando hay signos de necrosis, con reparación y fijación del muñón vaginal.
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19
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Ma X, Cao DY, Dai YX. Experience in the Management of Vaginal Cuff Dehiscence and Evisceration: A Retrospective 37-Year Single-Center Study. Front Surg 2022; 9:880875. [PMID: 36034385 PMCID: PMC9406508 DOI: 10.3389/fsurg.2022.880875] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 04/18/2022] [Indexed: 11/26/2022] Open
Abstract
Purpose Vaginal cuff dehiscence (and evisceration) (VCD(E)) is an extremely rare and late-onset complication of total hysterectomy (TH). Limited evidence is available to guide clinicians in managing VCD(E). This study aimed to summarize the clinical characteristics of patients with VCD(E) treated in our center and share our experience in managing VCD(E). Patients and methods From 1983 to 2020, a total of 14 cases of VCD(E), including 10 cases in our hospital and 4 cases in other hospitals, were included. Medical records were reviewed to summarize the clinical features and management of VCD(E). Results The incidence of VCD(E) in our hospital was 10/46,993 (0.02%), and all 10 patients underwent laparoscopic hysterectomy. The median TH-to-VCD(E) interval was 3.13 months (8 days–27.43 months), and 11/14 (78.57%) patients experienced VCD(E) after coitus. The 3 major symptoms included abdominal pain in 11 patients, irregular vaginal bleeding in 8, and sensation of bulging or prolapsed organs in 4. Except for 2, most patients presented to our hospital within 72 h since the onset of the discomfort. All 14 cases were diagnosed through speculum examination: 3 had simple VCD, and 11 had VCDE. The protruding bowels of 4 patients were immediately manually repositioned in the emergency department without anesthesia. Regarding the surgical approach, 11 patients underwent simple transvaginal, 2 patients underwent laparoscopic-vaginal combined (transvaginal cuff closures), and 1 patient underwent laparoscopic. All but 1 patient did not undergo resection of the eviscerated organs. The median follow-up period was 39.33 (7.9–159.33) months. No patients showed any evidence of recurrence to date. Conclusions Laparoscopic hysterectomy is a risk factor for VCD(E), and early initiation of sexual intercourse is the most common trigger of VCD(E). Clinicians should educate patients to postpone sexual intercourse for at least 3–6 months after TH. Immediate medical attention and patient-specific surgical management are crucial to avoid serious complications.
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Affiliation(s)
- Xiao Ma
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
- National Clinical Research Center for Obstetric & Gynecologic Diseases, Beijing, China
| | - Dong-Yan Cao
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
- National Clinical Research Center for Obstetric & Gynecologic Diseases, Beijing, China
- Correspondence: Yu-Xin Dai Dong-Yan Cao
| | - Yu-Xin Dai
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
- National Clinical Research Center for Obstetric & Gynecologic Diseases, Beijing, China
- Correspondence: Yu-Xin Dai Dong-Yan Cao
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20
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Kalkan Ü, Bakay K. A multimodal concept for vaginal cuff closure by modification of the Bakay technique in total laparoscopic hysterectomy: a randomized clinical study. BMC Womens Health 2022; 22:6. [PMID: 34996427 PMCID: PMC8742316 DOI: 10.1186/s12905-021-01591-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Accepted: 12/30/2021] [Indexed: 12/01/2022] Open
Abstract
Background The aim of this study was to compare the outcomes of modified Bakay technique (MT) to standard colpotomy (ST) and cuff closure in total laparoscopic hysterectomy (TLH). Methods This two-centre, randomized-controlled study included a total of 160 patients who were scheduled for TLH for benign diseases (ClinicalTrials.gov Identifier is NCT05080114 and the first posted date was 15/10/2021). The patients were allocated into two groups by a computer-based randomization programme as ST group and MT group. Total operative time, cuff closure time, length of hospital stay, intra- and postoperative complications according to the Clavien-Dindo classification, pre- and postoperative vaginal length, and patient satisfaction according to the Patient Global Impression of Improvement (PGI-I) questionnaire were assessed. Results Seventy-seven patients in the ST group and 80 patients in the MT group underwent TLH. The total operative time was significantly shorter in the MT compared to the ST (55.5 vs. 59 min, respectively; p = 0.001). The median total operative time for colpotomy, extraction of uterus, and vaginal cuff closure steps was 9 (range 6–12 in MT vs. 6 to 11 in ST) min in both groups. The median hospital stay was 2 (range 1–4) days in both groups. Intraoperative blood loss was not significantly different between the groups (90 mL in ST vs. 80 mL in MT; p = 0.456). The mean uterine weight for the ST group and MT group was comparable (258.6 ± 88.6 g vs. 232.9 ± 102.5 g, respectively; p = 0.107). The preoperative vaginal length was not significantly different between the groups (p = 0.502). The median postoperative vaginal length was significantly higher in the MT group compared to the ST group on Day 90 (8 cm vs. 7,5 cm, respectively; p = 0.001). The PGI-I questionnaire score on Day 90 postoperatively was 2 (range 1–5) in both groups (p = 0.636). The complication rates were similar between the groups (p = 0.230). Conclusion The MT can be safely performed in most of the cases requiring TLH with the advantages of vaginal cuff closure before the alteration of pelvic anatomy, support to primary healing of the vaginal cuff, and routine concomitant apical support. Supplementary Information The online version contains supplementary material available at 10.1186/s12905-021-01591-z.
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Affiliation(s)
- Üzeyir Kalkan
- Department of Obstetrics and Gynaecology, Koç University Hospital, Topkapı, Davutpaşa Cd. No: 4, 34010, Zeytinburnu, Istanbul, Turkey.
| | - Kadir Bakay
- Department of Obstetrics and Gynaecology, Faculty of Medicine, Ondokuz Mayis University, Samsun, Turkey
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21
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Abstract
Vaginal cuff dehiscence with small bowel evisceration is a serious but uncommon postoperative complication of total laparoscopic hysterectomies. The severity of surgical site dehiscence can range from small, partial to full-thickness wound dehiscence, manifesting with acute abdominal pain, vaginal bleeding, or discharge, and is often precipitated by sexual intercourse. While imaging, including a pelvic ultrasound and computed tomography (CT), may help in undifferentiated acute abdominal pain, vaginal cuff dehiscence remains a clinical diagnosis found on physical exam. Because vaginal cuff dehiscence is a clinical diagnosis, sparse data exist regarding radiographic sensitivities and specificities in the identification of vaginal cuff dehiscence. Despite the increasing literature suggesting that pelvic exams are invasive with often limited utility, the authors argue that pelvic exams remain essential in identifying complications of hysterectomies. The authors present a case of a 40-year-old woman with acute abdominal pain found to have loops of small bowel in the vaginal vault, discovered only on physical exam after negative CT and ultrasound imaging.
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Affiliation(s)
- Cody F Newell
- Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, USA
| | - Neil P Larson
- Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, USA
| | - Michael J Yoo
- Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, USA
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22
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Wan Hassan WA, Narasimhan V, Arachchi A, Manolitsas T, Teoh W. Small bowel evisceration from vagina. J Surg Case Rep 2021; 2021:rjab343. [PMID: 34408840 PMCID: PMC8364788 DOI: 10.1093/jscr/rjab343] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Accepted: 07/17/2021] [Indexed: 11/30/2022] Open
Abstract
Vaginal evisceration is a rare condition where abdominal contents herniate through a vaginal wall defect. The estimated incidence is 0.032–1.2% after hysterectomy, trachelectomy or upper vaginectomy. We present a 78-year-old lady who developed vaginal evisceration 2 years after radical cystectomy and hysterectomy for bladder cancer. It is rare surgical emergency that requires prompt recognition and damage control with bowel reduction and packing. We discuss the initial management and surgical options for definitive repair.
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Affiliation(s)
- Wan Amir Wan Hassan
- Colorectal Surgery, Department of Surgery, School of Clinical Science at Monash Health, Monash University, Melbourne Australia
| | - Vignesh Narasimhan
- Colorectal Surgery, Department of Surgery, School of Clinical Science at Monash Health, Monash University, Melbourne Australia
| | - Asiri Arachchi
- Colorectal Surgery, Department of Surgery, School of Clinical Science at Monash Health, Monash University, Melbourne Australia
| | - Thomas Manolitsas
- Colorectal Surgery, Department of Surgery, School of Clinical Science at Monash Health, Monash University, Melbourne Australia
| | - William Teoh
- Colorectal Surgery, Department of Surgery, School of Clinical Science at Monash Health, Monash University, Melbourne Australia
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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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24
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Margulies SL, Yeh J, Acevedo Alvarez M, Bercik R. Incidental Finding of Asymptomatic Vaginal Cuff Dehiscence with Evisceration of Abdominal Content During Prolapse Repair. J Gynecol Surg 2021. [DOI: 10.1089/gyn.2020.0195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Samantha L. Margulies
- Division of Urogynecology and Reconstructive Pelvic Surgery, Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Judy Yeh
- Yale Medicine, Section of Urogynecology and Pelvic Reconstructive Surgery, New Haven, Connecticut, USA
| | - Marian Acevedo Alvarez
- Department of Obstetrics and Gynecology and Urology, Loyola University Medical Center, Maywood, Illinois, USA
| | - Richard Bercik
- Yale Medicine, Section of Urogynecology and Pelvic Reconstructive Surgery, New Haven, Connecticut, USA
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25
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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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Lydrup E, Freccero C, Lydrup ML. Split-thickness skin graft as a treatment for voluminous vaginal fluid discharge after surgery due to vesico-intestino-vaginal fistulation: A case report and review of the literature. Gynecol Oncol Rep 2021; 36:100753. [PMID: 33889703 PMCID: PMC8050361 DOI: 10.1016/j.gore.2021.100753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 03/13/2021] [Accepted: 03/16/2021] [Indexed: 11/17/2022] Open
Abstract
•Repeated pelvic surgery in irradiated tissue increases the risk for vaginal rupture.•We present a rare case with heavy secretion from the ruptured vagina.•Split skin grafting was used as an unusual treatment for this complication.
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Affiliation(s)
- E. Lydrup
- Department of Plastic Surgery and Breast Surgery, Zealand University Hospital, Sygehusvej 10, 4000 Roskilde, Denmark
- Corresponding author at: Dept of Plastic Surgery and Breast Surgery, Zealand University Hospital, Sygehusvej 10, DK-4000 Roskilde, Denmark.
| | - C. Freccero
- Department for the Clinical Sciences, Unit for Plastic and Reconstructive Surgery, Skåne University Hospital, S-205 02 Malmo, Sweden
| | - ML. Lydrup
- Department of Surgery, Colorectal Unit, Skåne University Hospital, S-205 02 Malmö, Sweden
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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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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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Endometrial Cancer in Germline BRCA Mutation Carriers: A Systematic Review and Meta-analysis. J Minim Invasive Gynecol 2020; 28:947-956. [PMID: 33249269 DOI: 10.1016/j.jmig.2020.11.023] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Revised: 11/22/2020] [Accepted: 11/25/2020] [Indexed: 12/24/2022]
Abstract
OBJECTIVE Risk-reducing salpingo-oophorectomy (RRSO) is standard treatment among women with BRCA mutations. The aim of this meta-analysis is to evaluate the risk of endometrial cancer (EC) in BRCA1 or BRCA2 germline mutation carriers and to examine the justifiability of prophylactic hysterectomy at the time of RRSO. DATA SOURCES PubMed, Cochrane Central Register of Controlled Trials, BIOSIS, Medline (Ovid), Web of Science, ClinicalTrials.gov, and Google Scholar were searched. Eleven articles were selected and analyzed using the OpenMetaAnalyst 2012 software. METHODS OF STUDY SELECTION Randomized controlled studies, cohort studies, and case-control studies evaluating the risk of EC and specifically uterine papillary serous carcinoma (UPSC) in germline BRCA1/2 mutation carriers were included. Articles were excluded if they did not meet the inclusion criteria, or if data were not reported and the authors did not respond to inquiries. We assessed the methodological quality of the included studies on the basis of the Newcastle-Ottawa scale. Dichotomous results from each of the studies eligible for the meta-analysis were expressed as the proportion of patients with EC or UPSC per total number of BRCA mutation carriers, with 95% confidence interval (CI). The Mantel-Haenszel statistical method was used. TABULATION, INTEGRATION, AND RESULTS Eleven studies reported the outcome of interest and were included in the final meta-analysis. In total, 13 871 carriers of BRCA1 and BRCA2 mutations were identified. The pooled prevalence rates of EC and UPSC in BRCA1/2 mutation carriers were 82/13 827 (0.59%) and 19/11 582 (0.16%), respectively. The EC prevalence was 46/7429 (0.62%) in BRCA1 mutation carriers and 17/3546 (0.47%) in BRCA2 mutation carriers, with relative risk of 1.18 (95% CI, 0.7-2.0). For UPSC, the prevalence was 15/7429 (0.2%) and 3/3546 (0.08%) among BRCA1 and BRCA2 mutation carriers, respectively, (relative risk 1.39; 95% CI, 0.5-3.7). CONCLUSION Most studies in this meta-analysis suggest a slightly increased risk of EC in BRCA mutation carriers, mainly for BRCA1. The decision regarding concurrent hysterectomy should be tailored individually to each patient on the basis of the patient's age, type of mutation, future need for hormone replacement treatment, history of breast cancer, tamoxifen use, and personal operative risks.
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Four-arm polypropylene mesh for vaginal vault prolapse-surgical technique and outcomes. Eur J Obstet Gynecol Reprod Biol 2020; 255:203-210. [PMID: 33152564 DOI: 10.1016/j.ejogrb.2020.10.007] [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: 06/29/2020] [Revised: 10/02/2020] [Accepted: 10/08/2020] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Advanced vaginal vault prolapse (VVP) can occur rarely after any type of hysterectomy. Several types of procedures have been applied to correct this defect, but optimal management is still pending. The aim of this study was to describe the surgical technique and results of four-arm transvaginal mesh (FATVM) application for advanced VVP. STUDY DESIGN We followed up for 24 months, 160 patients with VVP > II vc (according to the Pelvic Organ Prolapse Quantification Scale (POPQ)), who underwent FAMTVM from 2014 to2017. FAMTVM was inserted with the anterior arms through the obturator foramens and the posterior arms through the ischiorectal fossas and sacrospinal ligaments. Clinical data were prospectively collected in a customized database and retrospectively analyzed. To assess QoL SF 36, KHQ and FSFI questionnaires were used. POPQ was employed to measure degree of VVP. Non-parametric tests (The Wilcoxon signed-rank test) were applied to verify statistical hypotheses. RESULTS According to SF 36, significant improvement was evident in almost all aspects of general QoL (PCS p = 0.002, MCS p = 0.01). KHQ showed statistically significant improvement in all domains. FSFI scores after surgery indicated significantly improvement in all domains of the questionnaire, apart from lubrication (p = 0.02). Intraoperative bladder injury occurred in 3.75 % (n = 6) of all cases. Five patients (3.1 %) complained of de novo stress urinary incontinence. VVP reoccurred in nine cases (5.6 %). Only two patients (1.25 %) saw mesh exposure after 6 months postoperative recovery. CONCLUSION We consider FAMTVM for VVP to be safe and effective. Hence, it applied as an optional treatment, especially in patients with contraindications to laparotomy and laparoscopy.
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Prolapsed epiploica of bowel after robotic hysterectomy: A case report. Ann Med Surg (Lond) 2020; 60:146-148. [PMID: 33145023 PMCID: PMC7595933 DOI: 10.1016/j.amsu.2020.10.055] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 10/20/2020] [Accepted: 10/21/2020] [Indexed: 11/22/2022] Open
Abstract
Purpose Vaginal cuff dehiscence with evisceration was defined as expulsion of intraperitoneal organs through the separated incision. Prolapsed epiploica of the colon is a rare complication after hysterectomy. The most common organ to prolapsed out from the dehiscence vaginal cuff is terminal ileum. We reported the first known case of prolapsed epiploica of the colon after robotic hysterectomy. Case This is a case who had prolapse of a vaginal tumor after sexual intercourse 5 months after robotic hysterectomy. Vaginal tumor resection and primary closure were performed successfully without complications. The final pathology revealed fat prolapse with foreign body reaction and confirmed prolapse of epiploica of the colon. Being aware of the risk factors and patients who are more likely to develop this complication is essential in making the correct diagnosis in time. Major conclusion Patients with a higher risk of vaginal cuff dehiscence are advised to avoid sexual activity for a longer period of time. Surgical intervention is the primary treatment. Prolapsed epiploica of the colon should be kept in mind for those who have undergone hysterectomy in order to provide appropriate treatment in time.
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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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O'Connor SK, Ryley DA, Obasiolu CW, Esselen KM, Skiadas CC, Kuohung W. Vaginal cuff dehiscence following transvaginal oocyte retrieval: a case report. FERTILITY RESEARCH AND PRACTICE 2020; 6:16. [PMID: 32905306 PMCID: PMC7469333 DOI: 10.1186/s40738-020-00085-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 08/05/2020] [Indexed: 11/10/2022]
Abstract
Background Vaginal cuff dehiscence (VCD) is a rare but potentially serious complication following hysterectomy with an estimated incidence of 0.14–1.4%. There is a wide range of risk factors thought to contribute to VCD, but due to its rare occurrence, much still remains to be learned about the true impact of risk factors leading to dehiscence. We present here the second known report of VCD to occur in a patient undergoing transvaginal oocyte retrieval during her fertility treatment. This case highlights what may become a more common clinical scenario as more premenopausal women are diagnosed with reproductive tract cancers and access assisted reproductive therapies to preserve fertility. Case presentation Our patient is a 35-year-old G1 P0 A1 who had undergone ovary-sparing total laparoscopic hysterectomy (TLH) following diagnosis of endometrial adenocarcinoma. She underwent two in-vitro fertilization (IVF) cycles after TLH to bank frozen blastocysts, the first vaginal oocyte retrieval (VOR) taking place 12 weeks following hysterectomy. She experienced VCD during her second VOR that occurred 17 weeks after TLH, the second case of VCD to be reported in the literature during fertility preservation treatment following hysterectomy. The patient underwent an emergent and uncomplicated repair of the defect vaginally the same day. Conclusions Currently there are no guidelines in place for women who have undergone hysterectomy with regard to when they can begin fertility treatment in the post-operative period. Based on now two case reports, it is worth considering extension of the typical 6-week timeline of avoidance of vaginal procedures to allow for full cuff healing. Infertility providers should also be mindful of limiting transvaginal ultrasounds where possible to reduce force along the cuff.
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Affiliation(s)
- Sarah K O'Connor
- Department of Obstetrics & Gynecology, Boston Medical Center, Boston, MA USA
| | | | | | - Katharine M Esselen
- Division of Gynecologic Oncology, Beth Israel Lahey Health Boston, Boston, MA USA
| | | | - Wendy Kuohung
- Department of Obstetrics & Gynecology, Boston Medical Center, Boston, MA USA
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Nezhat C, Nguyen K, Ackroyd E, Roman RA, Rambhatla A, Nezhat A, Asiaii A. Nerve-Sparing Modified Radical Hysterectomy for Severe Endometriosis and Complex Pelvic Pathology. Cureus 2020; 12:e9882. [PMID: 32963921 PMCID: PMC7500726 DOI: 10.7759/cureus.9882] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Accepted: 07/22/2020] [Indexed: 01/25/2023] Open
Abstract
Background Laparoscopic nerve-sparing modified radical hysterectomy with or without robotic assistance is known for its benefits as a definitive treatment for severe endometriosis. Undiagnosed endometriosis is common in patients with symptomatic fibroids or chronic pelvic pain. There are minimal studies that outline the safety and feasibility of nerve-sparing modified radical hysterectomy for other complex pelvic pathology in addition to endometriosis. Objectives The aim of this study is to evaluate the incidence of hospital readmission, intraoperative and postoperative complications, and long-term pain relief after laparoscopic nerve-sparing modified radical hysterectomy for severe endometriosis and complex benign pelvic pathology. Study design We performed a retrospective observational study of patients who underwent laparoscopic nerve-sparing modified radical hysterectomy with and without robotic-assistance with a high-volume minimally invasive endoscopic surgeon between November 2017 and December 2019. Results A total of 112 patients met the inclusion criteria. There were no cases of vaginal cuff dehiscence, venous thromboembolism, genitourinary system injury, gastrointestinal tract injury, vessel injury, nerve injury, sepsis, or death. Three patients required postoperative hospital admission for the management of umbilical cellulitis, acute blood loss anemia, and possible Addison's crisis. Other postoperative complications included allergic reaction to adhesives (1.8%) and urinary retention (0.9%). All patients reported significant pain relief at the time of their postoperative visits. Three patients reported return of pain symptoms within the first seven months after surgery, with one requiring an additional surgery for persistent pain. Conclusions Laparoscopic nerve-sparing modified radical hysterectomy with or without robotic assistance is a safe and feasible alternative that provides long-term symptom relief in patients undergoing hysterectomy for a variety of indications.
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Affiliation(s)
- Camran Nezhat
- Center for Special Minimally Invasive and Robotic Surgery, Camran Nezhat Institute, Palo Alto, USA
| | - Kimsa Nguyen
- Center for Special Minimally Invasive and Robotic Surgery, Camran Nezhat Institute, Palo Alto, USA
| | - Eliza Ackroyd
- Center for Special Minimally Invasive and Robotic Surgery, Camran Nezhat Institute, Palo Alto, USA
| | - Robert A Roman
- Center for Special Minimally Invasive and Robotic Surgery, Camran Nezhat Institute, Palo Alto, USA
| | - Anupama Rambhatla
- Center for Special Minimally Invasive and Robotic Surgery, Camran Nezhat Institute, Palo Alto, USA
| | - Azadeh Nezhat
- Center for Special Minimally Invasive and Robotic Surgery, Camran Nezhat Institute, Palo Alto, USA
| | - Atena Asiaii
- Center for Special Minimally Invasive and Robotic Surgery, Camran Nezhat Institute, Palo Alto, USA
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Minella C, Simeu B, Rohr S, Akladios C, Lecointre L. [Perineal vaginal evisceration of the hail through a fistulized elythrocele due to negligence of a pessary with ulceration: A case report]. GYNECOLOGIE, OBSTETRIQUE, FERTILITE & SENOLOGIE 2020; 48:464-465. [PMID: 31991175 DOI: 10.1016/j.gofs.2020.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/23/2019] [Indexed: 06/10/2023]
Affiliation(s)
- C Minella
- Service de Gynécologie, Hôpital universitaire de Strasbourg-hôpital d'Hautepierre, 1, avenue Molière, 67098 Strasbourg, France.
| | - B Simeu
- Service de chirurgie digestive, Hôpital Universitaire de Strasbourg, 1, avenue Moliere, 67098, Strasbourg, France
| | - S Rohr
- Service de chirurgie digestive, Hôpital Universitaire de Strasbourg, 1, avenue Moliere, 67098, Strasbourg, France
| | - C Akladios
- Service de Gynécologie, Hôpital universitaire de Strasbourg - hôpital d'Hautepierre, 1, avenue Molière, 67098 Strasbourg, France
| | - L Lecointre
- Service de Gynécologie, Hôpital universitaire de Strasbourg - hôpital d'Hautepierre, 1, avenue Molière, 67098 Strasbourg, France
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Delebecq J, Duraes M, Mandoul C, Rathat G, Taourel P, Millet I. Complications postopératoires du quotidien en gynécologie et obstétrique. IMAGERIE DE LA FEMME 2020. [DOI: 10.1016/j.femme.2020.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Ramani A, Testa G, Ghouri Y, Koon EC, Di Salvo M, McKenna GJ, Bayer J, Marie Warren A, Wall A, Johannesson L. DUETS (Dallas UtErus Transplant Study): Complete report of 6-month and initial 2-year outcomes following open donor hysterectomy. Clin Transplant 2019; 34:e13757. [PMID: 31758566 DOI: 10.1111/ctr.13757] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Revised: 11/12/2019] [Accepted: 11/17/2019] [Indexed: 12/20/2022]
Abstract
INTRODUCTION Uterus transplantation has shown success in treating women with uterine factor infertility who want to carry their own pregnancy. METHODS We report the medical, sexual, and psychological outcomes of our first cohort of 13 living donor hysterectomies. As we have transitioned from open to robotically assisted hysterectomy, this report represents the complete series of open donor hysterectomies at our center, all with ≥6-month postoperative outcomes. RESULTS The open donor hysterectomy had a median of a 6.5-hour surgical time, 0.8 L estimated blood loss, 6-day hospital stay, and 28-day sick leave. Three donors had a grade III or IV complications, one reported new-onset psychological symptoms, and 9 experienced transient sexual discomfort. All complications were addressed and resolved, and all donors returned to their presurgical social and physical activities. CONCLUSION Since uterus transplantation is not life-saving or life-extending, the risks in living uterus donation must be weighed against the benefit of giving another woman the opportunity to give birth to her own child. This report provides data to support more detailed informed consent regarding the medical, psychological, and sexual complications of open living donor hysterectomy and allows for further evaluation of the ethical acceptability of this procedure.
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Affiliation(s)
- Azaan Ramani
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX, USA
| | - Giuliano Testa
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX, USA
| | - Yumna Ghouri
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX, USA
| | - Eric C Koon
- Department of Obstetrics and Gynecology, Baylor University Medical Center, Dallas, TX, USA
| | - Marco Di Salvo
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX, USA
| | - Greg J McKenna
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX, USA
| | - Johanna Bayer
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX, USA
| | - Ann Marie Warren
- Division of Trauma, Acute Care, and Critical Care Surgery, Baylor University Medical Center, Dallas, TX, USA
| | - Anji Wall
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX, USA
| | - Liza Johannesson
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX, USA
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Orhan A, Ozerkan K, Kasapoglu I, Ocakoglu G, Cetinkaya Demir B, Gunaydin T, Uncu G. Laparoscopic hysterectomy trends in challenging cases (1995–2018). J Gynecol Obstet Hum Reprod 2019; 48:791-798. [DOI: 10.1016/j.jogoh.2019.06.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Revised: 06/11/2019] [Accepted: 06/21/2019] [Indexed: 12/26/2022]
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Peyser A, Hershlag A, Sakaris A, Singer T. Vaginal cuff dehiscence following controlled ovarian stimulation recognized during egg retrieval. FERTILITY RESEARCH AND PRACTICE 2019; 5:11. [PMID: 31741740 PMCID: PMC6849304 DOI: 10.1186/s40738-019-0064-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Accepted: 11/06/2019] [Indexed: 12/30/2022]
Abstract
Background Vaginal cuff dehiscence is a rare complication of hysterectomy. Those who choose to undergo controlled ovarian stimulation (COS) and oocyte cryopreservation following hysterectomy must be aware that elevated abdominal pressure from stimulation as well as transvaginal ultrasound use during monitoring may increase the risk of cuff dehiscence. Case We present a case of a 25-year-old patient who had undergone a hysterectomy four months prior for endometrial cancer who was found to have vaginal cuff dehiscence which was recognized at the time of egg retrieval after COS. Prompt recognition and appropriate management led to successful treatment. Conclusion Patients presenting for oocyte cryopreservation following hysterectomy are at risk for cuff dehiscence. Providers should allow ample time for proper cuff healing prior to COS and oocyte cryopreservation.
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Affiliation(s)
- Alexandra Peyser
- Division of Reproductive Endocrinology, Department of Obstetrics and Gynecology, North Shore University Hospital, Northwell Health, Zucker School of Medicine at Hofstra/Northwell, 300 Community Drive, Manhasset, NY 11030 USA
| | - Avner Hershlag
- Division of Reproductive Endocrinology, Department of Obstetrics and Gynecology, North Shore University Hospital, Northwell Health, Zucker School of Medicine at Hofstra/Northwell, 300 Community Drive, Manhasset, NY 11030 USA
| | - Antoinette Sakaris
- Division of Reproductive Endocrinology, Department of Obstetrics and Gynecology, North Shore University Hospital, Northwell Health, Zucker School of Medicine at Hofstra/Northwell, 300 Community Drive, Manhasset, NY 11030 USA
| | - Tomer Singer
- Division of Reproductive Endocrinology, Department of Obstetrics and Gynecology, North Shore University Hospital, Northwell Health, Zucker School of Medicine at Hofstra/Northwell, 300 Community Drive, Manhasset, NY 11030 USA
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Torres-de la Roche LA, Krentel H, Devassy R, de Wilde MS, Leicher L, De Wilde RL. Surgical repair of genital injuries after sexual abuse. GMS INTERDISCIPLINARY PLASTIC AND RECONSTRUCTIVE SURGERY DGPW 2019; 8:Doc14. [PMID: 31728263 PMCID: PMC6838733 DOI: 10.3205/iprs000140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Introduction: Genital injuries occur in half of cases of sexual assault through digital or penile penetration as well as the use of objects. Women aged >45 years are more likely to have physical injury and anogenital lesions, transmission of STI and HIV. This review focuses on the evidence about surgical reconstruction of the pelvic floor anatomy of adolescents and adult women sexually assaulted during adolescence or adulthood. Method: A systematic literature search was performed in PubMed and Orbis plus for articles published in English and German from June 2008 to June 2018. The literature search was performed in October 2018 by topic combining the following Medical Subject Headings: genital trauma, genital injuries, sexual assault, rape, surgical repair, treatment. Results: 34 records of descriptive studies were identified and 16 full-text articles were included in the present review. Due to the limited number of articles retrieved, articles were not excluded based on methodological design. Superficial genital lesions are common and usually left untreated. For deep vaginal or anal lacerations, intraperitoneal bleeding is usually assessed by means of and additional CT scan or diagnostic colposcopy, cystoscopy, rectoscopy and laparoscopy. Complete reconstruction of the injured is done after. To prevent rectovaginal fistula and uncomplicated primary wound healing a temporary colostomy can be performed. Conclusion: Although most of genital injuries due to sexual assault do not require any major surgical intervention, there is a lack of good quality evidence regarding the best diagnostic and surgical approach to restore deep lesions of genital organs as well lack evidence on contributors to poor wound healing. Therefore, clinical protocols that standardize examination as well as surgical management are encouraged to be developed.
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Affiliation(s)
| | - Harald Krentel
- Clinic for Obstetrics and Gynecology. St. Anna Hospital, Herne, Germany
| | - Rajesh Devassy
- Dubai London Clinic and Specialty Hospital, Dubai, United Arab Emirates
| | - Maya Sophie de Wilde
- University Hospital for Gynecology, Pius Hospital, Carl von Ossietzky University, Oldenburg, Germany
| | - Lasse Leicher
- University Hospital for Gynecology, Pius Hospital, Carl von Ossietzky University, Oldenburg, Germany
| | - Rudy Leon De Wilde
- University Hospital for Gynecology, Pius Hospital, Carl von Ossietzky University, Oldenburg, Germany
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Mısırlıoğlu S, Arslan T, Urman B, Taşkıran C. Step-by-step colpotomy in total laparoscopic hysterectomy: a technique to avoid apical support damage to the upper vagina. J Turk Ger Gynecol Assoc 2019; 20:131-132. [PMID: 30820883 PMCID: PMC6558352 DOI: 10.4274/jtgga.galenos.2019.2018.0123] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
The purpose of this video article is to demonstrate our colpotomy technique that enables maximal protection of the cervical ring, helps to prevent the ureteral injury by distancing, and avoids shortening of the vagina at total laparoscopic hysterectomy. Step-by-step explanation of the colpotomy technique is presented using educational video setting in university-affiliated private hospital. After the uterine artery transection, a VECTEC surgical uterine manipulator (VECTEC, Hauterive, France) was inserted into the vagina in place of the sharp curette. The plastic rotating blade of uterine manipulator was strongly pushed forward into the anterior vaginal fornix. Colpotomy incision was started from the uppermost middle point of an anterior vagina, and extended to both sides with a monopolar L-hook electrocautery at 40 watts cutting mode. Then the manipulator’s blade was maneuvered into the right lateral fornix, and THUNDERBEAT platform (Olympus Medical Systems Corp, Tokyo, Japan) was chosen as the modality of energy for the transection of the rest of the vagina. At the posterior part of colpotomy, the vaginal wall was cut from the uppermost part of uterosacral ligaments, as well. Finally, the left lateral fornix was cut by the same principles, and colpotomy was completed circumferentially. In conclusion, maximal preservation of paracervical ligaments with this technique preserve the apical support of vagina, and avoids shortening of vaginal length. The technique also minimizes the ureteral injury by distancing.
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Affiliation(s)
- Selim Mısırlıoğlu
- Clinic of Obstetrics and Gynecology, Koç University Hospital, İstanbul, Turkey
| | - Tonguç Arslan
- Women’s Health Center, American Hospital, İstanbul, Turkey
| | - Bülent Urman
- Women’s Health Center, American Hospital, İstanbul, Turkey,Department of Obstetrics and Gynecology, Koç University School of Medicine, İstanbul, Turkey
| | - Cağatay Taşkıran
- Women’s Health Center, American Hospital, İstanbul, Turkey,Department of Obstetrics and Gynecology, Koç University School of Medicine, İstanbul, Turkey
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Behbehani S, Yi J. Vaginal Cuff Dehiscence Mimicking Pelvic Organ Prolapse. J Minim Invasive Gynecol 2019; 27:13-14. [PMID: 31075446 DOI: 10.1016/j.jmig.2019.05.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Accepted: 05/01/2019] [Indexed: 12/11/2022]
Affiliation(s)
- Sadikah Behbehani
- Department of Gynecological Surgery, Mayo Clinic Hospital, Phoenix, Arizona (all authors)..
| | - Johnny Yi
- Department of Gynecological Surgery, Mayo Clinic Hospital, Phoenix, Arizona (all authors)
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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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