Sonographic assessment of the vaginal vault following hysterectomy

Vaginal vault drainage after complicated single-port access laparoscopic-assisted vaginal hysterectomy

Study objective:

To evaluate the feasibility and safety of vaginal vault drainage after complicated singleport access laparoscopic-assisted vaginal hysterectomy (SPA-LAVH).

Design:

Retrospective cohort study.

Setting:

Ulsan University Hospital (tertiary teaching hospital), South Korea.

Patients:

A total of 359 women underwent SPA-LAVH for the following conditions: benign uterine tumor, preinvasive uterine lesion, and microinvasive cervical cancer.

Interventions:

The participants included 124 women with vault drains and 235 women without drains.

Measurements:

Surgical outcomes, perioperative complications and morbidity, postoperative febrile morbidity.

Results:

There were no differences in background features between drain and no-drain groups. In surgical outcomes, mean uterine weight (364.2 ± 184.9 g vs. 263.7 ± 138.6 g; p < 0.001), operation time (87.4 ± 21.5 min vs. 73.0 ± 17.6 min; p < 0.001), blood loss (225.3 ± 122.2 mL vs. 150.4 ± 95.2 mL; p < 0.001), and hemoglobin decline (1.97 ± 0.96 g/dL vs. 1.42 ± 0.89 g/dL; p < 0.001) were significantly larger for the drain group compared with the no-drain group. However, with regard to postoperative morbidity and complications, there were no group differences in the transfusion rates (6.5% vs. 3.8%; p = 0.300), intraoperative complications (2.4% vs. 1.3%; p = 0.420), perioperative complications (2.4% vs. 0.9%; p = 0.345), and febrile morbidity ≥ 37.5°C (8.9% vs. 11.5%; p = 0.477), although the drain group was more prone to the development of pelvic fluid collection and febrile morbidity than the no-drain group.

Conclusion:

Vaginal vault drainage could be a safe alternative that allows for the management of postoperative morbidity and retains the advantages of minimally invasive surgery after complicated SPA-LAVH.

Evaluation of closure versus non-closure of vaginal vault after vaginal hysterectomy

This randomised prospective study in 53 women having vaginal hysterectomy for benign conditions compared a closed vault technique with an open technique. Twenty-seven had the vault closed (group A) whereas 26 patients had an open vault (group B). The primary outcomes include, vault haematoma (as detected by ultrasound on day 3) and fever. Secondary outcomes are haemorrhage, urinary tract infection, urinary retention and vault granulation tissue. The study did not show any statistical difference between either group. Prolapse of the fallopian tube was recorded in one case in the open vault group. A randomised controlled study on a larger scale is recommended.

Fibrin adhesive and the vaginal vault synthesis on female rabbits abdominal hysterectomies

PURPOSE

To investigate the effectiveness of fibrin glue in comparison with polyglycolic acid suture to promote the closure of rabbit's vaginal vault, after abdominal hysterectomy.

METHODS

Twenty female, adults, New Zealand rabbits, were submitted to abdominal hysterectomy and randomly distributed to polyglycolic acid suture (G-PA / n=10) or fibrin glue closure of vaginal vault (G-FG / n=10). Radiograph study allowed identifying vault vaginal suture disrupter or fistulas to urinary bladder or rectum. Videovaginoscopy study allowed identifying the presence of cellulites, abscess formation, tissue granulation or granuloma. Vaginal cuff burst test allowed to identify by the escape of air bubbles and rupture pression record. Histological sections stained with Picrosirius red allowed the measure of fibrous tissue healing.

RESULTS

The videovaginoscopy identified a significant difference (Fisher Test p<0.3142) of granulation tissue in the animals of G-PA (40%) in comparison with the G-FG (20%). The gross inspection showed the same relation in the granulation tissue occurrence (Fisher test p< 0.1749) with G-PA (50%) and G-FB (20%). The visceral adhesion to the vaginal vault wound was statistical significant (Fisher test p< 0.1749) with G-PA (50%) and G-FG (20%). The pressure of rupture (mm Hg) of the burst test was similar (p<0.0421) in the animals of G-PA (61.5+/-19.3) and G-FG (72.5+/-21.9). The collagen matrix of vault wound healing was similar (p< 0.0231) between the G-PA (31.63+/-15) and the G-FG (23.2+/-13.2).

CONCLUSION

The vaginal vault closure using the fibrin glue is a safe and reliable procedure after abdominal hysterectomy in female rabbit model.

Sonographically diagnosed vault hematomas following vaginal hysterectomy and its correlation with postoperative morbidity

OBJECTIVE

Our aim is to investigate sonographically detectable vault hematomas after vaginal hysterectomy and its relation to postoperative morbidity.

METHODS

We studied a group of 103 women who had undergone vaginal hysterectomy for benign causes apart from uterovaginal prolapse. Transabdominal ultrasound examinations were carried out 24 to 72 hours after surgery to assess the presence of vault hematomas. Ultrasound findings were correlated with clinical data and postoperative morbidity.

RESULTS

The incidence of vault hematoma was found 19.4% in present study. In these patients, 40% (8/20) had fever while only 2.4% (2/83) of cases without vault hematoma suffered from fever. Out of all women having vault hematoma, 70% (14/20) had small-sized hematoma and 30% (6/20) had large-sized hematoma. Fifty percent of patients (3/6) with large-sized hematoma, as compared to only 35% (5/14) with small-sized hematoma, suffered from febrile morbidity. Large-sized hematomas drained by vaginally, while all small-sized pelvic hematomas managed by watchful expectancy successfully. The significant difference was found mean hemoglobin drop and postoperative stay in the hematoma group or without hematoma group.

CONCLUSION

Sonographic detection of vaginal vault fluid collection is common after hysterectomy, but such a finding rarely indicates additional treatment. Though febrile morbidity was more in cases with vault hematoma, the number of such patients was too small to be significant. Vaginal ultrasound examination should not be performed routinely after hysterectomy.

Sonographic detection of fluid collections and postoperative morbidity following Cesarean section and hysterectomy

OBJECTIVES

To evaluate the clinical significance of sonographically detected fluid collections following Cesarean section and hysterectomy, and to identify risk factors associated with their formation.

METHODS

This was a prospective study including 280 women, 145 of whom had undergone a Cesarean section and 135 of whom had undergone abdominal or vaginal hysterectomy. Ultrasound examinations were carried out on all women on day 4 after surgery to assess the presence of abdominal wall or pelvic fluid collections. The sonographers were unaware of the clinical course before the examination and were not involved in any clinical decision-making. Ultrasound findings were correlated with clinical data and postoperative morbidity.

RESULTS

A fluid collection was found in 69 (48%) women after Cesarean section, and in 59 (44%) women who had undergone hysterectomy. No risk factors for the development of fluid collections after Cesarean section or hysterectomy were identified. The risk of developing febrile morbidity was not related to the presence, location or size of fluid collections.

CONCLUSIONS

Postoperative fluid collections are common after Cesarean section and hysterectomy. As fluid collections detected by sonography were not associated with postoperative morbidity, this finding is unlikely to be useful in the workup for postoperative fever.

Vault haematoma and febrile morbidity after vaginal hysterectomy

Vaginal hysterectomy is associated with significant risk of vaginal vault haematoma (40%) and febrile morbidity (30%). Numerous interventions have been used to try and avoid these complications but very few have been shown to be effective.

Prospective randomized comparison between an open and closed vaginal cuff in abdominal hysterectomy

OBJECTIVE

To compare an operative and postoperative course of open vaginal cuff hysterectomy and closed vaginal cuff hysterectomy, and to correlate the length of stay, febrile morbidity and the incidence of pelvic fluid collections to the type of surgery.

PARTICIPANTS

One-hundred women scheduled for hysterectomy were prospectively randomized into two groups that underwent either a closed or an open vaginal cuff technique.

RESULTS

The open vaginal cuff technique took on average 19% more time than the closed vaginal cuff operation (P < 0.05, t-test). The incidence and size of pelvic fluid collections was significantly higher after the closed vaginal cuff hysterectomy than after the open technique (P < 0.01, t-test). However, the postoperative length of stay, febrile morbidity and the rate of complications were similar.

CONCLUSIONS

Both techniques of hysterectomy produced a similar postoperative course despite the fact that the closed vaginal cuff technique resulted in a higher incidence of pelvic fluid collections. Therefore considering a shorter operation time for the closed vaginal cuff hysterectomy, this technique seems slightly preferable.

Ultrasound detection of vault haematoma following vaginal hysterectomy

OBJECTIVE

To assess whether ultrasound detection of vault haematoma can be used as a predictor of post-operative morbidity following vaginal hysterectomy.

DESIGN

Prospective observational study of consecutive cases of vaginal hysterectomy performed between 1991 and 1994.

SAMPLE

Two hundred and twenty-three women having undergone vaginal hysterectomy.

METHODS

All women had transvaginal ultrasound examination by an independent observer on the third post-operative day. Routine observations and clinical assessments were made by established management protocol, by staff blinded to the ultrasound findings.

MAIN OUTCOME MEASURES

Febrile morbidity; haemoglobin drop; need for blood transfusion; length of stay in hospital; re-admission rate and length of stay.

RESULTS

Of the 223 scanned women, 55 (25%) had a vault haematoma. This group was compared with the 168 women with no haematoma. Significant increases in febrile morbidity (31% vs 7%), post-operative haemoglobin drop (2.5 g/dL vs 1.6 g/dL), need for blood transfusion (14.5% vs 1.2%), representation to hospital (25.5% vs 5.4%) and length of hospital stay (8.87 days vs 6.25 days) were seen in the haematoma group.

CONCLUSION

Ultrasound detection of vault haematoma following vaginal hysterectomy is a common finding associated with increased febrile morbidity, need for blood transfusion, longer hospital stay and higher re-admission rate. In view of increasing demand for early discharge, driven by purchasers and patients, post-operative ultrasound identifies a high risk population and is both convenient and noninvasive. To further reduce morbidity, it also offers the opportunity to perform a controlled trial of prophylactic antibiotics in this identified subset.

Vault haematoma following laparoscopic hysterectomy

Thirty consecutive patients underwent transabdominal ultrasound scanning on day 2 postoperatively in order to provide data on the incidence of vaginal vault haematoma following laparoscopic hysterectomy. Details of postoperative morbidity, both inpatient and after discharge, were recorded. Results support the view that there is no significant association between the presence of vaginal vault haematoma (73%) and the incidence of posthysterectomy febrile morbidity (16.7%). Furthermore the incidence of vault haematoma after laparoscopic hysterectomy is comparable to literature figures for both abdominal and vaginal hysterectomy, whilst that of febrile morbidity is at least equivalent if not reduced for the laparoscopic approach. We believe this provides further evidence confirming the safety of the laparoscopic approach to hysterectomy.