Comparison of selective uterine artery double ligation at the isthmic level of uterus and bipolar uterine artery coagulation in total laparoscopic hysterectomy

Anatomic variation of a duplicated uterine artery

During the anatomical dissection of the pelvis, a duplication of the uterine artery was identified unilaterally on the left side in a 59-year-old Korean female cadaver. The first uterine artery was found to arise directly from the anterior division of the internal iliac artery and supply the upper uterine body and tube. The second uterine artery shared a common stem with the superior and inferior vesical arteries, supplying the lower uterine body. The external diameter of each uterine artery at its origin on the left side was smaller than that of the right uterine artery. One vaginal artery was identified to arise from the left internal pudendal artery. Embryologically, a duplicated uterine artery could imply the presence of two primordial arteries separately supplying the cranial and caudal parts of the Müllerian duct during the early fetal period. This case of variational anatomy is noteworthy: clinicians could elucidate it and successfully perform uterine artery embolization or hysterectomy with minimal complications.

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

STUDY OBJECTIVE

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

DATA SOURCES

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

METHODS OF STUDY SELECTION

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

TABULATION, INTEGRATION, AND RESULTS

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

CONCLUSION

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

The extremely rare vascular variant of a segmental duplicated uterine artery and its relevance for the interventionist and gynecologist: a case report

Background

Anatomic variants of the uterine artery are rare, with the absence of one of the uterine arteries presumably being the most abundant variant. A duplicated uterine artery is mentioned in the medical literature, but to the best of our knowledge, an angiographic study has never been published. A partially duplicated uterine artery is an extremely rare variant not previously mentioned in the literature, and it could lead to technical difficulties or cause problems in various gynecological interventions.

Case presentation

We present the case of a 45-year-old Caucasian woman with a uterine fibroid and typical fibroid-related symptoms who came to our department to get treated with fibroid embolization. During the procedure, angiography revealed a partial or segmental duplicated left uterine artery. This exceptionally rare anatomic variant proved to be beneficial for the safety of the embolization in our case; however, it is far more likely that such a variant would be unfavorable in some types of gynecological operative and minimally invasive techniques.

Conclusions

Knowledge of the anatomic variant of a partially duplicated uterine artery is important, especially for gynecologists performing minimally invasive surgical procedures.

Total laparoscopic hysterectomy via suture and ligation technique

OBJECTIVE

The term 'total laparoscopic hysterectomy (TLH) with classical suture method' refers to a surgical procedure performed using only sutures and ligations with intracorporeal or extracorporeal ties, without using any laser or electronic cauterization devices during laparoscopic surgery as in total abdominal hysterectomy. However, the method is not as widely used as electric coagulation equipment for TLH because further advances in technology and surgical technique are required and operative time can take longer. In the current study, we evaluated the benefits of the classical suture method for TLH.

METHODS

This study retrospectively reviewed patients who received TLH using the classical suture method from August 2005 to April 2014. The patients' baseline characteristics were analyzed, including age, parity, cause of operation, medical and surgical history. Surgical outcomes analyzed included the weight of the uterus, operative time, complications, changes in hemoglobin level, blood transfusion requirements, and postoperative hospital stay.

RESULTS

Of 746 patients who underwent TLH with the classical suture method, mean operation time was 96.9 minutes. Mean average decline in hemoglobin was 1.6 g/dL and transfusion rate was 6.2%. Urinary tract injuries were reported in 8 patients. Urinary tract injuries comprised 6 cases of bladder injury and 3 cases of ureter injury. There were no cases of vaginal stump infection, hematoma, bowel injury or abdominal wound complication. All cases involving complications occurred before 2010.

CONCLUSION

The classical suture method for TLH presents tolerable levels of complications and blood loss. Advanced surgical skill is expected to decrease operation time and complications.

Ligation of uterine vessels in total laparoscopic hysterectomy using Hem-o-lok clips

OBJECTIVE

The Hem-o-lok clip ligation has become the preferred method for vessel ligation. We evaluated the feasibility and safety of uterine vessel ligation using the Hem-o-lok clip during total laparoscopic hysterectomy.

MATERIALS AND METHODS

The clinical outcomes of 58 hysterectomies were compared between the following two groups: Hem-o-lok clip group (n = 29) and bipolar coagulation group (n = 29).

RESULTS

Of the 29 patients in the Hem-o-lok clip group, bilateral application of Hem-o-lok clips was completed in 25 patients (86%); unilateral use of the bipolar coagulator was needed in four patients for rapid control of bleeding from lacerated uterine vessels during dissection and/or because of anatomical difficulty. No complications, such as dislodgement, slippage, or bleeding, were identified in the Hem-o-lok clip group. No difference was identified in surgical outcomes, such as blood loss or operative time, between the two groups. Postoperative pelvic infections occurred in one patient from each group with unilateral and bilateral use of the Hem-o-lok clip; the ligated uterine vessels using the Hem-o-lok clip were intact, but the coagulated uterine vessels were weakened by the pelvic infections, which caused active uterine bleeding requiring emergent reoperation.

CONCLUSION

The Hem-o-lok clip could be used for ligation of uterine vessels and might be resistant to pelvic infections compared with bipolar coagulation. Prospective randomized trials are needed to confirm the real clinical benefit of this surgical approach.

Uterine artery ligation at the beginning of total laparoscopic hysterectomy reduces total blood loss and operation duration

The purpose of this study was to compare the feasibility, blood loss, duration of surgery and complications between patients in whom both uterine arteries were ligated by surgical clips and cut using a 5-mm ligature at the beginning of total laparoscopic hysterectomy (TLH) and patients in whom uterine arteries were not ligated at the beginning of TLH. In our prospective study, a total of 60 women underwent TLH. Uterine artery ligation (UAL) was done at the beginning of the procedure. Women were divided into TLH + UAL (n = 30) and TLH (n = 30) groups. In TLH group, TLH was done without ligating the uterine arteries at the beginning of the procedure. In TLH + UAL group, TLH was done with ligation of both uterine arteries at the beginning of the procedure. The mean operating time was longer for the TLH group (99.16 ± 7.01) than TLH + UAL group (63.27 ± 7.16). The median total blood loss was higher in TLH group (109.38 ± 33.03 mL) than TLH + UAL group (47.50 ± 8.12 mL). UAL at the beginning of TLH is a technically feasible procedure. It reduces the total blood loss and decreases the time taken for the procedure and length of hospital stay.