Morbidity of vaginal hysterectomy for benign tumors as a function of uterine weight

OBJECTIVE: To evaluate the relationship between uterine weight and morbidity in women undergoing vaginal hysterectomy. STUDY DESIGN: A prospective study of vaginal hysterectomy was carried out in women with benign uterine tumors. The only exclusion criteria were a suspected adnexal mass, a very narrow vagina and an immobile uterus. The women were stratified into 3 groups according to uterine weight. The groups were compared as regards indications, operative time, complication rates, analgesia requirements and postoperative recovery. RESULTS: A total of 214 women underwent vaginal hysterectomy: group 1, n = 114, uteri < 180 g; group 2, n = 73, uteri 180-500 g; group 3, n = 27, uteri > 500 g (maximum 1,350 g). The groups differed with respect to mean age (P = .003) and menopausal status (P = .002) but not gravidity, parity, previous pelvic surgery or preoperative hemoglobin levels. Concerning the indications for hysterectomy, only the incidence of pelvic compression differed between the groups (P = .04). There was no difference in the frequency of concomitant surgical procedures (e.g., adnexectomy) between the groups. Morcellation rate was 30% in group 1, 73% in group 2 and 100% in group 3. The overall complication rate was not significantly different between the groups: 20.1%, 15.0% and 22.2%, respectively. The only major complication was an injury to the in-fundibulopelvic ligament in a group 1 patient. Operative time increased significantly with uterine weight (82 +/- 35.4, 91.8 +/- 35.4 and 94.8 +/- 36.5 minutes, respectively; P = .01). There were no significant differences between the groups as regards perioperative hemoglobin loss, analgesia requirements, time to flatus and stool return or length of hospital stay. CONCLUSION: Vaginal hysterectomy can be performed successfully even in the case of greatly enlarged uteri; nulliparity and a history of pelvic surgery are not absolute contraindications.     

Laparoskopische Operationsverfahren in der Gynäkologie

The international significance of, for example, vaginal surgical techniques has been increased by laparoscopy. Surgery for extrauterine pregnancy, or adnexectomy and partial adnexal resection are only carried out with a laparotomy in exceptional cases; for the therapy of benign uterine diseases this is used in less than 10% of cases. The spectrum of laparoscopy ranges from endometrial ablation over hysteroscopic resection and laparoscopic enucleation of myomas, to the various types of hysterectomy: laparoscopic assisted vaginal hysterectomy (LAVH), laparoscopic assisted supracervical hysterectomy (LASH) and total laparoscopic hysterectomy (TLH). In addition, tumor surgery can be carried out, either partially or completely, using laparoscopy. Laparoscopic pelvic and para-aortic lymphadenectomy are also established techniques. Endoscopic surgical techniques are still not as widely used as could be. In 2003, 60% of hysterectomies in Germany still involved abdominal surgery. Future developments in operative techniques require our particular attention, as do the establishment of already evaluated procedures in their total breadth, especially in the training of the younger generations of gynecologists.     

Vaginal length and incidence of dyspareunia after total abdominal versus vaginal hysterectomy

Objective

To evaluate the vaginal length and incidence of dyspareunia after total abdominal hysterectomy compared to vaginal hysterectomy.

Study design

This is a prospective observational study. Sixty-six patients were invited to participate in the study who were already planned to undergo abdominal or vaginal hysterectomy for different benign indications in the OB/GYN department, Sohag University Hospital, during the period from March 2007 till April 2009. Patients were classified into two groups. Thirty-six patients who were planned to undergo total abdominal hysterectomy (TAH) represented the first group, and 30 patients who were planned to undergo vaginal hysterectomy (VH) represented the second group. Vaginal length was obtained just before the operation and three times postoperatively. Pre- and post-operative dyspareunia was reported.

Results

The mean pre-operative and post-operative vaginal lengths in the TAH group were nearly the same (10.5 ± 2.1 cm vs. 10.2 ± 1.8 cm) without statistically significant difference. In the VH group, there was a statistically significant difference between pre- and post-operative vaginal length (10.1 ± 1.9 cm vs. 8.4 ± 1.6 cm). In the TAH group, 2 patients (5%) reported a newly developed post-operative dyspareunia. In VH group, 6 patients (20%) developed dyspareunia after surgery.

Conclusion

Postoperative dyspareunia is more common after vaginal hysterectomy compared to abdominal hysterectomy. This may be attributed to postoperative shortening of the vagina secondary to excessive trimming of the vaginal walls especially if VH was done for utero-vaginal prolapse.     

Challenging generally accepted contraindications to vaginal hysterectomy

OBJECTIVE: A number of preexisting clinical conditions are generally accepted as contraindications to vaginal hysterectomy. The purpose of this study was to evaluate the validity of this concept. STUDY DESIGN: The study vaginal hysterectomy group consisted of 250 consecutive patients undergoing vaginal hysterectomy. These patients (1) had a large uterus (>180 g), (2) either were nulliparous or had no previous vaginal delivery, or (3) had a previous cesarean delivery or pelvic laparotomy. Three control groups used for comparison underwent (1) laparoscopically assisted vaginal hysterectomy, (2) vaginal hysterectomy, or (3) abdominal hysterectomy. The records for all patients were analyzed for age, weight, parity, primary diagnosis, uterine size, operative time, blood loss, analgesia, hospital stay, resumption of diet, incidence of morcellation, and surgical complications. Sample size calculations were based on previous studies of complications associated with vaginal hysterectomy (alpha =.05; beta =.20). RESULTS: Hysterectomy was successfully completed by the intended vaginal route in all study patients. Major and minor complications (3.2%) were significantly less (P <.001) than in the other groups as follows: vaginal hysterectomy, 10.4%; laparoscopically assisted vaginal hysterectomy, 11.6%; and abdominal hysterectomy, 13.6%. The decrease in hematocrit was 5.7% in the study vaginal hysterectomy group compared with 6.2% for vaginal hysterectomy, 6.5% for abdominal hysterectomy (P =.009), and 6.6% for laparoscopically assisted vaginal hysterectomy (P =.002). Hospital stay was shorter for the study group (2.1 days) than for vaginal hysterectomy (2.3 days; P <.001) and abdominal hysterectomy (2.7 days; P <.001). Operative time was shorter in the study vaginal hysterectomy group (49 minutes) than with laparoscopically assisted vaginal hysterectomy (76 minutes; P <.001) or abdominal hysterectomy (61 minutes; P <.001), although morcellation was carried out more frequently in the study group (34%) than with vaginal hysterectomy (4%) or laparoscopically assisted vaginal hysterectomy (11%). CONCLUSION: Our data indicate that a large uterus, nulliparity, previous cesarean delivery, and pelvic laparotomy rarely constitute contraindications to vaginal hysterectomy.     

Minilaparotomy-assisted vaginal hysterectomy.

OBJECTIVES: To determine the feasibility and acceptability of minilaparotomy-assisted vaginal hysterectomy. METHODS: A prospective pilot study in a general hospital was conducted. Twenty patients who were on the waiting list for abdominal hysterectomy were included in the study. All these patients had one or more relative contraindications to vaginal hysterectomy. The hysterectomy procedure was started vaginally in all cases. A minilaparotomy incision was performed to complete the procedure if vaginal hysterectomy was not feasible. Results were analyzed on the intention to treat basis. RESULTS: The procedure was successfully completed as intended in 19/20 patients (95%). Six patients had the procedure completed vaginally (30%). Thirteen patients had the procedure completed with minilaparotomy assistance (65%). The mean operative time was 63+/-24.8 min (+/-S.D.). The median estimated blood loss was 155 ml (range: 20-800). One bladder injury occurred. The overall post-operative complication rate was 35% (7/20). This included urinary retention necessitating catheterization for 24 h (n=3), urinary infection (n=2), vaginal infection (n=1) and wound hematoma (n=1). The mean post-operative pain score on a scale from 1 to 10 was 3.1. The overall patient satisfaction based on a scale from 1 to 10 was 9.23 (range: 8-10). CONCLUSIONS: Minilaparotomy-assisted vaginal hysterectomy is a feasible and safe procedure. Our results suggest that this approach is potentially useful in increasing the proportion of hysterectomies performed vaginally.     

Changing the route of hysterectomy: the results of a policy of attempting the vaginal approach in all cases of dysfunctional uterine bleeding

OBJECTIVE: To assess the effectiveness of a policy of performing a vaginal hysterectomy for as many cases of dysfunctional uterine bleeding without uterine prolapse as possible between 1997 and 2003. STUDY DESIGN: The study was prospective, with retrospective analysis of data. SETTING: Warwick Hospital. POPULATION: Eighty-seven women in a district hospital serving a population of 270,000 in South Warwickshire. METHODS: During 1997 and 2003, an effort was made to perform as many hysterectomies vaginally as possible, with oophorectomy where necessary, in women with dysfunctional uterine bleeding in the absence of prolapse. The trends of the three different operations, total abdominal hysterectomy, sub-total abdominal hysterectomy and vaginal hysterectomy over the 7-year period were analysed. MAIN OUTCOME MEASURES: The ability to undertake surgery successfully, complications rates, length of hospital stay and changes in surgical practice. RESULTS: Over this 7-year period, it has proved possible to change the emphasis from abdominal to vaginal hysterectomy for dysfunctional uterine bleeding. In 1997, the most common operation for dysfunctional uterine bleeding (72.7%) was subtotal hysterectomy+/-bilateral salpingo-oophorectomy, followed by (27.3%) total abdominal hysterectomy+/-bilateral salpingo-oophorectomy. No cases were undertaken vaginally. By 2003, however, the trend had completely reversed, with the only procedure undertaken being vaginal hysterectomy+/-bilateral salpingo-oophorectomy. There is no evidence that such an approach increases the complication rate, and the recovery rate from surgery is improved with a tendency towards earlier discharge in the vaginal surgery group. CONCLUSION: The vaginal approach is possible for an average gynaecologist working in a district general hospital, with no additional complications and an improved recovery rate for patients.     

Vaginal hysterectomy for the woman with a moderately enlarged uterus weighing 200 to 700 grams

Objectives: The purpose of this study was to compare the surgical outcomes of women with moderately enlarged uteri undergoing vaginal hysterectomy with those of women with uteri of normal size undergoing vaginal hysterectomy. A secondary objective was to investigate the roles of uterine morcellation and laparoscopically assisted vaginal hysterectomy in the treatment of these women. Study Design: Thirty consecutive women during a 2-year period with uterine enlargement to a weight of between 200 and 700 g underwent vaginal hysterectomy or laparoscopically assisted vaginal hysterectomy limited to lysis of adhesions or adnexectomy. These patients with uterine enlargement (group 1) were compared with 160 women with uteri weighing <200 g who also underwent vaginal hysterectomy or laparoscopically assisted vaginal hysterectomy during the same interval (group 2). The 2 groups were compared for total complications, operative time, hospital stay, perioperative hemoglobin concentration change, and use of vaginal uterine morcellation and laparoscopically assisted vaginal hysterectomy. Results: Operative time for vaginal hysterectomy was significantly longer for women in group 1 than for women in group 2 (66.6 ± 26.2 minutes vs 53.0 ± 25.5 minutes, P = .008). There was a linear relationship between uterine weight and operative time: Operative time = 47.156 + 0.056 × Uterine weight (r = 0.20, F = 7.66, degrees of freedom 1, 188, P = .006). Vaginal morcellation of the uterus was needed in 80.0% of the women in group 1 and in 10.0% of the women in group 2 (P < .001). Two women in group 1 (6.7%) and 9 women (5.6%) in group 2 had laparoscopically assisted procedures for lysis of adhesions, adnexectomy, or both, unrelated to uterine size (P = .69). There were no significant differences between the 2 groups with respect to perioperative hemoglobin concentration change or hospital stay. Finally, the rates of major surgical complications were similar in the 2 groups (3.3% in group 1 vs 4.3% in group 2, P > .99, 95% confidence interval –8.1% to 5.9%). Conclusions: Although vaginal hysterectomy requires a modest increase in operative time, it is as safe and effective for the woman with a moderately enlarged uterus as for the woman with a uterus of normal size. Vaginal uterine morcellation is the key to a successful operation and obviates the need for either abdominal or laparoscopically assisted hysterectomy solely to deal with moderate uterine enlargement. (Am J Obstet Gynecol 1999;180:1337-44.)     

Effects of Horizontal vs Vertical Vaginal Cuff Closure Techniques on Vagina Length After Vaginal Hysterectomy: A Prospective Randomized Study

Study ObjectiveTo compare the effects of horizontal and vertical vaginal cuff closure techniques on vagina length after vaginal hysterectomy.DesignProspective randomized study (Canadian Task Force classification I).SettingTeaching and research hospital, a tertiary center.PatientsFifty-two women with POP-Q stage 0 or 1 uterine prolapse were randomized into 2 groups using vertical (n = 26) or horizontal (n = 26) vaginal cuff closure.InterventionsAll patients underwent vaginal hysterectomy.Measurements and Main ResultsVagina length in the 2 groups was compared preoperatively, immediately after surgery, and at 6 weeks postoperatively. Mean (SD) preoperative vagina length in the horizontal and vertical groups was similar (7.87 [0.92] cm vs 7.99 [0.78] cm; p = .41). Immediately postoperatively, the vagina was significantly shorter in the horizontal group than in the vertical group (6.61 [0.89] cm vs 7.51 [0.74] cm; p < .001). At 6 weeks postoperatively, the vagina was still significantly shorter in the horizontal group (6.55 [0.89] cm vs 7.42 (0.73) cm; p < .001). The mean difference in vagina length before and after surgery was also significantly higher in the horizontal group than in the vertical group (–1.26 [0.12] cm vs 0.49 [0.11] cm; p < .001).ConclusionVertical cuff closure during vaginal hysterectomy seems to preserve vagina length better than does horizontal cuff closure.     

Hysterectomy by Transvaginal Natural Orifice Transluminal Endoscopic Surgery (NOTES): A Series of 137 Patients

Study ObjectiveTo evaluate the feasibility and safety of hysterectomy in benign disease using transvaginal natural orifice transluminal endoscopic surgery (NOTES).DesignProspective observational study (Canadian Task Force classification II-3).SettingTertiary referral medical center.PatientsFrom May 2010 to August 2011, consecutive patients who were scheduled to undergo laparoscopic hysterectomy and without virginity or suspected pelvic inflammation or cul-de-sac obliteration were included.InterventionTotal hysterectomy via transvaginal NOTES.Measurements and Main ResultsThe study included 137 patients, with mean (SEM) age 46.0 (0.4) years and body mass index 24.7 (0.4). Transvaginal NOTES was successfully performed in 130 patients (94.9%). Fifteen patients underwent concurrent adhesiolysis, and 17 underwent adnexal procedures. Mean (SEM) uterine weight was 450.0 (24.1) g; in 45 patients (34.6%), uterine weight was >500 g, and in 7 (5.4%) it was >1000 g. Operative time was 88.2 (4.1) minutes, with blood loss of 257.7 (23.9) mL. In 2 patients there was intraoperative hemorrhage or unintended cystotomy, and in another 5 transvaginal colpotomy failed because of a narrow vagina, cul-de-sac obliteration by bowel adhesions, or mass obstruction. Complications in these 7 patients (5.1%) were successfully managed via transabdominal laparoscopy. Five patients (3.6%) experienced postoperative urinary retention or febrile morbidity, and recovered uneventfully with conservative treatment.ConclusionTransvaginal NOTES is a feasible technique for performance of hysterectomy and can be used in procedures that are difficult to complete via conventional vaginal surgery because posterior colpotomy is achievable. This procedure was not impeded by uterine volume, and had the advantage of no abdominal incision.     

Rate of vaginal cuff separation following laparoscopic or robotic hysterectomy

Objective

Vaginal cuff separation is a rare but serious complication following hysterectomy. The goal of our study was to determine the rate of vaginal cuff separation and associated risk factors in patients undergoing laparoscopic or robotic hysterectomy.

Methods

We retrospectively identified patients who underwent a minimally invasive simple or radical hysterectomy at one institution between January 2000 and 2009. Fisher's exact test, Wilcoxon rank sum test and multiple logistic regression were used to determine associations between variables and increased risk of separation.

Results

A total of 417 patients underwent laparoscopic (n = 285) or robotic (n = 132) hysterectomy during the study period. Three hundred and sixty-two underwent simple hysterectomy (249 laparoscopic, 113 robotic) and 57 underwent radical hysterectomy (36 laparoscopic, 19 robotic). Seven (1.7%) patients developed a cuff complication and all had a diagnosis of malignancy. Three (1.1%) patients in the laparoscopy group suffered a vaginal cuff evisceration (n = 2) or separation (n = 1). Four patients in the robotic group (3.0%) had a vaginal evisceration (n = 1) or separation (n = 3). There was no difference based on surgical approach (p = 0.22). Vaginal cuff complications were 9.46-fold higher among patients who had a radical hysterectomy (p < 0.01). Median time to presentation of vaginal cuff complication was 128 days (range, 58-175) in the laparoscopy group and 37 days (range, 32-44) in the robotic group.

Conclusions

The overall risk of vaginal cuff complication was 1.7%. There appears to be no difference in cuff complication rates based on surgical approach. Radical hysterectomy, however, was associated with a 9-fold increase in vaginal cuff complications.     

中等大良性病变子宫经阴全子宫切除术的探讨

目的：探讨中等大、良性病变的非脱垂子宫经阴道行全子宫切除术的可行性。方法：87例施行此术式,其中子宫中等大（重200～750g）60例作为研究组,小子宫（＜200g）27例作为对照组,部分病例采用子宫分碎术。对两组因手术期情况进行分析。结果：研究组59倒成功地经阴道切除子宫,其中21例（35％）采用子宫分碎术,1例转经腹手术,转经腹手术率为1．7％,对照组则全部经阴道完整切除。研究组和对照组的子宫重量分别为280．18±100．40g、146．48±35．19g,差异有高度显著性（P＜0．001）;研究组的平均手术时间为83．93±26．26min,长于对照组的55．22±20．55min,差异有高度显著性（P＜0．001）;术中平均出血量为164．92±89．83ml,多于对照组的135．56±111．57ml,但差异无显著性（P＞0．05）;术后病率分别为3．33％与3．70％,差异无显著性（P＞0．05）;两组患者均无膀胱、直肠损伤,无阴道残端炎症。结论：对具备经阴道手术经验的术者,中等大、良性病变的子宫经阴道切除是安全可行的。部分病例需施行子宫分碎术,减小子宫体积,缩短手术时间,减少术中出血量和降低术后并发症。     

Vaginal evisceration after hysterectomy: a rare condition a gynecologist should be familiar with

Purpose  To report a case of vaginal vault rupture with intestinal herniation per vagina after hysterectomy and highlight the risk factors, clinical presentation and treatment options of this rare gynecologic emergency. Methods  A 70-year-old woman presented to the emergency department with vaginal evisceration, emerged 4 years after vaginal hysterectomy for uterine prolapse. Approximately 30 cm of the terminal ileum was irreducibly protruding through the vagina. Results  The patient was transferred to the operating theatre. The prolapsed bowel was reduced via the combined vaginal-abdominal route and the vaginal cuff was closed with non-absorbable interrupted sutures. Conclusion  Awareness as well as high suspicion index among gynecologists and all involved care givers, is important for early diagnosis, given that vaginal evisceration is a potentially life-threatening condition necessitating prompt surgical intervention.     

Vaginal removal of the benign nonprolapsed uterus: experience with 300 consecutive operations.

OBJECTIVE: To determine the effectiveness and safety of vaginal hysterectomy for benign nonprolapsed uteri. METHODS: Three hundred consecutive women with nonprolapsed uteri requiring hysterectomy for benign uterine conditions, without suspected adnexal disease, were treated prospectively by vaginal hysterectomy. Twenty-one women (7%) were nulliparous, and 219 (73%) had history of pelvic surgery (150 had previous cesareans). Operating time, estimated blood loss, surgical techniques (Heaney, Pelosi, uterine morcellation), operative complications, conversion to laparoscopy or laparotomy, and length of hospital stay were recorded for each case. RESULTS: Vaginal hysterectomy was successful in 297 women (99%). Morcellation (hemisection, intramyometrial coring, myomectomy, and wedge resection) was done in 170 cases (56.7%). The mean operating time was 51 minutes (range 20-130 minutes), mean estimated blood loss was 180 mL (range 50-1050 mL), and mean length of hospitalization was 22 hours (range 16-72 hours). Four operative complications occurred (three cystotomies, one rectal laceration) and were repaired transvaginally. One woman needed a blood transfusion. Eleven urinary tract infections occurred. Two conversions to laparotomy and one conversion to laparoscopy were necessary. CONCLUSION: Vaginal hysterectomy is an effective and safe procedure for benign nonprolapsed uteri irrespective of nulliparity, previous pelvic surgery, or uterine enlargement. We question the true need for laparoscopy or laparotomy in this setting.     

Laparoscopic management of early uterine cancer: 10-year experience in Asan Medical Center

OBJECTIVE: To assess the feasibility of laparoscopic surgery in the treatment of patients with early uterine cancer and to compare their outcomes with those of patients treated with laparotomy. METHODS: The records of 388 patients with clinical stage I or II uterine cancer treated by laparoscopic-assisted vaginal hysterectomy (LAVH) or total abdominal hysterectomy (TAH) between January 1997 and April 2006 were retrospectively reviewed. After excluding 39 patients with uterine sarcoma and 40 with upstaging or conversion to laparotomy procedures, the case-controlled study was performed. RESULTS: Laparoscopic procedures were converted to laparotomy in 10 of 188 patients (5.3%), whereas laparoscopic surgery was successful in 178 (94.7%). Histopathologic results led to upstaging of 32 of 349 patients (9.2%), including 15 of 188 (8.0%) in laparoscopy group and 17 of 161 (10.6%) in laparotomy group. The two groups were similar in age, parity, BMI, surgical stage, histological grade, tumor size, operating time and number of lymph nodes removed. Fewer complications and shorter hospital stay were observed in laparoscopy group. Between groups, recurrence rate did not differ significantly. Four recurrences in vaginal stump occurred in the only laparoscopy group, but the difference was not statistically significant. There were no significant differences between the two groups in progression-free and overall survival. CONCLUSION: Laparoscopy is a valid alternative to conventional laparotomy and does not worsen the prognosis of patients with early endometrial carcinoma. Efforts should be made during laparoscopic procedures to minimize the risk of vaginal recurrence.     

Hysterectomy trends over a 9-year period in an endoscopic teaching center

Objective

To investigate trends in the performance of hysterectomy at a single certified endoscopic teaching center.

Methods

Data were collected retrospectively from 953 patients who underwent hysterectomy between 2002 and 2010 for benign indications at UKSH, Germany. Preoperative risk scores were assigned to patients.

Results

The most frequent indications for hysterectomy were uterine myoma, adenomyosis, prolapse, endometrial hyperplasia, menstrual disorders, and endometriosis. The shortest operating time was recorded for vaginal hysterectomy (VH) and the longest for laparoscopically assisted VH (LAVH). The average uterine weight was highest for abdominal hysterectomy (AH) and lowest for VH. The major postoperative complication rate was 11.8% for laparoscopic supracervical hysterectomy (LSH) and 23.5% for AH. The highest intraoperative complication rate occurred with AH (46.4%) and the lowest with total laparoscopic hysterectomy (TLH; 3.6%). The minor postoperative complication rate was 5.9%. The mean preoperative score was 1.09 ± 1.51 for AH, 0.75 ± 0.96 for VH, 1.04 ± 1.30 for LSH, 1.0 ± 1.40 for LAVH, and 1.38 ± 1.52 for TLH.

Conclusion

Laparoscopic hysterectomies have become more common and were associated with decreased complication rates, despite the higher preoperative risk score of these patients.     

Uterosacral-cardinal ligament stretching prior to vaginal hysterectomy increases uterine descent: a novel technique

Objective

To examine the effect of uterosacral-cardinal ligament complex stretching prior to vaginal hysterectomy on uterine descent.

Study design

A prospective trial of 25 consecutive women undergoing vaginal hysterectomy. Pre-operative, apical, anterior and posterior wall POP-Q measurements were recorded for each patient before and after uterosacral-cardinal ligament complex stretching during general anesthesia.

Results

Uterosacral-cardinal ligament complex stretching yielded a significant increase in mean stage of uterine and anterior wall descent (2.6 ± 0.6 vs. 3.2 ± 0.6 cm, p < 0.001, and 2.5 ± 0.8 vs. 2.9 ± 0.8 cm, respectively, p < 0.004). There was no significant change in posterior wall prolapse measurements (1.3 ± 0.7 vs. 1.4 ± 0.8 cm, p = 0.05).

Conclusion

Uterosacral-cardinal ligament complex stretching prior to vaginal hysterectomy increase uterine descent.     

The Use of Barbed Suture for Laparoscopic Hysterectomy and Myomectomy: A Systematic Review and Meta-analysis

We conducted a meta-analysis comparing the efficacy of laparoscopic suturing with or without barbed suture for myomectomy or hysterectomy. We used a systematic electronic search strategy of published literature using the following databases: Cochrane Database of Systematic Reviews, MEDLINE, Embase, and OVID MEDLINE In-Process & Other Non-Indexed Citations databases. The following medical subject heading terms, key words, and their combinations were used: laparoscopy, myomectomy, hysterectomy, and barbed suture. Studies in which women undergoing laparoscopic myomectomy or hysterectomy using barbed suture or conventional suture were selected. The main outcome measures chosen for the current meta-analysis were operative time, suturing time, estimated blood loss or change in hemoglobin level, and degree of suturing difficulty. The results of the meta-analysis studies were expressed as the standardized mean difference (SMD) with 95% confidence intervals (CIs). Compared with the use of conventional suture, the total operative time of laparoscopic myomectomy (SMD = −0.58; 95% CI, −0.88 to −0.28) and the suturing time to close the uterine incision (SMD = −1.38; 95% CI, −1.86 to −0.90) were significantly reduced with the use of barbed suture. Meta-analysis on laparoscopic hysterectomy shows that the time to suture the vaginal vault, the total operative time, and the estimated blood loss were comparable with or without the use of barbed suture. The degree of suturing difficulty was reported in 2 randomized trials. Compared with the use of conventional suture, the degree of suturing difficulty was lower with the use of barbed suture (SMD = −1.39; 95% CI, −1.83 to −0.95). The use of barbed suture facilitates laparoscopic suturing of myomectomy incision and closure of the vaginal vault. Its use is associated with a reduced operative time of laparoscopic myomectomy.     

Vaginal herniation: case report and review of the literature

OBJECTIVE: The purpose of this study was to discuss the treatment of a case of spontaneous intestinal herniation per vagina in a patient who had undergone previous transabdominal hysterectomy and to review the related literature. STUDY DESIGN: A computer-based search of the English literature from January 1900 to October 2004 with the use of the terms vaginal herniation, vaginal evisceration, and vaginal trauma/injury was performed. Causes, presentation, and treatment were discussed and compared with a recent case that was treated locally in our hospital. RESULTS: Vaginal evisceration was described in the literature as early as 1864; since then <100 cases have been reported in the literature. It is more common in menopausal women with previous hysterectomy pelvic or vaginal surgery. Vaginal trauma, as in rough coitus, instrumentation, obstetric injury, is a recognized cause in premenopausal women. CONCLUSION: Vaginal evisceration is a rare, distressing emergency that requires aggressive resuscitation and urgent surgical intervention.     

Recovery from vaginal hysterectomy compared with laparoscopy-assisted vaginal hysterectomy: a prospective, randomized, multicenter study

OBJECTIVE: To evaluate short-term recovery of vaginal hysterectomy with those of laparoscopic assisted vaginal hysterectomy performed in a prospective, randomized multicentric study. STUDY DESIGN: Eighty patients referred for hysterectomy for benign pathology were randomized to either vaginal hysterectomy (40 patients) or laparoscopic assisted vaginal hysterectomy (40 patients). Inclusion criteria were uterine size larger than 280 g and one or more of the following: previous pelvic surgery, history of pelvic inflammatory disease, moderate or severe endometriosis, concomitant adnexal masses, and indication for adnexectomy. No upper limit of uterine size was set. All the laparoscopic and the vaginal hysterectomies were done under endotracheal general anesthesia. RESULTS: There was no statistically significant difference in terms of patient's age, parity, postmenopausal state, indication for surgery and mean uterine weight between the 2 groups. Laparoconversion was performed in three women in the laparoscopic group. Operative time was significantly shorter in the vaginal versus the laparoscopic groups 108+/-35 and 160+/-50 respectively (p<0.001). The use of paracetamol, non steroidal anti-inflammatory drugs, and opioid during hospitalization were similar in the 2 groups. There was no difference in the 1st day hemoglobin level drop, time of passing gas and stool, or hospital stay between the 2 groups. CONCLUSION: In contrast with earlier reports, there was no difference in short-term recovery between patients undergoing vaginal or laparoscopic hysterectomy. No advantage was found performing laparoscopic assisted vaginal hysterectomy in comparison with the standard vaginal hysterectomy.     

Faut-il conserver l’utérus lors de la cure de prolapsus ? Réflexions à partir des résultats anatomo-pathologiques

ObjectivesTo evaluate the rate of pre-cancerous and cancerous endometrial lesions in hysterectomy during vaginal reconstructive pelvic surgery.Patients and methodsIn this retrospective and continuous study, a vaginal procedure including reconstructive pelvic surgery with vaginal mesh, hysterectomy and adnexectomy was performed in 152 patients between April 2001 and January 2006. An ultrasonography evaluation was done before surgery. A histopathological analysis of uterus, ovaries and tubes was also performed.ResultsIn the analysis of 136 cases, precancerous and cancerous lesions have been diagnosed while ultrasonography or cervical smear were normal: 2 (1.4%) endocervical dysplasia, 1 (0.7%) cervical epidermoid carcinoma, 10 (7.35%) endometrial complex non-atypical hyperplasia, 7 (5.1%) endometrial atypical hyperplasia and 2 (1.4%) endometrioid endometrial carcinoma. There was not any cancerous lesions in tubes or ovaries. At 10 months, mesh exposure was low at 2.9% (four cases).Discussion and conclusionThe important rate of cancerous and precancerous lesions raise the question of hysterectomy or hysteroscopy and endometrial biopsy in case of uterine preservation during a vaginal reconstructive pelvic surgery.