Electrosurgical bipolar vessel sealing during vaginal hysterectomy.

OBJECTIVE: To compare electrosurgical bipolar vessel sealing (EBVS) with traditional suturing during vaginal hysterectomy. METHODS: In a randomized controlled trial involving 68 women undergoing vaginal hysterectomy for benign disease, 37 procedures were performed using EBVS and 31 using traditional suturing. The end points were procedure time, blood loss, number of ligatures used, postoperative pain score, and number of days in hospital. RESULTS: The procedure duration was shorter using EBVS (median duration, 32 vs. 40 min; P=.0003), with fewer ligatures (1 vs. 7; P<.0001) and less pain (median score, 4 vs. 6; P<.0001). There were no significant differences regarding blood loss (median, 100 vs. 160 mL; P=.36) and days in hospital (median, 2 vs. 2; P=.03). CONCLUSION: The EBVS system provided advantages over traditional suturing with regard to procedure time, number of ligatures used, and postoperative pain score.     

Operative outcomes of single-port-access laparoscopy-assisted vaginal hysterectomy compared with single-port-access total laparoscopic hysterectomy

ObjectiveThis study aims to compare between operative outcomes of single-port-access laparoscopy-assisted vaginal hysterectomy (SPA-LAVH) and single-port-access total laparoscopic hysterectomy (SPA-TLH), further subdivided by vaginal cuff closure via laparoscopic suture (VCC-L) or via the vaginal route (VCC-V).Materials and methodsA custom-made port was used for single-port laparoscopy in 111 patients who underwent SPA-LAVH (n = 33), SPA-TLH with VCC-L (n = 35), and SPA-TLH with VCC-V (n = 43) during October 2009–October 2010. Records were reviewed retrospectively.ResultsA significant difference in the operating time was observed among the groups (p = 0.009). SPA-TLH with VCC-L took a significantly longer time to be performed (118.6 ± 41.8 minutes) than SPA-TLH with VCC-V (98.6 ± 21.3 minutes) or SPA-LAVH (102.0 ± 20.3 minutes). The decrease in hemoglobin level on the 1^st day postsurgery was significantly smaller in case of SPA-LAVH (1.56 ± 0.97 g/dL, p = 0.005) compared with that in case of SPA-TLH with VCC-L (2.19 ± 0.95 g/dL) and SPA-TLH with VCC-V (2.24 ± 0.95 g/dL). No significant differences in other surgical outcomes were found.ConclusionSPA-TLH with laparoscopic vaginal suture required the longest operating time, and hemoglobin changes were smaller in the SPA-LAVH group than in the other groups. In patients undergoing SPA laparoscopy, we recommend the SPA-LAVH procedure.     

Surgical morbidity associated with total laparoscopic hysterectomy in women with prior diagnostic excision of the cervix

AIMS: To evaluate the feasibility, safety, and complications of total laparoscopic hysterectomy (TLH) in women undergoing prior diagnostic excision of the cervix. METHODS: A retrospective study (Canadian Task Force classification II-2) was conducted in a tertiary care university hospital. The medical records of women undergoing TLH between June 2003 and September 2004 were reviewed. RESULTS: Twenty-six women with stage IA1 cervical cancer (19) and persistent high grade cervical neoplasia (7) underwent TLH after diagnostic cervical excision. The operation was successfully performed in all cases without conversion to laparotomy. The mean age of the patients was 47.0 +/- 8.64 years (95% CI 43.5-50.5). 19 patients had previous loop electrosurgical excision procedure (LEEP), one had cold knife conization. Six patients underwent repeated LEEP for positive endocervical margin. The mean operating time was 253.0 +/- 66.7 min (95% CI 226.0-279.9). The median blood loss was 300 mL (range 50-1000 mL). Only one patient needed 1 unit of blood transfusion. The median post-operative hospital stay was 3 days (range 2-6 days). All hysterectomy specimens had negative surgical margins. Two patients had major complications, one with bladder injury requiring laparoscopic repair. The remaining one had ureteral injury detected 9 days after the operation requiring subsequent ureteroneocystostomy. Both complications occurred in the first four cases of this series. No significant morbidity was noted in 2 years of follow-up. CONCLUSION: TLH appears to be feasible and safe in patients with prior diagnostic excision of the cervix. Careful separation of the bladder from the cervix and identification of both ureters are recommended to minimize morbidity associated with this operation.     

三种子宫切除方法的对比研究

目的 对比分析开腹子宫切除术（TAH）、经阴道子宫切除术（VH）和腹腔镜下全子宫切除术（TLH）的短期临床效果。方法 回顾性地分析TAH54例、VH45例和TLH51例的临床病历记录，包括手术时间，术中出血量，术中、术后并发症和术后住院日。结果 TLH的手术时间明显长于TAH和VH，分别为130min、70min和75min。术后住院日TAH明显长于TLH和VH，后两者比较差异无显著性。TLH和VH各有1例中转开腹。TLH中，有1例术后出现膀胱阴道瘘。结论 VH具有手术时间短、微创、术后恢复快和价格低廉的优点。     

Robot-assisted laparoscopic radical hysterectomy: comparison with total laparoscopic hysterectomy and abdominal radical hysterectomy; one surgeon's experience at the Norwegian Radium Hospital

Objectives

The purpose of this study was to investigate the 3 years follow-up results regarding the recurrence pattern of robot-assisted laparoscopic radical hysterectomies and pelvic lymphadenectomies in the early stage cervical carcinoma patients and compare the results with both total laparoscopic radical hysterectomy and abdominal radical hysterectomy groups.

Methods

A total of 68 patients underwent radical hysterectomy and pelvic lymphadenectomy for early stage cervical carcinoma management. All cases (35 robot-assisted, 7 cases laparoscopy and 26 with laparotomy) were operated by the same surgeon at the Norwegian Radium Hospital. All cases were retrospectively reviewed to compare demographics, peri-operative variables such as mean operative time, estimated blood loss, lymph node counts, complications and follow-up results.

Results

The mean operating times (skin-to-skin) for patients undergoing robot-assisted laparoscopic radical hysterectomy (RALRH), total laparoscopic radical hysterectomy (TLRH) or abdominal radical hysterectomy (ARH) were 263 ± 70, 364 ± 57 and 163 ± 26 min respectively. Patients receiving laparotomy had shortest operative time, followed by those undergoing RALRH and then laparoscopy (p < 0.0001 for both). Estimated blood loss was significantly reduced in robot-assisted surgeries compared to surgeries involving laparoscopy and laparotomy (82 ± 74 ml vs. 164 ± 131 ml (p < 0.0001) and 595 ± 284 ml (p = 0.023), respectively). The mean follow-up times were 36 ± 14.4, 56.4 ± 14 and 70 ± 21 months in patients who underwent RALRH, TLRH and ARH respectively. Until now there have been 5 recurrences and one cervical cancer related death in the robot-assisted group and no recurrences in both the laparoscopy and the laparotomy group.One patient died due to primary lung cancer in the laparoscopic group and other patient died due to primary pancreatic cancer in the laparotomy group.

Conclusions

Robot-assisted laparoscopic radical hysterectomy and pelvic lymph node dissection is feasible and more precise because the instruments provide better flexibility and 3-D vision. We must proceed cautiously, however, if a new treatment modality appears to present an increased recurrence rate. Therefore, patients submitted to robot-assisted laparoscopic radical hysterectomy should be followed carefully and RALRH would be encouraged as protocol setting until the long-term oncological outcome data are available.     

Comparison of re-operation rates and complication rates after total laparoscopic hysterectomy (TLH) and laparoscopy-assisted supracervical hysterectomy (LASH)

Objective

To compare re-operation rates and complication rates after total laparoscopic hysterectomy (TLH) and laparoscopy-assisted supracervical hysterectomy (LASH).

Study design

Retrospective analysis of 867 women who underwent laparoscopic hysterectomy between January 2002 and December 2009 for benign gynaecological diseases. Total laparoscopic hysterectomy was performed in 567 women (TLH group) and laparoscopy-assisted supracervical hysterectomy was performed in 300 women (LASH group).

Results

The women in the LASH group were significantly younger (45.6 years) than those in the TLH group (47.9 years) and the uteri removed with LASH were significantly heavier (326.4 g) than those removed with TLH (242.7 g). The rate of salpingo-oophorectomy was significantly lower in the LASH group. The overall re-operation rates were equivalent in the two groups. Two method-specific reasons for re-operations were identified. A method-specific procedure after LASH was extirpation of the cervical stump, which was performed in 2.7% of the women. Vaginal cuff dehiscence was a method-specific problem leading to secondary operation after TLH and was observed in 0.7% of the patients. No differences between the intraoperative and postoperative complication rates were observed, although there was a trend toward lower complication rates after LASH.

Conclusions

There seem to be equivalent overall re-operation rates and complication rates after both hysterectomy procedures, making the two laparoscopic approaches for hysterectomy equivalent.     

Comparison study of single-port (Octoport™) and four-port total laparoscopic hysterectomy

Objective

To compare the perioperative surgical outcomes and complication rates between single-port total laparoscopic hysterectomy and conventional four-port total laparoscopic hysterectomy.

Study design

Between June 2009 and April 2011, 56 patients underwent total laparoscopic hysterectomy. Of these 56 patients, 28 underwent single-port (Octoport™) total laparoscopic hysterectomy and 28 underwent conventional four-port total laparoscopic hysterectomy. We analyzed the following parameters for all the patients: age, body mass index, operative time, blood loss, change in hemoglobin level, vaginal stump suture time and length of hospital stay.

Results

The general characteristics of the patients were similar in both groups. There were no statistically significant differences in blood loss, hemoglobin change, length of postoperative hospital stay and complication rate. However, the mean operative time of the single-port group was significantly longer than that of the four-port group (93.5 ± 24.0 min vs. 78.7 ± 17.4 min; P = 0.011). The operative time for vaginal stump suture was profoundly decreased with experience in the single-port group.

Conclusion

With the exception of operative time, the surgical outcomes and incidence of complications of the single-port group were comparable to those of the four-port group. However, the operative time decreased in the single-port group with increasing experience.     

Vaginal cuff closure with absorbable bidirectional barbed suture during total laparoscopic hysterectomy

Objective

Hysterectomy represents one of the most performed procedures in gynecological surgery. The minimally invasive approach increases patients’ benefits and reduces hospitalization costs. The aim of this study was to demonstrate the efficacy and safety of double barbed suture in vaginal cuff closure during total laparoscopic hysterectomy.

Study design

A retrospective cohort study of 88 consecutive patients treated with total laparoscopic hysterectomy for benign or precancerous conditions was undertaken from January 2010 to December 2011. Vaginal cuff suture was performed with traditional interrupted suture with polycolic acid (Vicryl™) in 40 patients and with bidirectional barbed device, Quill SRS™, in 48 patients.

Results

No difference in vaginal cuff dehiscence, major vaginal bleeding or spotting, and infection was evident between the two groups, with significant reduction in operative times for the bidirectional barbed suture group.

Conclusion

Vaginal cuff suture performed with bidirectional barbed QUILL SRS™ is a safe and well-tolerated procedure that reduces operative times.     

PK刀在腹腔镜辅助阴式子宫切除术中的应用

目的 探讨五合一双极PK等离子刀（Plasmakinetic^TM Tissue Management System，PK刀）在腹腔镜辅助阴式子宫切除术（LAVH）中的应用价值。方法 回顾性分析北京大学人民医院妇科2003年1月-2004年11月问，住院行LAVH的135例患者的临床资料结果，比较PK刀与五合一双极电凝切刀钳（双极）在LAVH中的手术时间、术中腹腔出血量、术中术后并发症和术后患者恢复情况。结果 与双极相比，PK刀明显减少术中出血量、显著缩短手术时间。结论 PK刀在LAVH中具有一定的优势，改变了双极凭经验掌握电凝程度的不足，避免了组织凝固不均、组织凝固过度炭化和凝固不全出血等缺点，并具有止血效果佳、热辐射损伤范围小、操纵简单等优点，值得推广使用。     

A case-controlled study of total laparoscopic radical hysterectomy with pelvic lymphadenectomy versus radical abdominal hysterectomy in a fellowship training program

To determine whether total laparoscopic radical hysterectomy (TLRH) is a feasible alternative to an abdominal radical hysterectomy (ARH) in a gynecologic oncology fellowship training program. We prospectively collected cases of all of the patients with cervical cancer treated with TLRH and pelvic lymphadenectomy by our division from 2000 to 2006. All of the patients from the TLRH group were matched 1:1 with the patients who had ARH during the same period based on stage, age, histological subtype, and nodal status. Thirty patients were treated with TLRH with a mean age of 48.3 years (range, 29-78 years). The mean pelvic lymph node count was 31 (range, 10-61) in the TLRH group versus 21.8 (range, 8-42) (P < 0.01) in the ARH group. Mean estimated blood loss was 200 cc (range, 100-600 cc) in the TLRH with no transfusions compared to 520 cc in the ARH group (P < 0.01), in which five patients required transfusions. Mean operating time was 318.5 min (range, 200-464 min) compared to 242.5 min in the ARH group (P < 0.01), and mean hospital stay was 3.8 days (range, 2-11 days) compared to 5.6 days in the ARH group (P < 0.01). All TLRH cases were completed laparoscopically. All patients in the TLRH group are disease free at the time of this report. In conclusion, it is feasible to incorporate TLRH training into the surgical curriculum of gynecologic oncology fellows without increasing perioperative morbidity. Standardization of TLRH technique and consistent guidance by experienced faculty is imperative.     

红外线输尿管系统在腹腔镜子宫切除术中的应用价值

目的探讨红外线输尿管显示系统在腹腔镜下全子宫切除术中的应用价值。方法腹腔镜下全子宫切除术中应用红外线输尿管显示系统76例(观察组),与未用红外线输尿管显示系统组(对照组)69例,比较两组手术时间、出血量、输尿管损伤及术后恢复情况等。结果观察组76例,手术时间为(71.2±28.6)min,出血量为(102.1±57.2)ml,无一例输尿管损伤。对照组69例,手术时间为(91.6±21.5)min,出血量为(163±65.5)ml。对照组输尿管损伤3例。对照组的手术时间、出血量均高于观察组,差异有统计学意义(P<005)。结论腹腔镜子宫切除术中应用红外线输尿管显示系统,手术时间短、出血量少、术后恢复快,可避免输尿管损伤。     

Comparison of the Use of LigaSure,HALO PKS Cutting Forceps,and ENSEAL Tissue Sealer in Total Laparoscopic Hysterectomy: A Randomized Trial

Study ObjectiveThere are many instruments with different energy modalities or with different properties that are available for use in total laparoscopic hysterectomy. The aim of the study was to compare the use of LigaSure (Valleylab, Boulder, CO), HALO PKS cutting forceps (Gyrus-ACMI, Maple Grove, MA), and ENSEAL tissue sealer (SurgRx, Inc. Redwood City, CA) in total laparoscopic hysterectomy with respect to operation time and blood loss as main outcomes. Perioperative complications, return of gastrointestinal activity, and hospitalization time were assessed as secondary outcomes.DesignRandomized prospective study (Canadian Task Force classification I).SettingAdana Numune Training and Research Hospital.PatientsForty-five patients with the indication of hysterectomy were randomized into 3 groups for total laparoscopic hysterectomy. Patients with malignancies, having 3 or more previous abdominal surgeries, a uterus larger than 12 weeks of gestation, and who had to undergo additional surgical procedures during the same operation were excluded.InterventionsTotal laparoscopic hysterectomy.Measurements and Main ResultsOperations were completed in all 15 patients in the LigaSure and HALO PKS Cutting Forceps groups with the planned instruments. In 2 patients in the ENSEAL group, bleeding could not be controlled with ENSEAL, and additional instruments were used. One patient in the ENSEAL group had bladder injury. The mean operation time and blood loss were 52.4 ± 12.8, 51.86 ± 14.11, and 55.7 ± 15.7 minutes (p > .05) and 138 ± 54.3, 118 ± 63.3, and 218 ± 115.9 mL (p < .05) in the LigaSure, HALO PKS, and ENSEAL groups, respectively. Changes in hemoglobin/hematocrit levels, return of gastrointestinal activity, and hospitalization time did not differ between groups.ConclusionThese 3 novel bipolar platforms had similar results in total laparoscopic hysterectomy. These instruments were not determined to be independent predictors of operating time and amount of blood loss.     

子宫血管缝扎术在腹腔镜下全子宫切除术中应用的临床分析

目的 探讨腹腔镜下全子宫切除术中子宫血管处理方法。方法 回顾性分析89例腹腔镜下全子宫切除术中子官动静脉处理方法。分析宫旁缝扎组的手术时间、术中出血量及术后病率，并与子宫动脉游离结扎组及腹腔镜联合阴式子宫切除术组进行比较。结果 子宫血管缝扎组与血管游离后处理组患者的手术时间、术后出血量及术后病率比较差异无显著性（P〉0．05）；子宫血管缝扎组与腹腔镜联合阴式子宫切除术组的手术时间及术后病率比较差异无显著性（P〉0．05），但子宫血管缝扎组出血量明显减少（P〈0．05）。结论 宫旁缝扎子宫动静脉后电凝切断子宫血管及主韧带，需要的器械简单，操作简便，手术野清晰，容易推广，在腹腔镜子官切除术中有较大的临床应用价值。     

Comparison of total laparoscopic hysterectomy (TLH) and laparoscopy-assisted supracervical hysterectomy (LASH) in women with uterine leiomyoma

Objective

To compare total laparoscopic hysterectomy (TLH) using the Hohl instrument with laparoscopy-assisted supracervical hysterectomy (LASH) in women with uterine leiomyoma.

Study design

231 women underwent laparoscopic hysterectomy for the treatment of symptomatic leiomyoma between January 2005 and December 2007. A total of 113 women decided to undergo complete hysterectomy with removal of the cervix (TLH group) and 118 women wished to preserve the cervix; LASH was carried out in the latter group (LASH group).

Results

No ureteral or bladder injury occurred in any of the patients. Two intraoperative complications and one postoperative complication occurred in the TLH group, while no complications occurred in the LASH group. When the TLH group was compared with the LASH group, the mean loss of hemoglobin was 1.6 ± 1.1 g/dL (95% CI 1.4–1.8) vs. 1.5 ± 1.4 g/dL (95% CI 1.2–1.7); the mean operating time was 114.0 ± 33.8 min (95% CI 107.6–120.2) vs. 116.5 ± 40 min (95% CI 109.3–124.0); and the mean uterus weight was 264.8 ± 133.6 g (95% CI 239.8–289.6) vs. 286.2 ± 209.3 g (95% CI 247.4–324.4). Hospital stay and use of analgesia in both groups were equal. No statistically significant differences were found.

Conclusions

TLH using the Hohl instrument is an option comparable with laparoscopy-assisted supracervical hysterectomy for women with uterine leiomyoma. However, the complication rates may be lower when LASH is performed.     

Randomized study of bipolar vessel sealing system versus conventional suture ligature for vaginal hysterectomy

Objective

This study was undertaken to compare the use of bipolar vessel sealing system (BVSS) with conventional suture ligature in vaginal hysterectomy (VH) on a non-prolapsed uterus.

Study design

Women referred for VH for uterine myoma were randomized to BVSS (n = 45) or conventional suture ligature VH (n = 45). Exclusion criteria were uterine prolapse and indication associated surgical procedures. Main outcome measures were operative time, blood loss, hospital stay, pain status, peri and post-operative complications. Data of patients were collected prospectively. Statistical analysis was performed using chi-square and Student's t-test as appropriate.

Results

There were no differences in patients’ mean age, parity and uterine size between groups. Patients in the BVSS group had a significantly reduced operating time (29.2 ± 2.1 min vs. 75.2 ± 5 min; p < 0.001), operative blood loss (84 ± 5.9 mL vs. 136.4 ± 89.1 mL; p = 0.001), requirement of surgical sutures (1.2 ± 0.6 units vs. 7.4 ± 0.3 units; p < 0.001), pain status (1.6 ± 0.4 vs. 3.6 ± 0.4; p < 0.001) and hospital stay (25.6 ± 0.9 h vs. 33.2 ± 1.7 h; p < 0.001) compared to the control group. The overall complication rate in the study was 7.8% (7/90), and did not differ between patients of the BVSS and control group.

Conclusion

Bipolar vessel sealing for vaginal hysterectomy appears to be an effective and safe haemostatic control method, with reduced operating time, peri-operative blood losses, post-operative pain and hospital stay.