A prospective,randomized study of closed-suction drainage after laparoscopic-assisted vaginal hysterectomy

STUDY OBJECTIVE: To estimate whether closed-suction drainage of the pelvis after laparoscopic-assisted vaginal hysterectomy reduces the risk of postoperative morbidity. DESIGN: Prospective, randomized study (Canadian Task Force classification 1). SETTING: Teaching medical center. PATIENTS: Three hundred twenty-four women. INTERVENTION: Laparoscopic-assisted vaginal hysterectomy. MEASUREMENTS AND MAIN RESULTS: The 160 women in group 1 had closed-suction (Jackson-Pratt) drains inserted into the peritoneal cavity and cul-de-sac, whereas the 164 in group 2 had no drains. Postoperative time to flatulence, hemoglobin, analgesic requirements, duration of hospital stay, rehospitalization, complications, febrile morbidity, and infection were studied. No statistically significant differences were seen between groups in demographics, outcome measures, postoperative infectious morbidity, or complications. The small power value may mean that no true differences existed for most tests. A statistically significant difference in analgesic requirement was found, with more oral analgesics taken by women in group 2. CONCLUSION: Prophylactic surgical drainage may not be necessary to prevent postoperative morbidity after laparoscopic-assisted vaginal hysterectomy when prophylactic and postoperative antibiotics are given. A drain still has its role in gynecologic laparoscopy in selected women, such as in those with persistent ooze from raw surfaces, bowel injury, or frank pus in the abdomen.     

Prospective randomized study to compare a closed vault technique using absorbable staples at the time of abdominal hysterectomy versus open vault technique.

The current prospective randomized study in 102 women having a hysterectomy compared closed vault technique using absorbable staples with open vault technique. Fifty-six patients had the cuff stapled while 46 patients had the vault sutured open. The groups were equivalent with respect to indications for operation as well as other surgical procedures performed in conjunction with the hysterectomy, although more patients were randomized to open vault. No patient left the study. Operating time in the group with staples was 24 minutes (standard deviation of seven minutes) compared with 33 minutes (standard deviation of eight minutes) with the group with the open vault (p<0.0001). Hemostasis was also better in the group with staples (p<0.0001). The frequency of postoperative granulation tissue at the apex of the vaginal vault and the incidence of vaginal discharge during 12 weeks of follow-up evaluation were also less in the group with staples.     

Incidence and patient characteristics of vaginal cuff dehiscence after different modes of hysterectomies

STUDY OBJECTIVE: The purposes of this study were to estimate and compare the incidence of vaginal cuff dehiscence after different modes of hysterectomies (abdominal, vaginal, laparoscopic-assisted vaginal and laparoscopic) and to review the characteristics of hysterectomies complicated by vaginal dehiscences. DESIGN: Observational case series (Canadian Task Force classification II-3). SETTING: Large, urban, university teaching hospital. PATIENTS: All patients undergoing a total hysterectomy or vaginal dehiscence repair at Magee-Womens Hospital (MWH) from January 2000 through March 2006 were analyzed. INTERVENTIONS: Vaginal repair of vaginal cuff separation with reduction of eviscerating organ when appropriate. MEASUREMENTS AND MAIN RESULTS: From January 2000 through March 2006, 7286 hysterectomies (7039 total and 247 supracervical) were performed at MWH by abdominal, vaginal, laparoscopic-assisted vaginal, or laparoscopic approach. Ten of these hysterectomies were complicated by vaginal cuff dehiscences and were repaired during this time period. The resulting overall cumulative incidence of vaginal cuff dehiscence after total hysterectomy at MWH was 0.14%. The annual cumulative incidence of vaginal dehiscences after total hysterectomy was 0%, 0%, 0%, 0%, 0.09%, 0.70%, and 0.31% from January 2000 to March 2006, respectively. There was a notable increase in the cumulative incidence of dehiscence in 2005 and thereafter. From January 2005 through March 2006, the cumulative incidence of vaginal dehiscence by mode of hysterectomy was 4.93% among total laparoscopic hysterectomies (TLH), 0.29% among total vaginal hysterectomies (TVH), and 0.12% among total abdominal hysterectomies (TAH). The relative risks of a vaginal cuff dehiscence complication after TLH compared with TVH and TAH were 21.0 and 53.2, respectively. Both were statistically significant, with 95% CIs of 2.6 to 166.9 and 6.7 to 423.4, respectively. Among the 10 dehiscences repaired, 8 (80%) were complications of TLHs, 1 (10%) was associated with TAH, and 1 (10%) followed a TVH. The median age at time of dehiscence was 39 years, and the median time between initial hysterectomy to vaginal dehiscence was 11 weeks. Six of the 10 patients presented with both cuff dehiscence and bowel evisceration. Six patients reported first postoperative intercourse as the trigger event. Half the patients with dehiscence report smoking cigarettes. All patients with dehiscence received preoperative prophylactic antibiotics at the time of hysterectomy. Until October 2006, there have been no reported recurrent dehiscences at MWH. CONCLUSIONS: Total laparoscopic hysterectomies may be associated with an increased risk of vaginal cuff dehiscence compared with other modes of total hysterectomy. We postulate that the use of thermal energy in addition to other factors unique to laparoscopic surgery may be responsible; however, prospective randomized trials are needed to support this hypothesis. When performing laparoscopic hysterectomies, a supracervical approach should be considered unless a clear indication for a TLH is present.     

Methods of vaginal cuff closure and preservation of vaginal depth during transvaginal hysterectomy

One hundred and twelve vaginal hysterectomies were performed over a 2.8-year period. Five different techniques of cuff closure were performed, and evaluated for their preservation of vaginal depth. We have concluded that all five methods are acceptable ways to close the vaginal cuff at the time of transvaginal hysterectomy as long as there is proper vault support. Each surgical closure is pictorially illustrated. Morbidity was minimal, and vaginal depth was retained.     

Short- and long-term clinical results of laparoscopic-assisted vaginal hysterectomy and total abdominal hysterectomy

STUDY OBJECTIVE: To compare short- and long-term clinical results of laparoscopic-assisted vaginal hysterectomy (LAVH) and total abdominal hysterectomy (TAH). DESIGN: Retrospective cohort study (Canadian Task Force classification II-1). SETTING: University-affiliated hospital. PATIENTS: One hundred fifty women who underwent LAVH and 146 who underwent TAH. INTERVENTION: Hysterectomy. MEASUREMENTS AND MAIN RESULTS: Blood loss during surgery, narcotic analgesic consumption, duration of hospital stay, and convalescence time were significantly higher for women who underwent TAH than for those who underwent LAVH (p <0.05). Operating time was significantly longer for LAVH than for TAH (152.2 +/- 32.4 vs 96.5 +/- 29.6 min, p = 0.014). Eight-year follow-up showed no statistically significant differences in vaginal vault prolapse, cystocele, rectocele, enterocele, postcoital spotting, and cuff granulation between procedures (p >0.05). CONCLUSIONS: Although short-term clinical results revealed some statistically significant differences between LAVH and TAH, long-term follow-up recorded similar frequencies of surgical sequelae.     

A comparison of 2 methods of vaginal cuff closure during robotic hysterectomy

ObjectiveTo compare 2 methods of vaginal cuff closure with regard to safety, ease of use, and postoperative outcome.MethodsAll patients undergoing robotic-assisted total hysterectomy by a gynecologic oncologist from July 1, 2010, to July 1, 2011, at Northwestern Memorial Prentice Women's Hospital were included in a retrospective analysis. Providers used either 2–0 monofilament synthetic absorbable suture to close the vaginal cuff in a running fashion, secured with an absorbable suture clip at the angles and then knotted in the middle, or 2–0 absorbable unidirectional barbed suture with a welded-loop closure in a running fashion.ResultsA total of 134 patients underwent robotic-assisted total hysterectomy. The 2–0 tied monofilament closure was used in 58 patients, and the 2–0 barbed knotless closure was used in 76 patients. There were no instances of vaginal cuff dehiscence or vaginal cuff cellulitis. Rates of vaginal spotting and bleeding were comparable between the groups (12.0% spotting in the monofilament suture group vs 13.0% spotting in the barbed suture group). All vaginal cuff bleeding resolved on its own without significant intervention.ConclusionThe use of either a 2–0 welded-loop unidirectional barbed suture or a 2–0 monofilament absorbable suture to close the vaginal cuff is safe and well tolerated.     

Analysis of survival after laparoscopic-assisted vaginal hysterectomy compared with the conventional abdominal approach for early-stage endometrial carcinoma: a review of the literature

STUDY OBJECTIVE: To assess potential differences in perioperative features and survival between laparoscopic-assisted vaginal hysterectomy and conventional transabdominal hysterectomy in stage I endometrial cancer. DESIGN: Retrospective, nonrandomized clinical study (Canadian Task Force classification II-2). SETTING: Acute-care, teaching hospital. PATIENTS: A total of 370 patients undergoing hysterectomy and bilateral salpingo-oophorectomy with surgical staging for primary treatment for clinical stage I endometrial cancer from January 1995 through June 2001. INTERVENTION: Clinical outcomes and survival in patients treated with laparoscopic-assisted vaginal hysterectomy (n = 55) and hysterectomy using the conventional abdominal approach (n = 315) were compared. MEASUREMENTS AND MAIN RESULTS: Baseline characteristics and histopathologic variables were similar in both groups. A total of 91.4% of patients underwent pelvic lymphadenectomy and 49.7% paraaortic lymphadenectomy. The median follow-up was 38.1 months. Blood loss, blood transfusions required, and length of stay were significantly lower in the laparoscopic group, but surgical time was significantly longer. The mean number of pelvic and aortic nodes recovered was higher in the laparoscopic group (p < .001). Differences in overall and recurrence-free survival rates were not observed. CONCLUSION: Surgical staging of early-stage endometrial cancer by laparoscopic-assisted vaginal hysterectomy is feasible, with lower perioperative morbidity and shorter hospital stay compared with transabdominal hysterectomy. Prognosis and survival were not affected by the laparoscopic vaginal approach to hysterectomy.     

Formation of vesicovaginal fistula: The role of suture placement into the bladder during closure of the vaginal cuff after transabdominal hysterectomy

OBJECTIVE: The objective of this study was to determine whether suture placement through the bladder during closure of the vaginal cuff at the time of transabdominal hysterectomy is associated with formation of postoperative vesicovaginal fistula. STUDY DESIGN: Virgin female New Zealand White rabbits were used to perform this study. The study protocol was approved by the institutional Animal Use and Care Committee. Animals were housed and maintained in the animal facilities at the University of Mississippi Medical Center according to appropriate guidelines. Thirty-two animals were randomized into two groups at a 2:1 ratio. All animals underwent transabdominal hysterectomy. Animals in group 1 (n = 21) had a figure-of-eight suture placed through the anterior vaginal cuff and intentionally into the bladder. Animals in group 2 (n = 11) were treated in an identical manner but care was taken to exclude the bladder when the suture was placed into the anterior vaginal cuff. Animals were put to death, and necropsy was performed 28 days after surgery. The bladder and vagina of each animal were harvested en bloc. Evidence of a fistula between the bladder and vagina was then determined in three distinct ways. Infant formula was infused into the bladder through a urethral catheter, and the vagina was inspected for leakage. Saline solution tinted with methylene blue was used in the same manner. Last, air was injected through the catheter into the bladder with the en bloc vagina and bladder preparation submerged in water. The vagina was observed for air leakage manifest by bubble formation. RESULTS: The two groups were comparable in regard to weight gain, intraoperative complications, and postoperative complications. One animal in each group died. Neither had a surgical complication directly related to the suture placement. During inspection of the vagina and bladder no animal was noted to have a vesicovaginal fistula. CONCLUSIONS: A suture placed through the bladder during closure of the vaginal cuff after transabdominal hysterectomy, as an isolated event, does not appear to be associated with formation of postoperative vesicovaginal fistula.(Am J Obstet Gynecol 1997;177:304)     

Contemporary views on perioperative complications and adhaesion formation after vaginal hysterectomy, in relation to peritoneal closure vs. non-closure in combination with open vs. closed vaginal cuff

There exists few evidence about peritoneal closure vs. non-closure at vaginal hysterectomy as well as only scanty evidence for open vs. sutured vaginal cuff. It seems that non-closure of the peritoneum at vaginal hysterectomy holds no risks and probably some advantages, e.g. faster resumption of bowel function. In the light of the rare direct evidence from vaginal surgery and the strong evidence from cesarean section and abdominal hysterectomy, we recommend abandoning the routine closure of the peritoneum at vaginal hysterectomy. The vaginal cuff left open is probably also a safe procedure, if the hemostasis has been done carefully. The most promising modification of the vaginal incision-and-closure seems to be the "Benenden-Hospital technique" (V-shaped posterior incision and running longitudinal closure of the vaginal skin with partially non-sutured peritoneum).     

Laparoscopic-assisted vaginal vs. abdominal surgery in patients with endometrial cancer stage 1

BACKGROUND: The development of new diagnostic and surgical methods has brought a differentiated approach to the surgery of endometrial cancer. The aim of this study was to verify the peri- and postoperative differences between laparoscopic and open procedures. METHODS: In the period from January 1995 to August 2001 a total of 86 patients were treated for endometrial cancer stage 1. Of these, 28 patients were treated by laparoscopic-assisted vaginal hysterectomy (LAVH) and bilateral salpingo-oophorectomy (BSO), while 58 patients were treated by total abdominal hysterectomy (TAH) and BSO. The two patient groups were comparable in all aspects. RESULTS: The average hospital stay in the LAVH group was 2.7 days compared to 5.4 days for the TAH group. There were fewer complications in the LAVH group (7%) compared to the laparotomy group (14%). CONCLUSIONS: Laparoscopic-assisted vaginal hysterectomy seems to be acceptable in the treatment of stage 1 endometrial carcinoma.     

The use of barbed sutures for vaginal cuff closure during laparoscopic hysterectomy

Purpose

To compare surgical outcomes and complications of 334 women who underwent total laparoscopic hysterectomy with or without the use of barbed sutures for vaginal cuff closure.

Methods

A retrospective study was conducted on a cohort of women who underwent total laparoscopic hysterectomy for benign gynecologic diseases at Dae-Jeon St. Mary’s Hospital, between May 2009 and May 2016. Surgical outcomes and complications were compared between the two groups.

Results

A total of 334 women were included: 212 cases of vaginal cuff suture performed with traditional suture material and 122 cases of vaginal cuff suture performed with the barbed suture. No difference in major complications including vaginal bleeding and vaginal cuff dehiscence was found between the two groups, with a significant reduction in operative times for the barbed suture group (P = 0.002). Underlying clinical variables including diabetes, pelvic adhesion, and obesity showed no significant differences in complication rate.

Conclusion

Vaginal cuff suture performed with barbed suture material is a safe and well-tolerated procedure and reduces operative times. We did not find any meaningful decrease in postoperative vaginal complications including vaginal cuff dehiscence based on the suture material.

     

Comparative study of vaginal,laparoscopically assisted vaginal and abdominal hysterectomies for uterine myoma larger than 6 cm in diameter or uterus weighing at least 450 g: a prospective randomized study

BACKGROUND: The purpose of this study was to compare peri-operative morbidity, preoperative sonographic estimation of uterine weight and postoperative outcomes of women with uterine fibroids larger than 6 cm in diameter or uteri estimated to weigh at least 450 g, undergoing either vaginal, laparoscopically assisted vaginal or abdominal hysterectomies. METHOD: Ninety patients who met the criteria of uterine fibroids larger than 6 cm by ultrasonographic examination were included in our prospective study. Patients were randomized into laparoscopic-assisted vaginal hysterectomy (30 patients), vaginal hysterectomy (30 patients) and abdominal hysterectomy (30 patients) groups. RESULTS: The laparoscopically assisted vaginal hysterectomy group had significantly longer operative times than the abdominal and vaginal hysterectomy groups (109 +/- 22 min, 98 +/- 16 min, and 74 +/- 22 min, respectively, p < 0.001). Blood loss for vaginal hysterectomy was significantly lower than for either abdominal or laparoscopically assisted vaginal hysterectomies (215 +/- 134 ml, 293 +/- 182 ml, and 343 +/- 218 ml, respectively, p = 0.04). Vaginal hysterectomy and laparoscopically assisted vaginal hysterectomy groups had shorter hospital stays, lower postoperative pain scores, more rapid bowel recovery and lower postoperative antibiotic use than the abdominal hysterectomy group. Uterine weight in the abdominal hysterectomy group was significantly heavier than in the vaginal and laparoscopically assisted vaginal hysterectomy groups (1020 +/- 383 g, 835 +/- 330 g, and 748 +/- 255 g, respectively, p = 0.02). We estimated that when a myoma measured between 8 and 10 cm, the uterus weighed approximately 450 g, and the sensitivity of this prediction was 57.5%. For a myoma larger than 13 cm, the estimated uterine weight was more than 900 g and the sensitivity of this prediction was 71%. CONCLUSION: The study shows vaginal hysterectomy and laparoscopically assisted vaginal hysterectomy can be performed in women with uterine weight of at least 450 g. Preoperative ultrasonographic examination can provide the surgeon with valuable information on the size of the fibroid and the estimated weight of the enlarged uterus before implementing a suitable surgical method.     

Patient selection and surgical technique may reduce major complications of laparoscopic-assisted vaginal hysterectomy

STUDY OBJECTIVE: To study the clinical outcome of patients who underwent laparoscopic-assisted vaginal hysterectomy especially with regard to early postoperative complications. DESIGN: Retrospective study (Canadian Task Force classification II-3). SETTING: Private hospital in Hamilton, New Zealand. PATIENTS: Four hundred eighteen women. INTERVENTION: Laparoscopic-assisted vaginal hysterectomy. MEASUREMENTS AND MAIN RESULTS: Primary indication for surgery, operating time, hospital stay, and major complications were analyzed. Major complications were defined as life-threatening injuries, unintended major surgical procedures, and conversions to laparotomy that occurred under duress (eg, intraoperative hemorrhage). Complications were reported up to 6 weeks of postoperative time. The total early postoperative complication rate was 11.24%. No patient had damage to the bowel, ureter, or bladder. There were no deaths. Major complications were three cases of partial vault dehiscence and one case of partial small bowel obstruction. The operation was performed successfully in 412 cases. Six patients needed laparotomy. CONCLUSIONS: This retrospective study shows that laparoscopic-assisted vaginal hysterectomy is a safe surgical procedure. The possible reasons for the low complication rate reported are the surgical technique of ureteral dissection, the use of suitable instruments to expose the vaginal fornices, a consistent team approach, and the selection of patients.     

Postcoital vaginal cuff rupture 10 months after a total vaginal hysterectomy. A case report

BACKGROUND: Transvaginal evisceration following total vaginal hysterectomy secondary to coitus is extremely rare. CASE: A woman presented 10 months following a total vaginal hysterectomy with complaints of progressive postcoital abdominal and shoulder pain as well as a pinkish vaginal discharge. Examination revealed a 3-cm defect at the left edge of the vaginal cuff. Corrective surgery followed overnight observation with pain management. CONCLUSION: Postcoital vaginal cuff disruption is rare, and complications can range from bowel evisceration to hemorrhage. Management should be tailored to the severity of the complications.     

A randomized comparison of vesicourethral function after laparoscopic hysterectomy with and without vaginal cuff suspension

STUDY OBJECTIVE: To compare vesicourethral function following laparoscopic hysterectomy (LH) with and without vaginal cuff suspension. DESIGN: Prospective study (Canadian Task Force classification I). SETTING: Tertiary teaching hospital. PATIENTS: Sixty-eight women scheduled for LH randomly assigned to either LH without vaginal cuff suspension (LH group; n = 36) or LH with suspension (LHS group; n = 32). INTERVENTION: All subjects received urinalysis, pelvic examination, Q-tip test, introital ultrasonography, and a urinary questionnaire before and 6 months after surgery. MEASUREMENTS AND MAIN RESULTS: The prevalence of stress urinary incontinence (SUI) decreased significantly from 46.9% (n = 15) preoperatively to 18.8% (n = 6) postoperatively in the LHS group (p = .022), but this was not so in the LH group. Similarly, the mean straining urethral angle and the number of women exhibiting bladder neck (BN) hypermobility significantly decreased after surgery in only the LHS group (p <.05; p <.01, respectively). During straining, the postoperative position of the BN localized more dorsally (p <.01), and its ventral mobility decreased significantly (p <.01) in the LH group. In the LHS group, significant postoperative reduction was found in both ventral and caudal movements of the BN during stress (p <.01), causing a more cranial and dorsal position of the BN (p <.01). CONCLUSION: Laparoscopic hysterectomy with cuff suspension strengthens the traction effect on the endopelvic fascia, reducing both BN mobility during stress and the chance of SUI. However, simply performing a cuff suspension is not adequate for the treatment of severe SUI.     

Randomized comparison of laparoscopy-assisted vaginal hysterectomy with standard vaginal hysterectomy in an outpatient setting.

OBJECTIVE: To compare outpatient laparoscopy-assisted vaginal hysterectomy with standard outpatient vaginal hysterectomy. METHODS: Fifty-six women scheduled for vaginal hysterectomy were randomly assigned to undergo either a laparoscopy-assisted vaginal hysterectomy with endoscopic staples (N = 29) or a standard vaginal hysterectomy (N = 27). There were no differences between the study groups with regard to age, gravidity, parity, preoperative indications, and previous operations. RESULTS: Twenty-eight of 29 laparoscopy-assisted vaginal hysterectomies and all 27 vaginal hysterectomies were completed without incident. When indicated, unilateral or bilateral oophorectomies were completed. The mean operating time was significantly longer for laparoscopy-assisted vaginal hysterectomy (120.1 versus 64.7 minutes). Fifty-three of the 55 patients completing surgery were discharged home by 12 hours from the time of admission. Complications with laparoscopic hysterectomy were related to the technical aspects of laparoscopy. The incidence of febrile morbidity was similar in the groups. Although patients having laparoscopy-assisted hysterectomy required statistically significantly more pain medication and had lower postoperative hematocrit measurements, this did not make a clinical difference in the postoperative courses. The mean hospital charge for laparoscopy-assisted vaginal hysterectomy was $7905 and for vaginal hysterectomy $4891. CONCLUSION: Other than cost, laparoscopy-assisted vaginal hysterectomy and standard vaginal hysterectomy appear comparable in patients who could otherwise undergo a vaginal hysterectomy.     

Low-dose carbenicillin prophylaxis for vaginal and abdominal hysterectomy.

A double-blind prospective study of 99 patients undergoing vaginal and abdominal hysterectomy was performed at North Carolina Baptist Hospital of the Bowman Gray School of Medicine at Wake Forest University. The study indicated that low-dose intravenous carbenicillin begun preoperatively and continued for 24 hours resulted in decreased febrile morbidity, postoperative infection rate, and shortened hospital stay in patients undergoing both vaginal and abdominal hysterectomy. The indications for operation, clinical characteristics of patients, and operative and postoperative management were similar for the control and study groups. For the vaginal hysterectomy group, febrile morbidity was reduced from 34.6% in the control group to 7.7% in the group receiving carbenicillin. For patients undergoing abdominal hysterectomy, febrile morbidity was reduced from 54.1% in the control group to 4.0% in the group receiving prophylactic carbenicillin. Similar reductions for the carbenicillin study group in fever index and average total hospital stay were also noted. Urinary tract infections were determined to be present more commonly in the group of patients with febrile morbidity receiving no prophylactic antibiotics. The incidence of pelvic infections were reduced in both carbenicillin-treated groups. This investigation suggests that low-dose carbenicillin prophylaxis is beneficial in reduction of morbidity following both vaginal and abdominal hysterectomy.     

Comparison of laparoscopic-assisted vaginal hysterectomy with traditional hysterectomy for cost-effectiveness to employers

OBJECTIVE: The purpose of this study was to compare the cost-effectiveness of laparoscopic-assisted vaginal hysterectomy to traditional total abdominal hysterectomy and total vaginal hysterectomy with regard not only to direct hospital costs but also to indirect costs. STUDY DESIGN: This was a combined retrospective cohort study (Canadian Task Force classification II-2) that was conducted in a suburban private practice. The cases of 268 patients who underwent hysterectomies over a 27-month period were analyzed to include clinical outcomes, direct hospital costs, and indirect costs (time to return to normal function, time to return to work, and time away from work required by other family members). RESULTS: For all patients, length of hospital stay and time of return to normal function were shorter for laparoscopic-assisted vaginal hysterectomy than for total abdominal hysterectomy and total vaginal hysterectomy. For working patients, time to return to work and time off for working family members were all significantly shorter after laparoscopic-assisted vaginal hysterectomy when compared with both total abdominal hysterectomy and total vaginal hysterectomy. Operating times were similar for total abdominal hysterectomy and laparoscopic-assisted vaginal hysterectomy, and complications were greater for total abdominal hysterectomy. In a comparison of all procedures, direct hospital costs were greatest for laparoscopic-assisted vaginal hysterectomy and least for total vaginal hysterectomy. CONCLUSION: For most patients, laparoscopic-assisted vaginal hysterectomy provides a minimally invasive way to accomplish a hysterectomy with a lower cost to employers (payers) on the basis of lost work hours.     

Outpatient vaginal hysterectomy: a pilot study.

To determine the feasibility and safety of outpatient vaginal hysterectomy, we conducted a prospective study of 35 patients. Inclusion criteria required that the patient: 1) had no medical problems requiring hospitalization, 2) had a working telephone and a support person during the first 48 postoperative hours, 3) signed an informed consent document and understood the postoperative instructions, 4) required no concomitant surgical procedure such as anterior or posterior colporrhaphy, 5) required no additional antibiotic therapy for valvular heart disease, and 6) sustained no intraoperative injury requiring hospital monitoring. A physician contacted the patient by telephone on the evening of surgery and on postoperative days 1 and 2, and a nurse saw each patient in her home on postoperative days 1 and 2. Total hospital stay from admission to discharge from the ambulatory surgery unit was 9.4 +/- 0.81 hours (range 7.8-10.6). The mean preoperative hematocrit was 37.0 +/- 3.5% (range 29.3-43.5), with a mean discharge hematocrit of 32.5 +/- 4.2% (range 27-39). Follow-up hematocrit measurements at 24 hours, 48 hours, and 1 week were unchanged (P greater than .05) from that at hospital discharge. Two patients required hospital readmission, one on postoperative day 7 for a vaginal cuff abscess and another on postoperative day 3 for a spinal headache. On a 13-item questionnaire, most subjects rated the entire outpatient experience positively. These data suggest that outpatient vaginal hysterectomy can be a safe procedure and is well-accepted by selected patients. Based on these preliminary findings, an expanded clinical trial is warranted.     

The modification in surgical technique of incision and closure vault of the vagina during vaginal hysterectomy on the incidence of vault haematoma

OBJECTIVES: Vault haematoma is one of the most common complication of vaginal hysterectomy. The aim of this work was to analyse the effects of a modification of incision and closure technique of the vaginal vault on the incidence of vault haematoma after vaginal hysterectomy. MATERIAL AND METHODS: The study group consisted of 333 women of whom 49 (group A) underwent vaginal hysterectomy traditional technique of incision and closure of the vaginal vault, an 284 (group B) modified technique. Following parameters were evaluated: number of vault haematomas, blood loss, postoperative fever, required antibiotics, length of hospital stay. RESULTS: The risk of vault haematoma was significantly lower in the group B (1,06% vs 12,4%). Loss of blood was higher in group A (310 ml vs 206 ml). Incidence of postoperative fever was in 12,2% patients from group A, and 1,4% from group B. The length of hospitalization was lower for women in group B (4,3 days compared with 7,3 days). CONCLUSIONS: The modification of incision and closure technique of the vaginal vault during vaginal hysterectomy is recommended to minimise intra- and postoperative complications.