Cuff Closure Research Articles

Application of Sensor Technology in the Objective Assessment of Vaginal Cuff Closure Utilizing a Validated Simulation Model

Application of Sensor Technology in the Objective Assessment of Vaginal Cuff Closure Utilizing a Validated Simulation Model

Techniques for Vaginal Cuff Closure in Robotic-Assisted Hysterectomy

Techniques for Vaginal Cuff Closure in Robotic-Assisted Hysterectomy

A Standard, Repeatable Bench-Top Method for Assessing Vaginal Cuff Closure Following Hysterectomy

Objective: To develop and evaluate a repeatable method for assessing the integrity of vaginal cuff closure following hysterectomy using a simulated tissue model.

708 - FlexDex for Post-Hysterectomy Vaginal Cuff Closure and Suspension

708 - FlexDex for Post-Hysterectomy Vaginal Cuff Closure and Suspension

Development of a Proficiency-Based Simulation Training Model for Laparoscopic Vaginal Cuff Closure

Faculty Advisor: Amy Boardman, MD PURPOSE: To evaluate if a low fidelity simulation model and training video will improve resident surgical performance of laparoscopic vaginal cuff closure. BACKGROUND: Laparoscopic surgical complexity and resident work-hour restrictions have increased the need for surgical simulation in OBGYN residencies. Evidence of transfer of acquired surgical skills from simulation to the operating room (OR) is limited. METHODS: This prospective, randomized study compares resident surgical skills acquisition after low-fidelity simulation training of vaginal cuff closure versus no intervention. Study phases include development of a vaginal cuff closure training video; video documentation of resident lab performance; and video assessment of resident surgical skill by blinded surgical experts using I – GOALS, II – error events, and III – surgical checklist. RESULTS: OBGYN residents (N=18) from MedStar Georgetown and Washington Hospital Center were randomized to control group (N=7) or intervention group (N=11). Intervention group reviewed the training video on laparoscopic vaginal cuff closure. All residents then used the low-fidelity cuff closure model and recorded baseline videos. Three surgeons scored the videos with an inter-rater reliability of 0.585, 0.531, and 0.825 for tests I, II, and III. Wilcoxon Rank Sum test was used to evaluate differences between groups by averaging all raters’ scores. There was significant difference between the control and intervention groups for Test II (P=.01) but no difference between the control and intervention groups for tests I and III. DISCUSSION: Simulation training of laparoscopic vaginal cuff closure reduces error events after immediate exposure. Continued research will evaluate if acquired skills transfer to OR performance.

Objective Assessment of Proficiency in Vaginal Cuff Closure Using Sensor Technology

Faculty Advisor: Karen Noblett, MD PURPOSE: Establish concurrent and construct validity of motion analysis in differentiating laparoscopic psychomotor skills when suturing laparoscopically on a validated vaginal cuff model. BACKGROUND: Surgical simulation is most useful when it provides metrics that are accurate and meaningful to the learner. Motion analytics provides objective data that allows a comprehensive evaluation to assist with deconstructing complex tasks. This information may assist with formative feedback and deliberate practice. METHODS: Participants were divided based on number of laparoscopic vaginal cuff closures after hysterectomy. 15 Early Novices (0-20 procedures), 5 Advanced Novices (21-50 procedures), and 15 Experts (>51 procedures) in conventional laparoscopy and 24 Early Novices, 4 Advanced Novices, and 7 Experts in robotic-assisted laparoscopy were instructed to secure three stitches on a previously validated vaginal cuff model. A motion sensor was attached to each instrument, which subsequently recorded the hand movement of each participant. Each task was graded using the Global Operative Assessment of Laparoscopic Skills scale and a validated laparoscopic suturing checklist. RESULTS: Comparison analysis indicated Experts in conventional laparoscopy operated with less hand movement (P<.01) and higher hand smoothness (P<.01) compared to Early Novices. Advanced Novices did not show any significant difference to Experts in terms of hand movement (P>.01) or smoothness (P>.01). In contrast, Experts in robotics did not show a difference between Early or Advanced Novices in either of these metrics. DISCUSSION: Using a validated vaginal cuff model, hand movement and smoothness were found to correlate with experience for conventional laparoscopy. Robotic experience did not correlate with improved hand movement or smoothness on a conventional laparoscopic simulator.

Laparoscopic vs Transvaginal Cuff Closure After Total Laparoscopic Hysterectomy: A Randomized Trial by the Italian Society of Gynecologic Endoscopy

(Abstracted from Am J Obstet Gynecol 2018;218:500.e1–500.e13) After the introduction of total laparoscopic hysterectomy (TLH) in 1989, the significant benefits of minimally invasive techniques for improved outcomes and lower costs have allowed a substantial decrease in the rate of open abdominal hysterectomies. However, these benefits have been paralleled by an increase in the rate of vaginal cuff dehiscence, an infrequent but potentially life-threatening complication.

Unidirectional barbed suture for vaginal cuff closure without backward stitch in total laparoscopic hysterectomy.

To evaluate the safety and efficacy of unidirectional barbed suture technique for vaginal cuff closure in total laparoscopic hysterectomy (TLH). In a retrospective chart review, data were analyzed from 165 patients who underwent a TLH with an unidirectional barbed suture technique for vaginal cuff closure from January 2012 to June 2016 at tertiary-care university-based teaching hospital and academic affiliated hospital. Vaginal cuff was closed by single layer 3/0 V-Loc unidirectional 9″, 180 day Absorbable Wound Closure Device (Covidien Healthcare, Mansfield, MA) and the suture was not stitched backward to secure distal end. A total of 165 patients were included and the median age was 50 years (range, 35-84 years). The median completion time for hysterectomy time was 100 min (range, 40-240 min) and the median vaginal cuff closure time was 7 min (range, 4-15 min). The median estimated blood loss was 87.8 mL (range 30-250 mL) and the median uterine weight was 200 g (range, 40-900 g). Intraoperative complication included bladder perforation (1.2%) and postoperative complications were vaginal cuff dehiscence (1.8%), cuff cellulitis (0.6%), vesicovaginal fistula (0.6%) and unexplained fever (0.6%). According to the results of current study, the use of unidirectional barbed suture without backward stitching appears to be safe for the vaginal cuff closure in TLH.

Tips on robotic single-site surgery suture technique: Screwing and clockwise direction suture technique for Robotic single-site surgery

ObjectivesUsing the da Vinci single-site platform, surgeons can perform more minimally invasive surgery. However, surgical challenges exist due to the limitations of single-site instrumental movements. To aid in the performance of successful robotic single-site hysterectomy, a new suturing technique using the current set of limited instruments is introduced in this study. Material & methodsNew vaginal cuff suturing techniques have been used in 55 robotic single-site hysterectomies in our institute over the past 2 years. A needle driver approach utilizing screwing and advancing the needle driver in the correct direction at an increasing angle from the transverse cuff margin with dragging and formation of an adequate loop of thread was used when suturing the vaginal cuff. ResultsUsing the new vaginal suturing techniques, easy and firm vaginal cuff closure with reduced operative time relative to previous hysterectomies was achieved. ConclusionThe new vaginal cuff suturing techniques may convince more surgeons to perform robotic single-site hysterectomies more frequently and with greater ease.

Canadian Surgeons Demonstrate 101 Ways to Close a Cuff

Video Abstract Summary: Our video presents a review of the diverse variation in techniques used for laparoscopic closure of the vaginal cuff by minimally invasive gynecologists across Canada. As experience and expertise in laparoscopic surgery has increased, a number of safe, effective and innovative methods for vaginal cuff closure have been developed. Surgeons across the country were asked to submit videos describing their techniques and accompanying rationale. We reviewed the videos submitted and classified them based on how the suture was secured. We present the various approaches as well as highlight the specific advantages of each method.

Case Series of Laparoscopic Retroperitoneal Hysterectomy: Outcomes, Cost and Patient Satisfaction [11D

INTRODUCTION: Laparoscopic Retroperitoneal Hysterectomy (LRH) is a minimally invasive hysterectomy approach incorporating retroperitoneal dissection to ligate the uterine arteries at the origin, lateralization of ureters, vaginal specimen extraction and transvaginal cuff closure. Our study evaluates LRH in terms of outcomes, cost, and patient satisfaction. METHODS: Retrospective chart review of 756 consecutive cases undergoing LRH for benign indications at a suburban hospital from 2011-2013. Data collected: patient characteristics and surgical outcomes. Direct hospital costs were estimated using a combination of micro- and gross-costing. Satisfaction surveys were mailed to the same patient population with a 12% response rate. RESULTS: Mean uterine size: 328.9g (SD 343.1), ranging from 20g to 9,314g. Mean operating time (OT): 61.8 min (SD 31.0). Average length of stay (LOS) 0.2 (SD 0.5) days with 88% discharged same day. Intraoperative and postoperative complication rates: 2.2% and 3.2%, respectively. Conversion to mini-laparotomy (<5cm) = 1.2% (9 cases). Conversion to laparotomy (>5cm) = 0.0%. Zero use of power morcellation. Average cost per case $4,061. Postoperative survey indicated 87.2% overall patient satisfaction rate. CONCLUSION: A distinguishing aspect of the LRH procedure is a standard retroperitoneal dissection with delineation of the ureter and control of the blood supply by uterine artery ligation at its origin. This technique is key to low complication rates, which minimizes OT, LOS, and costs, and contributes to patient satisfaction, and costs, and contributes to patient satisfaction. Further studies comparing LRH to the most widely performed minimally invasive hysterectomy approaches are warranted for this effective and cost-efficient procedure.

Validity evidence for procedural competency in virtual reality robotic simulation, establishing a credible pass/fail standard for the vaginal cuff closure procedure.

The use of robotic surgery for minimally invasive procedures has increased considerably over the last decade. Robotic surgery has potential advantages compared to laparoscopic surgery but also requires new skills. Using virtual reality (VR) simulation to facilitate the acquisition of these new skills could potentially benefit training of robotic surgical skills and also be a crucial step in developing a robotic surgical training curriculum. The study's objective was to establish validity evidence for a simulation-based test for procedural competency for the vaginal cuff closure procedure that can be used in a future simulation-based, mastery learning training curriculum. Eleven novice gynaecological surgeons without prior robotic experience and 11 experienced gynaecological robotic surgeons (> 30 robotic procedures) were recruited. After familiarization with the VR simulator, participants completed the module 'Guided Vaginal Cuff Closure' six times. Validity evidence was investigated for 18 preselected simulator metrics. The internal consistency was assessed using Cronbach's alpha and a composite score was calculated based on metrics with significant discriminative ability between the two groups. Finally, a pass/fail standard was established using the contrasting groups' method. The experienced surgeons significantly outperformed the novice surgeons on 6 of the 18 metrics. The internal consistency was 0.58 (Cronbach's alpha). The experienced surgeons' mean composite score for all six repetitions were significantly better than the novice surgeons' (76.1 vs. 63.0, respectively, p < 0.001). A pass/fail standard of 75/100 was established. Four novice surgeons passed this standard (false positives) and three experienced surgeons failed (false negatives). Our study has gathered validity evidence for a simulation-based test for procedural robotic surgical competency in the vaginal cuff closure procedure and established a credible pass/fail standard for future proficiency-based training.

Introduction of a Novel Modification in Laparoscopic Hysterectomy: The Bakay Technique

The last step of laparoscopic hysterectomy when the surgeon attempts to remove the uterus and close the vaginal cuff (colpotomy and cuff closure) is considered the most challenging part of the operation, and the procedure involves a steep learning curve for surgeons. Although various methods have been described and reviewed on vaginal cuff closure in laparoscopic hysterectomy, this study is the first to describe placing a single continuous running purse-string suture using the uterine manipulator to maintain a safe distance between adjacent structures while facilitating the closure before colpotomy.

Two-port robotic hysterectomy: a novel approach.

The objective of the study was to demonstrate a novel technique for two-port robotic hysterectomy with a particular focus on the challenging portions of the procedure. The study is designed as a technical video, showing step-by-step a two-port robotic hysterectomy approach (Canadian Task Force classification level III). IRB approval was not required for this study. The benefits of minimally invasive surgery for gynecological pathology have been clearly documented in multiple studies. Patients had fewer medical and surgical complications postoperatively, better cosmesis and quality of life. Most gynecological surgeons require 3-5 ports for the standard gynecological procedure. Even though the minimally invasive multiport system provides an excellent safety profile, multiple incisions are associated with a greater risk for morbidity including infection, pain, and hernia. In the past decade, various new methods have emerged to minimize the number of ports used in gynecological surgery. The interventions employed were a two-port robotic hysterectomy, using a camera port plus one robotic arm, with a focus on salpingectomy and cuff closure. We describe a transvaginal and a transabdominal approach for salpingectomy and a novel method for cuff closure. The transvaginal and transabdominal techniques for salpingectomy for two-port robotic-assisted hysterectomy provide excellent tension and exposure for a safe procedure without the need for an extra port. We also describe a transvaginal technique to place the vaginal cuff on tension during closure. With the necessary set of skills on a carefully chosen patient, two-port robotic-assisted total laparoscopic hysterectomy is a feasible procedure.

Comparison of barbed unidirectional suture with figure-of-eight standard sutures in vaginal cuff closure in total laparoscopic hysterectomy

The aim of the study was to compare postoperative vaginal cuff complications due to the use of barbed sutures (V-Loc™ 180 unidirectional suture; Covidien, Mansfield, MA) and standard braided sutures (Vicryl®; Ethicon Inc., Somerville, MA) during vaginal cuff closure of patients undergoing a total laparoscopic hysterectomy (TLH) due to benign diseases. Eighty-nine patients were in the standard suture group and 208 patients were included in the barbed suture group. Vaginal cuff dehiscence was identified in only three (3.3%) patients within the standard suture group and none in the barbed suture group. Five (5.6%) patients in the standard suture group and two (0.9%) patients in the barbed suture group developed postoperative cuff infection/cellulitis. Duration of the surgery was significantly shorter in the barbed suture group than in the standard suture group (p < .05). V-Loc™ 180 unidirectional barbed suture, which is used during TLH for vaginal cuff closure, is an applicable, safe and tolerable alternative to a standard suture.IMPACT STATEMENTWhat is already known on this subject: Barbed sutures are a relatively new type of suture that include sharp barbs inserted on monofilament material in various configurations, and are used for approximating tissues without any need for surgical knotting. They have increasingly been used in obstetrics and gynaecology in recent years, particularly in total laparoscopic hysterectomy and laparoscopic myomectomy. At present, there are a limited number of studies of V-Loc™ suture in the literature.What the results of this study add: We demonstrated that barbed sutures used for enabling vaginal cuff integrity did not cause major morbidity and mortality for the patient. We suggest that V-Loc™ 180 barbed sutures offer a practical, safe and tolerable alternative for surgeons because they are easy to use, do not cause a significant increase in vaginal cuff complications, and shorten the operating time. Our study with V-Loc™ 180 unidirectional barbed suture is the second largest series after the study of Cong et al.What the implications are of these findings for clinical practice and/or further research: We believe that the barbed suture, the surgery results of which are openly discussed in our study, will be more prominent in clinical practice owing to the shortened operating time, and that the use of these sutures does not cause a significant increase in vaginal cuff complications.

Laparoscopic vs transvaginal cuff closure after total laparoscopic hysterectomy: a randomized trial by the Italian Society of Gynecologic Endoscopy

Vaginal cuff dehiscence following hysterectomy is considered an infrequent but potentially devastating complication. Different possible techniques for cuff closure have been proposed to reduce this threatening adverse event. The aim of the present randomized study was to compare laparoscopic and transvaginal suture of the vaginal vault at the end of a total laparoscopic hysterectomy, in terms of incidence of vaginal dehiscence and vaginal cuff complications. Factors associated with vaginal dehiscence were also analyzed. This article presents the results of the interim analysis of the trial. Patients undergoing total laparoscopic hysterectomy for benign indications were randomized at the time of colpotomy to receive vaginal closure through transvaginal vs laparoscopic approach using a 1:1 ratio. Allocation concealment was obtained using a password-protected randomization database. Monopolar energy for colpotomy was set at 60W. Vaginal closure was performed with a single-layer running braided and coated 0-polyglactin suture. In all cases an attempt was performed to include the posterior peritoneum in the suture. Laparoscopic knots were tied intracorporeally. All patients were scheduled for a postoperative follow-up visit 3 months after surgery, to detect possible vaginal cuff complications. Univariate and multivariable analyses were performed to identify independent predictors of vaginal cuff dehiscence after total laparoscopic hysterectomy. After enrollment of 1408 patients, a prespecified interim analysis was conducted. Thirteen (0.9%) women did not undergo the postoperative assessment and were excluded. Baseline characteristics of the 1395 patients included (695 in the transvaginal group and 700 in the laparoscopic group) were similar between groups. Patients in the transvaginal group had a significantly higher incidence of vaginal dehiscence (2.7% vs 1%; odds ratio, 2.78; 95% confidence interval, 1.16-6.63; P= .01) and of any cuff complication (9.8% vs 4.7%; odds ratio, 2.19; 95% confidence interval, 1.43-3.37; P= .0003). Based on these findings, the data monitoring committee recommended that the trial be terminated early. After multivariable analysis, transvaginal closure of the vault was independently associated with a higher incidence of vaginal dehiscence and any vaginal complication; premenopausal status and smoking habit were independently associated with a higher risk of dehiscence. Laparoscopic closure of the vaginal cuff at the end of total laparoscopic hysterectomy is associated with a significant reduction of vaginal dehiscence, any cuff complication, vaginal bleeding, vaginal cuff hematoma, postoperative infection, need for vaginal resuture, and reintervention.

24: Abdominal vaginal cuff closure: Two-layer technique and clinical implications

The objective of this video is to illustrate our surgical technique for a two-layer vaginal cuff closure at the time of endoscopic and abdominal hysterectomy and discuss clinical implications of a secure closure. There are several surgical options for route and technique of suturing the vaginal cuff at the time of abdominal hysterectomy. We discuss the clinical implications of vaginal cuff dehiscence and vaginal mesh exposure after a sacrocolpopexy at the time of hysterectomy. Finally, we illustrate our two-layer cuff closure via abdominal and endoscopic approaches. A two-layer vaginal cuff closure at the time of hysterectomy may reduce the rate of vaginal cuff dehiscence and mesh exposure after sacrocolpopexy at the time of a hysterectomy.

25: Laparoscopic single and two-layer vaginal cuff closure

Laparoscopic suturing can be challenging and vaginal cuff dehiscence rates are higher with laparoscopic cuff closure. Therefore, excellent surgical technique and a systematic approach are crucial for successful laparoscopic vaginal cuff closure. In this video, we demonstrate a step-by-step approach to performing a single and two-layer vaginal cuff closure. We review appropriate port placement, dissection of the bladder flap and rectal adhesions, completion of colpotomy using monopolar energy, placement of vaginal cuff angle sutures for hemostasis, tissue elevation, and tissue alignment, and suturing a single and two-layer vaginal cuff closure. Mastery of laparoscopic vaginal cuff closure can be accomplished by setting yourself up for success from the start of the case and by practicing this systematic approach.

17: Automated skill classification using time and motion efficiency metrics in vaginal cuff closure

17: Automated skill classification using time and motion efficiency metrics in vaginal cuff closure

49: Techniques for vaginal cuff closure in robotic-assisted hysterectomies

49: Techniques for vaginal cuff closure in robotic-assisted hysterectomies