Cuff Complications Research Articles

Hysterectomy and Oophorectomy for Transgender Patients: Preoperative and Intraoperative Considerations

ObjectiveTo review the preoperative and intraoperative considerations for gynecologic surgeons when performing hysterectomy with or without oophorectomy for transgender patients. DesignStepwise demonstration of techniques with narrated video footage. SettingApproximately 0.3% of hysterectomies performed annually in the United States are for transgender men. While some transgender men choose hysterectomy for the same indications as cisgender women, the most prevalent diagnosis for the performed surgeries is gender dysphoria.1 Hysterectomy with or without oophorectomy can be offered to patients who have met the World Professional Association for Transgender Health (WPATH) criteria.2 InterventionsImportant perioperative counseling points for transgender patients include: establishing terminology for relevant anatomy as well as the patient's name and pronouns; if applicable, discussing options for fertility preservation if the patient desires biological children3,4 and discussing the use of hormone therapy post-oophorectomy to reduce the loss of bone density;5,6 and reviewing intraoperative and postoperative expectations.When performing an oophorectomy on a transgender patient for gender affirmation, it is especially important to minimize the risk for ovarian remnant syndrome and the need for additional surgery, such as due to persistent menstruation. The performance of a two-layer vaginal cuff closure should be considered to reduce the risk of vaginal cuff complications, which is preferable for patients whose pelvic organs cause gender dysphoria.7,8 ConclusionSpecial considerations outlined in this video and the WPATH guidelines should be reviewed by gynecologic surgeons to minimize transgender patients’ experiences of gender dysphoria before, during, and after surgery.

Technical aspects of reconstruction for inadequate left atrial cuff in lung transplantation

ObjectiveLung transplantation is the only life-saving treatment for lung diseases that do not respond to medical treatment. Heart-lung harvesting requires a careful procedure to protect an adequate donor left atrial cuff around the junction of the superior and inferior pulmonary veins. This study aims to describe inadequate left atrial cuff during harvest and techniques of reconstruction at the threshold of literature.MethodsLeft atrial cuff complications were retrospectively analyzed in consecutive lung transplant procedures between December 2016 and December 2021. Donor and patient demographics, reconstruction material and method of application and postoperative follow-up were examined.ResultsIn the study period, 84 consecutive lung transplant procedures were performed. Reconstruction of the inadequate left atrial cuff was 3.7% (6/162) for atrial anastomoses. However, the inadequate left atrial cuff was 9.1% (5/55) in heart-lung harvesting. Donor aorta graft was used in 4 patients and Dacron mesh was used on the bilateral atrial cuff in one patient. Hospital mortality occurred in one patient. One patient died 6 months later due to antibody-mediated rejection. The follow-ups of the other three patients are continuing without any problems.ConclusionsInadequate left atrial cuff complications occurring in heart-lung harvest seem to be more common than in the literature. Techniques of reconstruction for the inadequate left atrial cuff is vital for the patient who has reached irreversible progress in surgery for the recipient, as well as increasing the number of organs.

7578 Hysterectomy with or without Oophorectomy for Transgender Male Patients: Preoperative and Intraoperative Considerations

<h3>Study Objective</h3> To review the preoperative and intraoperative considerations for gynecologic surgeons when performing hysterectomy with or without oophorectomy for transgender male patients. <h3>Design</h3> Stepwise demonstration of techniques with narrated video footage. <h3>Setting</h3> Approximately 0.3% of hysterectomies performed annually in the U.S. are for transgender male patients, most commonly to alleviate gender dysphoria. A hysterectomy with or without oophorectomy can be offered to patients who have met criteria outlined by the World Professional Association for Transgender Health (WPATH) guidelines. <h3>Patients or Participants</h3> Transgender male patients seeking hysterectomy with or without oophorectomy. <h3>Interventions</h3> Important perioperative counseling points for transgender male patients include: •Establishing terminology to minimize gender dysphoria •Discussing options for fertility preservation •Discussing the importance of continuing testosterone therapy post-oophorectomy to reduce the loss of bone density •Reviewing intraoperative and postoperative expectations Important intraoperative considerations for the performance of safe and effective hysterectomy with or without oophorectomy for transgender male patients include: •Maintaining a margin of at least 2 cm between the surgical instrument and the ovary during coagulation and transection of the infundibulopelvic ligament to prevent ovarian remnant syndrome •Performance of a two-layer vaginal cuff closure to reduce the risk of vaginal cuff complications <h3>Measurements and Main Results</h3> The patients recovered well without any postoperative complications. <h3>Conclusion</h3> In conclusion, it is essential to minimize the patient's experience of gender dysphoria by providing gender-affirming care before, during and after surgery. In particular, the surgeon should take care to perform oophorectomy with an adequate margin to minimize the risk of ovarian remnant syndrome and use a two-layer laparoscopic vaginal cuff closure to decrease the risk of vaginal cuff complications.

Vaginal Cuff Closure by Endosuturing in Total Laparoscopic Hysterectomy as Compared to Transvaginal Route of Suturing

Introduction: In present times, Total Laparoscopic Hysterectomy (TLH) is one of the commonly performed gynaecological procedure. Vaginal vault or cuff closure is crucial and critical in performance of TLH. During TLH, vaginal vault or cuff closure is done using a variety of available sutures. The techniques of suturing and approaches, either endoscopic or transvaginal, can vary. The skill, experience and preference of the surgeon counts in the final outcome of the surgery. Aim: To compare and study the frequency of minor and major complication rates of intracorporeal (endosuturing) cuff closure technique and routinely used transvaginal route of suturing vaginal vault in TLH. Materials and Methods: This prospective cohort research was conducted in the tertiary care hospital from May 2018 to December 2019. A total of 102 TLH were studied. In 51 cases (50%), vault was sutured endoscopically and in other 51 cases (50%), vault was sutured transvaginal, using single continuous interlocking suturing of vaginal vault with Vicryl 1-0 in all cases. Statistical analysis was done using Statistical Package for the Social Sciences (SPSS) software version 24.0. Results: In the follow-up of three months period, there were no cases of Vaginal Cuff Dehiscence (VCD). In present study, 21 cases (20.6%) out of 102 presented with vaginal cuff complications. A 15.7% cases with minor vaginal cuff complications were noted in laparoscopic endosuturing group and 25.5% cases of vaginal suturing group presented with minor vaginal cuff complications. Conclusion: Both the techniques of suturing the vaginal vault following laparoscopic hysterectomy delivered the desired results. The laparoscopic route of suturing vaginal cuff following TLH had lesser complication rate though not statistically significant over vaginal route and none of the two groups had any major complication (VCD).

“Does a Two-Layer Vaginal Cuff Closure at the Time of Laparoscopic Hysterectomy Reduce Complications Vs. a One-Layer Closure?”

Study Objective This video reviews findings from our retrospective cohort study demonstrating that a two-layer vaginal cuff closure (2-LVC) decreases postoperative complications compared to a standard one-layer vaginal cuff closure (1-LVC) at time of time total laparoscopic hysterectomy (TLH). The 2-LVC technique is demonstrated in a stepwise approach. Design Results from our retrospective cohort study analyzing all postoperative complications within 30 days and vaginal cuff complications within 180 days of TLH are reviewed. The two-layer closure technique is demonstrated with narrated footage. Setting A single tertiary care center. Patients or Participants All women undergoing TLH for benign indications by Minimally Invasive Gynecology surgeons from 2011-2017. Interventions 1-LVC and 2-LVC at time of TLH are compared. Surgeon skill, colpotomy technique and suture material remained standardized. The 2-LVC technique is demonstrated with reapproximation of the vaginal mucosa followed by imbrication of the endopelvic fascia. Measurements and Main Results Of 2973 women who underwent TLH for benign indications, 40.8% (n= 1213) of vaginal cuffs were closed with 2-LVC and 59.2% (n=1760) with 1-LVC. There was no difference in intraoperative complications between groups. There were significantly less postoperative complications in the 2-LVC, due to the difference in cuff complications. No mucosal separations or cuff dehiscence in the 2-LVC occurred as compared to 16 cases in the 1-LVC. Conclusion 2-LVC significantly reduces total postoperative complications by lowering vaginal cuff complications and reducing the rate of vaginal cuff dehiscence. Although a rare event, the prevention of vaginal cuff dehiscence by adapting a two-layer vaginal cuff closure, as demonstrated in this video, into routine TLH practice patterns could notably diminish patient morbidity and health care cost. This video reviews findings from our retrospective cohort study demonstrating that a two-layer vaginal cuff closure (2-LVC) decreases postoperative complications compared to a standard one-layer vaginal cuff closure (1-LVC) at time of time total laparoscopic hysterectomy (TLH). The 2-LVC technique is demonstrated in a stepwise approach. Results from our retrospective cohort study analyzing all postoperative complications within 30 days and vaginal cuff complications within 180 days of TLH are reviewed. The two-layer closure technique is demonstrated with narrated footage. A single tertiary care center. All women undergoing TLH for benign indications by Minimally Invasive Gynecology surgeons from 2011-2017. 1-LVC and 2-LVC at time of TLH are compared. Surgeon skill, colpotomy technique and suture material remained standardized. The 2-LVC technique is demonstrated with reapproximation of the vaginal mucosa followed by imbrication of the endopelvic fascia. Of 2973 women who underwent TLH for benign indications, 40.8% (n= 1213) of vaginal cuffs were closed with 2-LVC and 59.2% (n=1760) with 1-LVC. There was no difference in intraoperative complications between groups. There were significantly less postoperative complications in the 2-LVC, due to the difference in cuff complications. No mucosal separations or cuff dehiscence in the 2-LVC occurred as compared to 16 cases in the 1-LVC. 2-LVC significantly reduces total postoperative complications by lowering vaginal cuff complications and reducing the rate of vaginal cuff dehiscence. Although a rare event, the prevention of vaginal cuff dehiscence by adapting a two-layer vaginal cuff closure, as demonstrated in this video, into routine TLH practice patterns could notably diminish patient morbidity and health care cost.

Two-Layer Compared With One-Layer Vaginal Cuff Closure at the Time of Total Laparoscopic Hysterectomy to Reduce Complications

To explore whether two-layer laparoscopic vaginal cuff closure at the time of laparoscopic hysterectomy is associated with a lower rate of postoperative complications compared with a standard one-layer cuff closure. A retrospective cohort study of total laparoscopic hysterectomies performed by fellowship-trained minimally invasive gynecologic surgeons between 2011 and 2017 was performed. Surgeons sutured the vaginal cuff laparoscopically, either in a two- or one-layer closure. The primary outcome was a composite of total postoperative complications, including all medical and surgical complications within 30 days and vaginal cuff complications within 180 days. Factors known to influence laparoscopic vaginal cuff complications including age, postmenopausal status, body mass index, tobacco use, and immunosuppressant medications were examined and controlled for, while surgeon skill, colpotomy technique, and suture material remained standardized. We conducted statistical analyses including χ2, Fisher exact test, logistic regression, and post hoc power calculations. Of the 2,973 women who underwent total laparoscopic hysterectomies, 40.8% (n=1,213) of vaginal cuffs were closed with a two-layer closure and 59.2% (n=1,760) with a one-layer technique. Two-layer vaginal cuff closure was associated with decreased numbers of total postoperative complications (3.5% vs 5.7%; P<.01). The primary difference stemmed from lower vaginal cuff complications within 180 days (0.9% vs 2.6%; P<.01); no differences in 30-day medical and surgical postoperative complications were observed between the two groups (2.6% vs 3.1%; P=.77). No patients in the two-layer vaginal cuff closure cohort experienced a vaginal cuff dehiscence or mucosal separation compared with 1.0% in the one-layer group (P<.01). Compared with a one-layer closure, a two-layer closure was protective from postoperative complications (adjusted odds ratio 0.38, 95% CI 0.19-0.74). Although postoperative complications with laparoscopic hysterectomies are rare, two-layer laparoscopic vaginal cuff closure is associated with lower total postoperative complications compared with a one-layer closure. The difference was primary driven by cuff complications.

Complications Following Total Laparoscopic Hysterectomies: A Cohort Study Analyzing One Vs. Two-Layer Laparoscopic Vaginal Cuff Closure

Study Objective To determine whether two-layer laparoscopic vaginal cuff closure during laparoscopic hysterectomies is associated with lower postoperative complications compared to standard one-layer closure. Design Retrospective cohort study. Setting Academic tertiary care center. Patients or Participants 2,973 patients. Interventions During a 6-year period, 1760 (59.2%) and 1213 (40.8%) patients underwent single (1-LVC) vs. two-layer (2-LVC) laparoscopic vaginal cuff closure, respectively. Factors influencing laparoscopic vaginal cuff complications including age, postmenopausal status, body mass index, tobacco use, immunosuppressant medications, and sexual activity were recorded. We compared total postoperative complications including visceral injury, blood transfusion, hematoma, thromboembolism, infection, and cuff complications. The latter were further examined for cuff dehiscence, mucosal separation, hematoma, cellulitis/abscess, granulation tissue and persistent vaginal bleeding. Statistical analyses included Chi-square and Wilcoxon rank sum testing. Measurements and Main Results 2-LVC closure was associated with decreased total postoperative complications (2-LVC: 3.38% vs. 1-LVC: 5.57%; p=0.006) without impacting intraoperative complications (1.40% vs. 1.25%; p=0.721) or emergency room/hospital readmissions (11.05% vs. 12.67%; p=0.181). 2.44% of 1-LVC patients experienced postoperative cuff complications compared to only 0.74% women in the 2-LVC group (p=0.002). No subjects in the 2-LVC cohort experienced a vaginal cuff dehiscence or mucosal separation compare to 0.63% and 0.23% of patients in the 1-LVC group, respectively. Granulation tissue (1-LVC: 0.40% vs. 2-LVC: 0.16%), persistent vaginal bleeding (0.57% vs. 0.16%), and cuff cellulitis (0.51% vs. 0.33%) were also more common in the 1-LVC cohort. Univariate analysis of total postoperative cuff complications revealed that a 2-LVC closure was protective of postoperative complications (OR=0.37, 95% CI: 0.188-0.712). Conclusion Although postoperative problems linked to laparoscopic hysterectomies are already exceptionally low, the added use of a 2-LVC closure further lowers postoperative total and vaginal cuff complications.

Long-Term Morbidity after Endometrial Cancer Surgery: a Comparison of Open vs. Robotic Approach.

This retrospective study is looking into the long-term morbidity after endometrial cancer staging surgery and compares the long-term morbidity of patients who underwent open staging surgery vs. robotic approach. One hundred twenty-nine patients who underwent staging surgery for endometrial cancer from January 2014 until June 2017 were included in the analysis. Morbidities occurring 1month after surgery-vault complications, incisional hernias, vault dehiscence, and lymphedema-were looked into. There were no statistically significant differences between the long-term complications in both groups (vault infection 5.1% vs. 1.4%, vaginal cuff dehiscence 1.6% vs. 0%, incisional hernia 6.8% vs. 0%, and lymphedema 11.8% vs. 10% in open vs robotic groups respectively). But as far as clinical significance was concerned, patients who underwent robotic staging surgery had a significant decrease in vaginal cuff complications and incisional hernia. Our study shows that robotic-assisted surgery can reduce even long-term morbidity in patients undergoing surgery for endometrial cancer.

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.

Surgical Outcomes of Patients Undergoing Extrafascial Hysterectomy After Neoadjuvant Radiotherapy With or Without Chemotherapy for Locally Advanced Endometrial Cancer Clinically Extending to the Cervix or Parametria.

Recent data have shown high rates of clinical and pathologic responses to neoadjuvant radiation therapy for locally advanced endometrial cancer. There are limited data on the surgical outcomes of these patients in the era of modern radiation and surgical techniques. We sought to characterize surgical outcomes after extrafascial hysterectomy in this population. Patients with endometrial cancer of all histologies clinically involving the cervix or parametria treated with neoadjuvant brachytherapy followed by extrafascial hysterectomy from 1999 to 2014 were identified. Patient charts were reviewed for data regarding treatment characteristics and postoperative outcomes. Pearson χ and logistic regression analyses were used to assess correlations between surgical complications and treatment-related variables. Twenty-nine patients met inclusion criteria. Mean operating time for the cohort was 115 minutes. Mean estimated blood loss was 100 mL. No visceral injuries occurred. Mean length of hospital stay was 1 and 4 days for the minimally invasive and laparotomy groups, respectively. Rates of postoperative ileus, blood transfusion, wound infection, and readmission were 3%, 3%, 6%, and 3%, respectively. No case of prolonged urodynamic dysfunction was noted. The rate of vaginal complications was significantly higher in the group of patients who underwent minimally invasive surgery as compared with laparotomy (33% vs 5%, P < 0.041). These data support adjuvant extrafascial hysterectomy after neoadjuvant radiotherapy for endometrial cancer with cervical or parametrial involvement as a safe and viable procedure, with low rates of postoperative complications. Extra care should be taken when closing the vaginal cuff to reduce the risk of vaginal cuff complications.

Hysterectomy for benign conditions: Complications relative to surgical approach and other variables that lead to post-operative readmission within 90 days of surgery.

Objective:To examine variables associated with hysterectomy-related complications, relative to surgical approach and other variables, that lead to readmission within 90 days of surgery.Methods:We conducted an observational cohort study for which data were extracted from electronic health records. Data were extracted of all patients (n = 3106) who underwent hysterectomies at 10 Kaiser Permanente Southern California medical centers between June 2010 and September 2011. Patients who were pregnant or had a cancer diagnosis were excluded from the study. To identify univariate associations between examined variables and procedure type, chi-square tests for categorical variables and t-tests or analysis of variance for continuous variables were used. Generalized estimating equations methods were used to test associations between independent variables and primary outcomes of interest. Statistical significance was determined using a p-value <.05.Results:Of 3106 patients, 109 experienced 168 post-operative complications. The most common post-operative complications were related to pelvic abscesses, bowel obstruction, or severe ileus, and the vaginal cuff. Pelvic abscesses were most frequent among total laparoscopic hysterectomy and total abdominal hysterectomy cases (p = .002), and vaginal cuff complications were most frequent among total laparoscopic hysterectomy cases (p = .015). Patients who underwent total vaginal hysterectomy (odds ratio = 2.13, confidence interval = 1.15–3.92), laparoscopic supracervical hysterectomy (odds ratio = 3.11, confidence interval = 1.13–8.57), and total laparoscopic hysterectomy (odds ratio = 5.60, confidence interval = 2.90–10.79) experienced increased occurrence of post-operative complications resulting in readmission. Other variables associated with an increased risk for readmission included high estimated blood loss (201–300 mL and 301+ mL, relative to 0–50 mL; odds ratio = 2.28, confidence interval = 1.24–4.18 and odds ratio = 2.63, confidence interval = 1.67–4.14) and long length of stay of 3 days or more (relative to 0 days; odds ratio = 2.93, confidence interval = 1.28–6.69). Pelvic specimen weight in the 151–300 g and 501+ g ranges appeared protective (odds ratio = 0.40, confidence interval = 0.25–0.64 and odds ratio = 0.54, confidence interval = 0.33–0.90). In a sub-analysis of 1294 patients, 74 hospital operative complications directly related to hysterectomy were identified among 59 patients. The most common hospital operative complications were excessive bleeding associated with surgery or injury to nearby structures. Among the sub-sample of 1294 patients, those with hospital operative complications were more likely to experience post-operative complications that lead to readmission (odds ratio = 3.82, confidence interval = 1.55–9.43, p = .004).Conclusion:The observed increased risk of complications among patients of Black race, who underwent laparoscopic supracervical hysterectomy or total laparoscopic hysterectomy, who experienced more than 300 mL surgical blood loss, who suffered hospital operative complications, and those whose hospitalization was 3 days or greater, offers an opportunity for higher scrutiny and preventive measures during usual hysterectomy care to prevent later readmission.

Overcoming the learning curve of single-port total laparoscopic hysterectomy with barbed suture: a single surgeon's initial experience.

IntroductionSingle-port total laparoscopic hysterectomy (TLH) has not been widely used because of its technical difficulty and steep learning curve, especially the laparoscopic suturing of the vaginal stump. Barbed suturing is a new technology that has the potential to greatly facilitate laparoscopic suturing.AimTo compare surgical outcomes and vaginal vault healing between barbed sutures and traditional sutures in the repair of the vaginal vault during single-port TLH.Material and methodsBetween August 2013 and June 2015, we performed single-port TLH in 85 consecutive patients for benign or premalignant gynecological conditions. The first 48 patients underwent single-port TLH with traditional interrupted sutures, and the next 37 patients underwent single-port TLH with absorbable unidirectional knotless barbed sutures for repair of the vaginal vault.ResultsThe patient characteristics (age, body mass index), procedures performed, uterine weight, and uterine disease were similar between the groups. There were no differences in blood loss, hemoglobin change, length of hospital stay, or perioperative complications. Operative time and the time required for vaginal cuff suturing were significantly shorter in the barbed suture group than in the traditional suture group (57.8 ±13.5 vs. 80.1 ±18.7 min, p < 0.001; 5.5 ±1.7 vs. 12.9 ±3.5 min, p < 0.001). Moreover, the use of barbed sutures significantly reduced the incidence of vaginal granulation tissue formation (2.7% vs. 35.4%, p < 0.001).ConclusionsUse of barbed sutures in single-port TLH reduced the operative time, suturing time of the vaginal vault, and formation of vaginal granulation tissue. Barbed suturing may help overcome surgical difficulties and vaginal cuff complications.

Robotic-Assisted Gynecologic Surgery and Perioperative Morbidity in Elderly Women

Study ObjectiveTo assess perioperative complications, conversions, and operative times in patients age ≥75 years undergoing robotic-assisted gynecologic surgery. DesignRetrospective cohort study (Canadian Task Force classification II-2). SettingHigh-volume, 2-physician gynecologic oncology practice. PatientsA total of 705 women who underwent any robot-assisted gynecologic procedure for benign (n = 380) or malignant (n = 325) conditions between July 2008 and May 2014. Fifty patients age ≥75 years (elderly group) were compared with 655 patients age <75 years (younger group). InterventionsOperative data were gathered prospectively for all robotic-assisted procedures. Demographic and perioperative outcomes were analyzed retrospectively for this study. Measurements and Main ResultsThe mean age was 81.3 ± 4.2 years (range, 75.0–90.5 years) in the elderly group and 52.8 ± 11.5 years (range, 22.9–74.6 years) in the younger group. The elderly group had higher rates of surgery for malignancy (90.0% vs 43.2%; p < .01) and lymphadenectomy (44.0% vs 23.4%; p < .01), and was more likely to have cardiovascular disease (88.0% vs 37.6%; p < .01). There were no between-group differences in body mass index or history of chronic obstructive pulmonary disease, diabetes mellitus, or more than 1 previous abdominal surgical procedure. The elderly group was more likely to have a length of stay greater than postoperative day one (30.0% vs 14.8%; p = .01) and had a higher incidence of postoperative cardiac arrhythmia (8.0% vs 1.2%; p < .01). The elderly group also had a smaller median uterine size (83.0 ± 49.1 g vs 126.0 ± 189.5 g; p < .01), but total operative time, rate of conversion (6.0% vs 1.8%) and rate of blood transfusion (2.0% vs 1.5%) were not significantly different between the 2 groups. Rates of bowel and genitourinary injury were <1% in both groups, and there was no between-group difference in postoperative infectious morbidity, vaginal cuff complications, or reoperation. ConclusionThe perioperative complication rates of robotic-assisted surgery are comparable in elderly women and younger women, despite a longer hospital length of stay and greater likelihood of postoperative arrhythmia in elderly women.

Analysis of a Standardized Technique for Laparoscopic Cuff Closure following 1924 Total Laparoscopic Hysterectomies.

Objective. To review the vaginal cuff complications from a large series of total laparoscopic hysterectomies in which the laparoscopic culdotomy closure was highly standardized. Methods. Retrospective cohort study (Canadian Task Force Classification II-3) of consecutive total and radical laparoscopic hysterectomy patients with all culdotomy closures performed laparoscopically was conducted using three guidelines: placement of all sutures 5 mm deep from the vaginal edge with a 5 mm interval, incorporation of the uterosacral ligaments with the pubocervical fascia at each angle, and, whenever possible, suturing the bladder peritoneum over the vaginal cuff edge utilizing two suture types of comparable tensile strength. Four outcomes are reviewed: dehiscence, bleeding, infection, and adhesions. Results. Of 1924 patients undergoing total laparoscopic hysterectomy, 44 patients (2.29%) experienced a vaginal cuff complication, with 19 (0.99%) requiring reoperation. Five patients (0.26%) had dehiscence after sexual penetration on days 30–83, with 3 requiring reoperation. Thirteen patients (0.68%) developed bleeding, with 9 (0.47%) requiring reoperation. Twenty-three (1.20%) patients developed infections, with 4 (0.21%) requiring reoperation. Three patients (0.16%) developed obstructive small bowel adhesions to the cuff requiring laparoscopic lysis. Conclusion. A running 5 mm deep × 5 mm apart culdotomy closure that incorporates the uterosacral ligaments with the pubocervical fascia, with reperitonealization when possible, appears to be associated with few postoperative vaginal cuff complications.

Electrosurgical Settings and Vaginal Cuff Complications.

Background and Objectives:After being encouraged to change the technique for opening the vaginal cuff during robotic surgery, this study was performed to determine the correlation between vaginal cuff complications and electrosurgical techniques.Methods:The study group consisted of patients who had their vaginal cuffs opened with a cutting current compared to the group of patients having their vaginal cuff opened with a coagulation current. Data were collected on 150 women who underwent robotic surgery for endometrial cancer. All patients received preoperative antibiotics. Data, including operative time, type of electrosurgery used, estimated blood loss, transfusion rate, and complications, were collected from the patients' records.Results:Surgeries in 150 women and the associated complications were studied. The mean age of the patients was not significantly different between the groups (P = .63). The mean body mass index was 38 kg/m2 in the coagulation arm and 36 kg/m2 in the cutting arm (P = .03). Transfusion was not required. Estimated blood loss and operative time were not significantly different in the coagulation versus the cutting arms (P = .29 and .5; respectively). No patients in the cutting arm and 4 patients (with 5 complications) in the coagulation arm had cuff complications (P = .02).Conclusions:Complications involving the vaginal cuff appear to occur more frequently when the vagina is entered by using electrosurgery with coagulation versus cutting in this cohort of patients undergoing robot-assisted surgery for endometrial cancer..

Evaluation of risk factors of vaginal cuff dehiscence after hysterectomy

ObjectiveThe purpose of this study was to evaluate risk factors of vaginal cuff dehiscence or evisceration according to the type of operation.MethodsMedical records of 604 women who underwent hysterectomies at Korea University Anam Hospital between June 2007 and June 2011 were reviewed. They were allocated to six groups. The six types of hysterectomies included robotic hysterectomy (n = 7), robotic radical hysterectomy and node dissection (RRHND, n = 9), total laparoscopic hysterectomy (TLH, n = 274), laparoscopy assisted vaginal hysterectomy (LAVH, n = 238), laparoscopic radical hysterectomy and node dissection (n = 11), and abdominal radical hysterectomy (ARH, n = 63). The characteristics and outcomes of each groups were compared.ResultsThere was no difference in the characteristics of patients between 6 groups. In total of 604 hysterectomies, 3 evisceration (0.49%) and 21 dehiscences (3.47%) occurred. Evisceration were found in RRHND (1/9, 11.1%), TLH (1/276, 0.36%), and ARH (1/63, 1.56%). Dehiscences occurred in TLH (15/274, 5.42%), LAVH (4/238, 1.68%), and ARH (2/63, 3.17%). In 169 cases of TLH with intra-corporeal continuous suture, 1 evisceration and 4 dehiscences occurred, whereas 11 dehiscences occurred in 105 TLH cases with vaginal continuous locking suture (2.96% vs. 10.47%, P = 0.02).ConclusionThe incidence of vaginal cuff dehiscenceand eviscerationwas significantly higher in TLH than LAVH. The intra-corporeal cuff suture was superior to the vaginal suture to prevent the vaginal cuff complications in TLH.

Does the Use of Oxidized Regenerated Cellulose Decrease the Incidence of Vaginal Cuff Complications in Patients Undergoing Laparoscopic Hysterectomy?

Does the Use of Oxidized Regenerated Cellulose Decrease the Incidence of Vaginal Cuff Complications in Patients Undergoing Laparoscopic Hysterectomy?

Vaginal cuff complications decreased in total robotic vs. laparoscopic hysterectomy in cancer and noncancer patients: Bidirectional barbed vs. conventional suture

Objective: The literature suggests that vaginal cuff dehiscence is highest with robotic procedures (1%-4%). The purpose of this study was to compare vaginal cuff complications among patients undergoing total robotic hysterectomy (TRH) vs. total laparoscopic hysterectomy (TLH) and the effect of bidirectional barbed suture used to close the vaginal cuff.

Evaluation of Risk Factors of Vaginal Cuff Problem after Hysterectomy

Study Objective: The purpose of this study was to evaluate risk factors of vaginal cuff dehiscence or evisceration (VCDE), according to the type of operation. Design: We assessed 6 types of hysterectomies performed in our hospital between June 2007 and June 2011. The type of hysterectomies included Robotic Hysterectomy (RH, n = 7), Robotic Radical Hysterectomy and Node Dissection (RRHND, n = 9), Total Laparoscopic Hysterectomy (TLH, n = 276) Laparoscopy Assisted Vaginal Hysterectomy (LAVH, n = 238), Laparoscopic Radical Hysterectomy and Node Dissection (LRHND, n = 11), and Abdominal Radical Hysterectomy (ARH, n = 63). Measurements and Main Results: There was no difference in the characteristics(age, BMI, parity) of patients between 6 groups. But, the age was significantly younger in patients of RRHND than ARH (p = 0.03). In total of 604 hysterectomies, 3 eviscerations (0.49%) and 21 dehiscences (3.47%) occurred. Eviscerations were found in RRHND (1/9, 11.1%), TLH (1/276, 0.36%), and ARH (1/64, 1.56%). Dehiscences occurred in TLH (15/ 276, 5.43%), LAVH (4/238, 1.68%), and ARH (2/63, 3.17%). The incidence of cuff complication showed no significant correlation in terms of the type of operation and suture technique of vaginal cuff closure. However, in TLH, there was a significant difference in vaginal cuff problems depending on the suture method of vaginal cuff. In 169 cases of TLH with intra-corporeal continuous suture, 1 evisceration and 4 dehiscences occurred, whereas 11 dehiscences occurred in 105 TLH cases with vaginal continuous locking suture (2.96% vs 10.47%, p = 0.02). Additionally, duration between the day of operation and VCDE in the cases of intra-corporeal suture was significantly longer than in the cases of vaginal suture (72.8 days vs 23.6 days, p = 0.01). Subanalysis included age, BMI, operation time, estimated amount of blood loss (EBL), post-operative fever, use of post-operative antibiotics, and none of these factors had correlation with VCDE (p = 0.99, p = 0.32, p = 0.46, p = 0.32, p = 0.74, p = 0.64, respectively). Conclusion: In our study, the intra-corporeal cuff suture was superior to the vaginal suture to prevent the vaginal cuff complications such as the evisceration and dehiscence in TLH.