Vault Haematoma Research Articles

Real-world surgical outcomes of a gelatin-hemostatic matrix in women requiring a hysterectomy: a matched case-control study.

The aim of this study was to compare adverse events and surgical outcomes of hysterectomy with or without use of a gelatin-hemostatic matrix (SURGIFLO(®) ). Prospective case-control study (Canadian Task Force classification II2) of total hysterectomy (Piver Type 1) provided by surgeons in Australia between November 2005 and May 2015. Data were collected via SurgicalPerformance, a web-based data project which aims to provide confidential feedback to surgeons about their surgical outcomes. Of 2440 records of women who received a hysterectomy, 1351 were eligible for these analyses; 107 received SURGIFLO(®) hemostatic matrix to prevent postoperative blood loss and 1244 did not. Patients with or without SURGIFLO(®) differed in age, Charlson comorbidity index, and American Society of Anesthesiologists physical status classification system score (ASA), and also differed in clinical outcomes. After matching for patient's age and ASA at surgery, patients with and without SURGIFLO(®) had comparable baseline characteristics. Matched patients with and without SURGIFLO(®) had comparable clinical outcomes including risk of developing vault hematoma, return to the operating room, transfusion of red cells, surgical site infection (pelvis), readmission within 30 days and unplanned ICU admission. In a sample matched by age and ASA, SURGIFLO(®) neither prevented nor caused additional adverse events in women undergoing hysterectomy. Surgeons used SURGIFLO(®) more commonly among women who were older, had more comorbidities and a higher ASA score. This indicates that it may be most useful in complicated surgery or cases.

Presentation and Management of Vaginal Vault Hematoma after Hysterectomy

Presentation and Management of Vaginal Vault Hematoma after Hysterectomy

Factores de riesgo asociados a hematoma de cúpula infectado post histerectomía vaginal

Objetivos: Determinar los factores de riesgo asociados con la presencia de hematoma de cúpula infectado posterior a una histerectomía vaginal. Diseño: Estudio retrospectivo, descriptivo y de correlación tipo casos y controles. Institución: Departamento de Obstetricia y Ginecología, Hospital Nacional Arzobispo Loayza, Lima, Perú. Participantes: Mujeres sometidas a histerectomía vaginal. Métodos: Se analizó 90 historias clínicas (30 casos y 60 controles) de pacientes sometidas a histerectomía vaginal, en los años 2008 y 2009. El análisis estadístico se realizó con el programa SPSS 17.0, dado que todas las variables en el estudio fueron adaptadas a denominación cualitativa y, siendo la variable dependiente dicotómica, se empleó un análisis de regresión logística simple y múltiple, para determinar las variables de asociación y confusión. Se consideró significativo un valor de p < 0,05. Principal medida de resultados: Hematoma de cúpula vaginal infectado. Resultados: Se encontró una prevalencia de 6,1% casos de hematoma de cúpula vaginal infectado. El análisis estadístico de regresión logística múltiple mostró que las variables con significancia estadística fueron: edad (OR 3,5, IC95% 1,3 a 9,6, p < 0,05); índice de masa corporal (OR 6, IC95% 2,1 a 17,4, p < 0,05) y sangrado postoperatorio (OR 4,3, IC)5% 1,3 a 13,8, p < 0,05). Existió una asociación estadística significativa entre sangrado estimado postoperatorio y la variación de hemoglobina entre el pre- y post operatorio, demostrada mediante un análisis de regresión lineal p<0,05. Conclusiones: La edad, el índice de masa corporal y el estimado de pérdida sanguínea postoperatoria constituyeron variables asociadas con la presencia de hematoma de cúpula infectado posterior a una histerectomía vaginal.

Vault Haematoma after Vaginal Hysterectomy

Electronic searches of literature published between 1980 and 2014 were undertaken using MEDLINE, Embase, CINHAL, and the Cochrane Database of Systemic reviews. Search items included: haematoma, hysterectomy, morbidity, ultrasound. The incidence of vault hematomas varied from 25- 59 % in various studies. Small hematomas can be managed conservatively and large and infected hematomas need incision and drainage. However various studies found no correlation between the presence of a collection and indices of postoperative morbidity. Also routine scan was not indicated. The incidence of vault hematomas is due to inadequate haemostasis and refining the surgical technique significantly reduces the risk of vault hematomas. DOI: http://dx.doi.org/10.3126/njog.v9i2.11768

Perioperative outcomes of three-port robotically assisted hysterectomy: a continuous series of 53 cases.

This study evaluated the feasibility and safety of 3-port robotically assisted laparoscopic hysterectomy (RALH), using a consecutive series of women who underwent 3-port RALH in a university hospital. From November 2010 until June 2013 we operated on 53 women, whose mean age was 48.4±7.7years (range 35-68years), and mean body mass index was 27.1±5.1kg/m(2) (range 19.5-42.9kg/m(2)). The indications for hysterectomy were myoma in 31 (58.5%), adenomyosis in 10 (18.9%), cervical dysplasia in 4 (7.5%), neoplasia in 4 (7.5%), and recurrent polyps or postmenopausal bleeding in the remaining 4 women (7.5%). We performed total RALH in 50 cases (94.3%) and subtotal in the others. The median duration of total intervention was 169min (interquartile range 147.5-206.5min). The mean weight of the uterus was 209.8±166.6g (range 36-790g) and mean estimated blood loss was 72.3±75.9ml (range 0-300ml). There were no perioperative complications, in particular no blood transfusions nor conversions to laparotomy. The median hospital stay was 4days (interquartile range 3-4days). One patient was reoperated 1month later for vaginal vault hematoma and another was readmitted 3weeks post-operatively due to vaginal vault dehiscence after premature intercourse, but did not require reoperation. Three-port RALH is feasible and safe for simple hysterectomy. We believe this experience using minimum ports to be useful to prepare for robotically assisted single-port hysterectomy.

Changing the Route of Hysterectomy into a Minimal Invasive Approach

Objective. To describe the route of hysterectomy in a county hospital and evaluate the shift towards a minimal invasive approach. Design. Retrospective cohort study. Setting. A county hospital in Norway. Population. All women were scheduled for hysterectomy. Methods. Audit the route of hysterectomy in the period 2004–2012. Analyze the outcome of total laparoscopic hysterectomies. Main Outcome Measures. Complications after total laparoscopic hysterectomy. Results. A shift towards a minimal invasive approach has been achieved during the study period. In 2012 only 17.4% of the hysterectomies were performed abdominally, compared to yearly percentages of above 50% in the period 2004–2009. Laparoscopic supracervical hysterectomy was introduced in 2003, but the percentage of abdominal hysterectomy remained above 50% until total laparoscopic hysterectomy was introduced in 2010. Since the introduction of total laparoscopic hysterectomy in April 2010, 58 procedures have been performed. There have been no major complications. Two vaginal vault hematomas and one case of urinary tract infection were reported. Conclusions. It is possible for a county hospital to alter their praxis and perform mini-invasive hysterectomies, but it requires dedicated gynecologists. This change to an advanced procedure like total laparoscopic hysterectomy could be achieved without patients suffering from major complications.

Vaginal hysterectomies in patients without uterine prolapse: ten-year experience

To review the results of vaginal hysterectomies in patients without uterine prolapse. Retrospective chart review. University affiliated hospital, Hong Kong. All patients who had vaginal hysterectomies in the absence of uterine prolapse from 1999 to 2005 inclusive (first period) and 2006 to 2009 inclusive (second period). The number of such hysterectomies, indications, operative procedures, complications, use of preoperative gonadotropin-releasing hormone agonist, and concomitant vaginal salpingo-oophorectomies performed. In all, 94 and 98 patients fulfilling the necessary inclusion criteria within the two respective periods underwent vaginal hysterectomy. The indications for hysterectomy in the respective groups were similar, and 89 (95%) and 90 (92%) of the patients were Chinese. The respective proportions having additional procedures were 11% versus 23% (P=0.018) and the respective vaginal bilateral salpingo-oophorectomy rates were 1% versus 15% (P<0.001). The vault haematoma rate decreased significantly in the second period (from 12% to 1%; P=0.002). There were no significant differences between the periods with respect to mean operative blood losses, uterine weights, and operating times. The use of gonadotropin-releasing hormone agonist resulted in reduced mean uterine sizes (12 weeks vs 10 weeks; P=0.041). A decreasing trend in mean operating times and blood losses was also observed after such use. Vaginal hysterectomy and bilateral salpingo-oophorectomies were successfully performed in 12 (80%) patients without laparoscopic assistance. For this procedure, a learning curve was also evident. Surgeons' experience can influence the complication rate and the chance of successful vaginal salpingo-oophorectomy. More liberal use of gonadotropin-releasing hormone agonist may further reduce the complication rate and allow more vaginal hysterectomies.

Single incision laparoscopic surgery (SILS) in gynaecology: Feasibility and operative outcomes

Single incision laparoscopic surgery (SILS) represents the latest advancement in minimally invasive surgery, combining the benefits of conventional laparoscopic surgery, such as less pain and faster recovery, with improved cosmesis. Although the successful use of this technique is well reported in general surgery and urology, there is a lack of studies on SILS in gynaecology. To evaluate the feasibility, safety, cosmesis and outcome of SILS in gynaecology. A prospective case series analysis of 105 women scheduled to undergo surgery by SILS from August 2010 to November 2011. Intra-operative data such as operative time, estimated blood loss, complications, additional ports and hospital stay were collected. Post-operative pain and cosmetic outcomes (scar size) were also recorded. Out of 105 women, SILS was performed for 84 (60 excisions of endometriosis, 13 divisions of adhesions, five hysterectomies, two mesh sacrohysteropexies and four ovarian cystectomies). SILS was not undertaken for 21 women because of a number of factors, including the lack of required equipment (eg bariatric scope, SILS port, roticulating instruments and diathermy leads). Four women required insertion of additional ports because of surgical difficulties. One intra-operative (uterine perforation) and seven post-operative complications (six wound infections and one vault haematoma) occurred. Mean operation times were as follows: mesh sacrohysteropexy - 60 min, excision of endometriosis - 55 min, hysterectomy - 150 min, laparoscopic division of adhesions - 62 min and ovarian cystectomy - 40 min. Our experience shows that SILS is a feasible and safe technique for the surgical management of various gynaecological conditions. Satisfaction is high because of improved cosmesis and reduced analgesic requirements post-operatively.

Outcomes of vaginal hysterectomy for uterovaginal prolapse: a population-based, retrospective, cross-sectional study of patient perceptions of results including sexual activity, urinary symptoms, and provided care

BackgroundVaginal hysterectomy is often used to correct uterovaginal prolapse, however, there is little information regarding outcomes after surgery in routine clinical practice. The objective of this study was to investigate complications, sexual activity, urinary symptoms, and satisfaction with health care after vaginal hysterectomy due to prolapse.MethodsWe analyzed data from the Swedish National Register for Gynecological Surgery (SNRGS) from January 1997 to August 2005. Women participating in the SNRGS were asked to complete surveys at two and six months postoperatively. Of 941 women who underwent vaginal hysterectomy for uterovaginal prolapse, 791 responded to questionnaires at two months and 682 at six months. Complications during surgery and hospital stay were investigated. The two-month questionnaire investigated complications after discharge, and patients' satisfaction with their health care. Sexual activity and urinary symptoms were reported and compared in preoperative and six-month postoperative questionnaires.ResultsAlmost 60% of women reported normal activity of daily life (ADL) within one week of surgery, irrespective of their age. Severe complications occurred in 3% and were mainly intra-abdominal bleeding and vaginal vault hematomas. Six months postoperative, sexual activity had increased for 20% (p = 0.006) of women and urinary urgency was reduced for 50% (p = 0.001); however, 14% (n = 76) of women developed urinary incontinence, 76% (n = 58) of whom reported urinary stress incontinence. Patients were satisfied with the postoperative result in 93% of cases and 94% recommended the surgery.ConclusionVaginal hysterectomy is a patient-evaluated efficient treatment for uterovaginal prolapse with swift recovery and a low rate of complication. Sexual activity and symptoms of urinary urgency were improved. However, 14% developed incontinence, mainly urinary stress incontinence (11%). Therefore efforts to disclose latent stress incontinence should be undertaken preoperatively.

Evaluation of closure versus non-closure of vaginal vault after vaginal hysterectomy

SummaryThis randomised prospective study in 53 women having vaginal hysterectomy for benign conditions compared a closed vault technique with an open technique. Twenty-seven had the vault closed (group A) whereas 26 patients had an open vault (group B). The primary outcomes include, vault haematoma (as detected by ultrasound on day 3) and fever. Secondary outcomes are haemorrhage, urinary tract infection, urinary retention and vault granulation tissue. The study did not show any statistical difference between either group. Prolapse of the fallopian tube was recorded in one case in the open vault group. A randomised controlled study on a larger scale is recommended.

Total laparoscopic hysterectomy: a 5-year experience

To evaluate our surgical technique with regards to the success of total laparoscopic hysterectomy (TLH) for the removal of the uterus by analysing its intra-operative and post-operative outcomes and complications in the hope of reducing their occurrence. Retrospective study based on TLH operations performed from January 2001 to December 2005. The KOH Colpotomizer System and the RUMI Uterine Manipulator were used. Five hundred and twelve women consented for TLH. Five hundred and three women (98.2%) had successful TLH with three mini-laparotomy and six laparotomy conversions (1.8% failure rate). Mean uterine size was 11 cm (5-17). Mean operating time was 133 min (40-257). Mean blood loss was 309 ml (50-1,500). Twenty patients (4%) required blood transfusion (five excessive bleeding). Injuries include bowel injury (5), bladder (2), uterine perforation (1), ureterovaginal fistula (1) and vaginal laceration (5). Post-operative complications include pyrexia (36), umbilical wound infection (5), urinary tract infection (UTI) (4) and vault haematoma (3). Mean hospital stay was 2.7 days (1-10). Eighteen patients (3.6%) were readmitted for vaginal bleeding (10), vault haematoma (2), UTI (1), anxiety (3), giddiness (1) and ureterovaginal fistula (1). Twenty-three women (4.5%) encountered major complications (laparotomy conversion, excessive bleeding requiring blood transfusion, hemorrhage > or =1,000 ml, ureteric injury, bowel injury and pulmonary embolus) which compares favourably with other centres (4-11%). Our mean operating time, mean estimated blood loss, mean hospital stay and readmission rate are comparable. TLH with adequate training is associated with low morbidity, few complications and a high success rate.

Sonographically Diagnosed Vault Hematomas Following Vaginal Hysterectomy and Its Correlation with Postoperative Morbidity

Objective. Our aim is to investigate sonographically detectable vault hematomas after vaginal hysterectomy and its relation to postoperative morbidity. Methods. We studied a group of 103 women who had undergone vaginal hysterectomy for benign causes apart from uterovaginal prolapse. Transabdominal ultrasound examinations were carried out 24 to 72 hours after surgery to assess the presence of vault hematomas. Ultrasound findings were correlated with clinical data and postoperative morbidity. Results. The incidence of vault hematoma was found 19.4% in present study. In these patients, 40% (8/20) had fever while only 2.4% (2/83) of cases without vault hematoma suffered from fever. Out of all women having vault hematoma, 70% (14/20) had small-sized hematoma and 30% (6/20) had large-sized hematoma. Fifty percent of patients (3/6) with large-sized hematoma, as compared to only 35% (5/14) with small-sized hematoma, suffered from febrile morbidity. Large-sized hematomas drained by vaginally, while all small-sized pelvic hematomas managed by watchful expectancy successfully. The significant difference was found mean hemoglobin drop and postoperative stay in the hematoma group or without hematoma group. Conclusion. Sonographic detection of vaginal vault fluid collection is common after hysterectomy, but such a finding rarely indicates additional treatment. Though febrile morbidity was more in cases with vault hematoma, the number of such patients was too small to be significant. Vaginal ultrasound examination should not be performed routinely after hysterectomy.

Safety and Efficacy of Using LigaSure Vessel Sealing System for Securing the Pedicles in Vaginal Hysterectomy: Randomised Controlled Trial

This article presents a comparison of the use of LigaSure (Autosuture; Valleylab, Boulder, CO) versus conventional suture ligation for securing the pedicles during vaginal hysterectomy. A total of 116 participants, recruited from the 261 women scheduled to undergo vaginal hysterectomy at the authors' institution between January 2001 and December 2001, were randomized to the LigaSure (group I, n = 57) or conventional (group II, n = 59) arm of the study. The LigaSure device uses low-voltage, high-power current with continuous feedback and computerized algorithms. The current is delivered with 2 disposable electrodes placed on the jaws of a handpiece that is attached to the LigaSure generator. The electrodes are positioned across the hysterectomy pedicles, locking tissue in the jaws, which are then ratcheted to the tightest position. A foot pedal is used to activate the electrical current, which continues until a 2-beep signal indicates complete coagulation has been achieved. The coagulated tissue is then cut and the handpiece removed. Conventional suturing is performed using Vicryl no. 1 suture (Polyglactin; Ethicon, Edinburgh, U.K.) to doubly ligate the pedicles after they are clamped, cut, and transfixed. There were no significant differences in the 2 groups in age, numbers of previous surgeries, indications for surgery, or concomitant procedures performed. Mean operating time was 57 minutes in the LigaSure group and 66 minutes for controls (P <.04). The complication rate was similar for both groups. There were 3 visceral injuries, including 1 bladder injury in each group and a bowel injury in the LigaSure group. All occurred before hemostatic control began and were recognized and treated immediately. Minor complications included 1 patient in each group with postoperative fever, 3 women in the control group who developed a bladder infection, and 1 in the LigaSure group who sustained a labial bum. Overall operative blood loss was similar for both groups. Four women in the conventional ligature group had perioperative bleeding. Two patients were converted to laparotomy to control bleeding from the hysterectomy pedicle, and 1 was returned to the operating room for reclamping and ligation of a bleeding pedicle. Six days after discharge, the fourth woman was readmitted for vaginal bleeding, which necessitated a blood transfusion. She was discovered to have a vault hematoma, which resolved with conservative management.

Safety and efficacy of using the LigaSure vessel sealing system for securing the pedicles in vaginal hysterectomy: randomised controlled trial

To assess the safety and efficacy of using the LigaSure vessel sealing system for securing the pedicles during vaginal hysterectomy in comparison with the conventional method of securing the pedicles by suture ligation. Randomised controlled trial. Gynaecology Department, Benenden Hospital, Kent. One hundred and sixteen women undergoing vaginal hysterectomy were prospectively randomised to either LigaSure (Group I) or suture ligation (Group II) for securing the pedicles. Data of patients were collected prospectively. Statistical analysis was performed using the Mann-Whitney U test, chi(2) and Fisher's exact test as appropriate. Operating time, operative blood loss and peri-operative complications. The operating time was significantly shorter in the LigaSure group compared with the control group (P < 0.04). There was no statistical significant difference between the two groups in operative blood loss (P= 0.433), but peri-operative haemorrhagic complications were less frequent in the LigaSure group (0%vs 6.8%, P= 0.057). Four patients in the control group required either conversion to laparotomy because of bleeding, return to theatre for immediate post-operative haemorrhage or readmission for vault haematoma, whereas none in the LigaSure group had bleeding from unsecured pedicles. The LigaSure vessel sealing system is a safe alternative for securing pedicles in vaginal hysterectomy when compared with conventional suture ligation. Larger studies are required to determine its place in gynaecological surgery.

A randomized, controlled trial of open versus closed vaginal vault at vaginal hysterectomy

The commonest complication associated with vaginal hysterectomy is vault hematoma (1), which has been detected by ultrasound in 34–59% cases postoperatively (1,2). This has been shown to increase febrile morbidity, need for blood transfusions, longer hospital stay, and higher readmission rate (2). We therefore designed a randomized, controlled trial to determine whether nonclosure of the vaginal vault reduced the risk of febrile morbidity. Local ethics committee approval was obtained, and written informed consent was taken from all patients. Our primary outcome measure was to examine a 75% reduction in febrile morbidity (pyrexia) rate, i.e. febrile morbidity rate of 7% in the vault open compared to 31% in the closed group (2). At 80% power at a significance level of 0·05 and allowing for a 20% loss to follow-up, 120 women were required. Randomization was done at the time of the operation by opening a sealed opaque envelope sequentially numbered 1–120. No mention of the vault closure was made in the operative notes. In the open group, the vaginal vault edges and the peritoneal edges were overseen with a continuous interlocking vicryl suture, incorporating the uterosacral ligaments into the vault. This achieved hemostasis at the vault edges but allowed a drain site for any potential vault collection. In the closed group, the vault edges were opposed with interrupted vicryl sutures to completely close the vault. A single standard prophylactic antibiotic dose and antithrombotic agents (stockings and heparin) was given to all patients. Postoperative management was standard in order to reduce bias. If the patient was pyrexial after the first postoperative day, a midstream specimen of urine and a transvaginal pelvic ultrasound scan was performed. Patients were reviewed at outpatient's clinic after 6 weeks to determine whether the vault was closed or not. Operative time, blood loss, and length of hospital stay were compared with the Mann–Whitney U-test. Twenty-three women were recruited in the open vault group and 27 women in the closed vault group. There were no differences between the patient baseline characteristics. Table I shows the surgical outcomes. There were no significant differences in any of the other surgical outcomes, but this was probably due to the small sample size. The study was prematurely stopped due to two serious complications in the open group. One woman had loops of small bowel prolapse through the vault and required a laparotomy at day 4 in order to check the integrity and viability of the bowel. No gangrene of the bowel was noted. The vaginal vault was closed, and she made an uneventful postoperative recovery. Another patient in the open group had symptomatic tubal prolapse and needed laparoscopic salpingectomy 4 months later. Our earlier nonrandomized pilot study established the feasibility and potential efficacy of leaving the vaginal vault open at hysterectomy in reducing febrile morbidity (3). This pilot study did not show any increased morbidity with this surgical technique (3). In contrast, two cases of organ prolapse occurred in the experimental arm (open vaginal vault group) of this current randomized trial, and these complications were considered serious enough to warrant premature closure of the trial. Consequently, the trial lacks the necessary power to answer our primary research question about febrile morbidity or allow any meaningful conclusions to be drawn regarding other surgical outcomes. However, we believe that this paper is important, because it demonstrates the need for randomized, controlled trials to determine the effectiveness of therapies, to rigorously identify and assess adverse events and in those circumstances our obligation as clinical trialists to stop trials, and to report both good and bad outcomes in order to avoid publication bias. We thank Mr Eddie O'Donnell, Mr Khalid Khan who helped recruit some patients in the trial, Mr John Pogmore for advice regarding trial continuation and Sister Tracy Bingham for follow-up of patients. Conflicts of interest: none declared.

Mass closure: a new technique for closure of the vaginal vault at vaginal hysterectomy.

A variety of methods of management of the vaginal vault have been described, all of which maintain certain principles. In techniques that advocate closure of the vault, the peritoneum and vaginal epithelium are treated with separate sutures. This leaves a potential space above the vaginal closure. We describe a simple technique of mass closure which obliterates this space and incorporates the pedicles to provide support for the vault. This method may hold potential advantages in terms of haemostasis, risk of vault haematoma, and post-operative vaginal cuff infections.

Mass closure: a new technique for closure of the vaginal vault at vaginal hysterectomy

A variety of methods of management of the vaginal vault have been described, all of which maintain certain principles. In techniques that advocate closure of the vault, the peritoneum and vaginal epithelium are treated with separate sutures. This leaves a potential space above the vaginal closure. We describe a simple technique of mass closure which obliterates this space and incorporates the pedicles to provide support for the vault. This method may hold potential advantages in terms of haemostasis, risk of vault haematoma, and post-operative vaginal cuff infections.

Real-time intraoperative ultrasound guidance: the transrectal approach.

To assess the role of real-time transrectal ultrasound guidance in complicated gynecologic procedures. In 1998-99, real-time guidance with transrectal ultrasound was utilized in our department to assist the gynecologic surgeon in two procedures: completing the evacuation of the uterine cavity after identification of uterine wall perforation during first trimester termination of pregnancy, and drainage of infected vaginal vault hematoma following hysterectomy. The technique was applied for 11 patients, six abortions and five infected hematomas. All the procedures were completed without any further complications and the patients were discharged on the following day. Follow-up was uneventful. On-line intraoperative transrectal ultrasound can effectively provide real-time assistance to the gynecologic surgeon during complicated pelvic procedures.

Refining surgical technique to prevent occurrence of vault haematoma after vaginal hysterectomy

We set out to analyse the effect of refinement of incision and closure technique of the vaginal vault on the incidence of vault haematoma after hysterectomy. All the surgery was performed in the Gynaecology Department, Benenden Hospital, Kent, UK. This was initially a retrospective study followed by a prospective analysis of postoperative morbidity related to vaginal vault haematomas and critical review of surgical technique over 5 years in all cases undergoing vaginal hysterectomy within our unit. Following refinement in surgical technique a significant reduction in the incidence of clinically significant vaginal vault haematomas from 15·7% to 1·7% ( P <0·001) was observed over a 4-year period. Adoption of the described surgical techniques is recommended to minimise the risk of clinically significant vaginal vault haematomas after vaginal hysterectomy.

CORRESPONDENCE

I congratulate the authors of the article vault haematoma and febrile morbidity after vaginal hysterectomy (Vol 61(8), 2000, p. 535) in addressing a relevant clinical issue. As there is no uniform policy, haematomas are dealt with individually. Factors which could contribute to this problem are: