By

MOUNIR M. F. El-HAO , MOUNIR M. F. El-HAO ,

PROF OF OB & GYN.AIN SHAMS PROF OF OB & GYN.AIN SHAMS UNIVERSITY , CAIRO , EGYPT..UNIVERSITY , CAIRO , EGYPT..

The need for CHANGE ? Patient,s BENEFIT or surgeon’s EGO ? Better technique ? Better results ?

INTRODUCTIONINTRODUCTION

Levy B. & Emery L. (2003): Randomized Trial of Suture versus Electrosurgical Bipolar Vessel Sealing in Vaginal Hysterectomy. ACOG; 102(1):147-51.

Australia 40%

USA 36%

Italy 15.5%

France 5.8%

Abdominal Vaginal LAVH LH TLH CISH MISH

INTRODUCTIONINTRODUCTION

Johnson N.; Barlow D.; Lethaby A., et al. (2005): Surgical approach to hysterectomy for benign gynaecological disease. Cochrane Database of Systematic Reviews, Issue 2: CD003677.

Abdominal 75%

Vaginal 25%

Surgeon

Preference

(Indication)

with abdominal and vaginal surgery

Experience

Despite fastest and least expensive it is used in only 23% of the hysterectomies performed in the United States

INTRODUCTIONINTRODUCTION

Kives S.L.; Levy B.S.; Levine R.L., et al. (2003): for the American Association of Gynaecologic Laparoscopists. Laparoscopic-assisted vaginal hysterectomy: J Am Assoc Gynaecol Laparosc: 10:135-8.

Achieving hemostasis is fundamental in all surgical approaches.

clips, staples, sutures, ultrasonic, and monopolar or bipolar coagulation.

Seals vessels from 1 to 7 mm in diameter,

Precise amount of bipolar energy and pressure to fuse collagen and elastin within the vessel walls.

withstand a minimum of three times normal systolic pressure.

Space requirements are less for EBVSEBVS

Sealing is achieved with minimal sticking and charring.

Thermal spread to adjacent tissues is approximately 0.5 to 2 mm.

The result is permanent.

the electrosurgical bipolar vessel sealing (EBVS)

system created seals that (were stronger than the other energy-based ligation methods and comparable in strength with that of mechanical ligation techniques. )

To assess the safety and efficacy of using the electrosurgical bipolar vessel sealing (EBVS) system for securing the pedicles during vaginal hysterectomy in comparison with the conventional method of securing the pedicles by suture ligation

& does it permit the expansion of the spectrum of vaginal hysterectomy indications.

AIM OF THE WORKAIM OF THE WORK

MOUNIR FAWZY ELHAO, PROF KHALED IBRAHIM , A PROF. IHAB SERAG, TUTOR. MOHAMMA ELLEITHY, A.TUTOR.

Vessels sealed using autologous tissues are unlikely to have adverse responses to foreign materials, such as sutures, staples, or clips. Finally, the reduction in needle use reduces the potential for injury during vessel ligation. Although in skilled hands vaginal hysterectomy may be performed using standard techniques even in difficult patients, the electrosurgical bipolar vessel sealer technology should permit the less experienced vaginal surgeon an opportunity to expand the indications for vaginal hysterectomy

The study was carried out in Ain-shams University maternity Hospital.

Study group: Women admitted for vaginal

hysterectomy for benign disease. Type of the study: Prospective randomized Double blind

controlled study.

Includes 100 patients undergoing vaginal hysterectomy [divided into 4 groups]:

Group L1: vaginal hysterectomy using electrosurgical bipolar vessel sealing system (EBVS) for securing the pedicles in the patients with the traditional indications for vaginal hysterectomy.

Group S1: vaginal hysterectomy using traditional suturing for securing the pedicles in the patients with the traditional indications for vaginal hysterectomy.

Group L2: vaginal hysterectomy using electrosurgical bipolar vessel sealing system (EBVS) for securing the pedicles in the challenging (difficult) vaginal hysterectomies.

Group S2: vaginal hysterectomy using traditional suturing for securing the pedicles in the challenging (difficult) vaginal hysterectomies.

1st or 2nd degree uterine descent. Uterine size < 10 weeks. Benign pathology. Multigravid patients. Vaginal canal should be ample. The posterior & lateral vaginal fornices

should be wide and deep. Subpubic angles > 90°.

TABLE 5

Operating Time (minutes) comparative data from randomized controlled trials

Published Reference

VHSUTURES (minutes)

VHEBVS (minutes)

No.

(sutures : EBVS)

(Cronje et al., 2005)

40 32 (31:37)

(Hefni et al., 2005)

61 30 (59:57)

(Levy et al., 2003)

60 48 (30:30)

The current study

90 52.5 (53:50)

Benign pathology. No uterine descent. Vaginal canal should be adequate. The posterior & lateral vaginal fornices

should be adequate. Subpubic angles = 70-90°. Uterine size 10-14 weeks or previous

uterine operation [caesarean section-myomectomy-surgery involving the tubes or the ovaries].

Operative time Operative blood loss Hospital stay. Any postoperative complications including:1. 1ry haemorrhage.2. 2ry haemorrhage.3. Postoperative infection and febrile morbidity.4. The need for readmission.5. The need for laparotomy

Started december 2004. Patient fit for vaginal hysterectomy

allocated sequentially randomised and blindly into two groups.

Comparing the efficacy of bipolar vessel sealing technique with routine vaginal hysterectomy.

PATIENTSPATIENTSSample Sample sizesize

GROUP L= L 1+ L2

ELECTROSURGICAL BIPOLAR VESSEL SEALING (EBVS)

GROUP S= S 1+ S2

TRADITIONAL SUTURE LIGATURE

METHODSMETHODS

ComplicationsComplications were reported including:

METHODSMETHODSpostoperative haemoglobin postoperative haemoglobin and haematocritand haematocrit

Statistical analysis was done on a personal computer using the Statistical Statistical Package for Social Sciences version Package for Social Sciences version 12.0 12.0 (SPSS©v. 12.0, SPSS Inc., Chicago, IL) .

METHODSMETHODS

STATISTICAL METHODSSTATISTICAL METHODS

RESULTSRESULTS

RESULTSRESULTS

factors responsible for the success of the surgery and its difficulty (Table 1). (modified from Sheth et al., 2002) 12

TABLE 1 Modified per-operative score for assessment of VH difficulty

0 1 2

Size ≤ 8 weeks 9-10 weeks > 10 weeks

Previous CS None - Present

Vagina >3 fingers 3 fingers < 3 fingers

Uterine descent 2nd degree 1st degree No descent

Uterine mobility Good Fair Poor

Subpubic angle > 90 degree 90 degree <90 degree

Fornices depth > 1 finger crease 1 finger crease < 1 finger crease

Surgeon experience Professor or Ass. prof Lecturer or Ass. lecturer

Resident

The score varied from a minimum of 0 to a maximum of 16

RESULTSRESULTS

RESULTSRESULTS

RESULTSRESULTS

RESULTSRESULTS

Patients who have indications for

traditional vaginal hysterectomy do

not need abdominal hysterectomy,or

laparoscopic hysterectomy.

Deserves to be studied in a well controlled trial

Good potentials. Easier. Quicker Bloodless. Less infection. Less pain.

Time ,Bleeding and recovery are all shorter than average for other techniques.

Sutureless vaginal hysterectomy using electrosurgical bipolar vessel sealer is a good alternative to the use of sutures in routine vaginal hysterectomy.

When the competent surgeon is equipped with such devices, conversion of an abdominal hysterectomy to the vaginal route is both attainable and preferred.

RESULTSRESULTS

Levy B. & Emery L. (2003): Randomized Trial of Suture versus Electrosurgical Bipolar Vessel Sealing in Vaginal Hysterectomy. ACOG; 102(1):147-51.

Cronje H.S. & de Coning E.C. (2005): Electrosurgical bipolar vessel sealing during vaginal hysterectomy. Int J Gynaecol Obstet; 91(3): 243-5.

Hefni M.A. (2005): Safety and efficacy of using the LigaSure vessel sealing system for securing the pedicles in vaginal hysterectomy: randomized controlled trial. BJOG 2005; 112(3): 329-33.

DISCUSSIONDISCUSSION

RESULTSRESULTS

RESULTSRESULTS

RESULTSRESULTS

Less manipulation, compression and traction.

.1No foreign material ;.2Tissue left distal to the suture or clip

(including nerves) can necrose post-operatively and may cause pain and infection.

Peirce S.C. & Crawford D.C. (2007): Centre for Evidence-based Purchasing; Purchasing and Supply Agency; Evidence review; Electrosurgical vessel sealing in vaginal hysterectomy. CEP 07019 November 2007.

pain with EBVS could be related to :