SUTURELESS VAGINALSUTURELESS VAGINALHYSTERECTOMY HYSTERECTOMY AN UPDATE…AN UPDATE…

ByBy

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..

STUDY TEAMSTUDY TEAM..

KHALED IBRAHIM , KHALED IBRAHIM , A PROF.A PROF. IHAB SERAG, IHAB SERAG, TUTOR.TUTOR. MOHAMMA ELLEITHY, MOHAMMA ELLEITHY,

A.TUTOR.A.TUTOR.

HISTORICAL BACKGROUNDHISTORICAL BACKGROUND..

SORANUSSORANUS of Ephesus (2nd of Ephesus (2nd century AD) century AD)

First hysterectomy for prolapse, First hysterectomy for prolapse, gangrenous uterusgangrenous uterus

Reported mortality rate 90%. Reported mortality rate 90%. Most doctors were of the opinion Most doctors were of the opinion it was unlikely that one could it was unlikely that one could survive a hysterectomy survive a hysterectomy

RECAMIERRECAMIER (1774-1852) (1774-1852)

1824: First successful vaginal 1824: First successful vaginal hysterectomy for cancer of the hysterectomy for cancer of the cervix cervix

SEMMELWEISSEMMELWEIS (1818-1865) and (1818-1865) and LISTERLISTER (1827-1912) (1827-1912)

RatesRates

AustraliaAustralia40%40%

USAUSA36%36%

ItalyItaly15.5%15.5%

FranceFrance5.8%5.8%

RatesRates..

Despite the fact that vaginal Despite the fact that vaginal hysterectomy is acknowledged hysterectomy is acknowledged to be the fastest and least to be the fastest and least expensive technique available expensive technique available to achieve removal of the to achieve removal of the uterus and cervix, it is used in uterus and cervix, it is used in only 23% of the hysterectomies only 23% of the hysterectomies performed in the United Statesperformed in the United States

Difficult casesDifficult cases..

Until recently, the procedure was Until recently, the procedure was rarely used in patients who have rarely used in patients who have difficult anatomy with limited difficult anatomy with limited visibilityvisibility,,

( including those with a narrow vagina without uterine ( including those with a narrow vagina without uterine decensus, an expanded lower uterine segment, a decensus, an expanded lower uterine segment, a bulky uterine fundus, extensive pelvic adhesions, or a bulky uterine fundus, extensive pelvic adhesions, or a history of prior pelvic radiation. Other commonly cited history of prior pelvic radiation. Other commonly cited contraindications to the vaginal approach have contraindications to the vaginal approach have included nulliparity, obesity, or previous pelvic included nulliparity, obesity, or previous pelvic surgery.) surgery.)

HaemostasisHaemostasis..

Achieving hemostasis is Achieving hemostasis is fundamental in all surgical fundamental in all surgical approaches. Traditionally, several approaches. Traditionally, several methods have been used, such as methods have been used, such as those using clips, staples, those using clips, staples, sutures, ultrasonic, and sutures, ultrasonic, and monopolar or bipolar coagulation. monopolar or bipolar coagulation.

The The electrosurgical bipolar vessel sealing electrosurgical bipolar vessel sealing (EBVS) system(EBVS) system, effectively seals vessels , effectively seals vessels from 1 to 7 mm in diameter, and these from 1 to 7 mm in diameter, and these seals can withstand a minimum of three seals can withstand a minimum of three times normal systolic pressure. [times normal systolic pressure. [99]]

This technology works by applying a This technology works by applying a precise amount of bipolar energy and precise amount of bipolar energy and pressure to fuse collagen and elastin pressure to fuse collagen and elastin within the vessel walls. The result is a within the vessel walls. The result is a distinctive, translucent seal zone, which is distinctive, translucent seal zone, which is permanent. [permanent. [9, 159, 15]]

Sealing is achieved with minimal Sealing is achieved with minimal sticking and charring. Thermal sticking and charring. Thermal spread to adjacent tissues is spread to adjacent tissues is approximately 0.5 to 2 mm. approximately 0.5 to 2 mm.

In a study comparing the In a study comparing the electrosurgical bipolar vessel electrosurgical bipolar vessel sealing (EBVS) system sealing (EBVS) system to ultrasonic coagulation, to ultrasonic coagulation,

bipolar coagulation, surgical clips, and sutures, thebipolar coagulation, surgical clips, and sutures, the electrosurgical bipolar vessel electrosurgical bipolar vessel sealing (EBVS) system sealing (EBVS) system created seals thatcreated seals that (were stronger than (were stronger than the other energy-based ligation methods and comparable in the other energy-based ligation methods and comparable in strength with that of mechanical ligation techniquesstrength with that of mechanical ligation techniques. . ))

A possible explanation for the A possible explanation for the reduced pain associated with reduced pain associated with radiofrequencyradiofrequency [RF] technology [RF] technology is that, is that, (in theory; radiofrequency [RF] destroys the (in theory; radiofrequency [RF] destroys the affected nerves immediately, preventing the propagation of affected nerves immediately, preventing the propagation of painful sensations. Suturing tends to strangulate and slowly painful sensations. Suturing tends to strangulate and slowly necroses nerves. )necroses nerves. )

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

ligation & does it permit the ligation & does it permit the expansion of the expansion of the spectrum of vaginal hysterectomy spectrum of vaginal hysterectomy indicationsindications..

AIM OF THE WORKAIM OF THE WORK

These new technologies also These new technologies also reduce the risk of adverse reduce the risk of adverse reactionsreactions: Vessels sealed using autologous tissues : Vessels sealed using autologous tissues are unlikely to have adverse responses to foreign materials, are unlikely to have adverse responses to foreign materials, such as sutures, staples, or clips. Finally, the reduction in such as sutures, staples, or clips. Finally, the reduction in needle use reduces the potential for injury during vessel needle use reduces the potential for injury during vessel ligation. Although in skilled hands vaginal hysterectomy may ligation. Although in skilled hands vaginal hysterectomy may be performed using standard techniques even in difficult be performed using standard techniques even in difficult patients, the electrosurgical bipolar vessel sealer technology patients, the electrosurgical bipolar vessel sealer technology

should permit the less experienced should permit the less experienced vaginal surgeon an opportunity to vaginal surgeon an opportunity to expand the indications for vaginal expand the indications for vaginal hysterectomy hysterectomy

SettingSetting::

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

Study groupStudy group:: Women admitted for vaginal Women admitted for vaginal

hysterectomy for benign diseasehysterectomy for benign disease.. Type of the studyType of the study:: ProspectiveProspective randomized sequential randomized sequential

controlled study.controlled study.

PopulationPopulation::

Includes Includes 100 patients100 patients undergoing vaginal hysterectomy undergoing vaginal hysterectomy [divided into 4 groups][divided into 4 groups]::

Group L1Group L1: : vaginal hysterectomyvaginal hysterectomy using using electrosurgical electrosurgical bipolar vessel sealing system (EBVS) for securing the bipolar vessel sealing system (EBVS) for securing the pediclespedicles in the patients with the traditional indications for in the patients with the traditional indications for vaginal hysterectomy.vaginal hysterectomy.

Group S1Group S1: : vaginal hysterectomyvaginal hysterectomy using using traditional traditional suturing for securing the pediclessuturing for securing the pedicles in the patients with the in the patients with the traditional indications for vaginal hysterectomy.traditional indications for vaginal hysterectomy.

Group L2Group L2: : vaginal hysterectomyvaginal hysterectomy using using electrosurgical electrosurgical bipolar vessel sealing system (EBVS) for securing the bipolar vessel sealing system (EBVS) for securing the pediclespedicles in the challenging (difficult) vaginal hysterectomies. in the challenging (difficult) vaginal hysterectomies.

Group S2Group S2: : vaginal hysterectomyvaginal hysterectomy using using traditional traditional suturing for securing the pediclessuturing for securing the pedicles in the challenging in the challenging (difficult) vaginal hysterectomies.(difficult) vaginal hysterectomies.

Inclusion criteria for L1 Inclusion criteria for L1 & S1 groups& S1 groups::

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

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

Exclusion criteria for Exclusion criteria for L1 & S1 groupsL1 & S1 groups Previous uterine operation [caesarean Previous uterine operation [caesarean

section-myomectomy-surgery involving the section-myomectomy-surgery involving the tubes or the ovaries].tubes or the ovaries].

Endometriosis.Endometriosis. Absent uterine descent with no adequate Absent uterine descent with no adequate

mobility.mobility. 3rd degree uterine descent.3rd degree uterine descent. Uterine size > 10 weeks.Uterine size > 10 weeks. Cervix flushed with the vagina.Cervix flushed with the vagina. Malignant pathology.Malignant pathology. Nulligravid patients.Nulligravid patients. Presence of ovarian mass. Presence of ovarian mass.

Inclusion criteria for L2 & Inclusion criteria for L2 & S2 groupsS2 groups::

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

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

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

Exclusion criteria for Exclusion criteria for L2 & S2 groupsL2 & S2 groups

Endometriosis.Endometriosis. Cervix flushed with the vagina.Cervix flushed with the vagina. Malignant pathology.Malignant pathology. Presence of ovarian mass. Presence of ovarian mass. Presence of uterine descent.Presence of uterine descent. Uterine size < 10 weeks Uterine size < 10 weeks

Then each patient in the Then each patient in the study will be tested for the study will be tested for the following endpointsfollowing endpoints Operative time defined as time from initial mucosal Operative time defined as time from initial mucosal

injection to closure of the vaginal cuff with satisfactory injection to closure of the vaginal cuff with satisfactory haemostasis. haemostasis.

Operative blood loss and the need for blood Operative blood loss and the need for blood transfusion.transfusion.

Hospital stay.Hospital stay. Any postoperative complications including:Any postoperative complications including: 1ry haemorrhage.1ry haemorrhage. 2ry haemorrhage.2ry haemorrhage. Postoperative infection and febrile morbidity.Postoperative infection and febrile morbidity. The need for readmission.The need for readmission. The need for laparotomyThe need for laparotomy

HysterectHysterectomyomy

RouteRoute

AbdominalAbdominal75%75%

VaginalVaginal25%25%

The extent of laparotomy The extent of laparotomy and vaginal surgery should and vaginal surgery should be based on thebe based on the

SurgeonSurgeon

Preference

(Indication)

with abdominal and vaginal surgery

Experience

TypesTypes

AbdominalAbdominal VaginalVaginal LAVHLAVH LHLH TLHTLH CISHCISH MISHMISH

Laparoscopic Laparoscopic HysterectomyHysterectomy

Shorter stay and recuperation timeShorter stay and recuperation time

Better ureteral identificationBetter ureteral identification

Ability for better hemostasisAbility for better hemostasis

Good pelvic lavageGood pelvic lavage

Economic!!!Economic!!!

First laparoscopic hysterectomy by First laparoscopic hysterectomy by

Harry Harry ReachReach in1989 in1989

Sutureless Vaginal Sutureless Vaginal HysterectomyHysterectomy..

The need for CHANGE ?The need for CHANGE ? Patient BENEFIT or surgeon’s EGO Patient BENEFIT or surgeon’s EGO

?? Better technique ?Better technique ? Better results ?Better results ?

In SurgeryIn Surgery..

BETTER IS MOREBETTER IS MORE DIFFICULT DIFFICULT UNTIL UNTIL YOUYOU LEARN MORELEARN MORE THEN BETTER THEN BETTER ISIS EASIEREASIER..

SVH how?SVH how?

Vessel sealing ( up to 7 mm.)Vessel sealing ( up to 7 mm.) Low temperature.Low temperature. Surgical precision.Surgical precision. Controlled penetration depth.Controlled penetration depth. Minimal scarring.Minimal scarring. Cut coag type ICut coag type I

VOLTAIREVOLTAIRE..

It is very dangerous to be right on a It is very dangerous to be right on a subject on which the established subject on which the established authorities are wrong.authorities are wrong.

Laparoscopic Laparoscopic hysterectomyhysterectomy……

PILOT STUDY ON SVHPILOT STUDY ON SVH..

Started december 2004.Started december 2004. Patient fit for vaginal Patient fit for vaginal

hysterectomy allocated hysterectomy allocated sequentially randomised and sequentially randomised and blindly into two groups.blindly into two groups.

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

SVSVHH

ResultsResults

Comparison Between SVH and Comparison Between SVH and V H with SUTURES V H with SUTURES Operative Time (incision-Operative Time (incision-Extraction of uterus.)Extraction of uterus.)

SVHSVH SUTURESSUTURES

<1515 00 00

3030 22 00

31-6031-60 1818 88

61-9061-90 44 1414

9191 120120 00 22

>240240 minmin 00 00

TotalTotal# # 2424 2424

Intraoperative Intraoperative ComplicationsComplications

1010 casescases 1010 casescases

SVHSVH VH with VH with SuturesSutures

Excessive BleedingExcessive Bleeding 11 00

Bowel InjuryBowel Injury 00 00

Bladder InjuryBladder Injury 00 00

Ureteric InjuryUreteric Injury 00 00

Vaginal InjuryVaginal Injury 00 00

TotalTotal# # 11 00

NB excessive bleeding more than 5oo ml.was not procedure related ,but NB excessive bleeding more than 5oo ml.was not procedure related ,but due to avultion of the pedicle with extraction of large uterusdue to avultion of the pedicle with extraction of large uterus

Intraoperative Blood Intraoperative Blood LossLoss

VH with VH with suturessutures SVHSVH

<200200 mlml 1212 2222

201-500201-500 1010 00

501-1000501-1000 22 22

>10001000 mlml 00 oo

TotalTotal# # 2424 2424

Early Postoperative Early Postoperative Complications (during Complications (during hospitalization)hospitalization)

VH with VH with suturessutures..

SVHSVH

1010 casescases

Internal Internal BleedingBleeding 00 00

Vaginal Vaginal BleedingBleeding 00 00

Febrile Febrile MorbidityMorbidity 44 00

Wound Wound InfectionInfection 00 00

IleusIleus 00 00

AnemiaAnemia 44 22

Stump Stump HematomaHematoma 00 00

TotalTotal# # 88 22

Postoperative Hospital Stay

(2-4 days) in both

SVH versus SUTURES

Recuperative Time

(2-3 weeks)

IN BOTH

VIDEOVIDEO..

ConclusionsConclusions

RATIONALRATIONAL

Patients who have indications for Patients who have indications for

traditional vaginal hysterectomy traditional vaginal hysterectomy do not do not

need abdominal hysterectomy,or need abdominal hysterectomy,or

laparoscopic hysterectomy. laparoscopic hysterectomy.

Post operative PainPost operative Pain..

Deserves to be studied in a well controlled trialDeserves to be studied in a well controlled trial

WHY SVH?WHY SVH?

This new technique deserves This new technique deserves attention since it carries good attention since it carries good potentials.potentials.

Easier.Easier. QuickerQuicker Bloodless.Bloodless. Less infection.Less infection. Less pain.Less pain.

Intra operativeIntra operative..

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

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

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

Thank you for your Thank you for your attention.attention.