Uterine artery ligation at the beginning of total laparoscopic hysterectomy reduces total blood loss and operation duration

Lateral closure of the uterine artery prior to laparoscopic hysterectomy: a systematic review

An alternative surgical technique with closure of the uterine artery at its origin, known as lateral approach prior to TLH, has been proposed and it may offer important benefits to both patients and surgeons. Our objectives were to review the current literature regarding surgical outcomes between lateral and conventional approach in relation to TLH. We followed the 'PRISMA' guidelines and conducted a systematic review, which involved searching PubMed and Embase databases for RCTs evaluating the topic. We identified four RCTs including 585 patients. Three of the four studies reported a significant lower bleeding during TLH with prior lateral approach. Operative time was also shorter in the lateral approach group compared to the conventional approach group in three studies.Our review provides evidence that lateral occlusion of the uterine arteries prior to total laparoscopic hysterectomy may be beneficial due to less blood loss and shorter perioperative time without compromising patient safety.

Prophylactic ligation of uterine arteries at its origin in laparoscopic surgical staging for endometrial cancer

AIM

The aim of this study was to compare the surgical outcomes between patients who were staged laparoscopically for early-stage endometrioid-type endometrial cancer (EC) between those who underwent prophylactic ligation of uterine arteries (UAs) prior to pelvic lymphadenectomy and the patients who were operated with standard procedure.

METHODS

This retrospective study was conducted in women diagnosed with early-stage and low/intermediate-risk endometrioid-type EC. The control group included patients who underwent standard laparoscopic pelvic lymphadenectomy and the study group concerned patients who underwent prophylactic ligation of UA prior to pelvic lymphadenectomy. The prophylactic ligation of UA procedure was performed at a point just proximal to its origin.

RESULTS

The mean lymph node count dissected in the study group was higher in terms of statistical significance (17.5 ± 2.2 vs. 19.8 ± 3.6, p = 0.003 and p ˂ 0.05). The rate of the patients who had a positive pelvic lymph node detected did not differ between groups (7.4% vs. 16.7%, p = 0.258 and p ˂ 0.05). The operation time (OT) of the patients in the study group did not differ between groups (p = 0.546 and p ˂ 0.05). Hemoglobin drop (-0.5 ± 0.7) and hematocrite drop (-0.8 ± 0.9) values in the study group were found to be lower in the study group (p = 0.000, p = 0.000, and p ˂ 0.05).

CONCLUSIONS

Performing prophylactic ligation of UA at its origin prevents unwanted bleeding and facilitates the laparoscopic pelvic lymphadenectomy procedure.

Uterine artery closure at the origin versus at the uterus level in total laparoscopic hysterectomy: A randomized controlled trial

INTRODUCTION

The transfusion rate in hysterectomies for benign pathology is almost 3%. However, despite the strong interest in reducing intraoperative bleeding, limited evidence is available regarding the technical aspects concerning uterine vessel management during a total laparoscopic hysterectomy (TLH). Uterine artery (UA) closure in TLH can be performed at the origin from the internal iliac artery or at the uterus level (UL). However, low-quality evidence is available regarding the superiority of one method over the other.

MATERIAL AND METHODS

We performed a single-blind randomized (1:1) controlled trial (NCT04156932) between December 2019 and August 2020. One hundred and eighty women undergoing TLH for benign gynecological diseases were randomized to TLH with UA closure at the origin from the internal iliac artery (n = 90), performed at the beginning of the procedure by putting two clips per side at the origin, versus closure at the UL (n = 90). Intraoperative blood loss estimated from suction devices was the primary outcome. Secondary end points were perioperative outcomes, the conversion rate from one technique to the other, and complication rates with 4 months of follow up.

RESULTS

Uterine artery closure at the origin was completed in all 90 patients (0%), whereas closure at the UL was converted to closure at the origin in 11 cases (12.2%; p < 0.001); failures were mainly associated with the presence of endometriosis (81.8% [9/11] versus 10.1% [8/79]; p < 0.001). In the intention-to-treat analysis, the intraoperative blood loss was higher in the group assigned to the closure at the UL (108.5 mL) than in the group with closure at the origin (69.3 mL); the mean difference was 39.2 mL (95% CI 13.47-64.93 mL; p = 0.003). Other perioperative outcomes and complications rates did not differ.

CONCLUSIONS

Uterine artery closure at the origin reduces intraoperative blood loss during a TLH and appears to be more reproducible than closure at the UL without higher complication rates. However, the absent translation in clinical benefits impedes the support of a clinical superiority in all women. Closure at the origin may provide clinical advantages in the presence of severe preoperative anemia or pelvic anatomic distortion.

Total laparoscopic hysterectomy (TLH) with endosuturing compared with conventional technique using energy sources

Background

The aim of the study was to demonstrate the technique of total laparoscopic hysterectomy (TLH) with intra-corporeal endosuturing using simple sutures and basic surgical instruments and compare with TLH using electric coagulation equipment i.e. energy sources with regard to operative time, blood loss, postoperative stay and pain scores.

Methods

A retrospective study was undertaken, in Max Super Specialty Hospital Saket, from June 2015 to May 2018, which included 586 cases of TLH (for benign gynecological conditions), of which 287 were performed using intra-corporeal endosuturing (Group 1) and 299 were performed using energy sources (Group 2). To avoid bias, baseline matching was done for body mass index (BMI), indications for surgery, size of uterus, previous abdominal surgeries and comorbidities like diabetes and hypertension after which there were 172 patients in each group.

Results

The mean age of patients was 48.24 ± 6.76 years. All operative outcomes including operative time (104.1 ± 22.6 vs 107.6 ± 32.6 mins, p=0.25), blood loss (78.9 ± 101.6 vs 99.7 ± 177.6 ml, p=0.19), pain score (2.5 ± 1.3 vs 2.7 ± 1.2, p=0.13) and post-operative stay (2.05 ± 0.2 vs 2.07 ± 0.3 days, p=0.36) were similar between the two groups. Uterine size was the major determinant of operative time and operative blood loss.

Conclusion

TLH with intracorporeal endosuturing can be performed safely and gives results comparable with TLH performed using energy sources. Advancement in suturing devices can decrease operative time further and potentially make it easier and more acceptable.

Perioperative Interventions to Minimize Blood Loss at the Time of Hysterectomy for Uterine Leiomyomas: A Systematic Review and Meta-analysis

STUDY OBJECTIVE

Hysterectomy for uterine leiomyoma(s) is associated with significant morbidity including blood loss. A systematic review and meta-analysis was conducted to identify nonhormonal interventions, perioperative surgical interventions, and devices to minimize blood loss at the time of hysterectomy for leiomyoma.

DATA SOURCES

Librarian-led search of Embase, MEDLINE, Web of Science, Scopus, Cumulative Index to Nursing and Allied Health Literature, and Cochrane databases from 1946 to 2018 with hand-guided updates.

METHODS OF STUDY SELECTION

Included studies reported on keywords of hysterectomy, leiomyoma, and operative blood loss/postoperative hemorrhage/uterine bleeding/metrorrhagia/hematoma. The review excluded a comparison of route of hysterectomy, morcellation, vaginal cuff closure, hormonal medications, vessel sealing devices for vaginal hysterectomy, and case series with <10 patients.

TABULATION, INTEGRATION, AND RESULTS

Surgical blood loss, postoperative hemoglobin (Hb) drop, hemorrhage, transfusion, and major and minor complications were analyzed and aggregated in meta-analyses for comparable studies in each category. A total of 2016 unique studies were identified, 33 of which met the inclusion criteria, and 22 were used for quantitative synthesis. The perioperative use of misoprostol in abdominal hysterectomy (AH) was associated with a lower postoperative Hb drop (0.59 g/dL; 95% confidence interval [CI], 0.39-0.79; p < .01) and blood loss (-96.43 mL; 95% CI, -153.52 to -39.34; p < .01) compared with placebo. Securing the uterine vessels at their origin in laparoscopic hysterectomy (LH) was associated with decreased intraoperative blood loss (-69.07 mL; 95% CI, -135.20 to -2.95; p = .04) but no significant change in postoperative Hb (0.24 g/dL; 95% CI, -0.31 to 0.78; p = .39) compared with securing them by the uterine isthmus. Uterine artery ligation in LH before dissecting the ovarian/utero-ovarian vessels was associated with lower surgical blood loss compared with standard ligation (-27.72 mL; 95% CI, -35.07 to -20.38; p < .01). The postoperative Hb drop was not significantly different with a bipolar electrosurgical device versus suturing in AH (0.26 g/dL; 95% CI, -0.19 to 0.71; p = .26). There was no significant difference between an electrosurgical bipolar vessel sealer (EBVS) and conventional bipolar electrosurgical devices in the Hb drop (0.02 g/dL; 95% CI, -0.15 to 0.20; p = .79) or blood loss (-50.88 mL; 95% CI, -106.44 to 4.68; p = .07) in LH. Blood loss in LH was not decreased with the LigaSure (Medtronic, Minneapolis, MN) impedance monitoring EBVS compared with competing EBVS systems monitoring impedance or temperature (2.00 mL; 95% CI, -8.09 to 12.09; p = .70). No significant differences in hemorrhage, transfusion, or major complications were noted for all interventions.

CONCLUSION

Perioperative misoprostol in AH led to a reduction in surgical blood loss and postoperative Hb drop (moderate level of evidence by Grading of Recommendations, Assessment, Development and Evaluation guidelines) although the clinical benefit is likely limited. Remaining interventions, although promising, had at best low-quality evidence to support their use at this time. Larger and rigorously designed randomized trials are needed to establish the optimal set of perioperative interventions for use in hysterectomy for leiomyomas.

Bilateral uterine artery coagulation in laparoscopic hysterectomy for benign disease in uteri more than 1000 g

AIM

We aimed to evaluate the efficacy of bipolar uterine artery coagulation in laparoscopic hysterectomy for uteri larger than 1000 g.

METHODS

Data from 674 patients who underwent laparoscopic hysterectomy were retrospectively analyzed. Among those, 75 patients with uteri weighing more than 1000 g were included. The clinical and surgical outcomes of patients with large uteri were compared according to bipolar uterine artery coagulation performance status.

RESULTS

The mean difference in intraoperative blood loss between the groups of patients with uterine artery occlusion and without uterine artery occlusion was statistically significant (89.26 ± 65.52 vs 227.94 ± 124.65 mL; P < 0.001). The hemoglobin decrease was also significantly lower in the patients with uterine artery occlusion (0.46 ± 0.23 vs 1.21 ± 0.79 g/dL; P < 0.001).

CONCLUSION

When performing laparoscopic hysterectomy of uteri weighing over 1000 g, the occlusion of the bilateral uterine arteries at the point of exit from the internal iliac arteries using bipolar coagulation at the beginning of the operation reduces intraoperative hemorrhage and hemoglobin decrease.

The Comparison of Outcomes between the "Skeleton Uterus Technique" and Conventional Techniques in Laparoscopic Hysterectomies

Aim

The aim of this study is to compare demographic characteristics, operative data, and complication rates of women who underwent total laparoscopic hysterectomy by the skeleton uterus technique (Skeleton-TLH) with those of women who underwent TLH by the standard technique (Standard-TLH) in a university teaching and research hospital.

Materials and Methods

This retrospective study included 932 laparoscopic hysterectomies in a university teaching and research hospital between January 1, 2013 and December 31, 2017. Clinical characteristics, operative outcomes, and complications were recorded and compared for the two techniques.

Results

In total, 932 laparoscopic hysterectomies were performed, 454 by Skeleton-TLH and 478 by Standard-TLH. The general demographic characteristics of the patients were similar; only gravida and parity were statistically significantly different between the groups (P < 0.001). Based on the primary outcomes (the operative data), total anesthesia time and main operation time were similar in the two groups. Estimated blood loss was statistically significantly lower in the Skeleton-TLH group than in the Standard-TLH group. Hospital stay was longer for the Skeleton-TLH group, and specimen weight was heavier. The secondary outcome was the complication rate. There were no differences between the Skeleton-TLH and Standard-TLH groups in the rates of all minor and major complications.

Conclusion

TLH with the skeleton uterus technique is feasible and safe, especially for advanced pelvic surgeons. This technique not only provides retroperitoneal access to the pelvic spaces and good anatomical visibility; but it also delivers a safer laparoscopic hysterectomy by clamping the uterine arteries and monitoring the ureter throughout the operation.

A Retrospective Review of Vaginal Cuff Dehiscence: Comparing Absorbable and Nonabsorbable Sutures

STUDY OBJECTIVE

To compare the rate of spontaneous and complete vaginal cuff dehiscence (VCD) using absorbable versus nonabsorbable sutures for vaginal cuff closure.

DESIGN

Retrospective comparative cohort design.

SETTING

Freestanding ambulatory surgery center in suburban Maryland.

PATIENTS

Women age >18 years old who underwent hysterectomy for benign conditions between October 2013 and April 2018.

INTERVENTION

Laparoscopic retroperitoneal hysterectomy was performed by 2 gynecologic surgical specialists. Transvaginal cuff closure was performed using either absorbable Vicryl (polyglactin 910) sutures (n = 881) or nonabsorbable Ethibond (polyester) sutures (n = 574). The nonabsorbable sutures were surgically removed after 90 days.

MEASUREMENTS AND MAIN RESULTS

No statistically significant differences in age, race, weight, body mass index, parity, uterine weight, or number of comorbidities were noted between the nonabsorbable and absorbable suture groups. Spontaneous vaginal cuff dehiscence (VCD) occurred in 3 patients (0.52%) in the nonabsorbable group and in 12 patients (1.4%) in the absorbable group (p = .183). Eleven of the 12 cases of VCD in the absorbable group were precipitated by intercourse and occurred within 90 days of surgery.

CONCLUSION

Our data suggest that use of a nonabsorbable suture may be an effective approach to prevent spontaneous VCD, but the benefits should be weighed against the inherent risk associated with a second procedure to remove sutures.

Value-based assessment of hysterectomy approaches

AIM

By evaluating operative outcomes relative to cost, we compared the value of minimally invasive hysterectomy approaches, including a technique discussed less often in the literature, laparoscopic retroperitoneal hysterectomy (LRH), which incorporates retroperitoneal dissection and ligation of the uterine arteries at their vascular origin.

METHODS

Retrospective chart review of all women (N = 2689) aged greater than or equal to 18 years who underwent hysterectomy for benign conditions from 2011 to 2013 at a high-volume hospital in Maryland, USA. Procedures included: laparoscopic supracervical hysterectomy, robotic-assisted laparoscopic hysterectomy (RALH), total laparoscopic hysterectomy, laparoscopic-assisted vaginal hysterectomy, total vaginal hysterectomy (TVH), and LRH.

RESULTS

Total vaginal hysterectomy had the highest intraoperative complication rate (9.6%; P < 0.0001) but the lowest postoperative complication rate (1.8%; P < 0.0001). Robotics had the highest postoperative complication rate (11.4%; P < 0.0001). LRH had the shortest operative time (71.2 min; P < 0.0001) and the lowest intraoperative complication rates (2.1%; P < 0.0001). LRH and TVH were the least costly (averaging $4061 and $6416, respectively), while RALH was the most costly ($9354). Taking both operative outcomes and cost into account, LRH, TVH and laparoscopic-assisted vaginal hysterectomy yielded the highest value scores; total laparoscopic hysterectomy, RALH, and laparoscopic supracervical hysterectomy yielded the lowest.

CONCLUSION

Understanding the value of surgical interventions requires an evaluation of both operative outcomes and direct hospital costs. Using a quality-cost framework, the LRH approach as performed by high-volume laparoscopic specialists emerged as having the highest calculated value.

Laparoscopic Hysterectomy Outcomes: Hospital vs Ambulatory Surgery Center

BACKGROUND AND OBJECTIVE

Compare operative outcomes of laparoscopic hysterectomy in an outpatient hospital setting versus freestanding ambulatory surgery center.

METHODS

Retrospective cohort study of two groups in an outpatient hospital surgery department and freestanding ambulatory surgical center, both serving the Washington, DC area. Women, 18 years or older, who underwent laparoscopic hysterectomy for benign conditions in an outpatient hospital setting between 2011 and 2014 (n = 821), and at an ambulatory surgery center between 2013 and 2017 (n = 1210). Laparoscopic hysterectomy with retroperitoneal dissection and early ligation of the uterine arteries at the origin, performed by gynecologic surgical specialists from a single practice. Patient characteristics, medical history, uterine weight, pathology, operating times, estimated blood loss, and complications were analyzed.

RESULTS

The mean uterine size between settings was not significantly different (Ambulatory Surgery Center, 349.4 g; Hospital, 329.7 g). The largest uteri removed at the surgery center was 3500 g; at the hospital it was 2489 g. The surgery center had a shorter average operating time than the hospital (53.7 and 61.3 minutes, respectively; P < .001). Intraoperative and postoperative complication rates were not significantly different between settings (2.7% and 3.7%, surgery center; 2.1% and 4.8%, hospital). There were two hospital transfers from the surgery center: 1 for blood transfusion, and 1 for low oxygen saturation. Same-day discharge occurred in 99.8% of surgery center patients versus 88% hospital patients.

CONCLUSIONS

Laparoscopic hysterectomy can be performed safely and effectively by skilled surgeons at a freestanding ambulatory surgery center, even in complex cases with large uteri.

Total laparoscopic hysterectomy via suture and ligation technique

OBJECTIVE

The term 'total laparoscopic hysterectomy (TLH) with classical suture method' refers to a surgical procedure performed using only sutures and ligations with intracorporeal or extracorporeal ties, without using any laser or electronic cauterization devices during laparoscopic surgery as in total abdominal hysterectomy. However, the method is not as widely used as electric coagulation equipment for TLH because further advances in technology and surgical technique are required and operative time can take longer. In the current study, we evaluated the benefits of the classical suture method for TLH.

METHODS

This study retrospectively reviewed patients who received TLH using the classical suture method from August 2005 to April 2014. The patients' baseline characteristics were analyzed, including age, parity, cause of operation, medical and surgical history. Surgical outcomes analyzed included the weight of the uterus, operative time, complications, changes in hemoglobin level, blood transfusion requirements, and postoperative hospital stay.

RESULTS

Of 746 patients who underwent TLH with the classical suture method, mean operation time was 96.9 minutes. Mean average decline in hemoglobin was 1.6 g/dL and transfusion rate was 6.2%. Urinary tract injuries were reported in 8 patients. Urinary tract injuries comprised 6 cases of bladder injury and 3 cases of ureter injury. There were no cases of vaginal stump infection, hematoma, bowel injury or abdominal wound complication. All cases involving complications occurred before 2010.

CONCLUSION

The classical suture method for TLH presents tolerable levels of complications and blood loss. Advanced surgical skill is expected to decrease operation time and complications.