Vaginal surgery: don't get bent out of shape.

Vaginal hysterectomy rates in the United States are decreasing, despite it being the recommended hysterectomy route for benign hysterectomy by multiple societies. Visualization issues are a known barrier to a medical student learning in the operating room, and it is likely that this also extends to resident training. In addition, vaginal surgery can be taxing on both the surgeons and assistants, with high rates of musculoskeletal work disorders reported in vaginal surgeons. The use of a camera is integral to endoscopic surgery, and table-mounted retractor systems have been used for decades in open surgery. We bring these 2 features into vaginal surgery, that is, using a table-mounted camera system and a table-mounted vaginal retractor. When used together as demonstrated in this video, these tools can improve visualization and may improve ergonomics for the entire surgical team, including learners, during vaginal surgery.

Single-Port/Pneumovagina Technique for Two Further Applications.

OBJECTIVE: To demonstrate a novel technique to surgically treat certain vaginal conditions. DESIGN: Technical video demonstrating 2 cases in which the technique is used. SETTING: Gynecological Minimally Invasive and Robotic Surgery Unit at Clínica Universitaria (private clinic), Concepción, Chile. INTERVENTIONS: Local institutional review board was consulted, and this study was exempted from approval. Institutional ethics committee approved the study and publication of these data. A 35-year-old woman with a bicornuate unicollis uterus presented with dyspareunia. Her examination revealed an incomplete longitudinal vaginal septum. Her right hemivagina was slightly wider than the left one. With the patient under spinal anesthesia, we performed a complete resection of the septum using the single-port/pneumovagina technique (SPPT). A 36-year-old woman who was nulligravida presented with dyspareunia. On clinical exam she had a 3-cm leiomyoma in the proximal vaginal third. Doppler-powered pelvic ultrasound ruled out any vascular communication with the cervix. We performed a vaginal myomectomy using the SPPT under spinal anesthesia. In this particular case we used a fourth trocar in the gel cap to use a myoma screw. With this technique we created a pneumovagina occluding the introitus with the aid of a single-port device (GelPoint Path; Applied Medical, Rancho Santa Margarita, CA). We selected this particular device, designed for transanal surgery, because its access channel avoids gas leakage after applying gentle pressure on the cap. The working cannel is 4 × 4.5 cm, and up to 4 trocars can be inserted in the gel cap. We use 12 mm Hg of pressure to create the pneumovagina and 5 L/min flow to maintain it. Similar approaches have been described for treating eroded and/or infected sacrocolpopexy mesh [1-3]. One could question the utility of this approach over conventional vaginal surgery, and in this sense we believe it provides both the surgeon and surgical assistant a much more comfortable and ergonomic position while performing surgery. It also improves the view of anatomic structures for the surgical team, which in conventional vaginal surgery is limited only to the surgeon. Both procedures were uneventful. The operation time for the first patient was 5 minutes, and the patient was discharged 4 hours later. The operation time for the second patient lasted 35 minutes, and she was discharged 12 hours later. CONCLUSION: The creation of a pneumovagina with the application of a single-port device provides an excellent view of vaginal structures and allows the application of laparoscopic techniques to perform vaginal surgeries in a much more ergonomic fashion compared with conventional vaginal surgery.

Transvaginal Natural Orifice Transluminal Endoscopic Hysterectomy and Apical Suspension of the Vaginal Cuff to the Uterosacral Ligament.

STUDY OBJECTIVE: Transvaginal natural orifice transluminal endoscopic surgery (vNOTES) offers similar advantages of traditional vaginal surgery including no incisional pain as well as a better cosmetic outcome. Furthermore, vNOTES allows the surgeon to overcome the limited surgical space and lack of exposure when using the traditional vaginal instrumentation. Vaginal uterosacral ligament suspension subsequent to vaginal hysterectomy has the advantages of a mesh-free, minimally invasive approach for the treatment of pelvic organ prolapse. The objective of this video is to demonstrate a surgical technique and a few tips and tricks for vNOTES hysterectomy and uterosacral ligament suspension. DESIGN: Stepwise demonstration of the vNOTES technique for hysterectomy and vaginal apical suspension to the uterosacral ligament with narrated video footage. SETTING: An academic tertiary referral center. The ethics committee ruled that approval was not required for this study. PATIENTS: A 53-year-old woman. INTERVENTIONS: vNOTES hysterectomy and apical suspension to the uterosacral ligament. MEASUREMENTS AND MAIN RESULTS: A 53-year-old woman (gravida 5, para 4) presented with Pelvic Organ Prolapse Quantification System stage III symptomatic uterine prolapse. The patient was selected to be operated on via a vaginal port. The video presents some tips and tricks to aid the surgeon to perform this surgery in a safe and timely manner using the vaginal GelPOINT system (Applied Medical, Rancho Santa Margarita, CA). CONCLUSION: vNOTES for repair of POP by uterosacral ligament suspension via a vaginal port is a feasible technique with promising cosmetic results. This technique allows the surgeon to expose the ureter well and lower the risk of ureteric injury. Additionally, this approach avoids mesh complications and should also decrease the risk of abdominal wound infection because of the absence of incisions on the abdomen.

Improved hemostasis with plasma kinetic bipolar sealing device in the vaginal steps of laparoscopic-assisted vaginal hysterectomy.

OBJECTIVE: During the vaginal steps of laparoscopic-assisted vaginal hysterectomy (LAVH), excessive bleeding occurs if the vascular pedicles are not securely clamped. Accordingly, this study investigates if an advanced bipolar sealing device (PlasmaKinetics [PK] Sealer), compared to conventional sutures, could improve the efficacy and safety in the vaginal steps of LAVH. MATERIAL AND METHODS: The medical records of 101 women who underwent LAVH for a non-malignant condition between June 2014 and August 2017 were retrospectively reviewed. Among the women, 60 received LAVH using conventional sutures (control group), while 41 using the PK Sealer during vaginal steps (PK group). RESULTS: A 35% reduction (76.1 vs. 117.3 mL) in the blood loss was observed in the PK group. The natural logarithm (ln) of the blood loss was significantly lower in the PK group than in the control group (P = .045). The percentage of cases which achieved the minimal blood loss goal (<50 mL) was significantly higher in the PK group than in the control group (61 vs. 48%, P = .044). After adjusting for confounding factors, the PK group still exhibited a significantly lower ln intraoperative blood loss (OR -0.477, P = .002) than the control group. CONCLUSION: The PK bipolar sealing device provides a safe and effective alternative in reducing blood loss in the vaginal steps of LAVH.

Use of Vessel-Sealing Devices during Vaginal Hysterectomy.

STUDY OBJECTIVE: To demonstrate the proper use of vessel-sealing devices during vaginal hysterectomy. DESIGN: Educational video (Canadian Task Force classification level III). SETTING: University hospital. INTERVENTION: The video reviews the principles on the use of energy in minimally invasive surgery. We focus on how vessel-sealing devices function and the benefits of their use in difficult vaginal hysterectomy. The video explains the 2 major types of complications, inadequate vessel sealing and undesired thermal injury, and demonstrates techniques to avoid these complications. MEASUREMENTS AND MAIN RESULTS: Laboratory, intraoperative, and cadaveric recordings demonstrate proper use and the complications that may arise in the setting of improper use. CONCLUSION: Vessel-sealing devices may be a useful tool for surgeons performing vaginal hysterectomy. This video demonstrates their use and underlines the importance of understanding the principles of energy devices and their proper usage in surgery.

Feasibility of early discharge following vaginal hysterectomy with a bipolar electrocoagulation device.

OBJECTIVE: To evaluate the safety and efficacy of vaginal hysterectomy for benign conditions (excluding prolapse) using the BiClamp (Erbe Elektromedizin, Tübingen, Germany) bipolar electrocoagulation system. METHODS: The present study was a prospective audit of a consecutive case series of patients who underwent vaginal hysterectomy for benign conditions, performed using the BiClamp between March 1, 2015, and June 30, 2016, at Norfolk and Norwich University Hospital, Norwich, UK. Surgeries performed for benign conditions were eligible, excluding prolapse; severe endometriosis with pelvic adhesions was an exclusion criterion. Patient demographics and past history were recorded, along with intraoperative findings and adverse events. Follow-up data were obtained via telephone interviews 24 hours after surgery and a nurse-led postoperative clinic 8 weeks postoperatively. RESULTS: The series included 75 patients; 32 (43%) were discharged on the same day as surgery and 70 (93%) within 23 hours. There were two patients who experienced vault hematomas and remained admitted for more than 24 hours. There was one intraoperative bladder injury that was repaired vaginally. No delayed adverse events occurred within 8 weeks. No patient required patient-controlled analgesia or an epidural injection for postoperative analgesia. CONCLUSION: Patients experienced low postoperative pain following BiClamp treatment and 93% were was discharged within 23 hours.

Efficiency of using a Foley catheter as a pelvic drain in vaginal hysterectomy.

OBJECTIVES: Vaginal hysterectomy can be associated with a significant risk of vault haematomas with consequent postoperative morbidity. The aim of this study was to assess the use of a Foley Catheter as a vaginal drain in premenopausal women undergoing a vaginal hysterectomy and the impact on different outcomes including development of vault haematoma, length of hospital stay, antibiotics usage, readmissions to the hospital and febrile morbidity in the immediate postoperative period. STUDY DESIGN: This study was conducted at a tertiary teaching hospital and was a retrospective cohort study of women undergoing a vaginal hysterectomy. The study compared 52 women in the study group with a Foley catheter drain to 51 age matched controls without a drain who underwent surgery for similar indications. Outcomes were compared using the Chi square test and student t-test. RESULTS: Comparing women with a drain to those without demonstrated a statistically significant difference with worse outcomes for all parameters in women without a drain: evidence of vault haematomas (0 vs 8; p = 0.0025); length of hospital stay over 2 days (3 vs 15; p = 0.001); discharge with antibiotics for vault haematomas (5 vs 0; p = 0.028) and readmission rates (0 vs 7; p = 0.005). There was no statistical difference in the number of women with temperatures over 38 °C (4 vs 2; p = 0.3) in either group. CONCLUSION: A Foley catheter used as a pelvic drain following a vaginal hysterectomy reduces postoperative complications associated with vault haematomas with shorter hospital stay, lower antibiotic usage and lower readmission rate.

A Novel Method to Facilitate Uterine Delivery at Robotic Hysterectomy.

Minimally invasive platforms have afforded women undergoing hysterectomy the advantages of improved postoperative pain control, reduced complication rates, and shorter inpatient recovery time. In patients where malignancy has been confirmed or suspected, the necessity for uterine delivery per vagina is imperative to maintain these advantages without compromising oncological outcome.A previously unreported technique of enlarging the apical circumference of the vagina during robotic hysterectomy facilitates intact uterine passage after extended reflection of the bladder and/or rectum. Significant increases in vault circumference can be gained through even small midline incisions of the vaginal wall, with an additional 5-cm incision almost doubling the apical aperture in certain cases.We present our series of 21 cases that support this safe, reliable, and simple method for intact uterine delivery during robotic hysterectomy in minimally invasive gynecological oncology practice.

A Swedish population-based evaluation of benign hysterectomy, comparing minimally invasive and abdominal surgery.

OBJECTIVE: The aim was to evaluate surgical routes for benign hysterectomy in a Swedish population, including abdominal and minimally invasive surgery. STUDY DESIGN: Prospectively collected data from the Swedish National GynOp Registry 2009-2015: 13 806 hysterectomy cases were included: abdominal (AH, n = 7485), vaginal (VH, n = 3767), conventional laparoscopic (LH, n = 1539) and robotically-assisted (RAH, n = 1015). RESULTS: The VH group had the shortest operation time at 75 min, AH 97 min and RAH 104 min. LH was longest at 127 min (p < 0.005). The mean estimated blood loss was higher in the AH group (250 ml) compared to all minimally invasive surgery (MIS, 65-172 ml); p < 0.005). Conversion rates were 10% for LH, 4.8% for VH and 1.6% for RAH (p < 0.005). Hospitalization and patient-reported time to normal activities of daily living (ADL) were longer for AH compared to MIS (p < 0.005). Time to return to work was eight days longer in the AH group (35 days) compared with the MIS groups (p < 0.005). Complications were fewest in the VH group at 5.4% compared with AH 7.6% and RAH 8.7% (both p < 0.001), but did not significantly differ from the LH group at 6.6%. Overall patient satisfaction was reported to be 86-94% one year after surgery. CONCLUSION: Women operated on for benign hysterectomy with minimally invasive methods in Sweden 2009-2015 had reduced length of hospitalization, as well as time to resuming normal ADL and return to work, compared to AH. Postoperative outcome measures were improved by minimally invasive methods and MIS should preferably be used.

Laparoscopic-assisted vaginal hysterectomy versus vaginal hysterectomy for benign uterine diseases: a prospective, randomized, multicenter, double-blind trial (LAVA).

OBJECTIVE: To compare the impact of peritoneal closure on postoperative pain after vaginal (VH) and laparoscopic-assisted vaginal hysterectomy (LAVH). STUDY DESIGN: A prospective, randomized, double-blind study was designed to investigate as primary outcome the postoperative pain after VH and LAVH with and without peritoneal closure. The postoperative pain was measured using visual analogue scale (VAS). RESULTS: The patients were recruited between August, 2007 and July, 2014. A total of 192 patients with benign uterine diseases were eligible for analysis and were divided in four groups: LAVH and VH with and without peritoneal closure (PC), respectively. The patients' characteristics including parity, BMI, previous abdominal operations, and uterus weight were well balanced between the groups. The patients who received LAVH were significantly younger (p = 0.0443). LAVH was associated with increased postoperative pain and reduced patients' mobility in the first 72 and 24 h, respectively, after surgery. The use of analgesics remained similar in all four groups. The operating time was significantly shorter after VH (VH + PC 59 ± 17; VH - PC 56 ± 19) than after LAVH (LAVH + PC 106 ± 29 min; LAVH - PC 99 ± 30) (p < 0.0001). The PC did not affect the patients' outcome. The blood loss, the hemoglobin drop, the hospital stay, and the rate of intra- and postoperative complications rate were similar in all four groups. No conversation to laparotomy occurred in whole study population. CONCLUSION: VH is associated with shorter operating time and reduced postoperative pain compared to LAVH.

Vaginal Hysterectomy using the ERBE BiClamp® Bipolar Vessel Sealing System: A Case Series.

The ERBE BiClamp® BVSS appears to be a safe and effective method of vaginal hysterectomy in this small single surgeon, single institution study; demonstrating efficient operative times, minimal blood loss and intraoperative morbidity with acceptable surgical outcomes. Its use contributes to the advancement of minimally invasive gynaecology and should be encouraged.

Imaging System for Vaginal Surgery.

BACKGROUND: The vaginal surgeon is challenged with performing complex procedures within a surgical field of limited light and exposure. INSTRUMENT: The video telescopic operating microscope is an illumination and imaging system that provides visualization during open surgical procedures with a limited field of view. The imaging system is positioned within the surgical field and then secured to the operating room table with a maneuverable holding arm. A high-definition camera and Xenon light source allow transmission of the magnified image to a high-definition monitor in the operating room. The monitor screen is positioned above the patient for the surgeon and assistants to view real time throughout the operation. EXPERIENCE: The video telescopic operating microscope system was used to provide surgical illumination and magnification during total vaginal hysterectomy and salpingectomy, midurethral sling, and release of vaginal scar procedures. All procedures were completed without complications. The video telescopic operating microscope provided illumination of the vaginal operative field and display of the magnified image onto high-definition monitors in the operating room for the surgeon and staff to simultaneously view the procedures. CONCLUSION: The video telescopic operating microscope provides high-definition display, magnification, and illumination during vaginal surgery.

[Vaginal hysterectomy for the enlarged non-prolapse uterus using morcellation techniques and/or Deschamps needle: a retrospective cohort study]. / Histerectomía vaginal para úteros grandes y sin prolapso mediante morcelación y aguja de Deschamps.

OBJECTIVE: To compare surgical outcomes in women who underwent vaginal hysterectomy with enlarged (> 12 weeks size) and non-prolapsed uterus utilizing different morcellation techniques with or without concomitant Deschamps needle use to vaginal hysterectomy for prolapsed uterus. MATERIAL AND METHODS: Retrospective cohort study in women who underwent vaginal hysterectomy performed between January 2009 and June 2014 in the National Institute of Perinatology. The study group comprised 48 women who had vaginal hysterectomy with enlarged and non-prolapsed uterus in which were utilized different morcellation techniques with or without concomitant Deschamps needle use and 50 women who had vaginal hysterectomy for prolapsed uterus served as control. RESULTS: The groups had statistical difference in age, number of cesarean sections, body mass index (BMI), grade of prolapse (Point Cx and D with POPQ quantification system) and surgical prediagnosis (p < 0.001); mean uterus weight was 182.5 g and 106 g, respectively (p < 0.001), as well as for transverse and antero-posterior dimensions and realization of morcellation with or without use of Deschamps needle. Both groups had no statistical difference in preoperative hemoglobin, concomitant surgeries for incontinence and prolapsed, estimated blood loss, operation time, length of stay and complications. CONCLUSION: Vaginal hysterectomy utilizing different morcellation techniques with or without concomitant Deschamps needle use in women with enlarged and non-prolapsed uterus is safe, effective, and with similar complications to vaginal hysterectomies in prolapse uterus.

Total Vaginal NOTES Hysterectomy: A New Approach to Hysterectomy.

The aim of this study was to demonstrate the feasibility of a total hysterectomy performed entirely by transvaginal natural orifice transluminal endoscopic surgery (vNOTES). Conventional, reusable laparoscopic instruments were used, inserted through an inexpensive, self-constructed single-port device. Ten total vaginal NOTES hysterectomies (TVNHs) were performed by a single surgeon. The self-constructed single-port device was made by assembling a surgical glove, a wound protector or modified laryngeal mask airway, 1 reusable 10-mm trocar, and 4 reusable 5-mm trocars. This gloveport was inserted into the vagina to create a pneumovagina. The conventional steps of a vaginal hysterectomy were followed, but performed endoscopically with standard reusable endoscopic instruments. The patient and perioperative data were analyzed. No conversion to standard laparoscopy or laparotomy was necessary in any of the 10 patients who underwent a TVNH. Mean operation time was 97 min (range: 60-120); mean drop in hemoglobin level was 1.5 g/dL (range: 0.5-2.4). There were no operative complications, and postoperative pain scores were very low. This first report on a small number of patients demonstrates that TVNH is possible. By incorporating the advantages of endoscopic surgery, TVNH broadens the indications for vaginal hysterectomy and helps overcome its limitations. At the same time, the NOTES approach avoids abdominal wall wounds and trocar-related complications. TVNH is feasible, even when performed with reusable, conventional laparoscopic instruments. This frugally innovative technique also enables surgeons to perform hysterectomies by vNOTES in low resource settings.

Vaginal cuff thermal injury by mode of colpotomy at total laparoscopic hysterectomy: a randomized clinical trial.

STUDY OBJECTIVE: To evaluate if the use of Valleylab mode ("V mode") (Covidien, Mansfield, MA) electrothermal energy for colpotomy during total laparoscopic hysterectomy (LH) results in a smaller margin of thermal injury to the upper vagina compared with traditional cut/coagulate (cut/coag) electrothermal energy. DESIGN: Prospective randomized clinical trial (Canadian Task Force classification I). SETTING: University medical center. PATIENTS: A total of 101 subjects who underwent LH between June 2010 and August 2012. INTERVENTIONS: Subjects were randomized to colpotomy by V mode electrothermal energy or cut/coag electrothermal energy. MEASUREMENTS AND MAIN RESULTS: The primary end point was the median depth of thermal injury measured in millimeters. The secondary end points included the proportion of subjects who developed granulation tissue, induration, infection, or dehiscence at the vaginal cuff at 4 weeks, 3 months, or 6 months postoperatively. There was no significant difference in the median depth of thermal injury in the cut/coag and V mode arms (anterior margin: 0.68 mm vs 0.63 mm [p = .94], posterior margin: 0.66 mm vs 0.70 mm [p = .87], respectively). Twenty-seven percent of subjects in each arm developed at least 1 of the clinical end points at 4 weeks, 3 months, or 6 months postoperatively (granulation tissue: 6%-18% vs 8%-21%, induration: 0%-2% vs 4%-5%, infection: 0%-4% vs 0%-10%, dehiscence: 2% vs 0% in the cut/coag and V mode arms, respectively), with no difference between arms (p = 1.0). CONCLUSION: The V mode does not reduce the depth of thermal injury compared with cut/coag electrothermal energy when used for colpotomy incision during total laparoscopic hysterectomy (Clinical Trials.gov ID: NCT02080546).

Preset ureter catheter in laparoscopic radical hysterectomy of cervical cancer.

The aim of this study was to evaluate the clinical efficacy of a temporary ureteral catheter in preventing iatrogenic ureteral damage in cervical cancer patients undergoing laparoscopic radical hysterectomy. All cases had confirmed diagnoses of cervical cancer preoperatively between December 2008 and December 2012 in our hospital and were in clinical stages IA2 to IIA. In total, 176 laparoscopic radical hysterectomy and lymphadenectomy procedures were performed. The 176 cases were divided into two groups: ureteral catheters were installed using cystoscopy before the operation in 86 patients (group A), and ureteral catheters were not placed in 90 patients (group B). These cases were retrospectively analyzed based on postoperative hospitalization time and intraoperative and postoperative complications. A total of 6 cases (3.41%) had ureteral injuries, and 4 of the cases (4.65%) of ureteral injuries occurred in group A. In two of these cases, urinary leaking appeared at the post-operative 8th and 9th days and at the 10th and 25th days, respectively. There were 2 cases (2.22%) of ureteral injuries in group B: 1 case of intraoperative direct injury and the other of urinary leaking, which appeared at post-operative day 21. Statistically significant differences between the two groups were observed in operating time and the incidence of hemorrhage, hematuria (including microscopic hematuria), post-operative urinary tract infection, and pain (P < 0.05). A ureteral catheter that is placed preoperatively can help to identify the ureter in laparoscopic radical hysterectomy, but does not decrease the incidence of ureteral injury.