Reducing blood loss at open myomectomy using triple tourniquets: a randomised controlled trial.

OBJECTIVES: To evaluate triple tourniquets in controlled conditions and for the first time to investigate the hypothesis that leaving a semi-permanent tourniquet around the uterine artery reduces post-operative bleeding from the uterine incisions. DESIGN: A randomised controlled trial. SETTING: Two University teaching hospitals. POPULATION: Twenty-eight patients with symptomatic fibroids and uterine sizes ranging from 14 to 24 weeks of gestation undergoing open myomectomy. METHODS: A number 1 polyglactin suture was tied around the cervix to occlude the uterine arteries, and polythene tourniquets were tied around the infundibulopelvic ligament to obstruct the ovarian vessels. At the end of the procedure, the ovarian ties were released but the uterine artery suture remained in situ. MAIN OUTCOME MEASURES: Intra-operative blood loss, post-operative blood loss, blood transfusion rates, operative morbidity, uterine blood flow and ovarian function. RESULTS: There was significantly less blood lost in the tourniquet group than in the control group (difference between means 1870 mL, 95% CI 1159-2580 mL, P < 0.0001; transfusion rates of 7% and 79%, P= 0.0003). The volume in the pelvic drain 20 min post-operatively and after 48 hours failed to reach statistical significance between the two groups (P= 0.10 and P= 0.165). There were no differences in uterine artery Doppler resistance indices at five days (P= 0.54), six weeks (P= 0.47), three months (P= 0.49) and at six months (P= 0.18). Day two serum FSH concentrations after surgery were unchanged (P= 0.45), compared with baseline values. CONCLUSIONS: Triple tourniquets are effective in reducing bleeding and transfusion rates. There appears no obvious adverse effect on uterine perfusion or ovarian function.

Sonographic depiction of postmenopausal endometrium with transabdominal and transvaginal scanning.

The thickness of the endometrium was measured in postmenopausal women by both the transvaginal and transabdominal ultrasound approaches in two separate groups of patients. The first group consisted of 90 women who received a transabdominal scan of the endometrium before dilatation and curettage or hysterectomy for either postmenopausal bleeding or uterine prolapse. The second group consisted of 111 women who underwent a transvaginal scan of the endometrium for similar postmenopausal conditions. Both methods suggested that an endometrial thickness of 5 mm may be used as a cut-off level in the conservative management of patients with postmenopausal bleeding or in a screening program for endometrial carcinoma. Patient acceptance and image quality were better in the group examined transvaginally. The proximity of the transvaginal probe to the endometrium, in the absence of a full bladder compressing the endometrium, revealed a unique group of patients with atrophic endometrium but thick endometrial cavity caused by intracavity fluid. In the presence of uterine fibroids distorting the uterine cavity, transvaginal scanning was better than transabdominal scanning for visualizing the endometrium. The transabdominal full-bladder technique can be of value in detecting asymptomatic bladder pathology.

The role of vaginal scan in measurement of endometrial thickness in postmenopausal women.

Transvaginal ultrasound scanning was performed on 111 postmenopausal women. Of these women, 103 had postmenopausal bleeding, and eight were undergoing hysterectomy. Of the 103 women with bleeding, 93 had dilatation and curettage (D&C) and 10 patients were treated conservatively with a repeat scan in six months. A correlation of ultrasound findings and endometrial histopathology was possible in 94 patients. In 59 of these (63%) the endometrium was atrophic and the ultrasound endometrial thickness was 5 mm or less. In 29 (31%) patients the endometrial histology was abnormal and ultrasound endometrial thickness was greater than 5 mm. In six patients the endometrium was atrophic, but the ultrasonic endometrial thickness was apparently greater than 5 mm due to intracavity fluid. We suggest that an endometrial thickness of 5 mm is an appropriate cut-off level for conservative management of patients with postmenopausal bleeding, or in screening for endometrial carcinoma.