1. SUTURELESS VAGINAL HYSTERECTOMY AN UPDATE…By
MOUNIR M. F. El-HAO ,
PROF OF OB & GYN.AIN SHAMS UNIVERSITY , CAIRO , EGYPT..

2. STUDY TEAM. KHALED IBRAHIM , A PROF. IHAB SERAG, TUTOR.
MOHAMMA ELLEITHY, A.TUTOR.

3. HISTORICAL BACKGROUND.
SORANUS of Ephesus (2nd century AD)
First hysterectomy for prolapse, gangrenous uterus

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

5. 1824: First successful vaginal hysterectomy for cancer of the cervix
SEMMELWEIS ( ) and LISTER ( )

6. Rates
Australia 40%
USA %
Italy %
France %

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

8. Difficult cases.
Until recently, the procedure was rarely used in patients who have difficult anatomy with limited visibility,
( including those with a narrow vagina without uterine decensus, an expanded lower uterine segment, a bulky uterine fundus, extensive pelvic adhesions, or a history of prior pelvic radiation. Other commonly cited contraindications to the vaginal approach have included nulliparity, obesity, or previous pelvic surgery.)

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

10. The electrosurgical bipolar vessel sealing (EBVS) system, effectively seals vessels from 1 to 7 mm in diameter, and these seals can withstand a minimum of three times normal systolic pressure. [9]
This technology works by applying a precise amount of bipolar energy and pressure to fuse collagen and elastin within the vessel walls. The result is a distinctive, translucent seal zone, which is permanent. [9, 15]

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

12. In a study comparing the electrosurgical bipolar vessel sealing (EBVS) system to ultrasonic coagulation, bipolar coagulation, surgical clips, and sutures, 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. )

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

14. AIM OF THE WORK
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.

15. These new technologies also reduce the risk of adverse reactions: 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

16. Setting:
The study will be carried out in Ain-shams University maternity Hospital.
Study group:
Women admitted for vaginal hysterectomy for benign disease.
Type of the study:
Prospective randomized sequential controlled study.

17. Population:
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.

18. Inclusion criteria for L1 & S1 groups:
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°.

19. Exclusion criteria for L1 & S1 groups
Previous uterine operation [caesarean section-myomectomy-surgery involving the tubes or the ovaries].
Endometriosis.
Absent uterine descent with no adequate mobility.
3rd degree uterine descent.
Uterine size > 10 weeks.
Cervix flushed with the vagina.
Malignant pathology.
Nulligravid patients.
Presence of ovarian mass.

20. Inclusion criteria for L2 & S2 groups:
Benign pathology.
No uterine descent.
Vaginal canal should be adequate.
The posterior & lateral vaginal fornices should be adequate.
Subpubic angles = 70-90°.
Uterine size weeks or previous uterine operation [caesarean section-myomectomy-surgery involving the tubes or the ovaries].

21. Exclusion criteria for L2 & S2 groups
Endometriosis.
Cervix flushed with the vagina.
Malignant pathology.
Presence of ovarian mass.
Presence of uterine descent.
Uterine size < 10 weeks

22. Then each patient in the study will be tested for the following endpoints
Operative time defined as time from initial mucosal injection to closure of the vaginal cuff with satisfactory haemostasis.
Operative blood loss and the need for blood transfusion.
Hospital stay.
Any postoperative complications including:
1ry haemorrhage.
2ry haemorrhage.
Postoperative infection and febrile morbidity.
The need for readmission.
The need for laparotomy

24. Hysterectomy

25. Route
Abdominal 75%
Vaginal 25%

26. The extent of laparotomy and vaginal surgery should be based on the
Surgeon
Preference
(Indication)
Experience
with abdominal and vaginal surgery

27. Types
Abdominal
Vaginal
LAVH LH
TLH
CISH
MISH

28. Laparoscopic Hysterectomy
Shorter stay and recuperation time
Better ureteral identification
Ability for better hemostasis
Good pelvic lavage
Economic!!!

29. First laparoscopic hysterectomy by Harry Reach in1989

30. Sutureless Vaginal Hysterectomy.
The need for CHANGE ?
Patient BENEFIT or surgeon’s EGO ?
Better technique ?
Better results ?

31. In Surgery.
BETTER IS MORE DIFFICULT UNTIL YOU LEARN MORE THEN BETTER IS EASIER.

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

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

35. Laparoscopic hysterectomy…

36. PILOT STUDY ON SVH. 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.

37. SVH

39. Results

40. Comparison Between SVH and V H with SUTURES Operative Time (incision-Extraction of uterus.)15 30 2
31-60 18 8
61-90 4 14
91 120
240 min
Total # 24

41. Intraoperative Complications
10 cases
SVH
VH with Sutures
Excessive Bleeding 1
Bowel Injury
Bladder Injury
Ureteric Injury
Vaginal Injury
Total #
NB excessive bleeding more than 5oo ml.was not procedure related ,but due to avultion of the pedicle with extraction of large uterus

42. Intraoperative Blood Loss
VH with sutures
SVH
200 ml 12 22 10 2
1000 ml o
Total # 24

43. Early Postoperative Complications (during hospitalization)
VH with sutures.
SVH
10 cases
Internal Bleeding
Vaginal Bleeding
Febrile Morbidity 4
Wound Infection
Ileus
Anemia 2
Stump Hematoma
Total # 8

44. Postoperative Hospital Stay
(2-4 days) in both
SVH versus SUTURES
Recuperative Time
(2-3 weeks)
IN BOTH

50. VIDEO.

52. Conclusions

53. RATIONAL
Patients who have indications for traditional vaginal hysterectomy do not need abdominal hysterectomy,or laparoscopic hysterectomy.

54. Post operative Pain.
Deserves to be studied in a well controlled trial

55. WHY SVH?
This new technique deserves attention since it carries good potentials.
Easier.
Quicker
Bloodless.
Less infection.
Less pain.

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

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

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

59. Thank you for your attention.