Long-term outcomes for different vaginal cuff closure techniques in robotic-assisted laparoscopic hysterectomy: A randomized controlled trial.

OBJECTIVE: This randomized controlled trial aimed to evaluate the outcomes of different vaginal cuff closure techniques in robotic-assisted total laparoscopic hysterectomy. STUDY DESIGN: Ninety women undergoing robotic-assisted total laparoscopic hysterectomy for benign disease were randomized to three vaginal cuff closure techniques: running 2.0 V-Lock™ (Arm 1), 0 Vicryl™ figure-of-eight (Arm 2), and running 0 Vicryl™ with Lapra-Ty® (Arm 3). Patients' records were reviewed for age, body mass index, smoking status and relevant co-morbidities. Operative times for vaginal closure and total length of surgery, estimated blood loss, and peri-operative complications were collected. Patients were evaluated at 2 and 6 weeks post-operatively, and interviewed 1year following surgery by a telephone survey. Outcomes evaluated were vaginal cuff dehiscence, pain, dyspareunia and bleeding. RESULTS: The study arms did not differ with respect to estimated blood loss (50mL in each arm; p=0.34), median vaginal cuff closure time (14.5, 12 and 13min, respectively; p=0.09) or readmission (p=0.55). In the 1-year follow-up (54/90 respondents; 60%), there were no significant differences among study arms for vaginal bleeding, cuff infection or dyspareunia. Only women belonging to arm 3 reported vaginal pain (0%, 0% and 23%, respectively; p=0.01). No cases of vaginal cuff dehiscence were observed. CONCLUSIONS: The type of closure technique has no significant impact on patient outcomes. In the absence of a clear advantage of one technique over the others, the decision regarding the preferred method to close the vaginal cuff in robotic-assisted total laparoscopic hysterectomy should be based on surgeons' preference and cost effectiveness.

Vaginal cuff closure during robotic-assisted total laparoscopic hysterectomy: comparing vicryl to barbed sutures.

BACKGROUND AND OBJECTIVES: Empirical evidence is needed to assess clinical appropriateness of any new surgical device or material. Differences in surgical outcomes between Vicryl figure-of-8 and V-Loc barbed sutures for vaginal cuff closure during robotic hysterectomy were assessed. METHODS: We examined the electronic medical records of 202 patients who underwent scheduled robotic-assisted total laparoscopic hysterectomy for benign indications, without concomitant urogynecologic procedures, between January 2008 and November 2010 at the Henry Ford Health System academic medical center. Cuff closure approach was selected by the surgeon. Data on demographics, vaginal cuff suture type, body mass index (BMI), estimated blood loss (EBL), perioperative hemoglobin change, procedure duration, hospital length of stay (LOS), specimen weight, and postoperative complications were obtained. RESULTS: The average age was 46 y (SD = 8.0 y). Women with Vicryl figure-of-8 closures (n = 133) were more likely than women with V-Loc barbed suture closures (n = 69) to have had a LOS > 1 d (48/133, 36.1% vs. 12/69, 17.4%; chi square P < .006), greater EBL (median 75 vs. 50 mL, Wilcoxon Rank Sum WRS P < .001), and longer procedure durations (175 vs. 135 min, WRS P < .001). These differences persisted even after considering uterine weight, BMI, smoking status, and concomitant oophorectomy. No differences with respect to the frequency of major (2 in each closure type) or minor complications were observed (P < .36). CONCLUSIONS: There were no differences in complications between the Vicryl figure-of-8 and V-Loc barbed sutures in our sample. However, the latter had lower EBL and shorter procedure duration and LOS.

Comparison of robotic-assisted hysterectomy to other minimally invasive approaches.

OBJECTIVE: To compare surgical outcomes for robotic assisted total laparoscopic hysterectomy (RH) to other minimally invasive hysterectomy (MIH) types, including total laparoscopic hysterectomy (TLH), laparoscopic-assisted vaginal hysterectomy (LAVH), and vaginal hysterectomy (VH). METHODS: Retrospective cohort study of all patients who underwent RH or MIH for benign indications between January 2007 and May 2010 at 2 Henry Ford Health System teaching hospitals. Age, race, body mass index (BMI), procedure duration, estimated blood loss (EBL), peri-operative hemoglobin change, uterine weight, length of hospital stay (LOS), and complications were collected from electronic medical records and were compared between RH and MIH groups. RESULTS: Included in the analysis were 135 RH and 162 MIH cases (n = 34 VH, n = 82 LAVH, n = 46 TLH). There were no differences in age, race, or BMI between groups, but RH patients had significantly larger uteri (P = .007; RH, 13.5%>500g; MIH 4.0%>500g). MIH patients had significantly greater EBL (P < .001) and drop in hemoglobin (P = .02) than RH patients with a 150 mL difference in median EBL (200 mL versus 50 mL) between groups. RH had longer procedure durations than MIH (P = .0002) overall, but not compared to the TLH subgroup. RH patients had a shorter LOS than MIH patients had (P = .02) who had a longer LOS for LAVH patients. Although readmission and major complication rates were similar in both groups, minor adverse events occurred more frequently in the MIH group (21.6%) than the RH group (8.9%) (P = .003). CONCLUSION: RH has comparable surgical outcomes, and possibly decreased blood loss, shorter length of stay, and fewer minor complications than other methods of MIH.

Laparoscopic management of pregnancy in a patient with uterus didelphys, obstructed hemivagina, and ipsilateral renal agenesis.

Pregnancy in a rudimentary uterine horn is a rare and potentially lethal condition. The highest risk of rupture is reported to be during the late first and second trimester. The risk of rupture correlates with the thickness of the myometrium surrounding the fetal pole. In 2005, a 20-year-old woman was incompletely diagnosed by imaging studies and laparoscopy to have an absent right kidney, a bicornate uterus with a right rudimentary uterine horn and a single cervix, a transverse vaginal septum with hematocolpos, and endometriosis caused by reflux menstruation. The transverse vaginal septum was excised, and the surgeon observed a single cervix. Oral contraceptives were prescribed as complementary treatment for the endometriosis and associated dysmenorrhea. In 2009, magnetic resonance imaging confirmed resolution of hematocolpos and revealed a right cervix connected to the right horn of a uterus didelphys and covered by a partial longitudinal vaginal septum. The patient had a contraception failure and presented in 2010 at 9(6/7) weeks' gestation. By ultrasonography and subsequent magnetic resonance imaging, the pregnancy was in the right uterus and the corpus luteum was on the left ovary. The myometrium was thinned to 2 to 3 mm atop the gestational sac. Using the Harmonic ACE, laparoscopic excision of the right fallopian tube and a supracervical right hysterectomy with an intact pregnancy was performed. This case supports the Acién hypothesis that the vagina forms from both Müllerian and Wolffian duct elements, and it illustrates the risk for uterine rupture when pregnancy forms in a rudimentary structure; presumed transperitoneal migration of an ovum that was captured by the opposite fallopian tube; and surgical management of the in situ pregnancy by laparoscopic supracervical excision of the rudimentary uterine body.

Effect of body mass index on robotic-assisted total laparoscopic hysterectomy.

STUDY OBJECTIVE: To estimate the impact of body mass index (BMI) on the surgical outcomes of patients undergoing robotic-assisted total laparoscopic hysterectomy. DESIGN: Retrospective cohort study. SETTING: Henry Ford Health System academic medical center (Henry Ford and Henry Ford West Bloomfield Hospitals) PATIENTS: A total of 135 patients who underwent scheduled robotic-assisted total laparoscopic hysterectomy for benign indications, without concomitant urogynecologic procedures between January 2008 and June 2010. INTERVENTIONS: Patients underwent robotic-assisted total laparoscopic hysterectomy as the intention to treat. Two cases were converted to laparotomy. MEASUREMENTS & MAIN RESULTS: Electronic medical records of all patients that underwent robotic-assisted total laparoscopic hysterectomy at Henry Ford Health System were reviewed. Data on demographics, BMI (kg/m(2)), estimated blood loss, perioperative hemoglobin change, procedure duration, hospital length of stay, specimen weight, pathology, and postoperative complications were obtained. The women's median age was 45 years (range 30-68), 61.5% were black, and BMI ranged from 14.8-56.2 kg/m2; 23.4% of women were normal weight or less (BMI <25, n = 31), 52.7% of women were obese (BMI >30, n = 70) and 36 of these patients (27.1%) were morbidly obese (BMI ≥35). BMI did not correlate with procedure duration (Spearman r = .12, p = .16), length of stay (Spearman r = .10, p = .24), or estimated blood loss (Spearman r = .12, p =.18). Our analysis did not identify any meaningful associations between BMI and absolute change in hemoglobin. In addition BMI was not associated with an increase in major or minor complications. CONCLUSION: BMI is not associated with blood loss, duration of surgery, length of stay, or complication rates in patients undergoing robotic-assisted total laparoscopic hysterectomy. Robotic assistance may help surgeons overcome adverse outcomes sometimes found in obese patients.