Vaginal Cuff Closure: How to Minimize Dehiscence and Prolapse
MODERATOR Stuart R. Hart, MD
FACULTY Kate O’Hanlan, MD & Michele Vignali, MD
Sponsored by AAGL Advancing Minimally Invasive Gynecology Worldwide
Professional Education Information
Target Audience This educational activity is developed to meet the needs of residents, fellows and new minimally invasive specialists in the field of gynecology.
Accreditation AAGL is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.
The AAGL designates this live activity for a maximum of 1.75 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
DISCLOSURE OF RELEVANT FINANCIAL RELATIONSHIPS As a provider accredited by the Accreditation Council for Continuing Medical Education, AAGL must ensure balance, independence, and objectivity in all CME activities to promote improvements in health care and not proprietary interests of a commercial interest. The provider controls all decisions related to identification of CME needs, determination of educational objectives, selection and presentation of content, selection of all persons and organizations that will be in a position to control the content, selection of educational methods, and evaluation of the activity. Course chairs, planning committee members, presenters, authors, moderators, panel members, and others in a position to control the content of this activity are required to disclose relevant financial relationships with commercial interests related to the subject matter of this educational activity. Learners are able to assess the potential for commercial bias in information when complete disclosure, resolution of conflicts of interest, and acknowledgment of commercial support are provided prior to the activity. Informed learners are the final safeguards in assuring that a CME activity is independent from commercial support. We believe this mechanism contributes to the transparency and accountability of CME.
Table of Contents
Course Description ...... 1
Disclosure ...... 2
Vaginal Cuff Closure: How to Minimize Dehiscence and Prolapse K. O’Hanlan ...... 3
Vaginal Cuff Closure: How to Minimize Dehiscence and Prolapse M. Vignali ...... 9
Cultural and Linguistics Competency ...... 20
Surgical Tutorial 4 Vaginal Cuff Closure: How to Minimize Dehiscence and Prolapse
Moderator: Stuart R. Hart
Kate O’Hanlan & Michele Vignali
This course provides rich video and didactic learning to overcome one of the strongest deterrents to TLH: confident laparoscopic closure of the vagina. The three key elements of closure that effectively prevent prolapse, as well as hemorrhagic and dehiscence complications, will be reviewed and demonstrated in detailed videos. Even if suture closure of the vagina is already possible, this tutorial can advance your skills to make it consistently reliable and effective.
Learning Objectives: At the conclusion of this course, the participant will be able to: 1) Differentiate the reasons why some patients have hemorrhagic, prolapse and dehiscence complications; 2) design a system for learning suture skills outside of the operating rooms; and 3) construct a plan for laparoscopic closure of the vaginal apex when closure cannot be accomplished any other way; 4) differentiate those cases who deserve a prophylactic vaginal vault suspension.
1 PLANNER DISCLOSURE The following members of AAGL have been involved in the educational planning of this workshop and have no conflict of interest to disclose (in alphabetical order by last name). Art Arellano, Professional Education Manager, AAGL* Viviane F. Connor Consultant: Conceptus Incorporated Kimberly A. Kho* Frank D. Loffer, Executive Vice President/Medical Director, AAGL* Linda Michels, Executive Director, AAGL* M. Jonathan Solnik* Johnny Yi*
SCIENTIFIC PROGRAM COMMITTEE Ceana H. Nezhat Consultant: Ethicon Endo-Surgery, Lumenis, Karl Storz Other: Medical Advisor: Plasma Surgical Other: Scientific Advisory Board: SurgiQuest Arnold P. Advincula Consultant: Blue Endo, CooperSurgical, Covidien, Intuitive Surgical, SurgiQuest Other: Royalties: CooperSurgical Linda D. Bradley* Victor Gomel* Keith B. Isaacson* Grace M. Janik Grants/Research Support: Hologic Consultant: Karl Storz C.Y. Liu* Javier F. Magrina* Andrew I. Sokol*
FACULTY DISCLOSURE The following have agreed to provide verbal disclosure of their relationships prior to their presentations. They have also agreed to support their presentations and clinical recommendations with the “best available evidence” from medical literature (in alphabetical order by last name). Stuart R. Hart Consultant: Boston Scientific, Covidien, Stryker Endoscopy Speakers Bureau: Boston Scientific, Covidien, Stryker Endoscopy Kate O’Hanlan Consultant: Cardinal Health, Medical Products and Services, CONMED Corporation, Covidien Speakers Bureau: Baxter, CONMED Corporation, Covidien Other: Medical Director: Laparoscopic Institute for Gynecologic Oncology Michele Vignali*
Asterisk (*) denotes no financial relationships to disclose. Vaginal Cuff Closure: How to Minimize Dehiscence and Prolapse • Consultant: Cardinal Health Medical Products and Services, CONMED Corporation, Covidien, Kate O’Hanlan, MD • Speakers Bureau: Baxter, CONMED Corporation, Covidien • Other: Medical Director: Laparoscopic Institute for Gynecologic Oncology Laparoscopic Institute for Gynecologic Oncology
Objectives Management of Dehiscence: Sx, when to suture, observe etc • Differentiate reasons risk factors for prolapse or dehiscence complications; • Risk factors: • Design a system for learning suture skills outside of the • Sx, when to suture, observe etc operating rooms; • Construct a plan for laparoscopic closure of the vaginal apex when closure cannot be accomplished any other way; • Differentiate those cases who deserve a prophylactic vaginal vault suspension.
Avoiding vaginal dehiscence Vaginal cuff dehiscence • Vaginal .18% (p<0.05) • 1-2% in most studies, 77days post-op. • Malignancy, diabetes, cigarette smoking, pelvic • Laparoscopic .64% adhesions, radical hyst greater risk. • Robotic 1.64% (p<0.05) • Suture cuff with same standards as open: –Stitch every 5-8mm, 5mm deep. Same as diameter. • Transvaginal suturing can reduce risk after TLH. • Two-layer closure better than single. » Hur, et al. (2007). "Incidence and patient characteristics of vaginal cuff • Monopolar no difference. dehiscence after different modes of hysterectomies." JMIG 14(3): 311-317. Uccella et al O&G Sept 2012 » Nick, et al. (2011). "Rate of vaginal cuff separation following laparoscopic or robotic hysterectomy." Gyn Onc 120(1): 47-51. » Jeung et al. (2010). "A prospective comparison of vaginal stump suturing techniques during total laparoscopic hysterectomy." Archives of • My take: Since you cannot close every patient gynecology and obstetrics 282(6): 631-638. transvaginally, learn to suture laparoscopically.
3 Vaginal dehiscence
• Related to placement of sutures during the vaginal closure. • Scope or Robot: place the same size stitches in the apex as for open. • Consider closing the bladder over the apex: – May prevent adhesions of small bowel to vaginal raw edges of apex. – May prevent though-and-through dehiscence from penetration.
Managing dehiscence • See immediately if SSx: – Copious serous or sanguinous discharge. – Pain after intercourse. • Suture vagina from below, or by scope if: No support to – see small bowel. Prep before put back. cuff from apex – Opening greater than 2cm. – Double ‘cidal antibiotics. – Pelvic rest another 6 weeks, then recheck. – Advise shallow. Consider foam donut for spouse. » Nick, A. M., J. Lange, et al. (2011). "Rate of vaginal cuff separation following laparoscopic or robotic hysterectomy." Gynecologic oncology 120(1): 47-51.
Good support to cuff from apex.
4 Cystocele repair can be accomplished laparoscopically
“Three to five mattress sutures are inserted through the fascia which becomes duplicated and shortened, thus strengthening the anterior vaginal wal and holding the bladder.”
Cysto/enterocele repair from above by Soferman et al International Surgery, 1974
“Suture is passed through the vagina and brought through both sacrouterine ligaments without tying. Another suture is passed through the cardinal ligaments...tying these approximates the ligaments to each other and to the vaginal wall.”
Cysto/enterocele repair from above by Soferman et al International Surgery, 1974 • Quadri et al, Transabdominal repair of cystocele by wedge colpectomy during combined abdominal-vaginal surgery. Int Urogynecol J Pelvic Floor Dysfunct. 1997
Support procedures that even a Gyn Oncologist can do……..
Digesu et al. A case of laparoscopic uterosacral ligaments plication: a new conservative approach to uterine prolapse. Eur J Obstet Gynecol Reprod Biol. 2004
5 Laparoscopic closure of the vaginal apex: when closure cannot be accomplished any other way
Resect enterocele
Ethibond 0 Suture
Obstacles to learning in the OR • Seniors won’t give away critical parts. – Newer surgeons take longer. Costs time. Design a system – Newer surgeons make more mistakes. for learning suture skills • Newest technology and techniques hard to outside of the operating rooms; learn on live patient in front of all. pelvic trainers, • Surgeons who trained on simulators had greater accuracy in vivo, made fewer holiotomy challenge. mistakes. • High tech “virtual reality” no better. Scott et al, JACS, 2000 Banks et al AJOG, 2007 Kundhal et al, Surg Endosc, 2009
6 JMIG, 2011 Intracorporeal suturing Novice incorporates all basic laparoscopic skills and is a prerequisite because it is needed to manage possible complications or in case of instrument failure.
Expert Residents with little or no previous laparoscopic experience are able to perform the task competently after a short training course.
Laparoscopic skills • Performance on trainers significantly improves competency in the OR. – Practice on trainers improves OR competency. – At least 5-7 suture repetitions needed til efficacy plateau. – At least 25 knots til efficacy plateau. • Self assessment and formal evaluation of skills possible on trainer.
Goff BA, Obstet & Gynecol, 2008. Kanumuri et al, JSLS, 2008.
The Holiotomy™ Challenges
• Complete three holiotomies™: – Two with three “figure of N” stitches, each piercing the dots. – Close one running. • Place your holiotomy™ repairs on the board at registration. • Get certificate!
www.LIGOcourses.com 292 9
7 www.LIGOcourses.com 313 1
Comfort performing procedures You get a way cool cap!!!! before and after a surgical course
P<.001 P<.001 NS P<.001
P<.001
1= very comfortable 2=somewhat 3‐neutral 4‐uncomfortable 5=very uncomfortable www.LIGOcourses.com 333 3
8 Surgical Tutorial 4 Vaginal Cuff Closure: How to Minimize Dehiscence I have no financial relationships to disclose. and Prolapse Moderator: Stuart R. Hart
Professor Michele VIGNALI, MD, PhD Associate Professor of Obstetrics and Gynecology Director of Endoscopic Gynecologic Surgery Unit
Department of Biomedic Science for the Health Macedonio Melloni Hospital University of Milan, Italy
At the conclusion of this activitiy, participants will be better able to: Differentiate the reasons why some patients have vaginal vault prolapse and dehiscence complications Part 1 – VAULT DEHISCENCE Identify those patients at risk who deserve a prophylactic vaginal vault suspension
Construct a plan for laparoscopic closure of the vaginal Incidence, Reasons and Risk Factors apex using different sutures Summarize the current literature regarding the diagnosis and management of vaginal vault dehiscence and prolapse.
[email protected] [email protected]
Can Med Assoc J. 1952 January; 66(1): 68
The first abdominal hysterectomy was performed by Charles Clay in Manchester, England in 1843, but only 1853 that Ellis Burnham from Lowell, Massachusetts achieved the first successful abdominal hysterectomy Vaginal hysterectomy dates back to ancient times. The procedure was performed by Soranus of Ephesus 120 years A.C. but the first planned, successful vaginal hysterectomy was performed in 1813 by Conrad Langenbeck, although he did not report the case until 1817
9 [email protected] [email protected]
[email protected] [email protected]
[email protected] [email protected]
Evisceration occurs in up to 70% of vaginal cuff dehiscence cases
10 [email protected] [email protected]
Obstet Gynecol 2004;103:572-576
The Mayo Clinic experience from 1970 through 2001 7039 total and 247 supracervical yielded a 0.032% incidence of vaginal evisceration after a pelvic operation The cumulative incidence of vaginal dehiscence by mode of hysterectomy
Aust N Z J Obstet Gynaecol. was 4.93% among TLH, 0.29% among VH, and 2007 Dec;47(6):516-9 0.12% among TAH Rupture of the vaginal vault with subsequent The relative risks of a vaginal cuff dehiscence extrusion of the peritoneal contents appears to be a rare occurrence, complicating less than one in 1000 complication after TLH compared with TVH and hysterectomies. However, it seems that this risk is TAH were 21.0 and 53.2, respectively. Both were significantly higher in TLH. statistically significant. JMIG 2007;14:311–317
[email protected] [email protected]
JMIG 2009;16:313–317 JMIG 2009;16:313–317
The incidence of vault dehiscence was higher after TLH The time interval between hysterectomy (1.14%) than after AH (0.10%, p.0001) and after VH and occurrence of vault dehiscence in the (0.14%, p.001) laparoscopic group (8.4±1.2 weeks) was 10 632 hysterectomies significantly shorter than in the abdominal hysterectomy (112.7±75.1 weeks, p<.01) and in vaginal hysterectomy (136.5±32.2 weeks, p<0.0001) groups, respectively
[email protected] [email protected]
Eur J Obstet Gynecol Reprod Biol 2011;158(2):308-313
34/8635 (0.39%) experienced vaginal evisceration. The laparoscopic route was associated with a significantly higher incidence of dehiscence (0.80%)
Obstet Gynecol 2012;120:516-523
TLH was associated with a higher incidence of cuff separations,comparedwithAH(0.64% compared with 0.21%, P.003) and VH (0.64% compared with 0.13%, P<.001).
11 [email protected] [email protected]
Vaginal cuff dehiscence can occur at any time after a pelvic surgical procedure and has been reported as early as 3 days and as late as 30 years postoperatively
In retrospective cohort studies and larger case series the mean time to cuff dehiscence varied between 6.1- weeks up to 1.6 years (range 2 weeks to 5.4 years)
[email protected] [email protected]
Obstet Gynecol Surv 2002;57(7):462-467
59 cases from 1900 to 2001 These symptoms Protruding mass in the vagina typically occur Abdominal pain after: sexual activity Vaginal bleeding or discharge vaginal instru- mentation Am J Obstet Gynecol 2012;206(4):284–288 increased intraabdominal pressure Pelvic or abdominal pain (58-100%) Vaginal bleeding or watery discharge (33%- 90%) Patients with evisceration of bowel into the vagina often describe feeling a mass or pressure
[email protected] [email protected]
WHY?-Risk Factors
Route of hysterectomy Increased age and JMIG 2007;14:311–317 hypoestrogenism 7039 total and 247 supracervical Increase in intra-abdominal pressure In addition, there are Swift return to everyday activities theoretical risks of and sexual activity incomplete full Obstet Gynecol 2011;118:794–801 thickness cuff closure VaginalWay of cuffvaginal infection/hematoma cuff closure or shallow suture The 10- year cumulative incidence of dehiscence The type and size of the suture placement less than after all modes of hysterectomy was 0.24% and material used to close the vault 1cmfromthevaginal 1.35% among total laparoscopic hysterectomies Tissue damage in the vaginal cuff cuff edges because of (Total abdominal hysterectomy was 0.38%, and due to electrocautery LPS magnification total vaginal hysterectomy was 0.11%).
12 [email protected] [email protected]
Am J Obstet Gynecol 2011;205:119.e1-12 Literature search 57 articles, 13.030 endoscopic hysterectomies + 635 TLH JSLS 2012;16:530–536
3/654 robotic-assisted TLH 0.4%
Obstet Gynecol 2009;114(2 Pt 1):369–371
TRANSVAGINAL colporraphy after TLH is “..Robotic instruments do not allow exerting associated with a 3- and 9-fold reduction in enough tension on the knots when cuff risk of vaginal cuff dehiscence compared closure is performed” with LPS and robotic suture, respectively “It has been speculated that because of The pooled incidence of vaginal dehiscence was LOWER for TV cuff closure (0.18%) electrosurgical energy at the time of colpotomy may account than for both LPS (0.64%) and robotic (1.64%) colporraphy. LPS cuff closure was for the observed increased risk of vaginal cuff dehiscence..” associated with a lower risk of dehiscence than robotic closure (OR=0.38)
[email protected] [email protected]
Gynecologic Oncology 120 (2011) 47–51 0.032%
362 underwent simple hysterectomy Obstet Gynecol 2004;103:572-576 (249 laparoscopic, 113 robotic) Mayo Clinic medical 57 underwent radical hysterectomy records (1970 –2001) (36 laparoscopic, 19 robotic). 7/417 (1.7%) developed a cuff complication Women with a history of 3/285 (1.1%) patients in the LPS group suffered a abdominal hysterectomy vaginal cuff evisceration (n=2) or separation (n=1) tended to rupture through 4/132 (3.0%) had a vaginal evisceration (n=1) or the vaginal cuff.. separation (n=3) No difference based on surgical approach (p=0.22) ..and those with a history of Vaginal cuff complications were 9.46-fold higher among vaginal hysterectomy patients who had a radical hysterectomy. Changes in the tended to rupture through a vaginal support and/or foreshortening of the vagina may play posterior enterocele a role in the development of vaginal cuff complications
[email protected] [email protected]
Obstet Gynecol 2012;120:516–23 JSLS 2013;17:414–417
Patients who underwent vaginal 463 TLH and 147 LAVH performed closure with LPS knots had a entirely by use of electrosurgery higher rate of cuff dehiscence There were no vaginal cuff dehiscences in the LAVH than patients who had suture with group compared with 17 vaginal cuff dehiscences (4%) in transvaginal knots (0.86% vs. 0.24%, P.028), When vaginal suture the TLH group (P=.02). Because all LAVHs were was performed transvaginally, no performed entirely by electrosurgery including colpotomy statistical difference in vaginal cuff and there were no vaginal cuff dehiscences in the LAVH dehiscence rate was observed group, it does not appear that ELECTROSURGERY plays a compared with both AH and VH major role in vaginal cuff dehiscence Use of at the time of colpotomy and Vaginal cuff closure suture was changed to 2-0 glyco- reducing the power of monopolar energy from 60 watts to 50 lide/lactide copolymer (delayed absorbable) and tissue watts when colpotomy was performed at the end of TLH didn’t suture placement was increased to at least 1.5 cm alter the rate of cuff separations.
13 [email protected] [email protected]
387 women 149 0-barbed suture Incidence of vaginal cuff (double layer) dehiscence 4.2% JMIG 2011;18:218–223 9 0-monofilament suture Aust N Z J Obstet Gynaecol. 2007 Dec;47(6):516-9 229 braided sutures comprised of polyglycolic acid (Vicryl) or Endo Stitch
Careful, full-thickness closure of the vaginal vault with a delayed absorbable suture is recommen- ded at TLH
It may be prudent to advise NO CASES of dehiscence among those who had closure women undergoing TLH to delay with bidirectional barbed suture (p=.008). Post OP bleeding, first intercourse postoperatively presence of granulation tissue, and cellulitis ALL occurred more frequently in patients without barbed suture closure.
[email protected] [email protected]
Eur J Obstet Gynecol Reprod Biol 2011;158(2):308-313 Gynecol Surg 2012;9:393–400
34/8635 (0.39%) experienced vaginal 8635 pts evisceration [8 (0.25%) AH, 4 (0.15%) 3194 (37%) AH VH, 22 (0.80%) TLH (p< 0.01)]. 2696 (31.2%) VH 2745 (31.8%) TLH The laparoscopic route was associated with a significantly higher incidence of dehiscence (0.80%) NO superiority of one of the suturing methods over the other was found. Regardless of the suturing method, the surgical No differences were found between the 6027 approach towards the colpotomy in TLH in comparison to the patients (69.8%) who had closure of the vaginal abdominal approach, with additional (extensive) application of cuff and the 2608 (30.2%) who had an coagulation, has inherent its specific side effects. unclosed cuff closure technique.
Vaginal Cuff Dehiscence is a rare complication of hysterectomy, but more frequently after TLH (0.4-0.8%) It is associated to vaginal evisceration in 70% of cases It can occur at any time but the mean time varied between 6.1- weeks up to 1.6 years after hysterectomy Part 2 – VAULT PROLAPSE TRANSVAGINAL colporraphy after TLH is associated with a 3- and 9-fold reduction in risk of vaginal cuff dehiscence compared with LPS and robotic suture Incidence, Reasons and Risk Factors Main symptoms are: protruding mass in the vagina, abdominal pain and vaginal bleeding or discharge
Discourage swift return to sexual activities
Prefer delayed absorbable sutures and big bites of tissue
14 [email protected] [email protected]
Int Urogynecol J 2008;19:1623–1629 Pelvic organ prolapse is a common problem, affecting 30% to 50% of women
The overall incidence of prolapse after hysterectomy was reported to be 3.6 per 1,000 The incidence was 1.1 women-years (Mant J et al, 1997). per 1,000 women-years if The incidence of vault initial hysterectomy was prolapse after performed for prolapse, compared with 0.2 per hysterec-tomy varies 1,000 women-years if the between 0.2% to 43%, hysterectomy was but realistically performed for other between 1.8 and reasons (hazard RR 5.8). 11.6%
[email protected] [email protected]
Int Urogynecol J 2008;19:1623–1629 The upper third of the vagina Am J Obstet Gynecol. 1992 Jun;166(6 Pt 1):1717-24 (level I) is suspended from the pelvic walls by vertical fibers of the paracolpium, 6,214 hysterectomies 4,304 (69.3%) abdominal hysterectomy which is a continuation of the 1,749 (28.1%) vaginal hysterectomy cardinal ligament 65 (1%) LAVH 96 (1.5%) TLH In the middle third of the vagina (level II) the para- 32/6214 (0.5%) were reope- colpium attaches the vagina rated for subsequent vault laterally to the arcus prolapse. tendineus and fascia of the The mean interval between levator ani muscles. the two operations was 6.2 Dissection reveals that the The vagina's lower third yrs (range 0.2 to 21.8 yrs). paracolpium's vertical fibers in fuses with the perineal membrane, levator ani The incidence of vault prolapse requiring surgical correction level I prevented prolapse of the vaginal apex and vaginal eversion muscles, and perineal body after hysterectomy was 0.36 per 1,000 women-years (level III).
[email protected] [email protected]
Curr Opin Obstet Gynecol 2010;22:420-424
Predisposing factors (growth and development, genetic factors, connective tissue weakness, joint mobility)
Inciting factors (childbirth, pelvic surgery)
Intervening factors (age- related changes, obesity, History of POP at the time of constipation, co-morbidities, hysterectomy has consistently been shown as a heavy occupationalwork,and strong and independent vigorous physical activity) predictor of POP recurrence
15 [email protected] [email protected]
Curr Opin Obstet Gynecol 2010;22:420-424 Apical support defects
The role of AGE is still controversial: To ensure durable apical
Advanced age is a indipendent factor support regardless of the anchoring site for the Younger patients have a higher risk of vaginal vault suspension, prolapse recurrence as a consequence of a major expectancy of lasting of the the surgeon should reconstructive procedures establish continuity of the anterior and OBESE women are considered a high-risk group for development of POP posterior vaginal fascia at the vaginal apex. BMI is a significant and indipendent risk factor
[email protected] [email protected]
Curr Opin Obstet Gynecol 2008;20:484–488 In 1927, Miller described the attachment of the USL to the vaginal vault for support
In 1957, McCall described passing a suture from one side of the vaginal cuff and USL through the peritoneum The USL is considered a major to the other side,effectively closing the cul-de-sac source of overall support for the uterus In 2000, Shull et al described a “high” uterosacral ligament suspension in which 3 nonabsorbable sutures The exact attachment of the USL are “placed in the ligament on either side..to secure the from the ischial spine has been the superior aspect of the transverse portion of pubocervical subject of controversy as some and rectovaginal fascia” to the vaginal cuff believe it connects to the sacrum, The purpose of the USL vault suspension is to whereas others postulate there are attach a strong segment of the USL to the attachments to the sacrospinous rectovaginal and anterior pubocervical fascia ligament and coccygeous muscle.
[email protected] [email protected]
Obstet Gynecol 2004;103:447–51 Curr Opin Obstet Gynecol 2008;20:484–488
At the cervix,itiscomposedofclosely packed bundles of smooth muscle, They extended over a small and medium-sized blood vessels mean craniocaudal and small nerve bundles distance of 218 mm In the intermediate third portion of (range 10–50) the USL, it is composed of connective tissue with a few scattered small Although uterosacral fibers, blood vessels and nerves ligament morphology In the sacral portion,itismade was similar bilaterally, its entirely of loose strands of connective tissue and sparse fat, vessels, nerves craniocaudal extent was greater on the right side and lymphatics
16 [email protected] [email protected]
Obstet Gynecol 2004;103:447–51 US Ligament Suspension Surgical Technique
Three regions of origin: cervix The ureters are identified alone (33%), cervix and vagina throughout their course below the in the same section (63%), and pelvic brim and a relaxing incision vagina alone (4%). is placed below the level of the Of 259 uterosacral insertion points, ureter within the peritoneum. 82% overlaid the sacrospinous The ischial spines identified by ligament/coccygeus muscle placing tension on the cuff in the complex, 7% the sacrum, and 11% contralateral direction the piriformis muscle, the sciatic foramen, or the ischial spine The USLs are attached to the Thus, if one does not artificially reattach the vaginal cuff to posterior surface of the vaginal the US ligaments, more than 2/3 of patients would retain vault some connections of the vaginal apex to the US ligaments
[email protected] [email protected]
Curr Opin Obstet Gynecol 2008;20:484–488 Int Urogynecol J (2012) 23:223–227
Permanent (polyester) and delayed absorbable (polydioxanone) During surgery, the ureters may be kinked, tied or injured sutures were compared
Wieslander et al. found that while placing sutures 105 pts: perma- vaginally within the USL in cadavers, the distal suture was nent suture approximately 14 mm from the ureter and 13 mm from 141 pts: delayed absorbable suture the rectal lumen
The rate of obstruction with high USL suspension was found to be 5.1%.
USL sutures can be placed close to the sacral foramina The use of permanent sutures for USLS of the vaginal and injury the sacral plexus (S1-S4) apex was associated with a lower failure rate than delayed absorbable sutures in the short-term
[email protected] [email protected]
Curr Opin Obstet Gynecol 2008;20:484–488
Success rates vary from 82 to 96%
Curr Opin Obstet Gynecol 2008;20:496–500
Diwan et al. compared the outcomes of 25 LPS USLS to 25 vaginal USLS among age-matched controls. Estimated blood loss and duration of hospitalization were significantly less in the LPS group There were 3 recurrences in the vaginal group diagnosed at 17, 34, and 58 weeks but NONE in the laparoscopic group.
17 [email protected] [email protected]
Surg Technol Int. 2012 Nov 18;XXII Surg Technol Int. 2012 Nov 18;XXII
A) to incorporate the suture through the B) to incorporate the USL stitch through right USL then through the anterior and the anterior and posterior endopelvic posterior endopelvic fascia across the fascia on each respective side without vaginal vault, and finish by incorporating crossing the midline. The initial stitch is the left USL. placed through the mid-portion of the The initial stitch is placed through the USL and then through the anterior and mid-portion of the USLs on stretch, and posterior endopelvic fascia on the lateral a second and third suture are placed aspect of the vaginal cuff on each sequentially more proximal through the respective side. The next stitch is placed USLs, with each stitch incorporating more proximal through the USL and then both anterior and posterior endopelvic more medially through the anterior and fascia. The suture is tied using posterior endopelvic fasciaon each extracorporeal knot tying technique respective side, until the midline vaginal cuff is incorporated.
Am J Obstet Gynecol. 2010 Feb;202(2):124-34 1966-2007 McCall Culdoplasty McCall ML. Posterior culdeplasty; surgical correction of enterocele during vaginal hysterectomy; a preliminary report. Obstet Gynecol. 1957 Dec;10(6):595-602
In the anterior, apical, and posterior compartments, the pooled rates for a successful outcome were 81.2%, 98.3%, Traction of the cul-de- and 87.4% sac and posterior vaginal epithelium and Uterosacral ligament suspension is a highly effective procedure placement of three for the restoration of apical vaginal support. A successful rows of sutures across the cul-de-sac outcome (stage 0 or 1) is observed in 98% of women from one uterosacral ligament to the other
[email protected] [email protected]
Obstet Gynecol Int. 2009;275621 J Minim Inv Gynecol 2007;14:397-398
..A permanent 3-0 suture was placed through the USL and the peritoneum of the cul-de-sac. A Am J Obstet Gynecol 1999;180(4):859-865 second suture was placed in the same way 1 cm above and parallel to the previous stitch. Sutures were kept to be tied after placement of the external suture. The external adsorbable 2-0 McCall suture was then placed through the posterior vaginal wall and peritoneum. This suture was then placed through the uterosacral ligaments and then brought back out through the vagina
Vaginal vault prolapse after hysterectomy varies Miller N. A new method of correcting complete inversion of the vagina: Crigler B, Zakaria M, Hart S. Total Laparoscopic Hysterectomy with between 1.8 and 11.6% with or without complete prolapse; report of two cases. Surg Gynecol Laparoscopic Uterosacral Ligament Suspension for the Treatment of Obstet 1927;44:550–555 Apical PelvicOrgan Prolapse. Surg Technol Int. 2012 Nov 18;XXII An alteration in the level of the fibers of the paracolpium McCall ML. Posterior culdeplasty; surgical correction of enterocele Margulies RU, Rogers MA, Morgan DM. Outcomes of transvaginal during vaginal hysterectomy;a preliminary uterosacral ligament suspension: systematic review and (level I) which suspend the upper third of the vagina report.ObstetGynecol1957;10:595–602 metaanalysis. Am J Obstet Gynecol. 2010 Feb;202(2):124-34 Shull BL, Bachofen C, Coates KW, Kuehl TJ. A transvaginal approach Chung CP, Miskimins R, Kuehl TJ, Yandell PM, Shull BL. Permanent could modify vault suspension to repair of apical and other associated sites of pelvic organ prolapse suture used in uterosacral ligament suspension offers better with uterosacral ligaments. Am J Obstet Gynecol 2000;183:1365-74 anatomical support than delayed absorbable suture. Int Urogynecol J. 2012 Feb;23(2):223-7 Risk factors: Genetic or structural factors, previous Wieslander CK, Roshanravan SM, Wai CY, et al. Uterosacral ligament suspension sutures: anatomic relationships in unembalmed female Umek WH, Morgan DM, Ashton-Miller JA, DeLancey JOL. cadavers. Am J Obstet Gynecol 2007; 197:672e1–672e6 Quantitative analysis of uterosacral ligament origin and insertion deliveries or pelvic surgery, co-morbidities, age, BMI points by magnetic resonance imaging. Diwan A, Rardin CR, Strohsnitter WC, et al. Laparoscopic uterosacral Obstet Gynecol. 2004 Mar;103(3):447-51 and history of prolapse at time of surgery ligament uterine suspension compared with vaginal hysterectomy with vaginal vault suspension for uterovaginal prolapse. Int Urogynecol J Cruikshank SH, Kovac SR. Randomized comparison of three surgical Pelvic Floor Dysfunct 2006; 17:79–83. methods used at the time of vaginal hysterectomy to prevent USLs suspension is highly effective procedure for the posterior enterocele. Am J Obstet Gynecol. 1999 Apr;180(4):859-65 Ricci P, Solà V, Pardo J, Guiloff E. Laparoscopic McCall culdoplasty. J restoration of apical vaginal support with a success Minim Invasive Gynecol. 2007 Jul-Aug;14(4):397-8 Salvatore S, Siesto G, Serati M. Risk factors for recurrence of genital prolapse. Curr Opin Obstet Gynecol. 2010 Oct;22(5):420-4 Diwadkar GB, Chen CC, Paraiso MF. An update on the laparoscopic rates varying from 82 to 96% approach to urogynecology and pelvic reconstructive procedures. Rardin CR, Erekson EA, Sung VW, Ward RM, Myers DL. Uterosacral Curr Opin Obstet Gynecol. 2008 Oct;20(5):496-500 colpopexy at the time of vaginal hysterectomy: comparison of laparoscopic and vaginal approaches. J Reprod Med. 2009 The rate of ureteral obstruction with high USL suspen- Dällenbach P, Kaelin-Gambirasio I, Jacob S, Dubuisson JB, Boulvain May;54(5):273-80 M. Incidence rate and risk factors for vaginal vault prolapse repair sion was found to be 5.1% after hysterectomy. Int Urogynecol J Pelvic Floor Dysfunct. 2008 Yazdany T, Bhatia N. Uterosacral ligament vaginal vault suspension: Dec;19(12):1623-9 anatomy, outcome and surgical considerations. Curr Opin Obstet Gynecol. 2008 Oct;20(5):484-8 McCall culdoplasty can be performed laparoscopically in Wattiez A, Mashiach R, Donoso M. Laparoscopic repair of vaginal vaultprolapse. Curr Opin Obstet Gynecol. 2003 Aug;15(4):315-9 Uzoma A, Farag KA. Vaginal vault prolapse. Obstet Gynecol order to correct enterocele and prevent vaginal prolapse Int.2009;2009:275621
DeLancey JO. Anatomic aspects of vaginal eversion after Ceccaroni M, Berretta R, Malzoni M, Scioscia M, Roviglione G, Spagnolo hysterectomy. Am J Obstet Gynecol. 1992 Jun;166(6 Pt 1):1717-24 E, Rolla M, Farina A, Malzoni C, De Iaco P, Minelli L, Bovicelli L. Vaginal cuff dehiscence after hysterectomy: a multicenter retrospective study. Eur Croak AJ, Gebhart JB, Klingele CJ, Schroeder G, Lee RA, Podratz J Obstet Gynecol Reprod Biol. 2011 Oct;158(2):308-13 KC. Characteristics of patients with vaginal rupture and evisceration. Obstet Gynecol. 2004 Mar;103(3):572-6 Robinson BL, Liao JB, Adams SF, Randall TC. Vaginal cuff dehiscence after robotic total laparoscopic hysterectomy. Obstet Gynecol. 2009 Siedhoff MT, Yunker AC, Steege JF. Decreased incidence of vaginal Aug;114(2 Pt 1):369-71 cuffdehiscence after laparoscopic closure with bidirectional barbed suture. J Minim Invasive Gynecol. 2011 Mar-Apr;18(2):218-23 Blikkendaal MD, Twijnstra AR, Pacquee SC, Rhemrev JP, Smeets MJ, de Kroon CD, Jansen FW. Vaginal cuff dehiscence in laparo-scopic Fanning J, Kesterson J, Davies M, Green J, Penezic L, Vargas R, hysterectomy: influence of various suturing methods of the vaginal vault. Harkins G. Effects of electrosurgery and vaginal closure technique on Gynecol Surg. 2012 Nov;9(4):393-400 postoperative vaginal cuff dehiscence. JSLS. 2013;17(3):414-7 Kashani S, Gallo T, Sargent A, Elsahwi K, Silasi DA, Azodi M. Vaginal Baskett TF. Hysterectomy: evolution and trends. Best Pract Res Clin cuffdehiscence in robotic-assisted total hysterectomy. JSLS. 2012 Oct- Obstet Gynaecol. 2005 Jun;19(3):295-305 Dec;16(4):530-6 Hur HC, Guido RS, Mansuria SM, Hacker MR, Sanfilippo JS, Lee TT. Cronin B, Sung VW, Matteson KA. Vaginal cuff dehiscence: risk factors Incidence and patient characteristics of vaginal cuff dehiscence after and management. Am J Obstet Gynecol. 2012 Apr;206(4):284-8 different modes of hysterectomies. J Minim Invasive Gynecol. 2007 May-Jun;14(3):311-7 Ramirez PT, Klemer DP. Vaginal evisceration after hysterectomy: a literature review. Obstet Gynecol Surv. 2002 Jul;57(7):462-7 Hobbs FS. Spontaneous evisceration through vagina. Can Med Assoc J. 1952 Jan;66(1):68 Agdi M, Al-Ghafri W, Antolin R, Arrington J, O'Kelley K, Thomson AJ, Tulandi T. Vaginal vault dehiscence after hysterectomy. J Minim Invasive Uccella S, Ceccaroni M, Cromi A, Malzoni M, Berretta R, De Iaco P, Gynecol. 2009 May-Jun;16(3):313-7 Roviglione G, Bogani G, Minelli L, Ghezzi F. Vaginal cuff dehiscence in a series of 12,398 hysterectomies: effect of different types of Nezhat CH, Nezhat F, Seidman DS, Nezhat C. Vaginal vault evisceration colpotomy and vaginal closure. Obstet Gynecol. 2012 after total laparoscopic hysterectomy. Obstet Gynecol. 1996 May;87(5 Pt Sep;120(3):516-23 2):868-70 Nick AM, Lange J, Frumovitz M, Soliman PT, Schmeler KM, Schlumbrecht Uccella S, Ghezzi F, Mariani A, Cromi A, Bogani G, Serati M, Bolis P. MP, dos Reis R, Ramirez PT. Rate of vaginal cuff separation following Vaginal cuff closure after minimally invasive hysterectomy: our laparoscopic or robotic hysterectomy. Gynecol Oncol. 2011 Jan;120(1):47- experience and systematic review of the literature. Am J Obstet 51 Gynecol. 2011 Aug;205(2):119.e1-12 Crigler B, Zakaria M, Hart S. Total Laparoscopic Hysterectomy with Hur HC, Donnellan N, Mansuria S, Barber RE, Guido R, Lee T. Laparoscopic Uterosacral Ligament Suspension for the Treatment of Vaginal cuff dehiscence after different modes of hysterectomy. Obstet Apical Pelvic Organ Prolapse. Surg Technol Int. 2012 Nov 18;XXII Gynecol. 2011 Oct;118(4):794-801
19 CULTURAL AND LINGUISTIC COMPETENCY
Governor Arnold Schwarzenegger signed into law AB 1195 (eff. 7/1/06) requiring local CME providers, such as the AAGL, to assist in enhancing the cultural and linguistic competency of California’s physicians (researchers and doctors without patient contact are exempt). This mandate follows the federal Civil Rights Act of 1964, Executive Order 13166 (2000) and the Dymally-Alatorre Bilingual Services Act (1973), all of which recognize, as confirmed by the US Census Bureau, that substantial numbers of patients possess limited English proficiency (LEP).
US Population California Language Spoken at Home Language Spoken at Home
Spanish English Spanish
Indo-Euro English Indo-Euro Asian Other Asian
Other 19.7% of the US Population speaks a language other than English at home In California, this number is 42.5%
California Business & Professions Code §2190.1(c)(3) requires a review and explanation of the laws identified above so as to fulfill AAGL’s obligations pursuant to California law. Additional guidance is provided by the Institute for Medical Quality at http://www.imq.org
Title VI of the Civil Rights Act of 1964 prohibits recipients of federal financial assistance from discriminating against or otherwise excluding individuals on the basis of race, color, or national origin in any of their activities. In 1974, the US Supreme Court recognized LEP individuals as potential victims of national origin discrimination. In all situations, federal agencies are required to assess the number or proportion of LEP individuals in the eligible service population, the frequency with which they come into contact with the program, the importance of the services, and the resources available to the recipient, including the mix of oral and written language services. Additional details may be found in the Department of Justice Policy Guidance Document: Enforcement of Title VI of the Civil Rights Act of 1964 http://www.usdoj.gov/crt/cor/pubs.htm.
Executive Order 13166,”Improving Access to Services for Persons with Limited English Proficiency”, signed by the President on August 11, 2000 http://www.usdoj.gov/crt/cor/13166.htm was the genesis of the Guidance Document mentioned above. The Executive Order requires all federal agencies, including those which provide federal financial assistance, to examine the services they provide, identify any need for services to LEP individuals, and develop and implement a system to provide those services so LEP persons can have meaningful access.
Dymally-Alatorre Bilingual Services Act (California Government Code §7290 et seq.) requires every California state agency which either provides information to, or has contact with, the public to provide bilingual interpreters as well as translated materials explaining those services whenever the local agency serves LEP members of a group whose numbers exceed 5% of the general population.
~
If you add staff to assist with LEP patients, confirm their translation skills, not just their language skills. A 2007 Northern California study from Sutter Health confirmed that being bilingual does not guarantee competence as a medical interpreter. http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2078538.
20