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AAGLAdvancing Minimally Invasive Gynecology Worldwide
Vaginal Cuff Closure: How to Minimize
Dehiscence and Prolapse
MODERATOR
Stuart R. Hart, MD
FACULTY
Kate O’Hanlan, MD & Michele Vignali, MD
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.
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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
Kate O’Hanlan, MD
Laparoscopic Institute for Gynecologic Oncology
• Consultant: Cardinal Health Medical Products and Services, CONMED Corporation, Covidien,
• Speakers Bureau: Baxter, CONMED Corporation, Covidien
• Other: Medical Director: Laparoscopic Institute for Gynecologic Oncology
Objectives• Differentiate reasons risk factors for prolapse or dehiscence complications;
• Design a system for learning suture skills outside of the 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.
Management of Dehiscence: Sx, when to suture, observe etc
• Risk factors:
• Sx, when to suture, observe etc
Vaginal cuff dehiscence
• Vaginal .18% (p<0.05)
• Laparoscopic .64%
• Robotic 1.64% (p<0.05)
• Transvaginal suturing can reduce risk after TLH.
• Monopolar no difference.Uccella et al O&G Sept 2012
• My take: Since you cannot close every patient transvaginally, learn to suture laparoscopically.
Avoiding vaginal dehiscence
• 1-2% in most studies, 77days post-op.
• Malignancy, diabetes, cigarette smoking, pelvic adhesions, radical hyst greater risk.
• Suture cuff with same standards as open:–Stitch every 5-8mm, 5mm deep. Same as diameter.
• Two-layer closure better than single.» Hur, et al. (2007). "Incidence and patient characteristics of vaginal cuff
dehiscence after different modes of hysterectomies." JMIG 14(3): 311-317.
» 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 gynecology and obstetrics 282(6): 631-638.
3
Vaginal dehiscenceVaginal 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.
• 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: – see small bowel. Prep before put back.
– 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 oncology120(1): 47-51.
No support to cuff from apexNo support to cuff from apex
Good support to cuff from apex.
Good support to cuff from apex.
4
Cysto/enterocele repair from above by Soferman et al International Surgery, 1974Cysto/enterocele repair from above by Soferman et al International Surgery, 1974
“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.”
“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.”
Cystocele repair can be accomplished laparoscopically
Cysto/enterocele repair from above by Soferman et al International Surgery, 1974Cysto/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.”
• Quadri et al, Transabdominal repair of cystocele by wedge colpectomy during combined abdominal-vaginal surgery. Int Urogynecol J Pelvic Floor Dysfunct. 1997
• Quadri et al, Transabdominal repair of cystocele by wedge colpectomy during combined abdominal-vaginal surgery. Int Urogynecol J Pelvic Floor Dysfunct. 1997
Digesu et al. A case of laparoscopic uterosacral ligaments plication: a new conservative approach to uterine prolapse. Eur J Obstet Gynecol Reprod Biol. 2004
Digesu et al. A case of laparoscopic uterosacral ligaments plication: a new conservative approach to uterine prolapse. Eur J Obstet Gynecol Reprod Biol. 2004
Support procedures that even a Gyn Oncologist can do……..
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Laparoscopic closure of the vaginal apex: when closure cannot be accomplished any other way
Resect enterocele
Ethibond 0 Suture
Obstacles to learning in the ORObstacles to learning in the OR
• Seniors won’t give away critical parts.– Newer surgeons take longer. Costs time.
– Newer surgeons make more mistakes.
• Newest technology and techniques hard to learn on live patient in front of all.
• Surgeons who trained on simulators had greater accuracy in vivo, made fewer mistakes.
• High tech “virtual reality” no better.
• Seniors won’t give away critical parts.– Newer surgeons take longer. Costs time.
– Newer surgeons make more mistakes.
• Newest technology and techniques hard to learn on live patient in front of all.
• Surgeons who trained on simulators had greater accuracy in vivo, made fewer mistakes.
• High tech “virtual reality” no better.Scott et al, JACS, 2000Banks et al AJOG, 2007Kundhal et al, Surg Endosc, 2009
Design a system for learning suture skills
outside of the operating rooms; pelvic trainers,
holiotomy challenge.
6
Intracorporeal suturing incorporates all basic laparoscopic skills and is a prerequisite because it is needed to manage possible complications or in case of instrument failure.
Residents with little or no previous laparoscopic experience are able to perform the task competently after a short training course.
Intracorporeal suturing incorporates all basic laparoscopic skills and is a prerequisite because it is needed to manage possible complications or in case of instrument failure.
Residents with little or no previous laparoscopic experience are able to perform the task competently after a short training course.
JMIG, 2011
Novice
Expert
Laparoscopic skillsLaparoscopic 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.
• 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.
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www.LIGOcourses.comwww.LIGOcourses.com29
The Holiotomy™ ChallengesThe 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!
• 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!
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www.LIGOcourses.comwww.LIGOcourses.com31
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www.LIGOcourses.comwww.LIGOcourses.com
Comfort performing proceduresbefore and after a surgical courseComfort performing procedures
before and after a surgical course
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1= very comfortable 2=somewhat 3‐neutral 4‐uncomfortable 5=very uncomfortable
P<.001P<.001
P<.001
P<.001NS
You get a way cool cap!!!!You get a way cool cap!!!!
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Surgical Tutorial 4
Vaginal Cuff Closure: How to Minimize Dehiscence
and ProlapseModerator: Stuart R. Hart
Professor Michele VIGNALI, MD, PhDAssociate Professor of Obstetrics and GynecologyDirector of Endoscopic Gynecologic Surgery Unit
Department of Biomedic Science for the HealthMacedonio Melloni HospitalUniversity of Milan, Italy
I have no financial relationships to disclose.
At the conclusion of this activitiy, participants will be betterable to:
Differentiate the reasons why some patients have vaginalvault prolapse and dehiscence complications
Identify those patients at risk who deserve a prophylacticvaginal vault suspension
Construct a plan for laparoscopic closure of the vaginalapex using different sutures
Summarize the current literature regarding the diagnosisand management of vaginal vault dehiscence and prolapse.
Part 1 – VAULT DEHISCENCE
Incidence, Reasons and Risk Factors
The first abdominal hysterectomy wasperformed by Charles Clay in Manchester,England in 1843, but only 1853 that EllisBurnham from Lowell, Massachusetts achievedthe first successful abdominal hysterectomy
Vaginal hysterectomy dates back to ancient times. Theprocedure was performed by Soranus of Ephesus 120years A.C. but the first planned, successful vaginalhysterectomy was performed in 1813 by ConradLangenbeck, although he did not report the case until 1817
Can Med Assoc J. 1952 January; 66(1): 68
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[email protected] [email protected]
[email protected] [email protected]
Evisceration occurs in up to 70%of vaginal cuff dehiscence cases
10
Obstet Gynecol 2004;103:572-576
The Mayo Clinic experience from 1970 through 2001yielded a 0.032% incidence of vaginal eviscerationafter a pelvic operation
Aust N Z J Obstet Gynaecol. 2007 Dec;47(6):516-9
Rupture of the vaginal vault with subsequentextrusion of the peritoneal contents appears to be arare occurrence, complicating less than one in 1000hysterectomies. However, it seems that this risk issignificantly higher in TLH.
The cumulative incidence of vaginaldehiscence by mode of hysterectomy
JMIG 2007;14:311–317
7039 total and 247 supracervical
The relative risks of a vaginal cuff dehiscencecomplication after TLH compared with TVH andTAH were 21.0 and 53.2, respectively. Both werestatistically significant.
was 4.93% among TLH, 0.29% among VH, and 0.12% among TAH
The incidence of vault dehiscence was higher after TLH(1.14%) than after AH (0.10%, p.0001) and after VH(0.14%, p.001)
10 632 hysterectomies
JMIG 2009;16:313–317 JMIG 2009;16:313–317
The time interval between hysterectomyand occurrence of vault dehiscence in thelaparoscopic group (8.4±1.2 weeks) wassignificantly shorter than in the abdominalhysterectomy (112.7±75.1 weeks, p<.01)and in vaginal hysterectomy (136.5±32.2weeks, p<0.0001) groups, respectively
Obstet Gynecol 2012;120:516-523
Eur J Obstet Gynecol Reprod Biol 2011;158(2):308-313
34/8635 (0.39%) experienced vaginal evisceration.The laparoscopic route was associated with asignificantly higher incidence of dehiscence (0.80%)
TLH was associated with a higher incidence of cuffseparations, compared with AH (0.64% compared with0.21%, P.003) and VH (0.64% compared with 0.13%,P<.001).
[email protected] [email protected]
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Vaginal cuff dehiscence can occur at any timeafter a pelvic surgical procedure and has beenreported as early as 3 days and as late as 30years postoperatively
In retrospective cohort studies andlarger case series the mean timeto cuff dehiscence varied between6.1- weeks up to 1.6 years (range2 weeks to 5.4 years)
[email protected] [email protected]
Obstet Gynecol Surv 2002;57(7):462-467
Protruding mass in the vagina Abdominal pain Vaginal bleeding or discharge
59 cases from 1900 to 2001
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
These symptomstypically occurafter: sexual activity vaginal instru-
mentation increased
intraabdominalpressure
Am J Obstet Gynecol 2012;206(4):284–288
[email protected] [email protected]
Route of hysterectomy
Increased age and hypoestrogenism
Increase in intra-abdominal pressure Swift return to everyday activities
and sexual activity
Vaginal cuff infection/hematoma
WHY?-Risk Factors
In addition, there aretheoretical risks ofincomplete fullthickness cuff closureor shallow sutureplacement less than1 cm from the vaginalcuff edges because ofLPS magnification
Way of vaginal cuff closure The type and size of the suture
material used to close the vault Tissue damage in the vaginal cuff
due to electrocautery
Obstet Gynecol 2011;118:794–801
JMIG 2007;14:311–317
7039 total and 247 supracervical
The 10- year cumulative incidence of dehiscenceafter all modes of hysterectomy was 0.24% and1.35% among total laparoscopic hysterectomies(Total abdominal hysterectomy was 0.38%, andtotal vaginal hysterectomy was 0.11%).
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Am J Obstet Gynecol 2011;205:119.e1-12 Literature search 57 articles, 13.030endoscopic hysterectomies + 635 TLH
The pooled incidence of vaginal dehiscence was LOWER for TV cuff closure (0.18%)than for both LPS (0.64%) and robotic (1.64%) colporraphy. LPS cuff closure wasassociated with a lower risk of dehiscence than robotic closure (OR=0.38)
TRANSVAGINAL colporraphy after TLH isassociated with a 3- and 9-fold reduction inrisk of vaginal cuff dehiscence comparedwith LPS and robotic suture, respectively
JSLS 2012;16:530–536
Obstet Gynecol 2009;114(2 Pt 1):369–371
3/654 robotic-assisted TLH 0.4%3/654 robotic-assisted TLH 0.4%
“It has been speculated that because ofelectrosurgical energy at the time of colpotomy may accountfor the observed increased risk of vaginal cuff dehiscence..”
“..Robotic instruments do not allow exertingenough tension on the knots when cuffclosure is performed”
Gynecologic Oncology 120 (2011) 47–51
362 underwent simple hysterectomy(249 laparoscopic, 113 robotic)
57 underwent radical hysterectomy(36 laparoscopic, 19 robotic).
7/417 (1.7%) developed a cuff complication 3/285 (1.1%) patients in the LPS group suffered a
vaginal cuff evisceration (n=2) or separation (n=1) 4/132 (3.0%) had a vaginal evisceration (n=1) or
separation (n=3)
No difference based on surgical approach (p=0.22)
Vaginal cuff complications were 9.46-fold higher amongpatients who had a radical hysterectomy. Changes in thevaginal support and/or foreshortening of the vagina may playa role in the development of vaginal cuff complications
Obstet Gynecol 2004;103:572-576
Mayo Clinic medical records (1970 –2001)
..and those with a history ofvaginal hysterectomytended to rupture through aposterior enterocele
Women with a history ofabdominal hysterectomytended to rupture throughthe vaginal cuff..
0.032%
Obstet Gynecol 2012;120:516–23
Patients who underwent vaginalclosure with LPS knots had ahigher rate of cuff dehiscencethan patients who had suture withtransvaginal knots (0.86% vs.0.24%, P.028), When vaginal suturewas performed transvaginally, nostatistical difference in vaginal cuffdehiscence rate was observedcompared with both AH and VH
Use of at the time of colpotomy andreducing the power of monopolar energy from 60 watts to 50watts when colpotomy was performed at the end of TLH didn’talter the rate of cuff separations.
JSLS 2013;17:414–417
463 TLH and 147 LAVH performedentirely by use of electrosurgery
There were no vaginal cuff dehiscences in the LAVHgroup compared with 17 vaginal cuff dehiscences (4%) inthe TLH group (P=.02). Because all LAVHs wereperformed entirely by electrosurgery including colpotomyand there were no vaginal cuff dehiscences in the LAVHgroup, it does not appear that ELECTROSURGERY plays amajor role in vaginal cuff dehiscence
Vaginal cuff closure suture was changed to 2-0 glyco-lide/lactide copolymer (delayed absorbable) and tissuesuture placement was increased to at least 1.5 cm
13
It may be prudent to advisewomen undergoing TLH to delayfirst intercourse postoperatively
Careful, full-thickness closure ofthe vaginal vault with a delayedabsorbable suture is recommen-ded at TLH
Aust N Z J Obstet Gynaecol. 2007 Dec;47(6):516-9
JMIG 2011;18:218–223
387 women 149 0-barbed suture
(double layer) 9 0-monofilament suture 229 braided sutures
comprised of polyglycolicacid (Vicryl) or Endo Stitch
Incidence of vaginal cuff dehiscence 4.2%
NO CASES of dehiscence among those who had closurewith bidirectional barbed suture (p=.008). Post OP bleeding,presence of granulation tissue, and cellulitis ALL occurredmore frequently in patients without barbed suture closure.
Gynecol Surg 2012;9:393–400
NO superiority of one of the suturing methods over the otherwas found. Regardless of the suturing method, the surgicalapproach towards the colpotomy in TLH in comparison to theabdominal approach, with additional (extensive) application ofcoagulation, has inherent its specific side effects.
Eur J Obstet Gynecol Reprod Biol 2011;158(2):308-313
No differences were found between the 6027patients (69.8%) who had closure of the vaginalcuff and the 2608 (30.2%) who had anunclosed cuff closure technique.
8635 pts 3194 (37%) AH 2696 (31.2%) VH 2745 (31.8%) TLH
34/8635 (0.39%) experienced vaginalevisceration [8 (0.25%) AH, 4 (0.15%)VH, 22 (0.80%) TLH (p< 0.01)].The laparoscopic route was associatedwith a significantly higher incidence ofdehiscence (0.80%)
Vaginal Cuff Dehiscence is a rare complication ofhysterectomy, 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 variedbetween 6.1- weeks up to 1.6 years after hysterectomy
TRANSVAGINAL colporraphy after TLH is associatedwith a 3- and 9-fold reduction in risk of vaginal cuffdehiscence compared with LPS and robotic suture
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 oftissue
Part 2 – VAULT PROLAPSE
Incidence, Reasons and Risk Factors
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Pelvic organ prolapse is a common problem,affecting 30% to 50% of women
The overall incidence of prolapse afterhysterectomy was reported to be 3.6 per 1,000women-years (Mant J et al, 1997).
The incidence of vaultprolapse afterhysterec-tomy variesbetween 0.2% to 43%,but realisticallybetween 1.8 and11.6%
Int Urogynecol J 2008;19:1623–1629
The incidence was 1.1per 1,000 women-years ifinitial hysterectomy wasperformed for prolapse,compared with 0.2 per1,000 women-years if thehysterectomy wasperformed for otherreasons (hazard RR 5.8).
32/6214 (0.5%) were reope-rated for subsequent vaultprolapse.The mean interval betweenthe two operations was 6.2yrs (range 0.2 to 21.8 yrs).
The incidence of vault prolapse requiring surgical correction after hysterectomy was 0.36 per 1,000 women-years
Int Urogynecol J 2008;19:1623–1629
6,214 hysterectomies 4,304 (69.3%) abdominal hysterectomy 1,749 (28.1%) vaginal hysterectomy 65 (1%) LAVH 96 (1.5%) TLH
The vagina's lower thirdfuses with the perinealmembrane, levator animuscles, and perineal body(level III).
The upper third of the vagina(level I) is suspended fromthe pelvic walls by verticalfibers of the paracolpium,which is a continuation of thecardinal ligament
In the middle third of thevagina (level II) the para-colpium attaches the vaginalaterally to the arcustendineus and fascia of thelevator ani muscles.
Dissection reveals that theparacolpium's vertical fibers inlevel I prevented prolapse of thevaginal apex and vaginal eversion
Am J Obstet Gynecol. 1992 Jun;166(6 Pt 1):1717-24
Curr Opin Obstet Gynecol 2010;22:420-424
Predisposing factors (growthand development, geneticfactors, connective tissueweakness, joint mobility)
Inciting factors (childbirth,pelvic surgery)
Intervening factors (age-related changes, obesity,constipation, co-morbidities,heavy occupationalwork,andvigorous physical activity)
History of POP at the time ofhysterectomy hasconsistently been shown as astrong and independentpredictor of POP recurrence
15
The role of AGE is still controversial:
Advanced age is a indipendent factor
Younger patients have a higher risk ofprolapse recurrence as a consequenceof a major expectancy of lasting of thereconstructive procedures
OBESE women are considered a high-risk groupfor development of POP
BMI is a significant and indipendent risk factor
Curr Opin Obstet Gynecol 2010;22:420-424
Apical support defects
To ensure durable apicalsupport regardless of theanchoring site for thevaginal vault suspension,the surgeon shouldestablish continuity ofthe anterior andposterior vaginal fasciaat the vaginal apex.
In 1927, Miller described the attachment of the USL tothe vaginal vault for support
In 1957, McCall described passing a suture from oneside of the vaginal cuff and USL through the peritoneumto the other side,effectively closing the cul-de-sac
In 2000, Shull et al described a “high” uterosacralligament suspension in which 3 nonabsorbable suturesare “placed in the ligament on either side..to secure thesuperior aspect of the transverse portion of pubocervicaland rectovaginal fascia” to the vaginal cuff
The purpose of the USL vault suspension is toattach a strong segment of the USL to therectovaginal and anterior pubocervical fascia
The purpose of the USL vault suspension is toattach a strong segment of the USL to therectovaginal and anterior pubocervical fascia
Curr Opin Obstet Gynecol 2008;20:484–488
The USL is considered a majorsource of overall support for theuterus
The exact attachment of the USLfrom the ischial spine has been thesubject of controversy as somebelieve it connects to the sacrum,whereas others postulate there areattachments to the sacrospinousligament and coccygeous muscle.
Curr Opin Obstet Gynecol 2008;20:484–488
At the cervix, it is composed of closelypacked bundles of smooth muscle,small and medium-sized blood vesselsand small nerve bundles
In the intermediate third portion ofthe USL, it is composed of connectivetissue with a few scattered smallfibers, blood vessels and nerves
In the sacral portion, it is madeentirely of loose strands of connectivetissue and sparse fat, vessels, nervesand lymphatics
They extended over amean craniocaudaldistance of 218 mm(range 10–50)
Although uterosacralligament morphologywas similar bilaterally, itscraniocaudal extent
Obstet Gynecol 2004;103:447–51
was greater on the right side
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Obstet Gynecol 2004;103:447–51
Three regions of origin: cervixalone (33%), cervix and vaginain the same section (63%), andvagina alone (4%).Of 259 uterosacral insertion points,82% overlaid the sacrospinousligament/coccygeus musclecomplex, 7% the sacrum, and 11%
Thus, if one does not artificially reattach the vaginal cuff tothe US ligaments, more than 2/3 of patients would retainsome connections of the vaginal apex to the US ligaments
Thus, if one does not artificially reattach the vaginal cuff tothe US ligaments, more than 2/3 of patients would retainsome connections of the vaginal apex to the US ligaments
the piriformis muscle, the sciatic foramen, or the ischial spine
US Ligament SuspensionSurgical Technique
The ureters are identifiedthroughout their course below thepelvic brim and a relaxing incisionis placed below the level of theureter within the peritoneum.
The ischial spines identified byplacing tension on the cuff in thecontralateral direction
The USLs are attached to theposterior surface of the vaginalvault
Curr Opin Obstet Gynecol 2008;20:484–488
During surgery, the ureters may be kinked, tied or injured
Wieslander et al. found that while placing suturesvaginally within the USL in cadavers, the distal suture wasapproximately 14 mm from the ureter and 13 mm fromthe rectal lumen
The rate of obstruction with high USL suspension wasfound to be 5.1%.
USL sutures can be placed close to the sacral foraminaand injury the sacral plexus (S1-S4)
Int Urogynecol J (2012) 23:223–227
The use of permanent sutures for USLS of the vaginalapex was associated with a lower failure rate thandelayed absorbable sutures in the short-term
Permanent (polyester) and delayedabsorbable (polydioxanone)sutures were compared
105 pts: perma-nent suture
141 pts: delayedabsorbable suture
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 USLSto 25 vaginal USLS among age-matched controls.Estimated blood loss and duration of hospitalizationwere significantly less in the LPS group There were 3recurrences in the vaginal group diagnosed at 17, 34,and 58 weeks but NONE in the laparoscopic group.
17
A) to incorporate the suture through the
right USL then through the anterior and
posterior endopelvic fascia across the
vaginal vault, and finish by incorporating
the left USL.
The initial stitch is placed through the
mid-portion of the USLs on stretch, and
a second and third suture are placed
sequentially more proximal through the
USLs, with each stitch incorporating
both anterior and posterior endopelvic
fascia. The suture is tied using
extracorporeal knot tying technique
Surg Technol Int. 2012 Nov 18;XXII
Surg Technol Int. 2012 Nov 18;XXII
B) to incorporate the USL stitch through
the anterior and posterior endopelvic
fascia on each respective side without
crossing the midline. The initial stitch is
placed through the mid-portion of the
USL and then through the anterior and
posterior endopelvic fascia on the lateral
aspect of the vaginal cuff on each
respective side. The next stitch is placed
more proximal through the USL and then
more medially through the anterior and
posterior endopelvic fasciaon each
respective side, until the midline
vaginal cuff is incorporated.
Am J Obstet Gynecol. 2010 Feb;202(2):124-34
In the anterior, apical, andposterior compartments, thepooled rates for a successfuloutcome were 81.2%, 98.3%,and 87.4%
1966-2007
Uterosacral ligament suspension is a highly effective procedurefor the restoration of apical vaginal support. A successfuloutcome (stage 0 or 1) is observed in 98% of women
McCall Culdoplasty
Traction of the cul-de-sac and posteriorvaginal epithelium andplacement of threerows of suturesfrom one uterosacral ligament to the other
across the cul-de-sac
McCall ML. Posterior culdeplasty; surgical correction ofenterocele during vaginal hysterectomy; a preliminaryreport. Obstet Gynecol. 1957 Dec;10(6):595-602
Obstet Gynecol Int. 2009;275621
Am J Obstet Gynecol 1999;180(4):859-865
[email protected] [email protected]
..A permanent 3-0 suture wasplaced through the USL and theperitoneum of the cul-de-sac. Asecond suture was placed in thesame way 1 cm above andparallel to the previous stitch.Sutures were kept to be tied afterplacement of the external suture.The external adsorbable 2-0 McCall suture was then placed through theposterior vaginal wall and peritoneum. This suture was then placedthrough the uterosacral ligaments and then brought back out throughthe vagina
J Minim Inv Gynecol 2007;14:397-398
18
Vaginal vault prolapse after hysterectomy variesbetween 1.8 and 11.6%
An alteration in the level of the fibers of the paracolpium(level I) which suspend the upper third of the vaginacould modify vault suspension
Risk factors: Genetic or structural factors, previousdeliveries or pelvic surgery, co-morbidities, age, BMIand history of prolapse at time of surgery
USLs suspension is highly effective procedure for therestoration of apical vaginal support with a successrates varying from 82 to 96%
The rate of ureteral obstruction with high USL suspen-sion was found to be 5.1%
McCall culdoplasty can be performed laparoscopically inorder to correct enterocele and prevent vaginal prolapse
Miller N. A new method of correcting complete inversion of the vagina:with or without complete prolapse; report of two cases. Surg GynecolObstet 1927;44:550–555
McCall ML. Posterior culdeplasty; surgical correction of enteroceleduring vaginal hysterectomy;a preliminaryreport.ObstetGynecol1957;10:595–602
Shull BL, Bachofen C, Coates KW, Kuehl TJ. A transvaginal approachto repair of apical and other associated sites of pelvic organ prolapsewith uterosacral ligaments. Am J Obstet Gynecol 2000;183:1365-74
Wieslander CK, Roshanravan SM, Wai CY, et al. Uterosacral ligamentsuspension sutures: anatomic relationships in unembalmed femalecadavers. Am J Obstet Gynecol 2007; 197:672e1–672e6
Diwan A, Rardin CR, Strohsnitter WC, et al. Laparoscopic uterosacralligament uterine suspension compared with vaginal hysterectomy withvaginal vault suspension for uterovaginal prolapse. Int Urogynecol JPelvic Floor Dysfunct 2006; 17:79–83.
Ricci P, Solà V, Pardo J, Guiloff E. Laparoscopic McCall culdoplasty. JMinim Invasive Gynecol. 2007 Jul-Aug;14(4):397-8
Diwadkar GB, Chen CC, Paraiso MF. An update on the laparoscopicapproach to urogynecology and pelvic reconstructive procedures.Curr Opin Obstet Gynecol. 2008 Oct;20(5):496-500
Dällenbach P, Kaelin-Gambirasio I, Jacob S, Dubuisson JB, BoulvainM. Incidence rate and risk factors for vaginal vault prolapse repairafter hysterectomy. Int Urogynecol J Pelvic Floor Dysfunct. 2008Dec;19(12):1623-9
Wattiez A, Mashiach R, Donoso M. Laparoscopic repair of vaginalvaultprolapse. Curr Opin Obstet Gynecol. 2003 Aug;15(4):315-9
Crigler B, Zakaria M, Hart S. Total Laparoscopic Hysterectomy withLaparoscopic Uterosacral Ligament Suspension for the Treatment ofApical PelvicOrgan Prolapse. Surg Technol Int. 2012 Nov 18;XXII
Margulies RU, Rogers MA, Morgan DM. Outcomes of transvaginaluterosacral ligament suspension: systematic review andmetaanalysis. Am J Obstet Gynecol. 2010 Feb;202(2):124-34
Chung CP, Miskimins R, Kuehl TJ, Yandell PM, Shull BL. Permanentsuture used in uterosacral ligament suspension offers betteranatomical support than delayed absorbable suture. Int Urogynecol J.2012 Feb;23(2):223-7
Umek WH, Morgan DM, Ashton-Miller JA, DeLancey JOL.Quantitative analysis of uterosacral ligament origin and insertionpoints by magnetic resonance imaging.Obstet Gynecol. 2004 Mar;103(3):447-51
Cruikshank SH, Kovac SR. Randomized comparison of three surgicalmethods used at the time of vaginal hysterectomy to preventposterior enterocele. Am J Obstet Gynecol. 1999 Apr;180(4):859-65
Salvatore S, Siesto G, Serati M. Risk factors for recurrence of genitalprolapse. Curr Opin Obstet Gynecol. 2010 Oct;22(5):420-4
Rardin CR, Erekson EA, Sung VW, Ward RM, Myers DL. Uterosacralcolpopexy at the time of vaginal hysterectomy: comparison oflaparoscopic and vaginal approaches. J Reprod Med. 2009May;54(5):273-80
Yazdany T, Bhatia N. Uterosacral ligament vaginal vault suspension:anatomy, outcome and surgical considerations. Curr Opin ObstetGynecol. 2008 Oct;20(5):484-8
Uzoma A, Farag KA. Vaginal vault prolapse. Obstet GynecolInt.2009;2009:275621
DeLancey JO. Anatomic aspects of vaginal eversion afterhysterectomy. Am J Obstet Gynecol. 1992 Jun;166(6 Pt 1):1717-24
Croak AJ, Gebhart JB, Klingele CJ, Schroeder G, Lee RA, PodratzKC. Characteristics of patients with vaginal rupture and evisceration.Obstet Gynecol. 2004 Mar;103(3):572-6
Siedhoff MT, Yunker AC, Steege JF. Decreased incidence of vaginalcuffdehiscence after laparoscopic closure with bidirectional barbedsuture. J Minim Invasive Gynecol. 2011 Mar-Apr;18(2):218-23
Fanning J, Kesterson J, Davies M, Green J, Penezic L, Vargas R,Harkins G. Effects of electrosurgery and vaginal closure technique onpostoperative vaginal cuff dehiscence. JSLS. 2013;17(3):414-7
Baskett TF. Hysterectomy: evolution and trends. Best Pract Res ClinObstet Gynaecol. 2005 Jun;19(3):295-305
Hur HC, Guido RS, Mansuria SM, Hacker MR, Sanfilippo JS, Lee TT.Incidence and patient characteristics of vaginal cuff dehiscence afterdifferent modes of hysterectomies. J Minim Invasive Gynecol. 2007May-Jun;14(3):311-7
Hobbs FS. Spontaneous evisceration through vagina. Can MedAssoc J. 1952 Jan;66(1):68
Uccella S, Ceccaroni M, Cromi A, Malzoni M, Berretta R, De Iaco P,Roviglione G, Bogani G, Minelli L, Ghezzi F. Vaginal cuff dehiscencein a series of 12,398 hysterectomies: effect of different types ofcolpotomy and vaginal closure. Obstet Gynecol. 2012Sep;120(3):516-23
Uccella S, Ghezzi F, Mariani A, Cromi A, Bogani G, Serati M, Bolis P.Vaginal cuff closure after minimally invasive hysterectomy: ourexperience and systematic review of the literature. Am J ObstetGynecol. 2011 Aug;205(2):119.e1-12
Hur HC, Donnellan N, Mansuria S, Barber RE, Guido R, Lee T.Vaginal cuff dehiscence after different modes of hysterectomy. ObstetGynecol. 2011 Oct;118(4):794-801
Ceccaroni M, Berretta R, Malzoni M, Scioscia M, Roviglione G, SpagnoloE, Rolla M, Farina A, Malzoni C, De Iaco P, Minelli L, Bovicelli L. Vaginalcuff dehiscence after hysterectomy: a multicenter retrospective study. EurJ Obstet Gynecol Reprod Biol. 2011 Oct;158(2):308-13
Robinson BL, Liao JB, Adams SF, Randall TC. Vaginal cuff dehiscenceafter robotic total laparoscopic hysterectomy. Obstet Gynecol. 2009Aug;114(2 Pt 1):369-71
Blikkendaal MD, Twijnstra AR, Pacquee SC, Rhemrev JP, Smeets MJ, deKroon CD, Jansen FW. Vaginal cuff dehiscence in laparo-scopichysterectomy: influence of various suturing methods of the vaginal vault.Gynecol Surg. 2012 Nov;9(4):393-400
Kashani S, Gallo T, Sargent A, Elsahwi K, Silasi DA, Azodi M. Vaginalcuffdehiscence in robotic-assisted total hysterectomy. JSLS. 2012 Oct-Dec;16(4):530-6
Cronin B, Sung VW, Matteson KA. Vaginal cuff dehiscence: risk factorsand management. Am J Obstet Gynecol. 2012 Apr;206(4):284-8
Ramirez PT, Klemer DP. Vaginal evisceration after hysterectomy: aliterature review. Obstet Gynecol Surv. 2002 Jul;57(7):462-7
Agdi M, Al-Ghafri W, Antolin R, Arrington J, O'Kelley K, Thomson AJ,Tulandi T. Vaginal vault dehiscence after hysterectomy. J Minim InvasiveGynecol. 2009 May-Jun;16(3):313-7
Nezhat CH, Nezhat F, Seidman DS, Nezhat C. Vaginal vault eviscerationafter total laparoscopic hysterectomy. Obstet Gynecol. 1996 May;87(5 Pt2):868-70
Nick AM, Lange J, Frumovitz M, Soliman PT, Schmeler KM, SchlumbrechtMP, dos Reis R, Ramirez PT. Rate of vaginal cuff separation followinglaparoscopic or robotic hysterectomy. Gynecol Oncol. 2011 Jan;120(1):47-51
Crigler B, Zakaria M, Hart S. Total Laparoscopic Hysterectomy withLaparoscopic Uterosacral Ligament Suspension for the Treatment ofApical Pelvic Organ Prolapse. Surg Technol Int. 2012 Nov 18;XXII
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).
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.
US Population
Language Spoken at Home
English
Spanish
AsianOther
Indo-Euro
California
Language Spoken at Home
Spanish
English
OtherAsian
Indo-Euro
19.7% of the US Population speaks a language other than English at home In California, this number is 42.5%
20
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