Presentation on theme: "By MOUNIR M. F. El-HAO, PROF OF OB & GYN.AIN SHAMS UNIVERSITY, CAIRO, EGYPT.."— Presentation transcript:
By MOUNIR M. F. El-HAO, PROF OF OB & GYN.AIN SHAMS UNIVERSITY, CAIRO, EGYPT..
The need for CHANGE ? Patient,s BENEFIT or surgeon s EGO ? Better technique ? Better results ?
INTRODUCTION Levy B. & Emery L. (2003): Randomized Trial of Suture versus Electrosurgical Bipolar Vessel Sealing in Vaginal Hysterectomy. ACOG; 102(1):
Australia40% USA36% Italy15.5% France5.8%
Abdominal Vaginal LAVH LH TLH CISH MISH
INTRODUCTION Johnson N.; Barlow D.; Lethaby A., et al. (2005): Surgical approach to hysterectomy for benign gynaecological disease. Cochrane Database of Systematic Reviews, Issue 2: CD
Surgeon Preference (Indication) with abdominal and vaginal surgery Experience
Despite fastest and least expensive it is used in only 23% of the hysterectomies performed in the United States
INTRODUCTION Kives S.L.; Levy B.S.; Levine R.L., et al. (2003): for the American Association of Gynaecologic Laparoscopists. Laparoscopic-assisted vaginal hysterectomy: J Am Assoc Gynaecol Laparosc: 10:135-8.
Achieving hemostasis is fundamental in all surgical approaches. clips, staples, sutures, ultrasonic, and monopolar or bipolar coagulation.
Seals vessels from 1 to 7 mm in diameter, Precise amount of bipolar energy and pressure to fuse collagen and elastin within the vessel walls. withstand a minimum of three times normal systolic pressure. EBVS Space requirements are less for EBVS
Sealing is achieved with minimal sticking and charring. Thermal spread to adjacent tissues is approximately 0.5 to 2 mm. The result is permanent.
the electrosurgical bipolar vessel sealing (EBVS) system created seals that (were stronger than the other energy-based ligation methods and comparable in strength with that of mechanical ligation techniques. )
To assess the safety and efficacy of using the electrosurgical bipolar vessel sealing (EBVS) system for securing the pedicles during vaginal hysterectomy in comparison with the conventional method of securing the pedicles by suture ligation & does it permit the expansion of the spectrum of vaginal hysterectomy indications. AIM OF THE WORK AIM OF THE WORK
MOUNIR FAWZY ELHAO, PROF KHALED IBRAHIM, A PROF. IHAB SERAG, TUTOR. MOHAMMA ELLEITHY, A.TUTOR.
Vessels sealed using autologous tissues are unlikely to have adverse responses to foreign materials, such as sutures, staples, or clips. Finally, the reduction in needle use reduces the potential for injury during vessel ligation. Although in skilled hands vaginal hysterectomy may be performed using standard techniques even in difficult patients, the electrosurgical bipolar vessel sealer technology should permit the less experienced vaginal surgeon an opportunity to expand the indications for vaginal hysterectomy
The study was carried out in Ain-shams University maternity Hospital. Study group : Women admitted for vaginal hysterectomy for benign disease. Type of the study: Prospective randomized Double blind controlled study.
Includes 100 patients undergoing vaginal hysterectomy [divided into 4 groups]: Group L1 : vaginal hysterectomy using electrosurgical bipolar vessel sealing system (EBVS) for securing the pedicles in the patients with the traditional indications for vaginal hysterectomy. Group S1 : vaginal hysterectomy using traditional suturing for securing the pedicles in the patients with the traditional indications for vaginal hysterectomy. Group L2 : vaginal hysterectomy using electrosurgical bipolar vessel sealing system (EBVS) for securing the pedicles in the challenging (difficult) vaginal hysterectomies. Group S2 : vaginal hysterectomy using traditional suturing for securing the pedicles in the challenging (difficult) vaginal hysterectomies.
1st or 2nd degree uterine descent. Uterine size < 10 weeks. Benign pathology. Multigravid patients. Vaginal canal should be ample. The posterior & lateral vaginal fornices should be wide and deep. Subpubic angles > 90°.
Benign pathology. No uterine descent. Vaginal canal should be adequate. The posterior & lateral vaginal fornices should be adequate. Subpubic angles = 70-90°. Uterine size weeks or previous uterine operation [caesarean section-myomectomy- surgery involving the tubes or the ovaries].
Operative time Operative blood loss Hospital stay. Hospital stay Any postoperative complications including: Any postoperative complications 1. 1ry haemorrhage. 2. 2ry haemorrhage. 3. Postoperative infection and febrile morbidity. 4. The need for readmission. 5. The need for laparotomy
Started december Patient fit for vaginal hysterectomy allocated sequentially randomised and blindly into two groups. Comparing the efficacy of bipolar vessel sealing technique with routine vaginal hysterectomy.
PATIENTS Sample size
GROUP L= L 1 + L 2 ELECTROSURGICAL BIPOLAR VESSEL SEALING (EBVS) GROUP S= S 1 + S 2 TRADITIONAL SUTURE LIGATURE
METHODS Complications Complications were reported including :
METHODS postoperative haemoglobin and haematocrit
RESULTS TABLE 2 Group L compared with Group S Group L (n=50) Group S (n=53) P value Circumcision time10 (5-20) Pedicle dissection time Vault closure time7.5 (5-15)10 (5-20) Total operative time Data are median (range) or mean (SD). P < 0.05 denotes statistical significance.
RESULTS TABLE 3 Group L 1 compared with Group S 1 Group L 1 (n=26) Group S 1 (n=28) P value Circumcision time10 (5-15)10 (5-20) Pedicle dissection time Vault closure time5 (5-15) Total operative time Data are median (range) or mean (SD). P < 0.05 denotes statistical significance.
RESULTS TABLE 4 Group L 2 compared with Group S 2 Group L 2 (n=24) Group S 2 (n=25) P value Circumcision time5 (5-20) Pedicle dissect time Vault closure time10 (5-15)10 (5-20) Total operative time Data are mean (SD) or median (range). P < 0.05 denotes statistical significance.
Patients who have indications for traditional vaginal hysterectomy do not need abdominal hysterectomy,or laparoscopic hysterectomy.
Deserves to be studied in a well controlled trial
Good potentials. Easier. Quicker Bloodless. Less infection. Less pain.
Time,Bleeding and recovery are all shorter than average for other techniques.
Sutureless vaginal hysterectomy using electrosurgical bipolar vessel sealer is a good alternative to the use of sutures in routine vaginal hysterectomy.
When the competent surgeon is equipped with such devices, conversion of an abdominal hysterectomy to the vaginal route is both attainable and preferred.
Levy B. & Emery L. (2003): Randomized Trial of Suture versus Electrosurgical Bipolar Vessel Sealing in Vaginal Hysterectomy. ACOG; 102(1): Cronje H.S. & de Coning E.C. (2005): Electrosurgical bipolar vessel sealing during vaginal hysterectomy. Int J Gynaecol Obstet; 91(3): Hefni M.A. (2005): Safety and efficacy of using the LigaSure vessel sealing system for securing the pedicles in vaginal hysterectomy: randomized controlled trial. BJOG 2005; 112(3): DISCUSSION
Less manipulation, compression and traction. 1.No foreign material; 2.Tissue left distal to the suture or clip (including nerves) can necrose post-operatively and may cause pain and infection. Peirce S.C. & Crawford D.C. (2007): Centre for Evidence-based Purchasing; Purchasing and Supply Agency; Evidence review; Electrosurgical vessel sealing in vaginal hysterectomy. CEP November pain with EBVS could be related to: