AAGL Vaginal Cuff Closure: How to Minimize Dehiscence and Prolapse

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, • Speakers Bureau: Baxter, CONMED Corporation, Covidien • Other: Medical Director: Laparoscopic Institute for Gynecologic Oncology Kate O’Hanlan, MD
Laparoscopic Institute for Gynecologic Oncology
Management of Dehiscence: Sx, when to suture, observe etc 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. • Risk factors:
• Sx, when to suture, observe etc Avoiding vaginal dehiscence
Vaginal cuff dehiscence
• Vaginal
.18%
• Laparoscopic .64%
• Robotic
1.64%
• 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:
(p<0.05)
(p<0.05)
– Stitch every 5-8mm, 5mm deep. Same as diameter.
• Two-layer closure better than single.
• Transvaginal suturing can reduce risk after TLH.
• Monopolar no difference.
» 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.
Uccella et al O&G Sept 2012
» 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.
• My take: Since you cannot close every patient
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.
No support to
cuff from apex
• 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 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
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
Quadri et al, Transabdominal repair of cystocele by wedge colpectomy during combined abdominal-vaginal surgery. Int
Urogynecol J Pelvic Floor Dysfunct. 1997
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.
Design a system for learning suture skills outside of the operating rooms; pelvic trainers, holiotomy challenge. – 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, 2000
Banks et al AJOG, 2007
Kundhal et al, Surg Endosc, 2009
6
JMIG, 2011
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.
Novice
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
29
2
9
7
31
3
1
www.LIGOcourses.com
Comfort performing procedures
before and after a surgical course
P<.001
You get a way cool cap!!!!
P<.001
NS
P<.001
P<.001
1= very comfortable 2=somewhat 3‐neutral 4‐uncomfortable 5=very uncomfortable 33
3
www.LIGOcourses.com
3
8
Surgical Tutorial 4
Vaginal Cuff Closure:
How to Minimize Dehiscence
and Prolapse
I have no financial relationships to disclose.
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
Identify those patients at risk who deserve a prophylactic
vaginal vault suspension
Part 1 – VAULT DEHISCENCE
Incidence, Reasons and Risk Factors
Construct a plan for laparoscopic closure of the vaginal
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
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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
yielded a 0.032% incidence of vaginal evisceration
after a pelvic operation
7039 total and 247 supracervical
The cumulative incidence of vaginal
dehiscence by mode of hysterectomy
was 4.93% among TLH, 0.29% among VH, and
0.12% among TAH
The relative risks of a vaginal cuff dehiscence
complication after TLH compared with TVH and
TAH were 21.0 and 53.2, respectively. Both were
statistically significant.
Aust N Z J Obstet Gynaecol.
2007 Dec;47(6):516-9
Rupture of the vaginal vault with subsequent
extrusion of the peritoneal contents appears to be a
rare occurrence, complicating less than one in 1000
hysterectomies. However, it seems that this risk is
significantly higher in TLH.
JMIG 2007;14:311–317
[email protected]
[email protected]unimi.it
JMIG 2009;16:313–317
JMIG 2009;16:313–317
The time interval between hysterectomy
and occurrence of vault dehiscence in the
laparoscopic group (8.4±1.2 weeks) was
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
 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
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[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, compared with AH (0.64% compared with
0.21%, P.003) and VH (0.64% compared with 0.13%,
P<.001).
11
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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)
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Obstet Gynecol Surv 2002;57(7):462-467
59 cases from 1900 to 2001



These symptoms
typically
occur
after:
 sexual activity
 vaginal instrumentation
 increased
intraabdominal
pressure
Protruding mass in the vagina
Abdominal pain
Vaginal bleeding or discharge
Am J Obstet Gynecol 2012;206(4):284–288



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
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WHY?-Risk Factors

Route of hysterectomy

Increased age and
hypoestrogenism
Increase in intra-abdominal pressure
In addition, there are
Swift return to everyday activities theoretical risks of
and sexual activity
incomplete
full
thickness cuff closure
Vaginal
infection/hematoma
Way of cuff
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
JMIG 2007;14:311–317
7039 total and 247 supracervical
Obstet Gynecol 2011;118:794–801
The 10- year cumulative incidence of dehiscence
after all modes of hysterectomy was 0.24% and
1.35% among total laparoscopic hysterectomies
(Total abdominal hysterectomy was 0.38%, and
total vaginal hysterectomy was 0.11%).
or shallow suture
placement less than
1 cm from the vaginal
cuff edges because of
LPS magnification
12
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Literature search  57 articles, 13.030
endoscopic hysterectomies + 635 TLH
Am J Obstet Gynecol 2011;205:119.e1-12
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
associated with a 3- and 9-fold reduction in
risk of vaginal cuff dehiscence compared
with LPS and robotic suture, respectively
“..Robotic instruments do not allow exerting
enough tension on the knots when cuff
closure is performed”
“It has been speculated that
because of
electrosurgical energy at the time of colpotomy may account
for the observed increased risk of vaginal cuff dehiscence..”
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 was
associated with a lower risk of dehiscence than robotic closure (OR=0.38)
[email protected]
[email protected]
0.032%
Gynecologic Oncology 120 (2011) 47–51





362 underwent simple hysterectomy
(249 laparoscopic, 113 robotic)

57 underwent radical hysterectomy
(36 laparoscopic, 19 robotic).
Obstet Gynecol 2004;103:572-576
Mayo Clinic medical
records (1970 –2001)
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)
Women with a history of
abdominal hysterectomy
tended to rupture through
the vaginal cuff..
..and those with a history of
vaginal
hysterectomy
tended to rupture through a
posterior enterocele
Vaginal cuff complications were 9.46-fold higher among
patients who had a radical hysterectomy. Changes in the
vaginal support and/or foreshortening of the vagina may play
a role in the development of vaginal cuff complications
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Obstet Gynecol 2012;120:516–23
JSLS 2013;17:414–417
Patients who underwent vaginal
closure with LPS knots had a
higher rate of cuff dehiscence
than patients who had suture with
transvaginal knots (0.86% vs.
0.24%, P.028), When vaginal suture
was performed transvaginally, no
statistical difference in vaginal cuff
dehiscence rate was observed
compared with both AH and VH
463 TLH and 147 LAVH performed
entirely by use of electrosurgery
There were no vaginal cuff dehiscences in the LAVH
group compared with 17 vaginal cuff dehiscences (4%) in
the TLH group (P=.02). Because all LAVHs were
performed entirely by electrosurgery including colpotomy
and there were no vaginal cuff dehiscences in the LAVH
group, it does not appear that ELECTROSURGERY plays a
major role in vaginal cuff dehiscence
Use of
at the time of colpotomy and
reducing the power of monopolar energy from 60 watts to 50
watts when colpotomy was performed at the end of TLH didn’t
alter the rate of cuff separations.
Vaginal cuff closure suture was changed to 2-0 glycolide/lactide copolymer (delayed absorbable) and tissue
suture placement was increased to at least 1.5 cm
13
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

Incidence of vaginal cuff
dehiscence 4.2%
Aust N Z J Obstet Gynaecol.
2007 Dec;47(6):516-9

Careful, full-thickness closure of
the vaginal vault with a delayed
absorbable suture is recommended at TLH

It may be prudent to advise
women undergoing TLH to delay
first intercourse postoperatively
JMIG 2011;18:218–223


387 women
149 0-barbed suture
(double layer)
9 0-monofilament suture
229 braided sutures
comprised of polyglycolic
acid (Vicryl) or Endo Stitch
NO CASES of dehiscence among those who had closure
with bidirectional barbed suture (p=.008). Post OP bleeding,
presence of granulation tissue, and cellulitis ALL occurred
more frequently in patients without barbed suture closure.
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Eur J Obstet Gynecol Reprod Biol 2011;158(2):308-313
Gynecol Surg 2012;9:393–400
34/8635 (0.39%) experienced vaginal
evisceration [8 (0.25%) AH, 4 (0.15%)
VH, 22 (0.80%) TLH (p< 0.01)].
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
approach towards the colpotomy in TLH in comparison to the
abdominal approach, with additional (extensive) application of
coagulation, has inherent its specific side effects.




8635 pts
3194 (37%) AH
2696 (31.2%) VH
2745 (31.8%) TLH
No differences were found between the 6027
patients (69.8%) who had closure of the vaginal
cuff and the 2608 (30.2%) who had an
unclosed cuff closure technique.
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




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
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
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
Part 2 – VAULT PROLAPSE
Incidence, Reasons and Risk Factors
14
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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
women-years (Mant J et al, 1997).

The incidence was 1.1
per 1,000 women-years if
initial hysterectomy was
performed for prolapse,
compared with 0.2 per
1,000 women-years if the
hysterectomy
was
performed
for
other
reasons (hazard RR 5.8).
The incidence of vault
prolapse
after
hysterec-tomy varies
between 0.2% to 43%,
but
realistically
between
1.8
and
11.6%
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Int Urogynecol J 2008;19:1623–1629
Am J Obstet Gynecol. 1992 Jun;166(6 Pt 1):1717-24





6,214 hysterectomies
4,304 (69.3%) abdominal hysterectomy
1,749 (28.1%) vaginal hysterectomy
65 (1%) LAVH
96 (1.5%) TLH
The upper third of the vagina
(level I) is suspended from
the pelvic walls by vertical
fibers of the paracolpium,
which is a continuation of the
cardinal ligament
In the middle third of the
vagina (level II) the paracolpium attaches the vagina
laterally
to
the
arcus
tendineus and fascia of the
levator ani muscles.
32/6214 (0.5%) were reoperated for subsequent vault
prolapse.
The mean interval between
the two operations was 6.2
yrs (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
Dissection
reveals
that
the
paracolpium's vertical fibers in
level I prevented prolapse of the
vaginal apex and vaginal eversion
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The vagina's lower third
fuses with the perineal
membrane,
levator
ani
muscles, and perineal body
(level III).
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Curr Opin Obstet Gynecol 2010;22:420-424
15

Predisposing factors (growth
and
development,
genetic
factors,
connective
tissue
weakness, joint mobility)

Inciting
factors
pelvic surgery)

Intervening
factors
(agerelated
changes,
obesity,
constipation,
co-morbidities,
heavy
occupationalwork,and
vigorous physical activity)
(childbirth,
History of POP at the time of
hysterectomy
has
consistently been shown as a
strong
and independent
predictor of POP recurrence
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Curr Opin Obstet Gynecol 2010;22:420-424
Apical support defects
The role of AGE is still controversial:



Advanced age is a indipendent factor

Younger patients have a higher risk of
prolapse recurrence as a consequence
of a major expectancy of lasting of the
reconstructive procedures
To ensure durable apical
support regardless of the
anchoring site for the
vaginal vault suspension,
the
surgeon
should
establish continuity of
the
anterior
and
posterior vaginal fascia
at the vaginal apex.
OBESE women are considered a high-risk group
for development of POP

BMI is a significant and indipendent risk factor
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
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
to the other side,effectively closing the cul-de-sac

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Curr Opin Obstet Gynecol 2008;20:484–488
In 2000, Shull et al described a “high” uterosacral
ligament suspension in which 3 nonabsorbable sutures
are “placed in the ligament on either side..to secure the
superior aspect of the transverse portion of pubocervical
and rectovaginal fascia” to the vaginal cuff
The purpose of the USL vault suspension is to
attach a strong segment of the USL to the
rectovaginal and anterior pubocervical fascia

The USL is considered a major
source of overall support for the
uterus

The exact attachment of the USL
from the ischial spine has been the
subject of controversy as some
believe it connects to the sacrum,
whereas others postulate there are
attachments to the sacrospinous
ligament and coccygeous muscle.
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Obstet Gynecol 2004;103:447–51
Curr Opin Obstet Gynecol 2008;20:484–488



At the cervix, it is composed of closely
packed bundles of smooth muscle,
small and medium-sized blood vessels
and small nerve bundles
In the intermediate third portion of
the USL, it is composed of connective
tissue with a few scattered small
fibers, blood vessels and nerves
In the sacral portion, it is made
entirely of loose strands of connective
tissue and sparse fat, vessels, nerves
and lymphatics
16

They extended over a
mean
craniocaudal
distance of 218 mm
(range 10–50)

Although
uterosacral
ligament
morphology
was similar bilaterally, its
craniocaudal extent was greater on the right side
[email protected]
[email protected]
Obstet Gynecol 2004;103:447–51
US Ligament Suspension
Surgical Technique
Three regions of origin: cervix
alone (33%), cervix and vagina
in the same section (63%), and
vagina alone (4%).
Of 259 uterosacral insertion points,
82% overlaid the sacrospinous
ligament/coccygeus
muscle
complex, 7% the sacrum, and 11%
the piriformis muscle, the sciatic foramen, or the ischial spine
Thus, if one does not artificially reattach the vaginal cuff to
the US ligaments, more than 2/3 of patients would retain
some connections of the vaginal apex to the US ligaments



The
ureters
are
identified
throughout their course below the
pelvic brim and a relaxing incision
is placed below the level of the
ureter within the peritoneum.
The ischial spines identified by
placing tension on the cuff in the
contralateral direction
The USLs are attached to the
posterior surface of the vaginal
vault
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Int Urogynecol J (2012) 23:223–227
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 sutures
vaginally within the USL in cadavers, the distal suture was
approximately 14 mm from the ureter and 13 mm from
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
and injury the sacral plexus (S1-S4)
Permanent (polyester) and delayed
absorbable
(polydioxanone)
sutures were compared
 105
pts: permanent suture
pts: delayed
absorbable suture
 141
The use of permanent sutures for USLS of the vaginal
apex was associated with a lower failure rate than
delayed absorbable sutures in the short-term
[email protected]
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Curr Opin Obstet Gynecol 2008;20:484–488

Success rates vary from 82 to 96%
Curr Opin Obstet Gynecol 2008;20:496–500

17
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.
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Surg Technol Int. 2012 Nov 18;XXII
Surg Technol Int. 2012 Nov 18;XXII
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
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.
[email protected]
Am J Obstet Gynecol. 2010 Feb;202(2):124-34
McCall Culdoplasty
1966-2007
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%,
and 87.4%
Traction of the cul-desac and posterior
vaginal epithelium and
placement of three
rows of sutures across the cul-de-sac
from one uterosacral ligament to the other
Uterosacral ligament suspension is a highly effective procedure
for the restoration of apical vaginal support. A successful
outcome (stage 0 or 1) is observed in 98% of women
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[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
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
Am J Obstet Gynecol 1999;180(4):859-865
18
[email protected]






Vaginal vault prolapse after hysterectomy varies
between 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 vagina
could modify vault suspension
Risk factors: Genetic or structural factors, previous
deliveries or pelvic surgery, co-morbidities, age, BMI
and history of prolapse at time of surgery
USLs suspension is highly effective procedure for the
restoration of apical vaginal support with a success
rates varying from 82 to 96%
The rate of ureteral obstruction with high USL suspension was found to be 5.1%
McCall culdoplasty can be performed laparoscopically in
order to correct enterocele and prevent vaginal prolapse
DeLancey JO. Anatomic aspects of vaginal eversion after
hysterectomy. Am J Obstet Gynecol. 1992 Jun;166(6 Pt 1):1717-24
Croak AJ, Gebhart JB, Klingele CJ, Schroeder G, Lee RA, Podratz
KC. 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 vaginal
cuffdehiscence after laparoscopic closure with bidirectional barbed
suture. 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 on
postoperative vaginal cuff dehiscence. JSLS. 2013;17(3):414-7
Baskett TF. Hysterectomy: evolution and trends. Best Pract Res Clin
Obstet 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 after
different modes of hysterectomies. J Minim Invasive Gynecol. 2007
May-Jun;14(3):311-7
Hobbs FS. Spontaneous evisceration through vagina. Can Med
Assoc 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 dehiscence
in a series of 12,398 hysterectomies: effect of different types of
colpotomy and vaginal closure. Obstet Gynecol. 2012
Sep;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: our
experience and systematic review of the literature. Am J Obstet
Gynecol. 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. Obstet
Gynecol. 2011 Oct;118(4):794-801
Miller N. A new method of correcting complete inversion of the vagina:
with or without complete prolapse; report of two cases. Surg Gynecol
Obstet 1927;44:550–555
Crigler B, Zakaria M, Hart S. Total Laparoscopic Hysterectomy with
Laparoscopic Uterosacral Ligament Suspension for the Treatment of
Apical PelvicOrgan Prolapse. Surg Technol Int. 2012 Nov 18;XXII
McCall ML. Posterior culdeplasty; surgical correction of enterocele
during
vaginal
hysterectomy;a
preliminary
report.ObstetGynecol1957;10:595–602
Margulies RU, Rogers MA, Morgan DM. Outcomes of transvaginal
uterosacral
ligament
suspension:
systematic
review
and
metaanalysis. Am J Obstet Gynecol. 2010 Feb;202(2):124-34
Shull BL, Bachofen C, Coates KW, Kuehl TJ. A transvaginal approach
to repair of apical and other associated sites of pelvic organ prolapse
with uterosacral ligaments. Am J Obstet Gynecol 2000;183:1365-74
Chung CP, Miskimins R, Kuehl TJ, Yandell PM, Shull BL. Permanent
suture used in uterosacral ligament suspension offers better
anatomical support than delayed absorbable suture. Int Urogynecol J.
2012 Feb;23(2):223-7
Wieslander CK, Roshanravan SM, Wai CY, et al. Uterosacral ligament
suspension sutures: anatomic relationships in unembalmed female
cadavers. Am J Obstet Gynecol 2007; 197:672e1–672e6
Diwan A, Rardin CR, Strohsnitter WC, et al. Laparoscopic uterosacral
ligament uterine suspension compared with vaginal hysterectomy with
vaginal vault suspension for uterovaginal prolapse. Int Urogynecol J
Pelvic Floor Dysfunct 2006; 17:79–83.
Ricci P, Solà V, Pardo J, Guiloff E. Laparoscopic McCall culdoplasty. J
Minim Invasive Gynecol. 2007 Jul-Aug;14(4):397-8
Diwadkar GB, Chen CC, Paraiso MF. An update on the laparoscopic
approach 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, Boulvain
M. Incidence rate and risk factors for vaginal vault prolapse repair
after hysterectomy. Int Urogynecol J Pelvic Floor Dysfunct. 2008
Dec;19(12):1623-9
Wattiez A, Mashiach R, Donoso M. Laparoscopic repair of vaginal
vaultprolapse. Curr Opin Obstet Gynecol. 2003 Aug;15(4):315-9
Ceccaroni M, Berretta R, Malzoni M, Scioscia M, Roviglione G, Spagnolo
E, Rolla M, Farina A, Malzoni C, De Iaco P, Minelli L, Bovicelli L. Vaginal
cuff dehiscence after hysterectomy: a multicenter retrospective study. Eur
J Obstet Gynecol Reprod Biol. 2011 Oct;158(2):308-13
Robinson BL, Liao JB, Adams SF, Randall TC. Vaginal cuff dehiscence
after robotic total laparoscopic hysterectomy. Obstet Gynecol. 2009
Aug;114(2 Pt 1):369-71
Blikkendaal MD, Twijnstra AR, Pacquee SC, Rhemrev JP, Smeets MJ, de
Kroon CD, Jansen FW. Vaginal cuff dehiscence in laparo-scopic
hysterectomy: 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. Vaginal
cuffdehiscence in robotic-assisted total hysterectomy. JSLS. 2012 OctDec;16(4):530-6
Cronin B, Sung VW, Matteson KA. Vaginal cuff dehiscence: risk factors
and management. Am J Obstet Gynecol. 2012 Apr;206(4):284-8
Ramirez PT, Klemer DP. Vaginal evisceration after hysterectomy: a
literature 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 Invasive
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after total laparoscopic hysterectomy. Obstet Gynecol. 1996 May;87(5 Pt
2):868-70
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MP, dos Reis R, Ramirez PT. Rate of vaginal cuff separation following
laparoscopic or robotic hysterectomy. Gynecol Oncol. 2011 Jan;120(1):4751
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Laparoscopic Uterosacral Ligament Suspension for the Treatment of
Apical Pelvic Organ Prolapse. Surg Technol Int. 2012 Nov 18;XXII
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Umek WH, Morgan DM, Ashton-Miller JA, DeLancey JOL.
Quantitative analysis of uterosacral ligament origin and insertion
points by magnetic resonance imaging.
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methods used at the time of vaginal hysterectomy to prevent
posterior enterocele. Am J Obstet Gynecol. 1999 Apr;180(4):859-65
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prolapse. Curr Opin Obstet Gynecol. 2010 Oct;22(5):420-4
Rardin CR, Erekson EA, Sung VW, Ward RM, Myers DL. Uterosacral
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Uzoma A, Farag KA. Vaginal vault prolapse. Obstet Gynecol
Int.2009;2009:275621
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
Language Spoken at Home
California
Language Spoken at Home
Spanish
English
Spanish
Indo-Euro
Asian
Other
Indo-Euro
English
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