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1.
Reducing patient's perception of postoperative vaginal bleeding after laparoscopic hysterectomy via independent closure of the vaginal cuff angles (RCT)
Radtke, S., Arms, R., Son, M. A., Sanchez, S., Singh, V., Bencomo, M., McCall, E., Rodriguez, S., Olivas-Cardiel, K.
European journal of obstetrics, gynecology, and reproductive biology. 2024;294:111-116
Abstract
STUDY OBJECTIVE Determine if independently suturing the vaginal cuff angles in addition to running barbed suture has an effect on patients' perception of postoperative bleeding after laparoscopic hysterectomy. DESIGN Randomized controlled trial. SETTING University-based medical center. PATIENTS Females ages 18-60 undergoing laparoscopic hysterectomy. INTERVENTIONS Patients were randomly assigned to either cuff closure via single layer of barbed suture (control) vs adding figure-of-eight stitches at each angle (intervention). A survey was given between 10 and 25 days after surgery inquiring about bleeding and dyspareunia. A second survey was given between postoperative days 90-114. Chart review was performed to record emergency room visits, complications, infections, and reoperations during the first 90 postoperative days. RESULTS n = 117 patients were analyzed. 62 (control) and 55 (intervention). Groups were similar in terms of age (42.92 v 44.29p =.35), BMI (33.79 v 34.06p =.85), diabetes (5.26 % (3/55) v 15.09 % (8/53) p =.08) p =.97). Bleeding was decreased in intervention arm (24.19 % (15/62) v 9.09 % (5/55) p =.03). Median (IQR) pelvic pain score was similar (2.0 (0-5.0) v 2.0 (0-4.0) p =.26). Median total operative time (IQR) (129 min (102, 166) v 139 min (120, 163) p =.39) and median EBL (IQR) (50 mL (30-75) vs 50 mL (20-75) p =.43) were similar. Cuff closure in seconds (IQR) was higher in intervention group (373 sec (323, 518) v 571 sec (520, 715) p <.01). 8/60 control patients visited the ED (13.33 %) v 7/54 (12.96 %) p =.95. Readmissions (1.67 % (1/60) v 1.85 % (1/55) p = 1), re-operations (0 % (0/60) v 1.85 % (1/55) p =.47) and postoperative infections (5.0 % (3/60) v 1.85 % (1/54) p =.62) were similar. Secondary survey showed no significant difference in bleeding (15.38 % (4/26) v 4.35 % (1/23) p =.35) and SF-36 results were similar. CONCLUSION Independently suturing the vaginal cuff angles reduces patients' perception of vaginal bleeding in the early postoperative period. Incidence of complications, reoperations, and long-term quality of life are similar.
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2.
Minimizing blood loss in laparoscopic myomectomy with temporary occlusion of the hypogastric artery
Balulescu, L., Nistor, S., Lungeanu, D., Brasoveanu, S., Pirtea, M., Secosan, C., Grigoras, D., Caprariu, R., Pasquini, A., Pirtea, L.
Frontiers in medicine. 2023;10:1216455
Abstract
INTRODUCTION Uterine leiomyomas are common benign pelvic tumors. Currently, laparoscopic myomectomy (LM) is the preferred treatment option for women in the fertile age group with symptomatic myomas. The authors hypothesize that combining LM with a bilateral temporary occlusion of the hypogastric artery (TOHA) using vascular clips minimizes uterine blood flow during surgery and can significantly reduce surgery-associated blood loss. MATERIALS AND METHODS This single-center, prospective randomized study was conducted at the Department of Obstetrics and Gynecology, Municipal Emergency Clinical Hospital Timisoara, Romania. Patients aged between 18 and 49 who preferred laparoscopic myomectomy and wished to preserve fertility were included, provided they had intramural uterine leiomyomas larger than 4 cm in diameter that deformed the uterine cavity. The study analyzed data from 60 laparoscopic myomectomies performed by a single surgeon between January 2018 and December 2020. Patients were randomly assigned to either: "LM + TOHA" group (29 patients), and "LM" group (31 patients). The study's main objective was to evaluate the impact of TOHA on perioperative blood loss, expressed as mean differences in Hb (delta Hb). RESULTS Delta Hb was statistically lower in the "LM + TOHA" group compared to "LM" group, with mean ± standard (min-max): 1.68 ± 0.67 (0.39-3.99) vs. 2.63 ± 1.06 (0.83-4.92) g/dL, respectively (p < 0.001). There was a statistically significant higher need for postoperative iron perfusion in the "LM" group, specifically 0 vs. 12 patients (p < 0.001), and lower postoperative anemia in "LM + TOHA" group (p < 0.001). Necessary artery clipping time was 10.62 ± 2.47 (7-15) minutes, with no significant impact on overall operative time: 110.2 ± 13.65 vs. 106.3 ± 16.48 (p = 0.21). There was no difference in the length of hospitalization or 12-month post-intervention fertility. DISCUSSION Performing bilateral TOHA prior to laparoscopic myomectomy has proven to be a valuable technique in reducing surgery-associated blood loss, while minimizing complications during surgery, with no significant increase in the overall operative time. CLINICAL TRIAL REGISTRATION ISRCTN registry, (www.isrctn.com), identifier ISRCTN66897343.
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3.
The Efficiency of a Uterine Isthmus Tourniquet in Minimizing Blood Loss during a Myomectomy-A Prospective Study
Balulescu, L., Brasoveanu, S., Pirtea, M., Balint, O., Ilian, A., Grigoras, D., Olaru, F., Margan, M. M., Alexandru, A., Pirtea, L.
Medicina (Kaunas, Lithuania). 2023;59(11)
Abstract
Background and Objectives: The objective of this study was to assess the effectiveness of using a peri-cervical tourniquet in reducing blood loss during a laparoscopic myomectomy. Materials and Methods: This prospective study evaluated the impact of performing a concomitant tourniquet placement during a laparoscopic myomectomy (LM). A total of 60 patients were randomly allocated to one of two groups: 30 patients who underwent an LM with a tourniquet placement (the TLM group) and 30 patients who benefited from a standard LM (the SLM group). This study's main objective was to evaluate the impact of tourniquet use on perioperative blood loss, which is quantified as the difference in the pre- and postoperative hemoglobin levels (Delta Hb) and the postoperative blood transfusion rate. Results: The mean Delta Hb was statistically lower in the TLM group compared to the SLM group: 1.38 g/dL vs. 2.41 g/dL (p < 0.001). The rate of postoperative iron perfusion in the TLM group was significantly lower compared to the SLM group (4 vs. 13 patients; p = 0.02). All four patients that required a blood transfusion were from the SLM group. On average, the peri-cervical tourniquet fastening time was 10.62 min (between 7 and 15 min), with no significant impact on the overall operative time: 98.50 min for the TLM group compared to 94.66 min for the SLM group. Conclusions: Fastening a tourniquet during a laparoscopic myomectomy is a valuable technique to effectively control intraoperative bleeding and enhance surgical outcomes.
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4.
Triple vs. single uterine tourniquet to reduce hemorrhage at myomectomy: a randomized trial
Gümüsburun, N., Yapca, O. E., Ozdes, S., Al, R. A.
Archives of gynecology and obstetrics. 2023
Abstract
PURPOSE This study aimed to compare the effect of triple uterine tourniquet and single tourniquet on intraoperative blood loss during open myomectomy. METHODS Women were randomized to undergo open myomectomy with a triple (n = 30) or single uterine tourniquet (n = 30). All symptomatic women aged 18-48 who had three or more myomas or at least one myoma greater than 8 cm if there were less than three myomas were eligible for the study. The primary outcome variable was the volume of intraoperative blood loss. The sample size was set to detect a 240 ml difference in blood loss with 80% power at α = 0.05, with an effect size of 0.8. The rate of transfusions, change in hemoglobin, volume of drains, operation time, tourniquet time, and perioperative complications were secondary outcomes. RESULTS We found no significant difference in intraoperative blood loss between triple and single uterine tourniquets (527 [102-2931]) ml vs. 508 [172-2764] ml, p = 0.238). Between the single and triple tourniquet groups, the median weight of myoma (379 [136-3850] vs. 330 [140-1636] g, p = 0.451) and median number (1 [1-18] vs. 2 (1-13), p = 0.214), total operation time (84 ± 31 min vs. 79 ± 27 min, p = 0.503), ischemia time (35 ± 21 min vs. 30 ± 14 min., p = 0.238), drain volume at 48th hour (196 ± 89)ml vs. 243 ± 148 ml, p = 0.144) and decrease in hemoglobin (2.3 ± 1.8 g/dl vs. 2.8 ± 1.4 g/dl, p = 0.437) were similar. Eight (27%) patients in the triple tourniquet group and 12 (40%) patients in the single tourniquet group were transfused (p = 0.273). One patient underwent hysterectomy 6-8 h after myomectomy in a single tourniquet group. CONCLUSION There was no clinically significant difference in intraoperative blood loss between triple and single uterine tourniquets during open myomectomy. CLINICAL TRIAL REGISTRATION NUMBER AND DATE OF REGISTRATION ClinicalTrials.gov ID: NCT02392585, 03/13/2015.
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5.
Efficacy and safety of V-Loc(™) barbed sutures versus conventional suture techniques in gynecological surgery: a systematic review and meta-analysis
Hafermann, J., Silas, U., Saunders, R.
Archives of gynecology and obstetrics. 2023
Abstract
PURPOSE One of the most challenging tasks in laparoscopic gynecological surgeries is suturing. Knotless barbed sutures are intended to enable faster suturing and hemostasis. We carried out a meta-analysis to compare the efficacy and safety of V-Loc(™) barbed sutures (VBS) with conventional sutures (CS) in gynecological surgeries. METHODS We systematically searched PubMed and EMBASE for studies published between 2010 and September 2021 comparing VBS to CS for OB/GYN procedures. All comparative studies were included. Primary analysis and subgroup analyses for the different surgery and suturing types were performed. Primary outcomes were operation time and suture time; secondary outcomes included post-operative complications, surgical site infections, estimated blood loss, length of stay, granulation tissue formation, and surgical difficulty. Results were calculated as weighted mean difference (WMD) or risk ratio (RR) and 95% confidence intervals (CI) with a random effects model, and a sensitivity analysis for study quality, study size, and outlier results was performed. PROSPERO registration: CRD42022363187. RESULTS In total, 25 studies involving 4452 women undergoing hysterectomy, myomectomy, or excision of endometrioma. VBS were associated with a reduction in operation time (WMD - 17.08 min; 95% CI - 21.57, - 12.59), suture time (WMD - 5.39 min; 95% CI - 7.06, - 3.71), surgical site infection (RR 0.26; 95% CI 0.09, 0.78), estimated blood loss (WMD - 44.91 ml; 95% CI - 66.01, - 23.81), granulation tissue formation (RR 0.48; 95% CI 0.25, 0.89), and surgical difficulty (WMD - 1.98 VAS score; 95% CI - 2.83, - 1.13). No difference between VBS and CS was found regarding total postoperative complications or length of stay. Many of the outcomes showed high heterogeneity, likely due to the inclusion of different surgery types and comparators. Most results were shown to be robust in the sensitivity analysis except for the reduction in granulation tissue formation. CONCLUSION This meta-analysis indicates that V-Loc(™) barbed sutures are safe and effective in gynecological surgeries as they reduce operation time, suture time, blood loss, infections, and surgical difficulty without increasing post-operative complications or length of stay compared to conventional sutures.
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6.
A comparison of the effect of placental extraction from exteriorized versus non-exteriorized uterus on blood loss during caesarean section in Nigerian women
Innocent, O., Osamudia, O., Patrick, I. O.
African journal of reproductive health. 2023;27(9):65-75
Abstract
The purpose of this study was to determine the effect of placenta extraction from exteriorized uterus versus placenta extraction from non- exteriorized uterus on blood loss during caesarean section (CS). It was a randomized control study in which 98 women undergoing caesarean section were allocated randomly to either the placental delivery from exteriorized uterus or placental delivery from non-exteriorized uterus. The main outcome measure was intraoperative blood loss, and Intention to treat analysis was used. More participants in the non-exteriorized placenta removal group had blood loss ≥500mls (P-value <0.001). Logistic regression showed about 5times likelihood of having blood loss of 500mls or more in the non-exteriorized group (P< 0.001; OR: 5.67; 95%CI: 2.38-13.40). The mean estimated blood loss was 54.1mL less in exteriorized placenta removal group (476.12±160.86 versus 530.20±145.18; P-value = 0.084). The mean changes in haemoglobin concentration in exteriorized and non-exteriorized groups were 0.68±0.19g/dL and 0.74±0.20g/dL; P = 0.131) respectively. This study showed statistically significant difference in blood loss of 500mls or more in the placenta delivery from non-exteriorized compared to the exteriorized group. However, there was no significant difference in the mean blood loss, duration of surgery, and change in haemoglobin between the two groups.
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7.
Efficacy and safety of robot-assisted laparoscopic myomectomy versus laparoscopic myomectomy: a systematic evaluation and meta-analysis
Sheng, Y., Hong, Z., Wang, J., Mao, B., Wu, Z., Gou, Y., Zhao, J., Liu, Q.
World journal of surgical oncology. 2023;21(1):230
Abstract
OBJECTIVE Systematic evaluation of the efficacy and safety of robotic-assisted laparoscopic myomectomy (RALM) versus laparoscopic myomectomy (LM). METHODS PubMed, Embase, The Cochrane Library, and Web of Science database were searched by computer to seek relevant literature in order to compare the efficacy and safety of RALM with that of LM from the establishment of the databases to January 2023, and Review Manager 5.4 software was utilized to perform a meta-analysis on the literature. RESULTS A total of 15 retrospective clinical controlled studies were included. There exists a total of 45,702 patients, among 11,618 patients in the RALM group and the remaining 34,084 patients in the LM group. Meta-analysis results revealed that RALM was associated with lesser intraoperative bleeding (MD = - 32.03, 95%CI - 57.24 to - 6.83, P = 0.01), lower incidence of blood transfusions (OR = 0.86, 95%CI 0.77 to 0.97, P = 0.01), shorter postoperative hospital stay (MD = - 0.11, 95%CI - 0.21 to - 0.01, P = 0.03), fewer transitions to open stomach (OR = 0.82, 95%CI 0.73 to 0.92, P = 0.0006), and lower incidence of postoperative complications (OR = 0.58, 95%CI 0.40 to 0.86, P = 0.006) than LM, whereas LM is more advantageous in terms of operative time (MD = 38.61, 95%CI 19.36 to 57.86, P < 0.0001). There was no statistical difference between the two surgical methods in terms of maximum myoma diameter (MD = 0.26, 95%CI - 0.17 to 0.70, P = 0.24). CONCLUSION In the aspects of intraoperative bleeding, lower incidence of blood transfusions, postoperative hospital stay, transit open stomach rate, and postoperative complications, RALM has a unique advantage than that of LM, while LM has advantages over RALM in terms of operative time.
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8.
Barbed versus conventional suture in laparoscopic myomectomy: A randomized controlled study
Ateş Tatar, S., Karadağ, B., Karadağ, C., Duranoğlu Turgut, G., Karataş, S., Mülayim, B.
Turkish journal of obstetrics and gynecology. 2023;20(2):126-130
Abstract
OBJECTIVE To compare the surgical and clinical results of traditional absorbable polyglactin 910 and barbed sutures in laparoscopic myomectomy. MATERIALS AND METHODS This single-center randomized study included 75 women who underwent laparoscopic myomectomy. The uterine wall defects were closed with a continuous conventional absorbable polyglactin 910 suture (Vicryl; Ethicon, Somerville, NJ, USA) in 41 women and with a unidirectional barbed suture (V-Loc 180; Covidien, Mansfield, MA, USA) in 34 women. RESULTS The time required to suture the uterine wall defect was lower in the V-Loc group than in the Vicryl group (p=0.007). However, no significant difference was observed in the operative time between the two study groups. The intraoperative blood loss and need for postoperative blood transfusion were significantly lower in the barbed group than in the Vicryl group (p=0.018 and p=0.048, respectively). CONCLUSION In laparoscopic myomectomy cases, the unidirectional barbed suture is more effective than the conventional absorbable suture. Barbed sutures facilitate the suturing process and reduce the time required to suture the uterine wall defect, blood loss, and the need for postoperative blood transfusion.
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9.
Effects of misoprostol in reducing blood loss during abdominal myomectomy in Nigeria
Nnagbo JE, Dim CC, Eze MI, Mba SG
Nigerian journal of clinical practice. 2023;26(4):454-462
Abstract
BACKGROUND Despite using a tourniquet to reduce bleeding during abdominal myomectomy, the procedure is still complicated by significant intraoperative bleeding. AIM: To determine whether misoprostol and tourniquet compared with tourniquet alone would significantly reduce bleeding during abdominal myomectomy at two tertiary hospitals in Enugu. MATERIALS AND METHODS This study is an open-label randomized controlled trial. A total of 126 consenting participants were recruited from women booked for abdominal myomectomy at the study centers over 7 months. They were randomized into groups A (vaginal misoprostol 400 μg) and B (no misoprostol) one hour before surgery. Intraoperatively, all participants had a tourniquet application. Intraoperative and postoperative blood loss was compared between the two groups. Descriptive and inferential analyses were carried out using IBM SPSS Version 22.0. A P- value of < 0.05 was considered statistically significant. RESULTS An intention-to-treat analysis was carried out. All 63 participants (100%) and 56 (90%) completed the study according to the protocol in groups A and B, respectively. Socio-demographic characteristics were not significantly different in both groups. The mean intraoperative blood loss in the "misoprostol group" (522.6 ± 127.91 ml) was significantly lower than in the "no-misoprostol group" (583.5 ± 186.20 ml), with P = 0.028. The difference in mean hemoglobin (g/dl) was lower in the "misoprostol group" than in the "no-misoprostol group" (1.3 ± 0.79 vs. 1.9 ± 0.89, P < 0.001). The mean 48 hours postoperative blood loss (ml) between the two groups was 323.8 ± 221.44 vs. 549.4 ± 519.72), with P = 0.001. CONCLUSION Among women receiving tourniquet during myomectomy in Enugu, the additional use of vaginal misoprostol 400 μg significantly reduced intraoperative blood loss.
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10.
Therapeutic effect of Internal iliac artery ligation and uterine artery ligation techniques for bleeding control in placenta accreta spectrum patients: A meta-analysis of 795 patients
Nabhan AE, AbdelQadir YH, Abdelghafar YA, Kashbour MO, Salem N, Abdelkhalek AN, Nourelden AZ, Eshag MME, Shah J
Frontiers in surgery. 2022;9:983297
Abstract
Placenta accreta spectrum (PAS) can cause complications like hysterectomy or death due to massive pelvic bleeding. We aim to evaluate the efficacy of two different arterial ligation techniques in controlling postpartum haemorrhage and minimizing bleeding complications. We searched six databases. 11 studies were finally included into our review and analysis. We graded their quality using the Cochrane tool for randomized trials and the NIH tool for retrospective studies. Our analysis showed that internal iliac artery ligation has no significant effect on bleeding control (MD = -248.60 [-1045.55, 548.35] P = 0.54), while uterine artery ligation significantly reduced the amount of blood loss and preserved the uterus (MD = -260.75, 95% CI [-333.64, -187.86], P < 0.00001). Uterine artery ligation also minimized the need for blood transfusion. Bleeding was best controlled by combining both uterine artery ligation with uterine tamponade (MD = 1694.06 [1675.34, 1712.78], P < 0.00001). This combination also showed a significant decrease in hysterectomy compared to the uterine artery ligation technique alone. Bilateral uterine artery ligation in women with placenta accreta spectrum can effectively reduce the amount of bleeding and the risk of complications. The best bleeding control tested is a combination of both, uterine artery ligation and cervical tamponade. These techniques may offer an easy and applicable way to preserve fertility in PAS patients. Larger randomized trials are needed to define the best technique.