Evaluation of Total Laparoscopic Hysterectomy With and Without the Use of Barbed Suture

Evaluation of Total Laparoscopic Hysterectomy With and Without the Use of Barbed Suture

GYNAECOLOGY Evaluation of Total Laparoscopic Hysterectomy With and Without the Use of Barbed Suture Ali Bassi, MD, Togas Tulandi, MD, MHCM Department...

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GYNAECOLOGY

Evaluation of Total Laparoscopic Hysterectomy With and Without the Use of Barbed Suture Ali Bassi, MD, Togas Tulandi, MD, MHCM Department of Obstetrics and Gynecology, McGill University, Montreal QC

Abstract Objective: To evaluate the outcome of total laparoscopic hysterectomy with and without the use of barbed suture. Methods: We conducted a retrospective study among patients who underwent total laparoscopic hysterectomy between February 2008 and August 2012. The parameters evaluated were age, BMI, operative time, hospital stay, pre- and postoperative hemoglobin levels, uterine weight, intraoperative blood loss, and postoperative complications. Results: A total of 202 women underwent total laparoscopic hysterectomy; barbed suture (V-Loc) was used in 63 women, and polydioxanone (PDS) in 139. Estimated blood loss, difference in hemoglobin level before and after surgery, operative time, and the duration of hospital stay were comparable between the two groups of patients. The incidence of postoperative fever was higher in the V-Loc group than in the PDS group (P = 0.003). Multiple linear regression analysis showed that the incidence of postoperative fever was related to BMI (P = 0.02, r = 0.22) and estimated blood loss (P = 0.004, r = 0.28) and not to age, operative time, or uterine weight. Conclusion: The use of barbed suture to close the vaginal vault after laparoscopic hysterectomy, compared with standard suture, results in similar operative time, blood loss, and duration of hospital stay. The use of barbed suture is technically less demanding than the use of regular sutures.

Résumé Objectif : Évaluer l’issue de l’hystérectomie laparoscopique totale, avec ou sans utilisation de sutures barbelées. Méthodes : Nous avons mené une étude rétrospective auprès de patientes ayant subi une hystérectomie laparoscopique totale entre février 2008 et août 2012. Les paramètres évalués étaient l’âge, l’IMC, la durée opératoire, le séjour à l’hôpital, les taux d’hémoglobine préopératoire et postopératoire, le poids utérin, la perte sanguine peropératoire et les complications postopératoires. Key Words: Barbed suture, laparoscopic hysterectomy, vaginal vault, V-Loc suture Competing Interests: See Acknowledgement. Received on December 31, 2012 Accepted on April 26, 2013

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Résultats : Au total, 202 femmes ont subi une hystérectomie laparoscopique totale; une suture barbelée (V-Loc) a été utilisée chez 63 femmes, tandis qu’une suture polydioxanone (PDS) a été utilisée chez les 139 autres femmes. La perte sanguine estimée, la différence entre le taux d’hémoglobine constaté avant la chirurgie et celui qui est constaté après celle-ci, la durée opératoire et la durée du séjour à l’hôpital étaient comparables dans les deux groupes de patientes. L’incidence de la fièvre postopératoire était plus élevée au sein du groupe « V-Loc » qu’au sein du groupe « PDS » (P = 0,003). L’analyse de régression linéaire multiple a indiqué que l’incidence de la fièvre postopératoire était liée à l’IMC (P = 0,02, r = 0,22) et à la perte sanguine estimée (P = 0,004, r = 0,28), mais non à l’âge, à la durée opératoire ou au poids utérin. Conclusion : L’utilisation d’une suture barbelée pour fermer le dôme vaginal à la suite d’une hystérectomie laparoscopique donne lieu à des résultats semblables à ceux de l’utilisation d’une suture standard en ce qui concerne la durée opératoire, la perte sanguine et la durée du séjour à l’hôpital. L’utilisation d’une suture barbelée est moins exigeante sur le plan technique que l’utilisation de sutures régulières.

J Obstet Gynaecol Can 2013;35(8):718–722

INTRODUCTION

H

ysterectomy is one of the most common gynaecologic operations performed among females aged 18 to 44 years. In the United States, more than 600 000 hysterectomies are performed each year.1 Hysterectomy is most commonly performed for the treatment of uterine fibroids, endometriosis, abnormal uterine bleeding, and gynaecologic malignancy,1 and it is usually performed by laparotomy. Depending on the surgeon’s preference and expertise, laparoscopic hysterectomy is an alternative approach. It is associated with less intraoperative blood loss, shorter hospitalization, and reduced hospital cost than hysterectomy performed by laparotomy,2 although suturing the vaginal cuff during laparoscopic hysterectomy can be challenging.2

Evaluation of Total Laparoscopic Hysterectomy With and Without the Use of Barbed Suture

Barbed suture is a new class of suture material that has been used in different surgical specialties since 2009. It is approved by the United States Food and Drug Administration and by Health Canada. V-Loc suture (Covidien, Mansfield, MA) is a form of barbed suture with unidirectional, shallow barbs with circumferential distribution. It has a needle at one end and a loop at another. These barbs and loop serve to anchor the tissue without knots. Use of barbed suture leads to a shorter time required for suturing.3 The tensile strength of V-Loc suture is 80% at one week after surgery, 75% at two weeks, and 65% at three weeks; the suture is totally absorbed by six months.4 Bidirectional suture (Quill, Angiotech Pharmaceutical Inc, Vancouver, BC) is another type of barbed suture. It is a knotless suture with one needle at each end and barbs facing in opposite directions from the suture midpoint.5 The tensile strength of Quill suture is 80% at four weeks after surgery, and 40% at six weeks. Like the V-Loc suture, it is completely absorbed by six months after surgery.6 This type of barbed suture is not used at McGill teaching hospitals. Because of its hemostatic property and ease of use, we have been using V-Loc suture for closure of the vaginal vault at laparoscopic hysterectomy since June 2011. The purpose of our study was to evaluate the outcome of total laparoscopic hysterectomy with and without the use of barbed suture.

Closure of the vaginal vault at laparoscopic hysterectomy. (A) insertion of the suture into the loop after the first bite at the right vaginal angle, (B) the vaginal vault has been closed with continuous running suture of V-Loc, (C) a sheath of oxidized regenerated cellulose (Surgicel) was used to cover the closed vaginal vault A

B

C

MATERIALS AND METHODS

We conducted a retrospective study of 245 patients who underwent total laparoscopic hysterectomy between February 2008 and August 2012 at McGill University Health Centre. Patients who underwent laparotomy, laparoscopic subtotal hysterectomy, robotic assisted laparoscopy, additional surgical procedures besides hysterectomy, and those with an incomplete medical file were excluded from the study. Data retrieved included age, BMI, type of procedure, any additional procedures, operative time, hospital stay, pre- and postoperative hemoglobin levels, uterine weight and volume, intraoperative blood loss, and postoperative complications. Laparoscopic hysterectomy was performed in the usual manner. From February 2008 to June 2011, closure of the vaginal vault was performed using three figure-of-eight sutures of 0-polydioxanone (PDS) suture (Ethicon Inc., Somerville NJ) that were tied intracorporeally. After June 2011, we used V-Loc continuous running suture to close the vaginal vault, and we covered the vaginal vault with a sheath of oxidized regenerated cellulose (Surgicel, Ethicon Inc., Somerville NJ) (Figure). The use of the cellulose sheath was

to prevent adhesions to the sutures that might cause bowel obstruction.7,8 In this study, all suturing was performed by a single surgeon (T.T.). All blood was suctioned from the pelvis and measured and recorded immediately after surgery. The Shapiro Wilks test was used to evaluate the distribution of the data. Comparisons were analyzed using Student t test or Mann–Whitney U test when appropriate. Proportions were compared with chi-square test or Fisher exact test. A P value of less than 0.05 was considered significant. The Research and Ethics Board of McGill University Health Centre approved the study. RESULTS

Of a total 245 patients who underwent laparoscopic hysterectomy, 202 cases were included for analysis and 43 cases were excluded. Of these excluded cases, 25 had AUGUST JOGC AOÛT 2013 l 719

Gynaecology

Table 1. Comparison of the profiles of women who underwent total laparoscopic hysterectomy and closure of the vaginal vault with PDS or V-Loc suture* Patient’s profile

V-Loc group (n = 63)

PDS group (n = 139)

Age, years

46.24 ± 1.13

45.84 ± 0.77

BMI, kg/m2

27.35 ± 1

26.7 ± 0.51

Uterus weight, g

191.35 ± 17.69

204.32 ± 15.71

Uterus volume, cm3

405.05 ± 49.82

402.34 ± 41.53

*Values are given as mean ± standard error of the mean

Table 2. Indications for surgery V-Loc group (n = 63) n (%)

PDS group (n = 139) n (%)

Symptomatic fibroid

28 (44.4)

61 (43.9)

Intractable menorrhagia

Variable

22 (34.9)

51 (36.7)

Gender reassignment

4 (6.3)

7 (5.0)

Prophylactic surgery for breast cancer

3 (4.8)

12 (8.6)

Chronic pelvic pain

2 (3.2)

5 (3.6)

Complex endometrial hyperplasia

2 (3.2)

2 (1.4)

Endometriosis

1 (1.6)

1 (0.7)

Persistent ovarian cyst after menopause

1 (1.6)

0 (0)

robotic assisted laparoscopic hysterectomy, 12 underwent additional procedures besides hysterectomy, five patients underwent supracervical hysterectomy, and another was converted to laparotomy. The V-Loc suture was used in 63 of the 202 procedures (31%), and PDS was used in 139 procedures (69%). Demographic characteristics and the main indication for surgery were comparable between the two groups of patients (Tables 1 and 2). Uterine fibroids and menorrhagia were the most common indications for surgery. Estimated blood loss, the difference in hemoglobin level before and after surgery, operative time, and the duration of hospital stay were comparable between the two groups (Table 3). None of the patients required blood transfusion or further surgery. Postoperative complications in the two groups of patients are shown in Table 4. The incidence of postoperative fever was higher in the V-Loc group than in the PDS group (P  =  0.003). On the other hand, the incidence of postoperative vaginal bleeding tended to be higher in the PDS group. Multiple linear regression showed that the incidence of postoperative fever was related to BMI 720 l AUGUST JOGC AOÛT 2013

(P = 0.02, r = 0.22) and blood loss (P = 0.004, r = 0.28) and not to age, operative time, or uterine weight. Fever usually resolved after a few days with antibiotic treatment. DISCUSSION

Barbed suture is a relatively new type of suture. It distributes the tension along the suture thread without the need for knot tying. In a review, Greenberg stated that the weakest spot in any surgical suture line is the knot, and using the knotless barbed suture may improve the tensile strength of the suture, leading to more secure closure and less blood loss.5 In this study, we evaluated the efficacy of vaginal vault closure using V-Loc suture versus PDS suture in 202 patients who underwent total laparoscopic hysterectomy. No significant differences between the two groups were found in operative time, blood loss, drop in hemoglobin level, and hospital stay. However, we found that suturing the vaginal cuff with V-Loc suture was technically less demanding than suturing with PDS suture. In fact, its availability has allowed more gynaecologists in our institution to perform laparoscopic

Evaluation of Total Laparoscopic Hysterectomy With and Without the Use of Barbed Suture

Table 3. Comparison of estimated blood loss, difference in hemoglobin level, operative time, and hospital stay* Variable Estimated blood loss, mL

V-Loc group (n = 63)

PDS group (n = 139)

153.97 ± 13.01

159.17 ± 8.38

Reduction in hemoglobin level, g/L

20.47 ± 1.36

20.48 ± 0.96

Operative time, minutes

115.9 ± 4.18

118.6 ± 2.42

1.0 ± 0.04

1.2 ± 0.06

Hospital stay, days

*Values are given as mean ± standard error of the mean

Table 4. Postoperative complications V-Loc group (n = 63) n (%)

PDS group (n = 139) n (%)

P

Pelvic abscess

2 (3.2)

1 (0.7)

NS

Postoperative fever

5 (7.9)

0 (0)

0.003

Type of complications

Vaginal bleeding

0 (0)

3 (2.2)

NS

Urinary tract infection

1 (1.5)

1 (0.7)

NS

Incisional hernia

1 (1.5)

0 (0)

NS

Wound hematoma

1 (1.5)

0 (0)

NS

NS: not significant

suturing. The use of V-Loc suture was also associated with good hemostasis. However, we did not measure the time required to close the vaginal vault. In a randomized study comparing the effectiveness of V-Loc and polyglactin 910 suture for closure of the uterine incision during laparoscopic myomectomy, Alessandri et al. reported that the time required for suturing was significantly decreased in the V-Loc group compared with the polyglactin 910 group.9 The mean difference was 5.9 minutes. They also found that blood loss in the V-Loc group was significantly lower than that in the polyglactin 910 group. However, in agreement with the results of our study, the total operative time was not significantly different.9 In another study of myomectomy with a historical control, the operative time in the V-Loc group was approximately 7 minutes shorter than in the control group.10 The time required to suture the vaginal vault after hysterectomy is certainly shorter than that required for closure of multiple myomectomy incisions. Yet this time difference might not be clinically relevant. The ease of using V-Loc suture and the apparently improved hemostasis are more important to both the surgeon and the patient than the suturing time.

The overall complication rate in the V-Loc group was 15.9% and in the PDS group was 3.6%. The incidence of postoperative fever was higher in the V-Loc group than in the PDS group. The occurrence of postoperative fever appeared to be related to increased BMI and blood loss. A possible complication of vaginal vault closure with barbed suture is bowel obstruction. Donnellan and Mansuria reported a case of small bowel obstruction after laparoscopic hysterectomy in which a 4 cm tail of a bidirectional barbed suture was found attached to the bowel mesentery and pulled tight across the bowel.7 These authors advocated applying a Lapra-Ty suture clip (Ethicon Endosurgery, Cincinnati OH) to allow the suture tail to be cut flush with the clip. They believed that cutting the suture flush with the tissue might be associated with retraction and loosening of the suture. Small bowel obstruction following the use of V-Loc suture at myomectomy has also been reported.8 The authors of this report found a segment of small bowel that was wrapped around a 4 cm length of unravelled V-Loc suture protruding from the myomectomy site. Because of concern about this possible complication, we recommend cutting the tail of the V-Loc suture almost flush with the tissue and then covering the vaginal vault with Surgicel. AUGUST JOGC AOÛT 2013 l 721

Gynaecology

The cost can be reduced by covering the vaginal vault with the peritoneum, eliminating the need to use Surgicel. It is unlikely that the use of Surgicel was associated with the increased incidence of postoperative fever. We noted three cases with postoperative vaginal bleeding in the PDS group and none in the V-Loc group. The bleeding resolved spontaneously. None of the patients had vaginal vault dehiscence. The limitation in our study is that we did not measure the time required for suturing the vaginal cuff. Furthermore, it was a retrospective study and the patients were followed up to only eight weeks postoperatively, after which they returned to the care of their primary gynaecologist. CONCLUSION

The use of barbed suture to close the vaginal vault after laparoscopic hysterectomy does not change operative time, blood loss, or duration of hospital stay compared with use of standard suture. Laparoscopic hysterectomy with the use of barbed suture to close the vaginal vault is associated with an increased incidence of postoperative fever, which appears to be related to increased BMI and blood loss. The use of barbed suture is technically less demanding than the use of regular sutures. ACKNOWLEDGEMENT

Dr Togas Tulandi is an advisor for Watson Pharma.

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REFERENCES 1. Merrill RM. Hysterectomy surveillance in the United States, 1997 through 2005. Med Sci Monit 2008;14:24–31. 2. Abenhaim HA, Azziz R, Hu J, Bartolucci A, Tulandi T. Socioeconomic and racial predictors of undergoing laparoscopic hysterectomy for selected benign diseases: analysis of 341 487 hysterectomies. J Minim Invasive Gynecol 2008;15:11–5. 3. Greenberg JA, Clark RM. Advances in suture material for obstetrics and gynecologic surgery. Rev Obstet Gynecol 2009;2:146–58. 4. Zorn K, Widmer H, Lattouf JB, Liberman D, Bhojani N, Trinh QD, et al. Novel method of knotless vesicourethral anastomosis during robot-assisted radical prostatectomy: feasibility study and early outcomes in 30 patients using the interlocked barbed unidirectional V-LOC180 suture. Can Urol Assoc J 2011;5:188–94. 5. Greenberg JA. The use of barbed sutures in obstetrics and gynecology. Rev Obstet Gynecol 2010;3:82–91. 6. Siedhoff MT, Yunker AC, Steege JF. Decreased incidence of vaginal cuff dehiscence after laparoscopic closure with bidirectional barbed suture. J Minim Invasive Gynecol 2011;18:218–23. 7. Donnellan NM. Mansuria SM. Small bowel obstruction resulting from laparoscopic vaginal cuff closure with a barbed suture. J Minim Invasive Gynecol 2011;18:528–30. 8. Kindinger L, Setchell T, Miskry T. Bowel obstruction due to entanglement with unidirectional barbed suture following laparoscopic myomectomy. Gynecol Surg 2012;9:357–8. 9. Alessandri F, Remorgida V, Venturini PL, Ferrero S. Unidirectional barbed suture versus continuous suture with intracorporeal knots in laparoscopic myomectomy: a randomized study. J Minim Invasive Gynecol 2010;17:725–9. 10. Angioli R, Plotti F, Montera R, Damiani P, Terranova C, Oronzi I, et al. A new type of absorbable barbed suture for use in laparoscopic myomectomy. Int J Gynaecol Obstet 2012;117:220–3.