- Original Article
- Open Access
Painless vaginal hysterectomy with thermal hemostasis (results of a series of 152 cases)
© Springer-Verlag Berlin / Heidelberg 2005
- Received: 23 February 2005
- Accepted: 23 March 2005
- Published: 25 May 2005
In a preceding paper the authors described a completely new approach for vaginal hysterectomy. The classical technique has been simplified, including thermal hemostasis with BiClamp, multimodal anesthesia, and ongoing research aimed at ensuring minimal trauma. The authors describe the first group of 152 patients who were treated with this new approach. The results show that it is possible to expand the range of vaginal indications while shortening the patient’s hospital stay to 1 day. Furthermore, this innovative surgery is becoming more generally accepted, resulting in better quality of life for the patients.
- Local anesthesia
Starting in March 2002, we developed an innovative technique for performing vaginal hysterectomy with the aim of fighting pain to obtain a fast postoperative recovery. The anesthetic and surgical procedures were published in March 2003 in a preliminary paper  and were then developed on a base of 152 cases in a review. In this article we present the results of this series, with comments.
The operative technique
Technological innovation through thermal hemostasis of the vessels with BiClamp (ERBE, Tübingen, Germany). BiClamp is a type of “electrical Jean-Louis Faure” clamp that allows safe hemostasis of large vessels; the two branches of the forceps act like the electrodes of a bipolar clamp. It is made to be used more than 50 times. Electric current is provided by the VIO electrosurgical generator (ERBE, Tübingen, Germany).
Multimodal anesthesia consisting of the combination of a general anesthetic with a locoregional anesthetic with a long-term effect; this multimodal approach has been proposed in order to control the pathophysiological problems caused by operative and postoperative nociceptive effects; it allows a better convalescence with reduced dosages and fewer side effects.
Ongoing research aimed at achieving minimal trauma (good information concerning the procedure, no shaving, no bladder catheterization, short hospital stay, etc.)
This series consists of the first 152 patients who were operated on between March 2002 and July 2004 by the same surgeon and with an identical anesthetic technique. The group was divided into three subgroups. Using a test series of 20 patients between March 2002 and September 2002, subgroup A, the feasibility of this technique was assessed, and together with the ERBE company the generator settings were subsequently optimized.
Between September 2002 and December 2002, a subgroup Bb with 25 patients was randomly compared with patients receiving classical vaginal hysterectomy with general anesthetic (subgroup Ba); this randomization particularly focused on the assessment of postoperative pain and the need for analgesics. Subgroup C consisted of the last 50 operated patients (excluding those with prolapse), who received the benefit of the technical, operative, and organizational improvements implemented by the operating team.
Three cases of burns to the vulva or vagina occurred at the beginning of our tests, which required subsequent local treatment over a period of 5 days.
Three cases of secondary bleeding of the vaginal incision required these patients to be readmitted to the hospital. This type of bleeding occurred during the period in which we used “Vicryl Rapide” 00 for closure of the vagina, which was a mistake: Two of these cases required a repeat of the vaginal suture under general anesthetic on the 18th and 21st days, respectively, whereas the third case required only a vaginal tampon.
On day 15 a surgical vaginal examination was carried out in one patient for pain assessment; the patient had had a hemorrhagic rupture of a follicular cyst.
A febrile and painful hematoma on day 5 was due to bleeding of the ovarian wall after a simultaneous vaginal cystectomy (cyst diameter 5 cm); this was treated medically at home.
One patient was readmitted on day 7 for 2 days because of febrile lateral pelvic pain; this rapidly normalized after antibiotic therapy.
One patient with pyelonephritis (prior illness) required longer hospitalization.
Reduction of morphine in comparative study (LRA locoregional anesthetic, VAS visual analog scale)
Ba (control group, n=25)
Bb (BiClamp + LRA, n=25)
Consumption of morphine (D1) (mg/24 h)
If no motor block and no block of the upper sympathicus (in contrast to a spinal block) is carried out and if the patient does not receive any morphine, then the sensation of uriesthesis will be unaffected, and bladder evacuation will continue to function [6, 7].
Duration of the procedure
Duration of the procedure was investigated in subgroup C with the last 50 patients. The medium length of time between the incision and closure of the vagina was 30 min (range 12–80 min); this is equal to or slightly less that for the classical technique.
The time required for thermal hemostasis may appear to be rather long. It requires positioning the BiClamp, removing the BiClamp after the generator has switched off automatically, and making a cut with scissors—that is, a total of three steps. However, achieving a classical hemostasis with sutures requires positioning the hemostasis clamp, cutting the pedicle with scissors, positioning the suture with a needle holder, knotting the sutures, removing the clamp, and cutting the suture with scissors—that is, a total of six steps with several changes of instruments.
In addition, thermal hemostasis also has a hemostatic effect on the two edges of the pedicle, preventing a backflow of blood and obviating the necessity of aspirating the blood or frequent swabbing with compresses. The visibility of the operative site is also improved, which in turn affects the length of the operation.
In 142 of the cases, the vaginal scar was assessed as perfect—soft and not grainy. Three patients had secondary bleeding of the vaginal scar, and in seven patients, examination at the 4th postoperative week led to the prescription of local trophic treatment and the postponement of sexual intercourse.
This excellent vaginal healing was achieved due to the absence of necrotic inflammatory magma from foreign matter (dissolution of sutures) and the absence of tissue necrosis in the stumps, and by the creation of a simple, well-placed, and not too taut suture made of resorbable monofilament thread No. 1. This healing makes it possible for patients to have satisfactory sexual intercourse; we have no randomization concerning this point, but a retrospective analysis that is still being carried out points in this direction.
The loss of blood was minimal; we examined the blood loss in group C based on the number of compresses and gauze pads used. Each procedure required 1.3 gauze strips and six damp compresses on average. The insignificant blood loss was much appreciated by the patients, who often suffered from anemia or iron deficiency, and is yet another benefit of the operation, as uterine morcellation or adnexal exeresis are possible without the need for haste and under good conditions of safety.
At the beginning of the study (subgroup A)
The hospital stay of this group was long due to our uncertainty about the procedure; the average stay was 6 days (OP day +4 days).
In subgroup B
The average stay was shortened to 4.1 days (OP day +2.1 days).
In subgroup C
We hoped to be able to carry out this intervention on a purely outpatient basis. We were able to achieve this goal in six out of 50 vaginal hysterectomies. We discovered in this connection that in France the obstacles that had to be overcome were more of an organizational and sociological nature than purely medical.
Subgroup C: a homogenous series of the last 50 patients
Average weight of fibromatous uterus (g)
Duration of the operative procedure (last 50 patients)
Outpatient, less than 12 h
Less than 24 h
Discharged on day 2
Discharged on day 3
The patients not only benefit from the reduced risk of hospital-acquired infection or/and thromboembolism but also from the “transparent” technique and the minimal psychological stress.
The staff can apply the policy of quality assurance in a global and quantifiable project.
This medical innovation is an important contribution in the battle against the lack of beds and staff and represents an improvement in healthcare efficiency.
The operating team is interested in applying it to other pathologic situations, thereby extending this new paradigm.
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