Page 23 - Peer Reviewed Laparoscopic Jornal

Raquel Maciel, Tânia Freitas

Different from total vaginal hysterectomy and total revealed no statistically significant difference between the
abdominal hysterectomy for TLHs: two suture methods (incidence of VCD: 1.2%).
1. Use of energy sources to make the vaginal colpotomy Several methods are described for laparoscopic intra-
may result in tissue destruction beyond the incision, abdominal cuff closure. Interrupted or continuous sutures
potentially increasing tissue necrosis and leading to poor may be tied intracorporeally with a needle driver and grasper
healing of the vaginal cuff compared with a sharp or extracorporeally with a knot pusher. 15
colpotomy that is made using a scalpel or scissors.
Different electrosurgical instruments (e.g. bipolar and TEM Clips
monopolar devices) or ultrasonic devices produce Another method already adopted, off label, in the vaginal
varying amounts of tissue destruction. cuff closure, is a suturing technique commonly used in
2. Laparoscopic magnification of the surgical field may transanal endoscopic microsurgery (TEM).
distort the view and cause the surgeon to place sutures In this technique, a regular Vicryl no. 0 with a suture
too close to the vaginal cuff edge (<1 cm) or not achieve staple placed at the distal end of the wire is sutured from
full thickness closure. the right to the left angle of the vaginal cuff, after which
3. Laparoscopic suturing to close the vaginal cuff requires another suture staple is placed at the proximal end to secure
advanced training to achieve secure knots via extra- the suture (suture clip forceps for TEM, Richard Wolf
corporeal or intracorporeal techniques. Inappropriate use GmbH, Knittlingen, Germany). In all suturing methods, both
of the laparoscopic knot pusher or poor intracorporeal uterosacral ligaments are incorporated in the repair, and the
knot tying technique may compromise suture integrity. peritoneum is unclosed.
Recently, several studies compared the influence of This way, cuff closure using a running vicryl suture with
various vaginal vault closure techniques on the incidence TEM clips, is a newly appointed alternative to other suturing
of VCD after TLH. Internationally, the etiology of VCD techniques currently in use. Although it is an easy method
is still a matter of concern. Either in its technique (TLH) to adopt, based on data, no statistical superiority of this
as in the used technology (electrosurgical colpotomy suturing procedure could be proven. 13
and/or suturing method), an explanation could be found
13
for the higher incidence of VCD. Preventive measures Barbed Suture
to minimize the risk of VCD after hysterectomy are Barbed suture is a relatively recent concept in gynecologic
uncertain since the causes are not well-established. 7 surgery. The Quill SRS bidirectional barbed suture
This study aims to review laparoscopic surgical (Angiotech Pharmaceuticals, Inc Vancouver BC, Canada)
tecnhiques in the minimal invasive hysterectomy and its was FDA approved for soft tissue approximation in 2004 16
association with VCD. and has been commercially available in the United States
A literature review was performed using PubMed, since 2007.
Medscape reference, HighWire Press and Up-to-date. The Bidirectional barbed sutures are created by cutting barbs
search was conducted using the keywords ‘laparoscopic into the suture with the barbs facing in an opposite direction
vaginal vault dehiscence’, ‘laparoscopic vaginal cuff closure to the needle. The barbs change direction at the midpoint of
techniques’, ‘vaginal cuff laparoscopic suture methods’ and the suture (Fig. 1) and needles are swaged onto both ends
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‘electrosurgery laparoscopic hysterectomy’. of the suture. Due to its decreased effective diameter, the
Fifty-eight citations were found. Among these studies, straight-pull tensile strength of barbed suture is rated one
a second selection of articles was performed according the suture size greater than smooth suture (e.g. A 0 barbed suture
purpose of this review. The selected papers were also equals a 2-0 smooth suture).
screened for further references. At the end of the process, The anchoring of bidirectional barbed suture resists
29 articles were reviewed. migration and can be conceptualized as a ‘continuous
interrupted’ suture without knots and has been shown to
LAPAROSCOPIC SUTURING METHODS
have at least equal tissue holding performance as comparable
Interrupted vs Running Sutures with Knot knot anchored suture has. 18,19 This offers several advantages.
Although techniques for suturing of the vaginal cuff have Since, bidirectional barbed sutures self anchor and are
changed rapidly over the past years, only one prospective balanced by the countervailing barbs, no knots are required.
14
study on this subject has been published. This study Furthermore, barbed suture self anchors at every 1 mm of
compared laparoscopic closure with interrupted and running tissue, yielding more consistent wound opposition. Finally,
sutures, however, with a double-layer suturing method and knotless barbed suture can securely reapproximate tissues
with an extracorporeal knotting technique. The study with less time, cost and aggravation. 20,21
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