In another randomized trial of vessel sealing versus suturing involving 68 women undergoing vaginal hysterectomy, pain was markedly reduced in the vessel-sealing group (median score, 4 vs 6; P<.0001). Operative time again was shorter with vessel sealing than with suturing (median of 32 vs 40 minutes; P = .003), but there were no differences in blood loss and hospitalization.7
Silva-Filho and colleagues randomly allocated 90 women to bipolar vessel sealing or suturing during vaginal hysterectomy.8 Vessel sealing provided reduced postoperative pain (pain score [SD] of 1.6 [0.4] vs 3.6 [0.4]; P<.001), shorter operative time (mean of 29.2 [2.1] vs 75.2 [5] minutes; P<.001), less blood loss (mean of 84 [5.9] vs 136.4 [89.1] mL; P = .001), and a shorter hospital stay (mean of 25.6 [0.9] vs 33.2 [1.7] hours; P<.001).8
A systematic review and meta-analysis by Kroft and Selk found that vessel sealing reduced: operative time by a mean of 17.2 minutes (95% confidence interval [CI],
7.5–27.0); blood loss by a mean of 47.7 mL (95% CI, 15.5–79.9); and hospital stay by a mean of 0.25 days (95% CI, 0.13–0.37) during vaginal hysterectomy.9
And in a randomized controlled trial from the Netherlands, women undergoing vaginal hysterectomy reported significantly less pain the evening after surgery in the
vessel-sealing group, compared with the suturing group (pain score of 4.5 vs 5.7 on a scale of 1 to 10; P = .03).10 They also had a shorter operative time than women in the suturing group (60 vs 71 minutes; P = .05). Blood loss and hospital stays did not differ between groups, and there were no major differences in cost.
A reduction in pain is an especially important indicator of surgical success. In an interesting twist, Candiani and colleagues compared laparoscopic and vaginal hysterectomy for a number of variables, including pain, for benign pathology.11 They found less postoperative pain the day of surgery and a reduced number of days of analgesic request in the laparoscopic group, compared with vaginal hysterectomy. One reason:
Hemostasis was achieved via vessel sealing in the laparoscopic group, compared with clamping and suturing in the vaginal group.11
Lighted suction irrigator facilitates visualization “around corners”
Many years ago, I conducted some informal studies for industry that showed—as one might guess intuitively—that the ability to see well during surgery cuts operative time. We all know that light is good. One useful lighting aid I’ve adopted of late is the Vital Vue (Covidien/Medtronic) suction irrigator. It has a disposable tip like all suction devices, but it includes 3 channels: one for a fiber optic cord, another for fluid, and the third for suction (FIGURE 1). It plugs into a regular suction machine, with a reusable box that provides the fiber optic light.
Because the suction tip is curved, the device makes it possible to illuminate the surgical field “around corners” if need be. Any bleeding can be irrigated to clear the field.
When selecting a vessel-sealing device for vaginal hysterectomy, keep in mind a number of factors:
- size of the vessels that will need to be controlled. Most devices on the market today control vessels 7 mm in size or smaller.
- amount of steam it releases, which can damage adjacent tissue
- overall size of the device
- size of the pedicles that will need to be
controlled
- overall space required for use
- cost of the device.
In other words, to choose an appropriate device, you will need to think in advance about the specifics of the case you are
planning, as not all hysterectomies are alike. The type of vessel sealer best for the surgery will vary with these details.
Both bipolar electrosurgical and ultrasonic devices now provide consistent hemostasis, increased functionality, and greater efficiency. What’s more, they cause minimal to no damage to surrounding tissue.
Designed for open surgeries, the VITOM system (Karl Storz) is an innovative tool for displaying procedures in which surgical access is limited. It’s an external telescope, or “exoscope,” with a 90° lens. It clips onto the table, providing visualization for the entire operative team (FIGURE 2).
As we all know, the advent of the camera made an enormous difference in laparoscopic procedures and in teaching because it enabled the assistant to see what the surgeon was doing and anticipate his or her needs. This device offers the same advantages for vaginal hysterectomy. In my opinion, it’s a game changer.
The VITOM system provides outstanding image quality and depth of view. It is placed at a distance of 25 cm to 75 cm from the surgical field and thus does not impinge on the surgeon’s workspace. Because it is compact, it facilitates the use of long instruments, if necessary. In addition, because it can be sterilized, the VITOM system can be manipulated directly by the surgeon or assistant.
