Obstet Gynecol Sci.  2013 Nov;56(6):389-399. 10.5468/ogs.2013.56.6.389.

Laparoscopic vaginal vault closure with conventional straight instruments in single-port access total laparoscopic hysterectomy

• Park D
• Kim J
• Jun HS
• Jeong H
• Park Y

• KMID: 1500373
• DOI: http://doi.org/10.5468/ogs.2013.56.6.389

Abstract

OBJECTIVE
Laparoscopic vaginal vault closure with conventional straight instruments is the final barrier to single-port access total laparoscopic hysterectomy (SPA-TLH). The aim of this study is to find out the safer, easier, simpler, faster, and even cheaper way to overcome it.
METHODS
Vaginal vault suturing techniques of 152 consecutive single-port access total laparoscopic hysterectomy cases performed by the author in Gangnam CHA Hospital, CHA University from October 1, 2003 to June 30, 2012, were retrospectively analysed with medical records and DVDs.
RESULTS
Of 152 patients who were attempted SPA-TLH, 119 patients (78%) were finished their operations without conversion to multi-port laparoscopy or laparotomy. Of women with successful SPA-TLH, 8 cases (7%) were closed their vaginal vaults vaginally (median, 20 minutes; range, 15-44 minutes), and 111 cases (93%) laparoscopically (median, 44 minutes; range, 13-56 minutes). Laparoscopic vault closure techniques were continuous suture (4 cases, 3%; median, 36 minutes; range, 30-45 minutes), interrupted sutures using knot-pusher (7 cases, 6%; median, 52 minutes; range, 48-56 minutes) Endo Stitch suture (2 cases, 2%; median, 32 minutes; range, 13-50 minutes), continuous vault closure using percutaneous sling sutures (PCSS) (92 cases, 77%; median, 40 minutes; range, 19-56 minutes), and continuous vault closure without PCSS (6 cases, 5%; median, 23 minutes; range, 16-31 minutes).
CONCLUSION
Laparoscopic vault closure using PCSS in SPA-TLH only with conventional straight instruments is the best way to overcome the barrier and the short-cut to shorten the learning curve to date.

Keyword

Hysterectomy; Laparoscopy; Suture technique

MeSH Terms

Female
Humans
Hysterectomy*
Laparoscopy*
Retrospective Studies
Suture Techniques*
Sutures

Figure

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  Fig. 1 (A) Breakdown of triangulation in single port access surgery. (B) Semi-lunar incision (vertical incision: left upper). (C) Insertion of Allexis retraction ring. (D) Finial view of home-made port. (E) Vaginal repair. (F) Endo Stitch suture (articulating ES: left).

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  Fig. 2 (A) Vaginal manual ligation. (B) Vaginal assistance by second assistant with traumatic grasper. (C) 3 PCSS with continuous suture in SPA-TLH (schematic view). (D) Insertion of straight needle (1-0 vicryl) to abdomen. (E) Outside view of 3 PCSS. (F) Inside view of 3 PCSS in SPA-TLA. PCSS, percutaneous sling suture; SPA-TLH, single-port access total laparoscopic hysterectomy.

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  Fig. 3 (A) Extracorporeal tie with knot-pusher (arrow: vaginal assistance). (B) Vaginal vault prolapsed after SPA-TLH (salpinx). (C) Prolapsed salpinx removed after ligation. (D) Vault suture in 4-port TLH (continuous suture, schematic view). (E) Insertion of Monocryl 1-0 for vault closure (arrow: needle). (F) Continuous suture on cut-end of vesicocervical (left arrow), uterosacral (right arrow) ligament. SPA-TLH, single-port access total laparoscopic hysterectomy.

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  Fig. 4 (A) Continuous suture of pelvic peritoneum. (B) Retrieval of Monocryl. (C) Extracorporeal knot tying with knot-pusher. (D) 1 PCSS with continuous suture in SPA-TLH (schematic view). (E) Outside view of 1 PCSS. (F, G) View of vaginal vault before and after vaginal ligation. PCSS, percutaneous sling suture; SPA-TLH, single-port access total laparoscopic hysterectomy.

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  Fig. 5 (A) Outside view of 2-port laparoscopy. (B) MiniLap. (C) Barbed suture. (D) Anchoring sutures for easier port-site closure sckematic view. (E) Anchoring sutures for easier port-site closure.

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