A multimodal concept of vaginal cuff closure by modification of the Bakay technique in laparoscopic total hysterectomy: a randomized clinical study | BMC Women’s Health

The main results of the study revealed a shorter operating time; longer postoperative vaginal length; similar complication rate and patient satisfaction for TM compared to ST.

Various techniques of incision and closure of the vaginal cuff in TLH have been described in the literature. [4, 12, 13]. In this study, the Bakay technique [14] has been modified to achieve routine concomitant effective apical support to prevent future vaginal vault prolapse and primary vaginal cuff scarring using cold knife colpotomy, instead of electrosurgical colpotomy, in addition to the old one objective of the technique which was to close the vaginal cuff with secure suture margins before the pelvic anatomy was altered by the removal of the uterus. The clinical and surgical results of MT have shown positive results compared to ST.

The colpotomy and cuff closure steps are technically the most difficult and prolonged parts of TLH. In addition, the most common complications of TLH, which are ureteral damage and bleeding, mainly occur during these stages. One of the main advantages of TM is to place the sutures before the pelvic anatomy is altered by colpotomy / uterine removal, which keeps the required suture margins at a safe distance of the bladder, ureters and intestines in a shorter total operation. time.

To our knowledge, there is no study specifically comparing cold knife colpotomy to electrosurgical TLH colpotomy. During colpotomy, the monopolar current applied at 60 W for 1 s has an average critical deviation of 3.5 mm; however, the spread exceeds 20 mm when applied for ≥ 2 s [19]. Thus, a longer direct current may increase the extent of collateral damage. Current recommendations for colpotomy and cuff closure in TLH are to minimize lateral thermal spread to maintain tissue integrity and to place sutures well beyond the thermal damage limit to prevent dehiscence and l evisceration of the vaginal cuff [20]. In TM, using cold knife colpotomy, instead of electrosurgical colpotomy, we wanted to eliminate extensive tissue necrosis and devascularization leading to thicker inflammatory infiltrate and late tissue healing (per secundam intentionem). As a good practice point, this can help prevent cuff cellulite, cuff dehiscence and secondary cuff hemorrhages by promoting primary healing of the vaginal cuff. In addition, our technique can tolerate small purchases on the sutured vaginal cuff caused by laparoscopic magnification of the surgical field. In this study, there was no significant difference in the rates of postoperative complications between groups, although the sample size was too small to specifically compare the rate of complications such as cuff cellulitis, dehiscence, granulation and secondary cuff hemorrhages. This could be the subject of a future comparative study with a larger sample.

In the present study, the total vaginal length was well preserved by our technique, which may be important for sexual function. MT was associated with a longer postoperative vaginal length, compared to ST, which can be attributed to better cuff healing achieved by cold colpotomy which prevents loss of vaginal tissue bounded by thermal damage. In the literature, there are few studies examining the effect of vaginal length on sexual function showing a weak correlation as measured by the Female Sexual Function Index questionnaire. [21,22,23]. However, the assessment was usually done soon after the hysterectomy (i.e. three months). It can be a distress factor contributing negatively to sexual function. Thus, long-term sexual function assessment can rule out this factor. It should be noted that the effect of our technique on sexual function was not within the scope of our study due to the short-term evaluation and the small sample size.

It is evident from the literature that the omission of a concomitant apical support procedure during hysterectomy increases reoperation rates for pelvic organ prolapse in the future. [9]. Despite this, apical support procedures are not performed in most cases without utero-vaginal prolapse. Even in cases of utero-vaginal prolapse, only half of them receive a concomitant apical assist procedure [10]. Due to this underuse, AAGL recommends USL suspension at the time of TLH to prevent future vaginal vault prolapse. [11]. In our technique, suspension and / or plication of LSUs was a routine step, leading to concomitant support of the vaginal apex to prevent future vaginal vault prolapse. The procedure could be performed safely, while the margins of the LSUs and adjacent structures such as the ureters were still prominent and the pelvic anatomy was not altered. The number of suture loops depended on the protruding length of the LSUs (usually 1-3 stitches). Thus, at least with a single puncture, the USL suspension was possible, while the USL kink could also be achieved with two or three punctures.

In the present study, the total operative time for colpotomy, uterine extraction, and vaginal cuff closure were not significantly different between groups, although TM was associated with greater total operative time. short as the ST. When the videos of the procedures were revisited, we found that the loss of time leading to this difference was mainly related to the checks to reassure the safety margins of the bladder or the thermal damage dividing line and the control of the bladder. hemostasis for small bleeding in folded areas around the cuff and setting after closing the cuff. Using TM, placing the sutures before the pelvic anatomy is altered, slight retraction of both ends of the sutures preventing unwanted bleeding during colpotomy and cold colpotomy likely eliminated the need for additional checks, thereby shortening the total surgical time.

Bladder injury was reported in each group, which is consistent with the literature [24]. Both injuries occurred in patients who had previous pelvic surgery. The rate of bladder lesions varies from 0.2 to 1.8% in the literature and is mainly associated with a previous laparotomy. [24]. Unlike previous studies [14], an involuntary cut of the suture line during cold colpotomy which increases operative time did not occur in this study. This was probably due to the experience gained from the increase in the number of cases. Also, a limiting factor for the Bakay technique was the size of the uterus, as was reported in the previous study. [14]. Although there was no statistically significant difference between the groups in terms of uterine weight, we analyzed the data to determine the largest uterus removed by ST and MT in our study. The results were 465 g and 510 g respectively, indicating that gaining experience in this technique could overcome the limitations described in the previous study – to some extent – related to the large size of the uterus due to ” inadequate visualization of the posterior area.

In our study, there was no significant difference in terms of postoperative complication rate and patient satisfaction scores between groups at three months postoperative. In both groups, patients described their postoperative condition as “much better” compared to the preoperative condition.

However, there are some limitations to this study. The locations of the auxiliary ports in this study are symmetrical (contralateral). Therefore, a possible difficulty with circular cuff suturing for surgeons working with ancillary trocars ipsilaterally may exist until they adapt to the technique. It is not possible to conclude on the effects of TM on pelvic organ prolapse with short-term follow-up (90 days). Long-term TM outcomes related to cuff healing and pelvic organ prolapse should be evaluated in future prospective studies with adequately sized samples. Although the sample size for this study is adequate to test most of the operative data, larger studies are needed to assess any possible complications of the new technique. Further large-scale multicenter studies involving multiple numbers of surgeons are needed to test the applicability and uptake of the technique in surgical practice. Additionally, a possible difficulty in circular cuff suturing for surgeons working with ancillary trocars ipsilaterally can be considered.


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