{"paper_id":"58604732-326e-4280-9802-76cbd7b117ad","body_text":"ORIGINAL ARTICLE\nH. Clave´Æ H. Baar Æ P. Niccolaı¨\nPainless vaginal hysterectomy with thermal hemostasis\n(results of a series of 152 cases)\nReceived: 23 February 2005 / Accepted: 23 March 2005 / Published online: 25 May 2005\n/C211Springer-Verlag Berlin / Heidelberg 2005\nAbstract In a preceding paper the authors described a\ncompletely new approach for vaginal hysterectomy. The\nclassical technique has been simplified, including ther-\nmal hemostasis with BiClamp, multimodal anesthesia,\nand ongoing research aimed at ensuring minimal trau-\nma. The authors describe the first group of 152 patients\nwho were treated with this new approach. The results\nshow that it is possible to expand the range of vaginal\nindications while shortening the patient’s hospital stay\nto 1 day. Furthermore, this innovative surgery is\nbecoming more generally accepted, resulting in better\nquality of life for the patients.\nKeywords Hysterectomy Æ Electrosurgery Æ Local\nanesthesia Æ Outpatient Æ Fibroma\nIntroduction\nStarting in March 2002, we developed an innovative\ntechnique for performing vaginal hysterectomy with the\naim of fighting pain to obtain a fast postoperative\nrecovery. The anesthetic and surgical procedures were\npublished in March 2003 in a preliminary paper [ 1] and\nwere then developed on a base of 152 cases in a review.\nIn this article we present the results of this series, with\ncomments.\nMaterials and methods\nThe operative technique\nAs detailed earlier, this technique is based on three pil-\nlars of modern surgery:\n1. Technological innovation through thermal hemosta-\nsis of the vessels with BiClamp (ERBE, Tu ¨ bingen,\nGermany). BiClamp is a type of ‘‘electrical Jean-\nLouis Faure’’ clamp that allows safe hemostasis of\nlarge vessels; the two branches of the forceps act like\nthe electrodes of a bipolar clamp. It is made to be\nused more than 50 times. Electric current is provided\nby the VIO electrosurgical generator (ERBE, Tu ¨ b-\ningen, Germany).\n2. Multimodal anesthesia consisting of the combination\nof a general anesthetic with a locoregional anesthetic\nwith a long-term effect; this multimodal approach has\nbeen proposed in order to control the pathophysio-\nlogical problems caused by operative and postoper-\native nociceptive effects; it allows a better\nconvalescence with reduced dosages and fewer side\neffects.\n3. Ongoing research aimed at achieving minimal trauma\n(good information concerning the procedure, no\nshaving, no bladder catheterization, short hospital\nstay, etc.)\nThe participants\nThis series consists of the first 152 patients who were\noperated on between March 2002 and July 2004 by the\nsame surgeon and with an identical anesthetic technique.\nThe group was divided into three subgroups. Using a\ntest series of 20 patients between March 2002 and Sep-\ntember 2002, subgroup A, the feasibility of this tech-\nnique was assessed, and together with the ERBE\ncompany the generator settings were subsequently\noptimized.\nH. Clave´(&)\nDepartment of Gynecological Surgery,\nSaint-George Clinic, Nice, France\nE-mail: clave.henri@wanadoo.fr\nTel.: +33-4-92148302\nFax: +33-4-92148309\nH. Baar\nDepartment of Anesthesia,\nSaint-George Clinic, Nice, France\nP. Niccolaı¨\nDepartment of Anesthesia, Princess Grace Hospital,\nMonte Carlo, Monaco\nGynecol Surg (2005) 2: 101–105\nDOI 10.1007/s10397-005-0112-x\n\nBetween September 2002 and December 2002, a\nsubgroup Bb with 25 patients was randomly compared\nwith patients receiving classical vaginal hysterectomy\nwith general anesthetic (subgroup Ba); this randomiza-\ntion particularly focused on the assessment of postop-\nerative pain and the need for analgesics. Subgroup C\nconsisted of the last 50 operated patients (excluding\nthose with prolapse), who received the benefit of the\ntechnical, operative, and organizational improvements\nimplemented by the operating team.\nParticipant selection for the study was carried out in\naccordance with specifications in the literature [ 3–5]. The\nage distribution showed no specific characteristics.\nIndications for inclusion were benign syndromes: fibro-\nmas, adenomyosis, uterine prolapse, and dysplasias\n(Fig. 1). The average weight of fibromatous uteri was\n355 g (range 40–900 g).\nResults\nComplications\nThe interest in this first publication on 152 vaginal\nhysterectomies with thermal hemostasis is due to the\ncomplete absence of any substantial complications. In-\ndeed, no serious immediate or secondary bleeding oc-\ncurred, no thermal trauma to ureter or intestine was\nnoted, and no fistulas developed. The complications that\ndid occur are described below.\n– Three cases of burns to the vulva or vagina occurred\nat the beginning of our tests, which required sub-\nsequent local treatment over a period of 5 days.\n– Three cases of secondary bleeding of the vaginal\nincision required these patients to be readmitted to the\nhospital. This type of bleeding occurred during the\nperiod in which we used ‘‘Vicryl Rapide’’ 00 for\nclosure of the vagina, which was a mistake: Two of\nthese cases required a repeat of the vaginal suture\nunder general anesthetic on the 18th and 21st days,\nrespectively, whereas the third case required only a\nvaginal tampon.\n– On day 15 a surgical vaginal examination was carried\nout in one patient for pain assessment; the patient had\nhad a hemorrhagic rupture of a follicular cyst.\n– A febrile and painful hematoma on day 5 was due to\nbleeding of the ovarian wall after a simultaneous\nvaginal cystectomy (cyst diameter 5 cm); this was\ntreated medically at home.\n– One patient was readmitted on day 7 for 2 days be-\ncause of febrile lateral pelvic pain; this rapidly nor-\nmalized after antibiotic therapy.\n– One patient with pyelonephritis (prior illness) required\nlonger hospitalization.\nPain\nOn the basis of a visual analog scale (VAS) and the\namount of analgesics used, the analysis of the random-\nized subgroup B demonstrated a substantial reduction of\npain with this technique [ 1] (Fig. 2).\nIn addition, the side effects associated with the usual\nadministration of postoperative analgesics did not occur\n(Table 1), which meant that these patients’ postopera-\ntive experiences were completely different. In fact, the\nmajority of patients were able to get out of bed only a\nfew hours after the operation to go to the toilet and save\nthemselves unpleasant and sometimes futile efforts with\nbedpans.\nIf no motor block and no block of the upper sym-\npathicus (in contrast to a spinal block) is carried out and\nif the patient does not receive any morphine, then the\nsensation of uriesthesis will be unaffected, and bladder\nevacuation will continue to function [ 6, 7].\nDuration of the procedure\nDuration of the procedure was investigated in subgroup\nC with the last 50 patients. The medium length of time\nbetween the incision and closure of the vagina was\n30 min (range 12–80 min); this is equal to or slightly less\nthat for the classical technique.\nThe time required for thermal hemostasis may appear\nto be rather long. It requires positioning the BiClamp,\nremoving the BiClamp after the generator has switched\noff automatically, and making a cut with scissors—that\nis, a total of three steps. However, achieving a classical\nhemostasis with sutures requires positioning the hemo-\nstasis clamp, cutting the pedicle with scissors, position-\ning the suture with a needle holder, knotting the sutures,\nremoving the clamp, and cutting the suture with scis-\nsors—that is, a total of six steps with several changes of\ninstruments.\nFig. 1 Operative indications\n102\n\nIn addition, thermal hemostasis also has a hemostatic\neffect on the two edges of the pedicle, preventing a\nbackflow of blood and obviating the necessity of aspi-\nrating the blood or frequent swabbing with compresses.\nThe visibility of the operative site is also improved,\nwhich in turn affects the length of the operation.\nVaginal scarring\nIn 142 of the cases, the vaginal scar was assessed as\nperfect—soft and not grainy. Three patients had sec-\nondary bleeding of the vaginal scar, and in seven pa-\ntients, examination at the 4th postoperative week led to\nthe prescription of local trophic treatment and the\npostponement of sexual intercourse.\nThis excellent vaginal healing was achieved due to the\nabsence of necrotic inflammatory magma from foreign\nmatter (dissolution of sutures) and the absence of tissue\nnecrosis in the stumps, and by the creation of a simple,\nwell-placed, and not too taut suture made of resorbable\nmonofilament thread No. 1. This healing makes it pos-\nsible for patients to have satisfactory sexual intercourse;\nwe have no randomization concerning this point, but a\nretrospective analysis that is still being carried out points\nin this direction.\nBlood loss\nThe loss of blood was minimal; we examined the blood\nloss in group C based on the number of compresses and\ngauze pads used. Each procedure required 1.3 gauze\nstrips and six damp compresses on average. The insig-\nnificant blood loss was much appreciated by the pa-\ntients, who often suffered from anemia or iron\ndeficiency, and is yet another benefit of the operation, as\nuterine morcellation or adnexal exeresis are possible\nwithout the need for haste and under good conditions of\nsafety.\nHospitalization\nAt the beginning of the study (subgroup A)\nThe hospital stay of this group was long due to our\nuncertainty about the procedure; the average stay was\n6 days (OP day +4 days).\nIn subgroup B\nThe average stay was shortened to 4.1 days (OP day\n+2.1 days).\nIn subgroup C\nWe hoped to be able to carry out this intervention on a\npurely outpatient basis. We were able to achieve this\ngoal in six out of 50 vaginal hysterectomies. We dis-\ncovered in this connection that in France the obstacles\nthat had to be overcome were more of an organizational\nand sociological nature than purely medical.\nWe adjusted to this situation and were able to offer\nthe patients in subgroup C a standard hospital stay of\n1 day (with the exception of prolapse cases), which was\npossible for 43 out of 50 patients. The patients were\nsatisfied with being admitted only a short time before the\nFig. 2 Assessment of\npostoperative pain in subgroup\nB\nTable 1 Reduction of morphine in comparative study ( LRA loco-\nregional anesthetic, VAS visual analog scale)\nBa (control group,\nn=25)\nBb (BiClamp\n+ LRA, n=25)\nVAS/D1 38±9 25±10; p<0.05\nConsumption of\nmorphine (D1) (mg/24 h)\n21.6±6.8 0; p<0.0001\nSide effects: 11 1; p<0.05\nNausea 4 1\nVomiting 3\nUrinary retention 4\nDrowsiness 1\n103\n\nintervention and were reassured by the knowledge that\nthey could spend the first postoperative night in a\nmonitored environment (Table 2).\nComments\nThis technique, which, to the best of our knowledge, has\nnot been described previously in the literature, is the\nresult of the experience of a team of surgeons and\nanesthetists and offers many benefits to the patients, the\nnursing team, and society.\nFrom the anesthetist’s point of view\nThis technique is based on the publications of Kehlet; in\nthe Kehlet concept, postoperative pain is controlled\nusing a prophylactic multimodal approach. This ap-\nproach has already been described for intestinal [ 8],\northopedic [ 9], ENT [ 10], and proctologic surgical pro-\ncedures, and it appears to be suitable for use in gyne-\ncological surgery.\nThe use of a locoregional anesthetic with a long-term\neffect makes the administration of morphine prepara-\ntions unnecessary, and the effect of this absence of\nmorphine on the lungs and the urinary and digestive\nsystems contributes to the patients’ postoperative well-\nbeing.\nThe goal of ‘‘zero tolerance’’ of pain is possible only\nin an operative environment that places the highest\npriority on avoiding unnecessary trauma. This will help\npromote rapid healing [ 11].\nFrom the surgeon’s point of view\nThe important advantage of this series is the confirma-\ntion that no accidents occurred during or after the\noperation and that pain, which up to now was the\ngreatest drawback of this operative procedure, could be\nclearly reduced.\nThe surgeon’s contribution to the multimodal ap-\nproach for the prophylaxis of postoperative pain is the\nuse of thermal hemostasis. Although, because of its de-\nsign, this series cannot offer final proof, we can point to\nthe absence of tissue necrosis (stemming from the\ncrushing of the pedicles at the ligatures) and less\nresorption and phagocytosis of necrotic tissue and of\nforeign matter (thread), which in turn leads to decreased\ninflammatory and painful symptoms. These facts have\nalready been emphasized by the endoscopic surgical\nteam [ 12], who have been using bipolar current in hys-\nterectomy procedures for many years. For the assess-\nment of pain [ 13], a comparison of vaginal hemostasis\nwith sutures and endoscopic methods with thermal he-\nmostasis has demonstrated—despite the implications of\na peritoneal and parietal intervention—the advantage of\nthe endoscopic method.\nWe believe these studies have essentially demonstrated\nthat thermal hemostasis is less painful than traditional\nhemostasis with sutures. Purohit confirmed this and\nnoted a decrease in the use of analgesics in 88% of cases if\nvaginal hysterectomies were carried out with laparo-\nscopic bipolar forceps [ 14]. In a recent paper Zubke et al.\n[15] decreased the dose of pain medication in 65% of cases\nwith the use of BiClamp instead of classical ligatures.\nThis procedure offers a simpler and less traumatic\napproach. The simultaneous use of only two instruments\nat any single time during the different operative phases\nmakes vaginal access feasible and thereby avoids a\npainful expansion with the holders. This intervention\nalso avoids unnecessary and painful traction.\nThis procedure offers a less aggressive operative\nenvironment. A list was made of all avoidable aggressive\nand anxiety-causing elements surrounding the opera-\ntion, and such elements were subsequently avoided:\npreoperative shaving; pre-, peri-, or postoperative\nbladder catheterization; and need to empty the bladder\nusing a bedpan.\nIn addition, we offered the following:\n– complete and detailed oral, written, and multimedia\npreoperative information\n– hospital admission on the day of the intervention\n– hospital discharge on the same day or on the follow-\ning day\n– resumption of normal feeding as soon as the patient\ndesired\nWith this series we were also able to confirm that this\ntechnique can be applied in most adnexectomy proce-\ndures; in prolapse cases, because the ligament stumps are\ndiscernable; and in cases of a narrow vagina or an\nimmobile uterus, as fewer instruments are employed\nthan with the classical technique, and these can be kept\nnear the middle of the vaginal shaft. This means that the\nnumber of vaginal hysterectomies will increase.\nEconomic aspects\nThe following factors will result in a substantial reduc-\ntion of costs in the healthcare sector:\n– BiClamp forceps can be reused up to 50 times and are\nsuitable for use with the optional module of the new\nTable 2 Subgroup C: a homogenous series of the last 50 patients\nAverage weight of fibromatous\nuterus (g)\n355 (40–900)\nDuration of the operative\nprocedure (last 50 patients)\n30 min (12–80)\nHospitalization\nOutpatient, less than 12 h 6 12%\nLess than 24 h 37 74%\nDischarged on day 2 4 8%\nDischarged on day 3 3 6%\n104\n\nmultifunctional VIO generator series. This instrument\nis suitable for many different interventions (gastroin-\ntestinal, urology, etc.).\n– The number of instruments for standard procedures is\nmuch reduced (reduced costs for purchasing, han-\ndling, sterilization, etc.).\n– Only one suture is needed.\n– Nursing care is less time-consuming.\n– The hospital stay is shorter than with a standard\nvaginal hysterectomy [ 16], but the convalescence per-\niod is almost unchanged (3 weeks).\nConclusion\nPainless hysterectomy with thermal hemostasis and\nmultimodal analgesia offers several important advanta-\nges for the patients, the nursing staff, the public\nhealthcare system, and the team of surgeons and anes-\nthetists:\n– The patients not only benefit from the reduced risk of\nhospital-acquired infection or/and thromboembolism\nbut also from the ‘‘transparent’’ technique and the\nminimal psychological stress.\n– The staff can apply the policy of quality assurance in a\nglobal and quantifiable project.\n– This medical innovation is an important contribution\nin the battle against the lack of beds and staff and\nrepresents an improvement in healthcare efficiency.\n– The operating team is interested in applying it to other\npathologic situations, thereby extending this new\nparadigm.\nReferences\n1. 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