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258 - INTERVENTIONS TO REDUCE THE RISK OF VAGINAL VAULT HAEMATOMAS: A SYSTEMATIC REVIEW

258

INTERVENTIONS TO REDUCE THE RISK OF VAGINAL VAULT HAEMATOMAS: A SYSTEMATIC REVIEW

RACHANENI, A. DUA;
Urogynaecology, Derriford Hosp., Devon, United Kingdom.

Introduction: Vaginal vault haematoma, a recognised complication of vaginal hysterectomy that may be associated with significant postoperative morbidity. Haematoma may be often asymptomatic but on occasion may result in pyrexia, anaemia, pelvic discomfort, secondary haemorrhage, blood transfusion, hospital readmission and return to theatre for evacuation of haematoma. The incidence of vault haematoma after vaginal hysterectomy is variably reported—from approximately 25% to as much as 59%. Steps to reduce this perioperative complication may include meticulous haemostasis and modification of surgical technique. Traditional vault closure might involve closing the peritoneum separately to the vaginal vault leaving a potential space between the two. The principles of vault closure are to extra-peritonealise vascular pedicles, maintain support of the vaginal vault, and secure haemostasis of the vaginal edge. The majority of textbooks describe techniques involving separate closure of peritoneum and vaginal vault and incorporation of the uterosacral and cardinal ligaments for support. Modification of the vault closure with incorporation of peritoneal edges into the vaginal vault up to the uterosacral ligaments may reduce the incidence of the vault haematoma.
Objective: To assess the impact of modified surgical closure of vaginal vault incorporating peritoneal edges in reducing the incidence of vaginal vault haematomas.
Methods: We carried out a systematic search of Cochrane, MedLine, Embase, CINAHL, metaRegister of Controlled Trials (mRCT), pubmed, CENTRAL and Google Scholar databases from inception until January 2017. Abstracts presented in conferences and hand search of journals were also included in the review. Keywords and medical subject headings searched for, included terms and word variations for ‘Vaginal Vault Haematoma’, ‘Vaginal hysterectomy’ and ‘surgical technique’. Our four-part clinical questionnaire for this systematic review was as follows: Population: Adult women undergoing vaginal hysterectomy Interventions: Modified vault closure technique with inclusion of peritoneum in vault closure Comparison: Conventional vault closure technique where only vaginal skin was closed with or without the inclusion of peritoneum. Outcome: Incidence of clinically significant vault hematomas
Results: Out of the 28 articles identified during our systematic search, two retrospective studies satisfied our inclusion criteria. The first study of 581 women undergoing vaginal hysterectomy carried over a five year period showed a reduction in clinically significant vault haematomas from 15.7% (conventional vault closure technique) to 1.7%. In another study of 70 women with mass closure of peritoneum and vaginal vault incorporating uterosacral ligaments, symptomatic vault haematoma rate was reported to be 5.7%. The slightly higher incidence of vault haematomas may be explained by the fact that 34% of women underwent bilateral salping-oophorectomy at the time of vaginal hysterectomy.
Conclusions: The simple intervention of inclusion of peritoneal edges in closure of vaginal vault skin may reduce the incidence of vault hematomas and reduce the postoperative morbidity associated with vaginal hysterectomies.
References: 1. Journal of Obstetrics and Gynaecology (2001) Vol. 21, No. 4, 379-382 2. British Journal of Obstetrics and Gynaecology December 2001, Vol. 108, pp. 1295-1297

Characteristics of included studies

Year, study design

Setting

Inclusion criteria

Methods

Intervention(I) and Comparison(C)

Outcome measures and follow-up

Retrospective case note analysis,2001

Single centre

(n=581)

Women undergoing vaginal hysterectomy over a 5 year period

Retrospective study followed by prospective analysis of postoperative morbidity

Inclusion of peritoneum in vault closure up to and including the uterosacral ligaments(I) compared to Closure or non-closure of peritoneum separate to the vaginal skin during vault closure(C)

Inclusion of peritoneum in vault closure up to and including the uterosacral ligaments(I) compared to Closure or non-closure of peritoneum separate to the vaginal skin during vault closure(C)

2001,Retrospective study

Single centre

(n=70)

Women undergoing vaginal hysterectomy

70 consecutive women undergoing vaginal hysterectomy without repair; 24 of these women (34%) underwent simultaneous bilateral salpingo-oophorectomy.

The modified technique included mass closure of the vaginal edges along with the peritoneum including the uterosacral ligaments(I) compared to traditional closure with purse stringing of the peritoneum at the vaginal vault and closing the vaginal edges separately(C)

Vault haematomas were reported in 5.7% in the modified technique group. The authors did not have a control group and compared their outcomes to that of previously published data