Reducing Postoperative Bleeding After Hysterectomy Via Independent Closure of Vaginal Cuff Angles
Condition: Postoperative Bleeding; Patient Satisfaction; Complications; Operative Time
MeSH terms: Hemorrhage; Postoperative Hemorrhage
Study type: Interventional

Summary: 
      The investigators propose prospectively evaluating if adding separate sutures to the angles
      of the vaginal cuff before running barbed suture reduces the incidence of patient's
      perception of bleeding after surgery.
    

Detailed description: 
      Hysterectomy is the most common surgical procedure in the United States, with over 600,000
      performed annually.1 There has been a dramatic improvement in expected postoperative course
      secondary to the advancement of minimally invasive gynecologic surgery.2 With the advent of
      laparoscopy and robotic surgery, even the most complex cases can be successfully performed
      via a minimally invasive approach. What used to be a major surgery that required a prolonged
      inpatient stay has become an outpatient procedure where patients are discharged home a few
      hours after the operation.3 Although the recovery period is shorter than in the past, there
      are still some postoperative complaints that are relatively common, and can impair quality of
      life. One of them is postoperative vaginal bleeding. Although this can be a sign of a more
      serious problem such as vaginal cuff dehiscence, the grand majority of times it is related to
      granulation tissue in the vaginal cuff that although may be self-limiting, can be bothersome
      and concerning to patients. Not only does this bleeding impair quality of life, but it's one
      of the most common reasons for emergency room visits after surgery. Multiple studies have
      shown that postoperative vaginal bleeding and return to the hospital significantly affect
      patient satisfaction. 4,5 Anecdotally, bleeding originates from granulation tissue at the
      angles of the closure, although there hasn't been any studies specifically investigating
      this. A common approach to laparoscopic cuff closure involves a running barbed suture, with
      or without separate closure of the lateral angles.6,7 Recently, laparoscopic closure of the
      vaginal cuff was found to be superior when compared to vaginal closure in terms of vaginal
      cuff dehiscence8. This RCT also evaluated vaginal cuff bleeding as a secondary outcome, but
      this was recorded as he presence of bleeding at 3 months after surgery. The closure technique
      in this study was a running non-barbed suture, without independent suturing of the angles.
      Although a running suture placed laparoscopically may provide adequate tensile strength
      throughout the cuff to promote healing, the tension at the corners may be less than at the
      center when using barbed suture, hence potentially increasing the risk of bleeding.
      Furthermore, the second angle may be more difficult to access when the remainder of the cuff
      is re-approximated.

      The investigators propose prospectively evaluating if adding separate sutures to the angles
      of the vaginal cuff before running barbed suture reduces the incidence of patient's
      perception of bleeding after surgery.
    

Intervention name(s): Angle stitch
Intervention type(s): Procedure
Intervention description(s): Surgeon will use 0 polyglactin 910 suture on a tapered needle to place figure of 8 sutures on both (left and right) vaginal cuff apexes.
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Triple (Participant, Investigator, Outcomes Assessor)
Primary purpose: Treatment
Keywords: bleeding; hysterectomy; cuff; closure