الفهرس 
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Abstract
Hysterectomy is one of the commonest major
gynecological operations, with over 100, 000 procedures
performed annually in England and 600, 000 in the United
States.
Total Laparoscopic hysterectomy (TLH) has gained
widespread acceptance as an alternative to standard
abdominal hysterectomy. In comparison with the
conventional abdominal hysterectomy, (TLH) is associated
with small incisions and better cosmetic result, less blood
loss, less tissue trauma, less post-operative pain, shorter
hospital stay, faster recovery with an earlier return to work
and full activity, and fewer post-operative adhesion
formation. (TLH) also allows better visualization of the
pelvic pathology through magnification and targeted
lighting, access to the uterine vessels, vagina and rectum,
and the ability to achieve complete hemostasis and clot
evacuation (Wattiez et al., 2002; Johnson et al., 2005).
The aim of this work was to compare laparoscopic
route and vaginal route in vaginal vault closure in TLH,
comparing vertical and horizontal direction. It was a
Prospective Randomized Controlled Study that was carried
out in Ain shams university maternity hospital and Helwan
University Maternity Hospital in the period from March
2018 to October 2018, the study enrolled a total of 32
patients of those attending the outpatient gynecologic clinic
Summary
(89)
who were candidate for hysterectomy for benign
gynecological disorders.
Patients were randomly assigned into two groups :
group Ι: 16 patients underwent laparoscopic vault closure,
group ΙΙ: 16 patients underwent vaginal vault closure. Each
group were further subdivided into two groups horizontal
(8 patients) and vertical (8 patients). Each patient in the
study was tested for operative time, suturing time, difficulty
of suturing, intra operative blood loss, intra-operative
complications including, need for blood transfusion and
postoperative pain.
Total operative time from introduction of the
laparoscopic camera till removal of the last port. Suturing
time was calculated from first holding the needle till cutting
the thread after the last suture. Time was measured in
minutes using the video recording afterwards . Difficulty
was assessed by VAS scale (Visual Analogue Scale) by the
operator where 1 is the easiest and 10 the most difficult.
Intraoperative blood loss was estimated via calculating the
amount of blood in suction bottle in ml. Postoperative pain
was assessed using VAS where 10 (unbearable pain) to
zero (no pain). This was assessed after 6hrs, 12hrs and
24hrs from the operation.
The technique of TLH was stabilized in all cases. In
the vaginal closure horizontal : stay suture at the left side of
the patient then continuous suturing to the other side then
tying on the stay suture. In the vaginal closure vertical : one
Summary
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suture from the left high to the right high then left low to
right low then tying. In the laparoscopic Horizontal : stay
suture in the right of the patient then continuous suturing to
the other side then tying on the stay suture. In the
laparoscopic closure vertical : one suture from the right
high to the left high then right low to left low then tying.
All laparoscopic suturing and vaginal closure by the same
team.
Both groups were comparable regarding age, BMI,
parity, previous CS, previous surgery, co-morbidities and
indications of hysterectomy. Adenomyosis was the most
common indication for both groups.
The total blood loss was comparable with insignificant
P value. The total operative time was significantly shorter
in the vaginal group with P value 0.021. The suturing time
was significantly shorter in the vaginal group with P value
0, 002. VAS score in the vaginal group was statistically less
than the laparoscopic group with P value 0, 004.
Multivariate regression analysis revealed that
Vaginal horizontal suturing have statistically insignificant
suturing time and VAS score in relation to vaginal vertical.
Meanwhile, laparoscopic horizontal have statistically
significant longer suturing time and more VAS score in
relation to laparoscopic vertical.
Conclusions and Recommendations
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Conclusions and Recommendations
- Vaginal vault closure can be performed safely and
effectively both vaginally and laparoscopically.
- Vaginal route for vault closure was shorter and easier
than laparoscopic route.
- Vaginal horizontal suturing was comparable to vaginal
vertical.
- Laparoscopic vertical was easier and faster than
laparoscopic horizontal