Vaginal cuff closure in laparoscopic hysterectomy (TLH) was compared between polyglactin 910 suture and unidirectional barbed suture. In a study of 68 patients, vaginal cuff complications, postoperative vaginal bleeding, long term complications, and closure duration were estimated. Patients were divided into two groups - Group 1 used polyglactin 910 suture (n=44) and Group 2 used unidirectional barbed suture (n=24). Postoperative vaginal bleeding occurred in 32.5% of Group 1 and 18.8% of Group 2, showing a significant reduction with barbed suture. No other short or long term complications showed a significant difference between

1. Vaginal cuff closure in TLH
with
unidirectional barbed suture
vs
polyglactin 910 suture
DR SANGHAMITRA DASH
CHIEF CONSULTANT, LIFE INSTITUTE OF GASTROENTEROLOGY AND GYNAECOLOGY,
CUTTACK
ASST. PROF, O & G, SCBMCH, CUTTACK

2. Objective of my study :
Vaginal cuff closure in TLH with a unidirectional barbed
suture vs polyglactin 910 suture.
 To estimate –
 incidence of vaginal cuff complication,
 Postoperative vaginal bleeding,
 long term complication,
 duration of closure

3. Material and methods
 Retrospective analysis of a longitudinal , prospective study without randomisation.
 Exclusion Criteria :
 Cases where vault was closed transvaginally after specimen removal (n=3).
 Indications : All patients operated for malignant causes.
 Inclusion criteria:
 68 patients who underwent total laparoscopic hysterectomy (n=68) between june 2016 to
march 2017.
 Indications : All patients operated for benign causes.
 On admission patients were grouped into 2 groups
 Group1 : vault closure performed with polyglactin 910 suture 1 (n=44)
 Group2 : vault closure performed with unidirectional barbed suture 00 (n=24)

4. VS

5. Material and methods
 Indication of surgery in all included patients :
 Uterine fibroid
 Endometriosis
 AUB not responding to medical therapy
 Endometrial hyperplasia with or without atypia
 Procedural Details :
 Laparoscopic hysterectomy proceeded routinely . 4 port laparoscopy ports, one 10 –
mm umbilical port and three 5-mm accessory ports.
 Colpotomy was performed with pure cutting current
 Vaginal cuff closed horizontally , full thickness closure incorporating vaginal
epithelium and pubocervical fascial tissue in each bite
 Uterosacral ligament incorporated at each angle.
 Patients were discharged on POD 3rd /4th .

6. Material and methods
 Follow up visits:
 First visit after 7days from discharge (with instuctions to report if bleeding or leaking
of vaginal fluid, poorly controlled pain abdomen upto 2wks, advice for abstinence for
2months).
 Second visit after 6 weeks (vault examination)
 Third visit after 3 months (vault examination).
 Data presented as the mean and standard deviation (SD) for normally
distributed sample and compared between groups using a two – sample t- test.
 Categorical data are presented as counts with proportions and compared
between groups using Fisher s exact test .

7. Factors compared between both groups:
 The time of closure in both groups.
 Postoperative vaginal bleeding – genital bleeding or spotting .
 Immediate Post op complication i.e fever, blood loss, need for reoperation,
ureteric injury, hematoma, bladder injury , paralytic ileus
 Long term complication like SAIO , dyspareunia after 6 months .
 Surgical Video
Material and methods

8. Demographic Characteristics and
indication
Demographic Characteristics and indication (n=68)
Characteristics
• Age (years) 48.1 ± 7.2
• Gravity 3.4 ± 1.7
• Parity 2.6 ± 1.4
• Premenopausal n (%) 26 (40.6%)

9. Demographic Characteristics and
indication
Demographic Characteristics and indication (n=68)
• Postmenopausal (n%) 18 (26.4%)
• Abnormal uterine bleeding n (%) 17 (25%)
• Uterine fibroids n (%) 24(35.2%)
• Premalignant conditions n (%) 4 (%)
• Others n (%) 5(7%)

10. Univariate Analysis Stratified by Suture Type
Variable Polyglactin 910 Barbed Suture Significancea (P value)
• No. of patients 44 24
• Age (y) 45.5 44.9 .54
• Pregnancies 2.2 2 .16
• Vaginal deliveries 1 1
• Previous cesarean section 20(47%) 11(49%) .81
• Previous laparotomy or laparoscopy 22(50%) 15(66%) .02
• Diabetes 1(2%) 0 .19
• Immunosuppression 1(1.8%) 0 .26

11. Variable Polyglactin 910 Barbed Suture
• Surgical time (min) 64 45
• Specimen weight (g) 204.2 206
• Blood loss (mL) 77 56
• Intraoperative complication) 4 4
• Length of hospitalization(d) 2.6 2.6
• Length of suturing time(min)
9.2 6.2
• Follow-up time (mo) 8.82 6.8
Results :

12. Outcomes by Suture Type
• Outcome Polyglactin 910 44
(%)
Barbed Suture
24(%)
Rra 95% CI Significancea
(P Value)
• Postop vaginal bleeding 14 (32.5%) 4(18.8%) 0.57 0.34- 0.9 .03
• Admission to
emergency department
6(14.7%) 3(15.9%) 1.1 0.57-2.1 .81
• Vaginal cuff dehiscence 1(2.4%) 0 0.6 0.07-5.2 .63
• Infectious
complications
1(2.2%) 1(4.01%) 2.4 0.34- 16.4 .37
• Paralytic Ileus 0 0
• Fever 0 0
• Inflammatory or
granulation tissue
0 0

13. Conclusion:
In TLH “suture line of most significance” : The closure of the vaginal cuff.
 Bacterial contamination  vaginal cuff cellulitis and pelvic abscess.
 Persistent granulation tissue  vaginal discharge and bleeding.
 With excessive potential disruptive forces  suture with some prolonged strength.
 Newer, increased the use of thermal energy  less viable tissue at cuff edges and subsequent
delays in wound healing.
The ideal suture :
 minimize bacterial growth
 elicit minimal tissue reactivity
 be pliable
 maintain a reasonable amount of tensile strength for at least 3 to 4 weeks.

14.  Barbed suture is a relatively new but exciting addition to the
variety of suture materials.
 O & G surgeons who are interested in choosing the best
materials for their operations should benefit from better
understanding the underlying principles of wound healing and
suture material biomechanics, and may discover many
advantages to the use of barbed suture.
Conclusion:

16. Original research
Dramatically reduced incidence of vaginal cuff dehiscence in gynecologic patients undergoing endoscopic closure with
barbed sutures: A retrospective cohort study
Author : panelMark A.RettenmaieraLisa N.AbaidaJohn V.BrownIIIaAlberto A.MendivilaKatrina L.LopezbBram H.Goldsteina
Introduction
This retrospective study documented the rate of vaginal cuff dehiscence (VCD) in a large series of gynecologic patients
who were treated with an endoscopic (robotic-assisted or laparoscopic) hysterectomy that incorporated either delayed
absorbable monofilament barbed or vicryl running sutures.
Method
We sought to discern any prognostic associations between operative variables (e.g., closure type (barbed or vicryl
sutures), endoscopic approach (robotic-assisted or laparoscopic), and energy source (Harmonic Ace Shears or
monopolar/bipolar electro-surgery)) and the risk for VCD via patient chart review. Statistical evaluation was comprised
of univariate analyses and multiple regression.
Results
We identified 1876 subjects; there were 14 cases (0% with barbed suture and 0.99% with vicryl suture) of VCD (an overall
incidence of 0.75%), nearly all of which were associated with a robotic-assisted hysterectomy involving vicryl sutures (p
= 0.034). However, the type of endoscopic surgery (P = 0.11) and energy source (P = 0.28) were not significant prognostic
factors. The VCD patients' exhibited a median duration of 47 days (range, 14–116) until the development of their
condition.
Conclusion
Vaginal cuff separation subsequent to laparoscopic closure is a rare occurrence. While our incidence of VCD was low
and comparable to other reported rates in the literature, we did not observe any cases of VCD following laparoscopic
hysterectomy performed with barbed suture closure.

17. Barbed Suture for Vaginal Cuff Closure in Laparoscopic Hysterectomy
Byron Cardoso Medina, MD, Cristian Hernández Giraldo, MD,corresponding author Giovanni Riaño, MD, Luis R.
Hoyos, MD, and Camila Otalora
Abstract
Background and Objectives:
Our aim was to evaluate whether the use of barbed suture for vaginal cuff closure is associated with a decrease in
postoperative vaginal bleeding compared with cuff closure with polyglactin 910 in patients who have undergone
laparoscopic hysterectomy.
Methods:
We performed a cohort study of patients who underwent laparoscopic hysterectomy between January 2008 and July
2012 by the minimally invasive gynecologic surgery division of the Gynecology, Obstetrics and Human
Reproduction Department at Fundación Santa Fe de Bogotá University Hospital, Bogotá, Colombia.
Results:
A total of 232 women were studied: 163 were in the polyglactin 910 group, and 69 were in the barbed suture group.
The main outcome, postoperative vaginal bleeding, was documented in 53 cases (32.5%) in the polyglactin 910
group and in 13 cases (18.8%) in the barbed suture group (relative risk, 0.57; 95% confidence interval, 0.34–0.9; P =
.03). No statistically significant differences were found in other postoperative outcomes, such as emergency
department admission, vaginal cuff dehiscence, infectious complications, and the presence of granulation tissue.
Conclusion:
In this study an inverse association was observed between the use of barbed suture for vaginal cuff closure during
laparoscopic hysterectomy and the presence of postoperative vaginal bleeding.