Reducing Blood Loss and Time in Vaginal Hysterectomy

Abstract & Commentary

Synopsis: An electrosurgical bipolar vessel sealer reduces the operating time and blood loss in a series of vaginal hysterectomies.

Source: Levy B, Emery L. Obstet Gynecol. 2003;102: 147-151.

In a single surgeon’s practice, 60 patients scheduled for vaginal hysterectomy were randomly assigned to 1 of 2 operative techniques for hemostasis: sutures or electrosurgical bipolar vessel sealer. The vessel sealer technique resulted in statistically shorter operative time (39 vs 54 minutes) and less blood loss (69 mL vs 127 mL). Complication rates and hospital lengths of stay were similar. Since the same surgical technique was used by a single surgeon for all cases, it appears that the use of the electrosurgical bipolar vessel sealer is an effective option to sutures, resulting in less time in the operating room and less blood loss.

Comment by Frank W. Ling, MD

This certainly looks good, doesn’t it? A simple, well-designed study that could change the way we do vaginal hysterectomy. We are being told about a surgical technique that reduces blood loss as well as time spent in the operating room. Sounds like a "no brainer," right? The new instrument can seal vessels and vascular bundles up to 7 mm in diameter. It delivers both mechanical and electrosurgical energy. The entire cycle of sealing and subsequent cooling takes about 5 seconds. It’s basically a standard Heaney-type clamp modified with a bipolar electrode so that it clamps, seals, and cuts. It was used on the cardinal, uterine vessel, and upper pedicles. The study has many things going in its favor.

First, it’s randomized. That definitely speaks in favor of the study results, since so many surgical papers do not randomize patients. They even did a power analysis. That is extremely unusual in a surgical paper. Because it was a single surgeon doing the cases, technique is as standardized as it could be. Another good aspect of study design was that blood loss was estimated by the anesthesia personnel to avoid surgeon bias. Not so fast, though! What is blunting my enthusiasm for this technology?

Even though we’d love to embrace new modalities that help the patient, we should do so cautiously. For example, one must first look at the financial disclosure statement: Dr. Emery works for the manufacturer and Dr. Levy is a member of its advisory group and gives educational talks for the company. Remember also that even though it was randomized, the surgeon had to know what technique for hemostasis was being used. As a result, one must wonder whether the surgeon performed with equal efficiency in all cases and whether the reduction of surgical time was attributable to the instrument only. In fact, Levy and Emery readily admit that the surgical time saving had no clinical significance because 78% of patients were done as outpatients anyway, and the rate of hospitalization was not greater with one technique or the other.

If the savings in the operating time wasn’t clinically significant, wasn’t the blood loss clinically significant? Again, one must look carefully at a couple of aspects. First, the accuracy must be evaluated. Even though it was done by anesthesia personnel, were they blinded as to the overall study design and the specific hemostatic technique in each case? Doubtful on both, so bias could have been introduced into the estimated blood loss. Even more relevant: Does the loss of an additional 60 mL of blood make a difference? You be the judge. So if the accuracy and clinical importance of blood loss are both in question, how significant is the study and its results? Why is it even being presented?

The good news related to a study such as this is that gynecologic surgery technique is not standing still. New instruments are being developed and people are trying to study them in a scientifically sound method. Are there flaws here? Sure there are, but that doesn’t mean that the overall message should be lost. The technique can potentially allow vaginal surgeons who wish to find a slight advantage to do so. Maybe more vaginal cases can be done, with less morbidity. Certainly, the individual surgeon must decide for himself/herself. As practitioners, however, we should always be looking for techniques and devices that really do help us take better care of our patients.

Is this instrument one of those great leaps forward? You be the judge.

Dr. Ling is UT Medical Group Professor and Chair, Department of Obstetrics and Gynecology, University of Tennessee Health Science Center, Memphis, TN