Innovations Stem Blood Loss in Hysterectomy

OB/GYN News, June 15, 2001 by Kathryn Demott

CHICAGO -- Innovations aimed at refining abdominal hysterectomy are significantly stemming the loss of blood during the procedure, experts said at the annual meeting of the American College of Obstetricians and Gynecologists.

Among the estimated 390,000 abdominal hysterectomies performed annually in the United States, hemorrhage requiring transfusion is the leading major complication, said Dr. Cynthia 0kin of the University of Pittsburgh.

In a study involving 50 patients undergoing total abdominal hysterectomy, those who were randomly assigned to undergo hemostasis using a device called LigaSure lost an average of 74.2 cc of blood, compared with 118.7 cc among patients who received conventional ligation, said Dr. Raffaele Bruno of Lahey Clinic, Burlington, Mass.

Dr. Bruno holds no financial interest in LigaSure or Valleylab Inc., the Boulder, Colo.-based manufacturer of the device.

The LigaSure technique uses much lower voltages and higher current flows than conventional ligation with an electrosurgical generator. With the LigaSure device, collagen and elastin are denatured to the point where the intimal layers of the vessel wall can be compressed and collapsed into a single layer. The lumen of that blood vessel is completely obliterated, Dr. Bruno explained.

In contrast, traditional methods of ligation use much higher voltages and lower current flows, which create more heat in the vessel wall. The wall of the lumen then shrinks, disrupting blood flow. This in turn causes a clot to form in the proximal section of the vessel. It's this clot that actually creates the hemostasis, he said.

During the entire LigaSure procedure, the level of impedance in the vessel tissue is automatically measured in the jaws of a clamp. The amount of energy delivered to the vessel wall adjusts depending on the tissue impedance so that the integrity of the seal is maximized without causing thermal damage to surrounding tissue.

In the study, procedure times were also significantly reduced from 48 minutes in the conventional group to 31 minutes in the LigaSure group.

Patients in the LigaSure group received an average of only 5 sutures, compared with 17 sutures in the conventional ligation group. LigaSure may be safer than conventional hemostasis methods for surgical staff, as well, since fewer sharp needles were transferred between the surgeon and the operating staff, he noted.

There were no reports of postoperative hemorrhage. One patient in each study arm required blood transfusions, but these were primarily for an associated medical problem. One patient in each arm had a urinary tract infection. One wound infection occurred in the LigaSure group, affecting a morbidly obese diabetic patient having surgery for endometrial cancer.

In a separate randomized, placebo-controlled trial, Dr. Okin and her associates at the University of Pittsburgh found that an injection of vasopressin into the uterus at the time of abdominal hysterectomy reduced blood loss by as much as 40% without increasing morbidity. The 51 patients in the study were all undergoing abdominal hysterectomy for a leiomyomatous uterus. Patients received 10 U of vasopressin in 10 mL of normal saline or 10 mL of normal saline alone. Bilateral 5-mL injections were given 1 cm medial to the uterine vessels into the lower uterine segment.

Total average blood loss was 445.4 mL in the vasopressin group, compared with 748.4 mL for the placebo group, a statistically significant difference. There were no major complications in either group; however, there was a trend toward an elevation in blood pressure in the vasopressin group immediately after the procedure.