Search

Vaginal hysterectomy rates in the United States are decreasing, despite it being the recommended hysterectomy route for benign hysterectomy by multiple societies. Visualization issues are a known barrier to a medical student learning in the operating room, and it is likely that this also extends to resident training. In addition, vaginal surgery can be taxing on both the surgeons and assistants, with high rates of musculoskeletal work disorders reported in vaginal surgeons. The use of a camera is integral to endoscopic surgery, and table-mounted retractor systems have been used for decades in open surgery. We bring these 2 features into vaginal surgery, that is, using a table-mounted camera system and a table-mounted vaginal retractor. When used together as demonstrated in this video, these tools can improve visualization and may improve ergonomics for the entire surgical team, including learners, during vaginal surgery., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Objective: To demonstrate a novel technique to surgically treat certain vaginal conditions., Design: Technical video demonstrating 2 cases in which the technique is used., Setting: Gynecological Minimally Invasive and Robotic Surgery Unit at Clínica Universitaria (private clinic), Concepción, Chile., Interventions: Local institutional review board was consulted, and this study was exempted from approval. Institutional ethics committee approved the study and publication of these data. A 35-year-old woman with a bicornuate unicollis uterus presented with dyspareunia. Her examination revealed an incomplete longitudinal vaginal septum. Her right hemivagina was slightly wider than the left one. With the patient under spinal anesthesia, we performed a complete resection of the septum using the single-port/pneumovagina technique (SPPT). A 36-year-old woman who was nulligravida presented with dyspareunia. On clinical exam she had a 3-cm leiomyoma in the proximal vaginal third. Doppler-powered pelvic ultrasound ruled out any vascular communication with the cervix. We performed a vaginal myomectomy using the SPPT under spinal anesthesia. In this particular case we used a fourth trocar in the gel cap to use a myoma screw. With this technique we created a pneumovagina occluding the introitus with the aid of a single-port device (GelPoint Path; Applied Medical, Rancho Santa Margarita, CA). We selected this particular device, designed for transanal surgery, because its access channel avoids gas leakage after applying gentle pressure on the cap. The working cannel is 4 × 4.5 cm, and up to 4 trocars can be inserted in the gel cap. We use 12 mm Hg of pressure to create the pneumovagina and 5 L/min flow to maintain it. Similar approaches have been described for treating eroded and/or infected sacrocolpopexy mesh [1-3]. One could question the utility of this approach over conventional vaginal surgery, and in this sense we believe it provides both the surgeon and surgical assistant a much more comfortable and ergonomic position while performing surgery. It also improves the view of anatomic structures for the surgical team, which in conventional vaginal surgery is limited only to the surgeon. Both procedures were uneventful. The operation time for the first patient was 5 minutes, and the patient was discharged 4 hours later. The operation time for the second patient lasted 35 minutes, and she was discharged 12 hours later., Conclusion: The creation of a pneumovagina with the application of a single-port device provides an excellent view of vaginal structures and allows the application of laparoscopic techniques to perform vaginal surgeries in a much more ergonomic fashion compared with conventional vaginal surgery., (Copyright © 2019 AAGL. Published by Elsevier Inc. All rights reserved.)

Study Objective: Transvaginal natural orifice transluminal endoscopic surgery (vNOTES) offers similar advantages of traditional vaginal surgery including no incisional pain as well as a better cosmetic outcome. Furthermore, vNOTES allows the surgeon to overcome the limited surgical space and lack of exposure when using the traditional vaginal instrumentation. Vaginal uterosacral ligament suspension subsequent to vaginal hysterectomy has the advantages of a mesh-free, minimally invasive approach for the treatment of pelvic organ prolapse. The objective of this video is to demonstrate a surgical technique and a few tips and tricks for vNOTES hysterectomy and uterosacral ligament suspension., Design: Stepwise demonstration of the vNOTES technique for hysterectomy and vaginal apical suspension to the uterosacral ligament with narrated video footage., Setting: An academic tertiary referral center. The ethics committee ruled that approval was not required for this study., Patients: A 53-year-old woman., Interventions: vNOTES hysterectomy and apical suspension to the uterosacral ligament., Measurements and Main Results: A 53-year-old woman (gravida 5, para 4) presented with Pelvic Organ Prolapse Quantification System stage III symptomatic uterine prolapse. The patient was selected to be operated on via a vaginal port. The video presents some tips and tricks to aid the surgeon to perform this surgery in a safe and timely manner using the vaginal GelPOINT system (Applied Medical, Rancho Santa Margarita, CA)., Conclusion: vNOTES for repair of POP by uterosacral ligament suspension via a vaginal port is a feasible technique with promising cosmetic results. This technique allows the surgeon to expose the ureter well and lower the risk of ureteric injury. Additionally, this approach avoids mesh complications and should also decrease the risk of abdominal wound infection because of the absence of incisions on the abdomen., (Copyright © 2019 AAGL. Published by Elsevier Inc. All rights reserved.)

Study Objective: To demonstrate the proper use of vessel-sealing devices during vaginal hysterectomy., Design: Educational video (Canadian Task Force classification level III)., Setting: University hospital., Intervention: The video reviews the principles on the use of energy in minimally invasive surgery. We focus on how vessel-sealing devices function and the benefits of their use in difficult vaginal hysterectomy. The video explains the 2 major types of complications, inadequate vessel sealing and undesired thermal injury, and demonstrates techniques to avoid these complications., Measurements and Main Results: Laboratory, intraoperative, and cadaveric recordings demonstrate proper use and the complications that may arise in the setting of improper use., Conclusion: Vessel-sealing devices may be a useful tool for surgeons performing vaginal hysterectomy. This video demonstrates their use and underlines the importance of understanding the principles of energy devices and their proper usage in surgery., (Copyright © 2018 American Association of Gynecologic Laparoscopists. Published by Elsevier Inc. All rights reserved.)

Objective: During the vaginal steps of laparoscopic-assisted vaginal hysterectomy (LAVH), excessive bleeding occurs if the vascular pedicles are not securely clamped. Accordingly, this study investigates if an advanced bipolar sealing device (PlasmaKinetics [PK] Sealer), compared to conventional sutures, could improve the efficacy and safety in the vaginal steps of LAVH., Material and Methods: The medical records of 101 women who underwent LAVH for a non-malignant condition between June 2014 and August 2017 were retrospectively reviewed. Among the women, 60 received LAVH using conventional sutures (control group), while 41 using the PK Sealer during vaginal steps (PK group)., Results: A 35% reduction (76.1 vs. 117.3 mL) in the blood loss was observed in the PK group. The natural logarithm (ln) of the blood loss was significantly lower in the PK group than in the control group (P = .045). The percentage of cases which achieved the minimal blood loss goal (<50 mL) was significantly higher in the PK group than in the control group (61 vs. 48%, P = .044). After adjusting for confounding factors, the PK group still exhibited a significantly lower ln intraoperative blood loss (OR -0.477, P = .002) than the control group., Conclusion: The PK bipolar sealing device provides a safe and effective alternative in reducing blood loss in the vaginal steps of LAVH., (Copyright © 2018. Published by Elsevier B.V.)

Objective: To evaluate the safety and efficacy of vaginal hysterectomy for benign conditions (excluding prolapse) using the BiClamp (Erbe Elektromedizin, Tübingen, Germany) bipolar electrocoagulation system., Methods: The present study was a prospective audit of a consecutive case series of patients who underwent vaginal hysterectomy for benign conditions, performed using the BiClamp between March 1, 2015, and June 30, 2016, at Norfolk and Norwich University Hospital, Norwich, UK. Surgeries performed for benign conditions were eligible, excluding prolapse; severe endometriosis with pelvic adhesions was an exclusion criterion. Patient demographics and past history were recorded, along with intraoperative findings and adverse events. Follow-up data were obtained via telephone interviews 24 hours after surgery and a nurse-led postoperative clinic 8 weeks postoperatively., Results: The series included 75 patients; 32 (43%) were discharged on the same day as surgery and 70 (93%) within 23 hours. There were two patients who experienced vault hematomas and remained admitted for more than 24 hours. There was one intraoperative bladder injury that was repaired vaginally. No delayed adverse events occurred within 8 weeks. No patient required patient-controlled analgesia or an epidural injection for postoperative analgesia., Conclusion: Patients experienced low postoperative pain following BiClamp treatment and 93% were was discharged within 23 hours., (© 2018 International Federation of Gynecology and Obstetrics.)

Objectives: Vaginal hysterectomy can be associated with a significant risk of vault haematomas with consequent postoperative morbidity. The aim of this study was to assess the use of a Foley Catheter as a vaginal drain in premenopausal women undergoing a vaginal hysterectomy and the impact on different outcomes including development of vault haematoma, length of hospital stay, antibiotics usage, readmissions to the hospital and febrile morbidity in the immediate postoperative period., Study Design: This study was conducted at a tertiary teaching hospital and was a retrospective cohort study of women undergoing a vaginal hysterectomy. The study compared 52 women in the study group with a Foley catheter drain to 51 age matched controls without a drain who underwent surgery for similar indications. Outcomes were compared using the Chi square test and student t-test., Results: Comparing women with a drain to those without demonstrated a statistically significant difference with worse outcomes for all parameters in women without a drain: evidence of vault haematomas (0 vs 8; p = 0.0025); length of hospital stay over 2 days (3 vs 15; p = 0.001); discharge with antibiotics for vault haematomas (5 vs 0; p = 0.028) and readmission rates (0 vs 7; p = 0.005). There was no statistical difference in the number of women with temperatures over 38 °C (4 vs 2; p = 0.3) in either group., Conclusion: A Foley catheter used as a pelvic drain following a vaginal hysterectomy reduces postoperative complications associated with vault haematomas with shorter hospital stay, lower antibiotic usage and lower readmission rate., (Crown Copyright © 2018. Published by Elsevier B.V. All rights reserved.)

Objective: The aim was to evaluate surgical routes for benign hysterectomy in a Swedish population, including abdominal and minimally invasive surgery., Study Design: Prospectively collected data from the Swedish National GynOp Registry 2009-2015: 13 806 hysterectomy cases were included: abdominal (AH, n = 7485), vaginal (VH, n = 3767), conventional laparoscopic (LH, n = 1539) and robotically-assisted (RAH, n = 1015)., Results: The VH group had the shortest operation time at 75 min, AH 97 min and RAH 104 min. LH was longest at 127 min (p < 0.005). The mean estimated blood loss was higher in the AH group (250 ml) compared to all minimally invasive surgery (MIS, 65-172 ml); p < 0.005). Conversion rates were 10% for LH, 4.8% for VH and 1.6% for RAH (p < 0.005). Hospitalization and patient-reported time to normal activities of daily living (ADL) were longer for AH compared to MIS (p < 0.005). Time to return to work was eight days longer in the AH group (35 days) compared with the MIS groups (p < 0.005). Complications were fewest in the VH group at 5.4% compared with AH 7.6% and RAH 8.7% (both p < 0.001), but did not significantly differ from the LH group at 6.6%. Overall patient satisfaction was reported to be 86-94% one year after surgery., Conclusion: Women operated on for benign hysterectomy with minimally invasive methods in Sweden 2009-2015 had reduced length of hospitalization, as well as time to resuming normal ADL and return to work, compared to AH. Postoperative outcome measures were improved by minimally invasive methods and MIS should preferably be used., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Minimally invasive platforms have afforded women undergoing hysterectomy the advantages of improved postoperative pain control, reduced complication rates, and shorter inpatient recovery time. In patients where malignancy has been confirmed or suspected, the necessity for uterine delivery per vagina is imperative to maintain these advantages without compromising oncological outcome.A previously unreported technique of enlarging the apical circumference of the vagina during robotic hysterectomy facilitates intact uterine passage after extended reflection of the bladder and/or rectum. Significant increases in vault circumference can be gained through even small midline incisions of the vaginal wall, with an additional 5-cm incision almost doubling the apical aperture in certain cases.We present our series of 21 cases that support this safe, reliable, and simple method for intact uterine delivery during robotic hysterectomy in minimally invasive gynecological oncology practice.

Objective: To compare the impact of peritoneal closure on postoperative pain after vaginal (VH) and laparoscopic-assisted vaginal hysterectomy (LAVH)., Study Design: A prospective, randomized, double-blind study was designed to investigate as primary outcome the postoperative pain after VH and LAVH with and without peritoneal closure. The postoperative pain was measured using visual analogue scale (VAS)., Results: The patients were recruited between August, 2007 and July, 2014. A total of 192 patients with benign uterine diseases were eligible for analysis and were divided in four groups: LAVH and VH with and without peritoneal closure (PC), respectively. The patients' characteristics including parity, BMI, previous abdominal operations, and uterus weight were well balanced between the groups. The patients who received LAVH were significantly younger (p = 0.0443). LAVH was associated with increased postoperative pain and reduced patients' mobility in the first 72 and 24 h, respectively, after surgery. The use of analgesics remained similar in all four groups. The operating time was significantly shorter after VH (VH + PC 59 ± 17; VH - PC 56 ± 19) than after LAVH (LAVH + PC 106 ± 29 min; LAVH - PC 99 ± 30) (p < 0.0001). The PC did not affect the patients' outcome. The blood loss, the hemoglobin drop, the hospital stay, and the rate of intra- and postoperative complications rate were similar in all four groups. No conversation to laparotomy occurred in whole study population., Conclusion: VH is associated with shorter operating time and reduced postoperative pain compared to LAVH.

The ERBE BiClamp ® BVSS appears to be a safe and effective method of vaginal hysterectomy in this small single surgeon, single institution study; demonstrating efficient operative times, minimal blood loss and intraoperative morbidity with acceptable surgical outcomes. Its use contributes to the advancement of minimally invasive gynaecology and should be encouraged., Competing Interests: Provenance: externally peer-reviewed Disclosure of Interests, Funding and Contribution to Authorship: We disclose no interests and no funding was obtained. The authors are solely responsible for this paper. GVB, LH and DQ collected the data. GVB and JPB conducted data analysis and the write up. GJD, DQ and JPB participated in the surgery and GJD was the supervising consultant and lead surgeon or surgeon directly supervising trainees. Ethical Approval: As this project was solely an audit of intra- and post-operative outcomes for the purposes of service evaluation it was not deemed necessary to submit to the Regional Ethics Committee for approval.

Background: The vaginal surgeon is challenged with performing complex procedures within a surgical field of limited light and exposure., Instrument: The video telescopic operating microscope is an illumination and imaging system that provides visualization during open surgical procedures with a limited field of view. The imaging system is positioned within the surgical field and then secured to the operating room table with a maneuverable holding arm. A high-definition camera and Xenon light source allow transmission of the magnified image to a high-definition monitor in the operating room. The monitor screen is positioned above the patient for the surgeon and assistants to view real time throughout the operation., Experience: The video telescopic operating microscope system was used to provide surgical illumination and magnification during total vaginal hysterectomy and salpingectomy, midurethral sling, and release of vaginal scar procedures. All procedures were completed without complications. The video telescopic operating microscope provided illumination of the vaginal operative field and display of the magnified image onto high-definition monitors in the operating room for the surgeon and staff to simultaneously view the procedures., Conclusion: The video telescopic operating microscope provides high-definition display, magnification, and illumination during vaginal surgery.

The aim of this study was to demonstrate the feasibility of a total hysterectomy performed entirely by transvaginal natural orifice transluminal endoscopic surgery (vNOTES). Conventional, reusable laparoscopic instruments were used, inserted through an inexpensive, self-constructed single-port device. Ten total vaginal NOTES hysterectomies (TVNHs) were performed by a single surgeon. The self-constructed single-port device was made by assembling a surgical glove, a wound protector or modified laryngeal mask airway, 1 reusable 10-mm trocar, and 4 reusable 5-mm trocars. This gloveport was inserted into the vagina to create a pneumovagina. The conventional steps of a vaginal hysterectomy were followed, but performed endoscopically with standard reusable endoscopic instruments. The patient and perioperative data were analyzed. No conversion to standard laparoscopy or laparotomy was necessary in any of the 10 patients who underwent a TVNH. Mean operation time was 97 min (range: 60-120); mean drop in hemoglobin level was 1.5 g/dL (range: 0.5-2.4). There were no operative complications, and postoperative pain scores were very low. This first report on a small number of patients demonstrates that TVNH is possible. By incorporating the advantages of endoscopic surgery, TVNH broadens the indications for vaginal hysterectomy and helps overcome its limitations. At the same time, the NOTES approach avoids abdominal wall wounds and trocar-related complications. TVNH is feasible, even when performed with reusable, conventional laparoscopic instruments. This frugally innovative technique also enables surgeons to perform hysterectomies by vNOTES in low resource settings., (Copyright © 2015 AAGL. Published by Elsevier Inc. All rights reserved.)

Objective: To compare surgical outcomes in women who underwent vaginal hysterectomy with enlarged (> 12 weeks size) and non-prolapsed uterus utilizing different morcellation techniques with or without concomitant Deschamps needle use to vaginal hysterectomy for prolapsed uterus., Material and Methods: Retrospective cohort study in women who underwent vaginal hysterectomy performed between January 2009 and June 2014 in the National Institute of Perinatology. The study group comprised 48 women who had vaginal hysterectomy with enlarged and non-prolapsed uterus in which were utilized different morcellation techniques with or without concomitant Deschamps needle use and 50 women who had vaginal hysterectomy for prolapsed uterus served as control., Results: The groups had statistical difference in age, number of cesarean sections, body mass index (BMI), grade of prolapse (Point Cx and D with POPQ quantification system) and surgical prediagnosis (p < 0.001); mean uterus weight was 182.5 g and 106 g, respectively (p < 0.001), as well as for transverse and antero-posterior dimensions and realization of morcellation with or without use of Deschamps needle. Both groups had no statistical difference in preoperative hemoglobin, concomitant surgeries for incontinence and prolapsed, estimated blood loss, operation time, length of stay and complications., Conclusion: Vaginal hysterectomy utilizing different morcellation techniques with or without concomitant Deschamps needle use in women with enlarged and non-prolapsed uterus is safe, effective, and with similar complications to vaginal hysterectomies in prolapse uterus.

Study Objective: To evaluate if the use of Valleylab mode ("V mode") (Covidien, Mansfield, MA) electrothermal energy for colpotomy during total laparoscopic hysterectomy (LH) results in a smaller margin of thermal injury to the upper vagina compared with traditional cut/coagulate (cut/coag) electrothermal energy., Design: Prospective randomized clinical trial (Canadian Task Force classification I)., Setting: University medical center., Patients: A total of 101 subjects who underwent LH between June 2010 and August 2012., Interventions: Subjects were randomized to colpotomy by V mode electrothermal energy or cut/coag electrothermal energy., Measurements and Main Results: The primary end point was the median depth of thermal injury measured in millimeters. The secondary end points included the proportion of subjects who developed granulation tissue, induration, infection, or dehiscence at the vaginal cuff at 4 weeks, 3 months, or 6 months postoperatively. There was no significant difference in the median depth of thermal injury in the cut/coag and V mode arms (anterior margin: 0.68 mm vs 0.63 mm [p = .94], posterior margin: 0.66 mm vs 0.70 mm [p = .87], respectively). Twenty-seven percent of subjects in each arm developed at least 1 of the clinical end points at 4 weeks, 3 months, or 6 months postoperatively (granulation tissue: 6%-18% vs 8%-21%, induration: 0%-2% vs 4%-5%, infection: 0%-4% vs 0%-10%, dehiscence: 2% vs 0% in the cut/coag and V mode arms, respectively), with no difference between arms (p = 1.0)., Conclusion: The V mode does not reduce the depth of thermal injury compared with cut/coag electrothermal energy when used for colpotomy incision during total laparoscopic hysterectomy (Clinical Trials.gov ID: NCT02080546)., (Copyright © 2015 AAGL. Published by Elsevier Inc. All rights reserved.)

The aim of this study was to evaluate the clinical efficacy of a temporary ureteral catheter in preventing iatrogenic ureteral damage in cervical cancer patients undergoing laparoscopic radical hysterectomy. All cases had confirmed diagnoses of cervical cancer preoperatively between December 2008 and December 2012 in our hospital and were in clinical stages IA2 to IIA. In total, 176 laparoscopic radical hysterectomy and lymphadenectomy procedures were performed. The 176 cases were divided into two groups: ureteral catheters were installed using cystoscopy before the operation in 86 patients (group A), and ureteral catheters were not placed in 90 patients (group B). These cases were retrospectively analyzed based on postoperative hospitalization time and intraoperative and postoperative complications. A total of 6 cases (3.41%) had ureteral injuries, and 4 of the cases (4.65%) of ureteral injuries occurred in group A. In two of these cases, urinary leaking appeared at the post-operative 8th and 9th days and at the 10th and 25th days, respectively. There were 2 cases (2.22%) of ureteral injuries in group B: 1 case of intraoperative direct injury and the other of urinary leaking, which appeared at post-operative day 21. Statistically significant differences between the two groups were observed in operating time and the incidence of hemorrhage, hematuria (including microscopic hematuria), post-operative urinary tract infection, and pain (P < 0.05). A ureteral catheter that is placed preoperatively can help to identify the ureter in laparoscopic radical hysterectomy, but does not decrease the incidence of ureteral injury.

The objective of our study was to evaluate surgical outcome of minimally invasive vaginal hysterectomy (MIVH), using the bipolar vessel sealing system (BVSS; BiClamp®). The design was a retrospective analysis (Canadian Task-force Classification II-3). The setting was a secondary care hospital. Records of patients who underwent vaginal hysterectomy for benign indications in our centre between November 2005 and March 2011 were reviewed. The demographic patients' data, indications for surgery, patient history with regard to previous surgery, duration of surgery, blood loss (postoperative hemoglobin drop '∆Hb'), perioperative complications, and length of inpatient stay were collected from the medical records. The intervention was vaginal hysterectomy using BVSS (BiClamp®). Results showed that the mean duration of surgery was 48.9 ± 15.3 min (95% CI, 49.2-52.5). The mean duration of hospital stay was 3.2 ± 1.2 days (95% CI, 2.8-3.2). The mean ∆Hb was 1.4 ± 1.8 g/dl. Overall, conversion to laparotomy was required in three cases (0.6%). Only one haemoperitoneum occurred (0.2%) and this is the only case who required blood transfusion. The main indication for VH was uterine prolapse in 52.0% (n = 260) of cases; uterine fibroids in 37.4% (n = 187); adenomyosis uteri in 4.2% (n = 21); cervical dysplasia in 22 patients (4.4%) and in 2% (n = 10) of patients, endometrial hyperplasia and other pathologies were the indications for VH. It was concluded that electrosurgical bipolar vessel sealing by (BiClamp®) can provide a safe and feasible alternative to sutures in vaginal hysterectomy, resulting in reduced operative time and blood loss, with acceptable surgical outcomes.

Objective: To compare the efficacy of 2 bipolar systems during total laparoscopic hysterectomy (TLH): the pulsed bipolar system (PlasmaKinetic; Olympus, Japan) vs. conventional bipolar electrosurgery (Kleppinger bipolar forceps; Richard Wolf Instruments, Vernon Hills, IL)., Methods: We retrospectively reviewed medical records of 80 women who underwent TLH for benign gynecologic disease between 2009 and 2010. Forty women received TLH using the conventional bipolar system and another 40 using the pulsed bipolar system. The clinical outcomes and complications were compared between the 2 groups., Results: No significant differences between the 2 groups were observed in terms of age, body mass index, and hospital stay. However, the blood loss was greater (515.3 ± 41.2mL vs. 467.9 ± 33.4mL, P < .05) and the operation time was longer (173.4 ± 33.4min vs. 157.3 ± 21.3min, P < .05) in the conventional group. Additionally, the uterine weight was lighter in the conventional group (218.5 ± 23.4g vs. 299.4 ± 41.1g, P < .05). None of the surgeries were required to be converted to laparotomy. No significant differences were found in intraoperative or postoperative complications between the groups., Conclusion: The pulsed bipolar system has some advantages over the conventional system, and therefore, may offer an alternative option for patients undergoing TLH.

Purpose: The medical and economic benefits of the transvaginal approach over the abdominal and laparoscopic methods are demonstrated in many studies. Vaginal hysterectomy with bipolar vessel sailing (BiClamp(®)) represents an example of mininvasive surgery and could be a valid and cost-benefit alternative in the surgical treatment of benign gynaecologic disease. BiClamp(®) may be carried out according to Clavè's technique with a good result in postoperative pain., Methods: Prospective randomized study (Canadian Task Force classification I). We compared the vaginal hysterectomy with salpingo-oophorectomies with BiClamp(®) and multimodal anaesthesia (group A 30 patients) with vaginal hysterectomy with salpingo-oophorectomies and spinal anaesthesia (group B 30 patients)., Results: The median operating time was 33.5 min for group A and 54.5 min for group B (p < 0.0001). The median blood loss was 59.25 ml in group A and 81.75 ml in group B. The median hospital stay was 1.6 ± 0.58 days for group A and 2.55 ± 0.66 days for group B. Postoperative pain was statistically different between groups in the immediate postoperatory times, at 2 and at 6 h from the surgery and at 10 p.m. (p < 0.0001). Analyses of cost-effectiveness have stated advantages in terms of costs and indirect-direct benefits but also in earlier resumption of working., Conclusions: BiClamp(®) technique with multimodal anaesthesia has advantages from surgical, anaesthesiology and economic point of view. It is a minimally invasive surgery characterised by lower morbidity, quicker surgery times and reduced costs when compared to classical vaginal hysterectomy. BiClamp(®) technique represents a new border in vaginal surgery.

With widespread use of laparoscopy in patients with gynecologic malignancy, occasionally port-site metastasis is an item of concern. Herein we report a case of leiomyosarcoma of the uterus that metastasized to an accessory port after laparoscopic-assisted vaginal hysterectomy. A 46-year-old woman with a preoperative diagnosis of leiomyoma underwent laparoscopic-assisted vaginal hysterectomy. Final histopathologic findings revealed leiomyosarcoma. A postoperative abdominopelvic computed tomography scan demonstrated no evidence of metastatic tumor. The patient received 6 courses of combined chemotherapy consisting of cisplatin and ifosfamide. Follow-up computed tomography was performed because of pelvic pain at 4 months after treatment and revealed a recurrent pelvic tumor and a metastatic mass at previous right trocar site. At debulking surgery, a pelvic mass measuring 10 cm was observed, and a subcutaneous nodule measuring 4 cm was noted at the site of the right accessory port, with intact underlying peritoneum. After complete removal of both tumors, concurrent chemoradiation consisting of external radiotherapy and cisplatin was administered. Six months after the second surgery, a pelvic mass measuring 15 cm was observed. A second debulking surgical procedure was performed. However, the patient died of the disease 6 months after the second recurrence., (Copyright © 2012 AAGL. Published by Elsevier Inc. All rights reserved.)

Objectives: To determine if opening the vaginal cuff during laparoscopic sacrocolpopexy influences the rate of mesh exposure., Methods: A total of 390 medical records were retrospectively reviewed for demographic information, operative technique, and relevant outcomes., Results: Eleven mesh exposures (2.8%) and 14 suture extrusions (3.6%) were found, none involving visceral organs. Mesh exposure was more common when the vaginal cuff was opened, either during hysterectomy or when allowing transvaginal attachment of mesh in patients with a prior hysterectomy (4.9% vs 0.5%; relative risk [RR], 9.0, P = 0.012). In cases where concomitant hysterectomy was performed, a higher mesh exposure rate was seen in open-cuff hysterectomy (total vaginal hysterectomy/laparoscopically assisted vaginal hysterectomy) compared to supracervical hysterectomy (4.9% [9/185] vs 0% [0/92]; P = 0.032). Mesh exposure was more common when the mesh was sutured laparoscopically compared with transvaginally in patients undergoing open-cuff hysterectomy (14.3% [5/35] vs 2.7% [4/150]; RR, 5.4; P = 0.013). Permanent suture extrusion was significantly associated with laparoscopic versus transvaginal suturing of mesh (5.6% vs 0.6%; RR, 8.8; P = 0.010). Five patients underwent reoperation for mesh exposure, whereas most suture extrusions were asymptomatic; and all were managed nonsurgically., Conclusions: We found that preserving the integrity of the vaginal cuff led to a lower incidence of mesh exposure in patients undergoing laparoscopic sacrocolpopexy. When hysterectomy is indicated, a supracervical technique should be strongly considered as the mesh exposure rate was significantly lower. If removal of the cervix is indicated, the risk for mesh exposure remains low and should not preclude total hysterectomy, though transvaginal mesh attachment may be preferable.

Laparoscopic hysterectomies increase recently due to several advantages of minimally invasive surgery. Controversy exists for laparoscopic hysterectomies for large uteri weighing >500g because some reports show increased complications and morbidities and high laparoconversion rate in the past. With familiarity of laparoscopic procedures and progress in surgical techniques, the issue should be discussed and reviewed by evidence again. Hence, we conducted a systematic review of laparoscopic hysterectomies for large uteri., (Copyright © 2011. Published by Elsevier B.V.)

Background: Single-port laparoscopic-assisted vaginal hysterectomy (S-LAVH) uses only one transumbilical incision site and has better cosmetic result than conventional multiport LAVH. This study aimed to evaluate our initial experience with S-LAVH compared with the more conventional three-port LAVH in women with benign uterine diseases., Methods: Between April 2009 and April 2010, S-LAVH was attempted on 183 patients with benign uterine diseases through a transumbilical incision for a 12-mm trocar, and conventional LAVH was performed on 275 patients by the same surgeon. The medical records of patients were reviewed. The age, body mass index, operative time, blood loss, and uterine weight on pathologic report were compared., Results: Two of 183 patients in the S-LAVH group were converted to two- or three-port surgery, compared with none in the conventional group. Data analysis was done for 181 patients in the S-LAVH group and 275 patients in the conventional LAVH group. No major complications, including ureteral or bladder injuries, occurred in any of the patients. No statistically significant differences were found in mean age, mean body mass index, mean operative time, mean anesthesia time, mean estimated blood loss, or mean postoperative days to passage of flatus, but the mean uterine weights on the pathologic reports were significantly reduced in the S-LAVH group., Conclusion: S-LAVH could be a feasible alternative method for removal of the uterus with a better cosmetic outcome resulting from single wound in selected patients. For patients with large-sized uterus, more surgical experience and improvement in instruments suitable for S-LAVH are needed.

Purpose: The aim was to identify the advantages and disadvantages of using bipolar coagulation forceps in vaginal hysterectomy and to compare the effects of this method with those of the conventional technique., Methods: A group of 30 patients was operated on with bipolar coagulation forceps and the next 30 were operated on using the traditional method. The following parameters were observed: duration of procedure, blood loss, complications, postoperative pain, hospitalization time and cost of treatment., Results: The duration of the surgical procedure and hospitalization time were similar in both groups. Blood loss was lower in the BiClamp group. There were no serious complications in either group. In one case with BiClamp, laparotomy was performed to stop persistent bleeding; the after-effects of the laparotomy were not statistically significant. The patients in the BiClamp group reported less pain, experienced shorter recuperation times and incurred lower treatment costs., Conclusions: The BiClamp technique is a good alternative to traditional hysterectomy methods as it causes lower blood loss during surgery, causes less post-operative pain and is economically more favorable for the patient and hospital.

Women affected by early stage invasive cancer of the cervix are usually treated by surgery. Radical abdominal hysterectomy with pelvic lymphadenectomy is the most widely used technique. Because the morbidity of the abdominal approach can be important, the radical vaginal hysterectomy has gained acceptance in gynaecologic oncology. New instrumentation in laparoscopy also opens the possibility of treating cervical cancer by laparoscopically assisted vaginal radical hysterectomy and also total laparoscopic radical hysterectomy. Before these techniques become widely accepted, it has to be shown that safety and efficacy are comparable with the 'standard' abdominal approach. In this chapter, we review the technique of radical vaginal hysterectomy with pelvic lymphadenectomy and evaluate results of published studies, comparing the abdominal, vaginal and laparoscopic approaches., (2010 Elsevier Ltd. All rights reserved.)

Objective: To compare the immediate results of patients undergoing either two-channel single-port laparoscopic-assisted vaginal hysterectomy or conventional multiport laparoscopic-assisted vaginal hysterectomy., Methods: Patients were randomly assigned to undergo laparoscopic-assisted vaginal hysterectomy using the single-port (n=50) or conventional (n=50) approach. The outcome measures included blood loss, operative time, intraoperative and immediate postoperative complications, time to flatus passage after operation, and postoperative pain (assessed by the visual analog scale score and postoperative analgesics use)., Results: The general characteristics of the patients were similar in both groups. There were no statistically significant differences in operative time, estimated blood loss, time to first flatus, intraoperative and immediate postoperative complications, shoulder tip pain, or length of hospital stay between the two groups. However, postoperative pain was significantly less in the single-port group compared with the conventional group, as evidenced by lower mean scores on the visual analog scale (3.64±2.75 compared with 5.08±2.76 at 24 hours, P=.011 and 1.94±2.31 compared with 2.84±2.07 at 48 hours, P=.043) and less mean accumulated dose of postoperative analgesics (74.40±24.25 mg compared with 104.80±57.08 mg of meperidine, P=.001; 16±13.40 mg compared with 33.6±28.7 mg of tenoxicam, P<.001)., Conclusion: Transumbilical two-channel single-port laparoscopic-assisted vaginal hysterectomy significantly decreases postoperative pain and analgesic use., Clinical Trial Registration: Clinical Trials.gov, www.clinicaltrials.gov, NCT01048931., Level of Evidence: I.

Purpose: Transumbilical single-incision laparoscopic surgery has been used more frequently in general surgery to reduce the invasiveness of traditional laparoscopy. However, few reports of single-incision laparoscopic surgery have been described in the field of gynecology. We used single-incision laparoscopic surgery to laparoscopically assisted vaginal hysterectomy (LAVH). We performed single-incision LAVH in ten patients and compared the operative results with the conventional multiport, multi-incision LAVH., Methods: We began applying single-incision LAVH in July 2009 and completed this method for uterine myoma in ten cases. Operative time, weight of resected uterus, and body mass index (BMI) were recorded and compared to those of conventional multiport LAVH., Results: Comparative outcomes of single-incision LAVH versus conventional multiport LAVH were as follows. The mean operative time was 76 ± 15.5 versus 71.4 ± 21.7 min (P = 0.57). The mean weight of resected uterus was 366.3 ± 144 versus 354 ± 95.5 g (P = 0.85). BMI was 23.3 ± 2.75 versus 22.2 ± 3.76 kg/m(2) (P = 0.52). No significant difference was observed between single incision and conventional LAVH., Conclusions: Single-incision LAVH can be undertaken safely and with similar operative results to conventional multiport LAVH. We consider that it is a promising alternative method for the treatment of some patients with uterine myomas as incision-free gynecological operation.

This paper describes a novel method of facilitating laparoscopically assisted vaginal hysterectomy (LAVH) uniquely distinguished by commencing vaginally and finishing laparoscopically. For this technique a specially designed uterine manipulator has been developed., (© 2010 The Author. Journal of Obstetrics and Gynaecology Research © 2010 Japan Society of Obstetrics and Gynecology.)

Objective: Total Laparoscopic hysterectomy (TLH) has became more commonly procedures for gynaecological surgery, but high incidence of complications and the technical challenges are still problematic among less-experienced surgeons. To accomplish these difficulties, we developed the new uterine manipulator; Anurach uterine manipulator (AUM) to simplify TLH with the modified technique. Our objective was to evaluate the feasibility of the new uterine manipulator; AUM, with the modified total laparoscopic hysterectomy in an initial cohort of patients., Material and Method: From October 2007 though September 2008, one hundred cases of hysterectomy were done by modified technique of TLH using A UM. After installation of AUM, a modified technique of TLH was started by posterior colpotomy, then extended to anterior colpotomy. The operation was performed using bipolar and harmonic scapel for coagulation and cutting the vascular pedicles and ligaments. The entire procedure was done laparoscopically and the uterus was removed vaginally. The vaginal cuff was closed by continuous suture, double layers with PDS material., Results: Most common indication was symptomatic leiomyoma, the uterine size was 64-620 grams. Mean operation time was 98 +/- 27.1 minutes. Estimated blood loss was 188 +/- 87.5 ml. There were no bowel or ureteric injuries, except 2 cases of bladder injury which had been repaired laparoscopically., Conclusion: The modified technique using AUM could be the option to simplify TLH, in reducing the complications and having more favorable operative outcomes.

There is no doubt that laparoscopic surgeries have replaced open surgeries in many gynecologic operations and have led to the development of novel techniques such as single-port laparoscopic surgery. Single-port surgery has been performed mainly for hysterectomy or adnexectomy recently, and it has also been carefully considered for other possible single-port surgeries such as cancer operations. Although pelvic lymph node dissection is a common procedure in gynecologic cancer operations, it has been rarely performed with single-port laparoscopic access because of technical difficulties. In this report, we present a detailed description of single-port laparoscopic pelvic lymph node dissection with modified radical vaginal hysterectomy in 2 patients with cervical cancer, stage IA2. Combining either classic or modified Schauta radical vaginal hysterectomy with single-port laparoscopic technique could be a good option for the management of patients with cervical cancer.

In this article, we would like to compare the clinical characteristics and effectiveness of selective uterine artery double ligation and bipolar uterine artery coagulation in total laparoscopic hysterectomy (TLH) retrospectively. TLH was performed on 72 patients with selective uterine artery double ligation and on 312 patients with uterine artery bipolar coagulation in tertiary university hospital from January 2004 through January 2006. Both groups were similar with respect to age, body mass index, parities, rate of menopause and uterine weight. The mean transfusion, postoperative hospital stay and drain insertion in the selective uterine artery double ligation group were significantly lower than those in the bipolar uterine artery coagulation group in TLH, respectively (p < .05). There were no differences in the hemoglobin, hematocrite change, additional operations, operation time, rate of complication between the two kinds of operation (p > .05). In conclusion, selective uterine artery double ligation in TLH showed lower transfusion rate, less hospitalization and less discomfort due to drain than bipolar uterine artery coagulation. Also, it did not take a longer time for operation and thus provides a feasible and secure method to manage uterine vessels at the level of uterine isthmus inside of the broad ligament.

Introduction: The purpose of this report is to evaluate our experience with transvaginal application of a laparoscopic bipolar cutting forceps to assist vaginal hysterectomy in extremely obese women with endometrial cancer in whom obesity precluded LAVH/BSO and lymphadenectomy and vaginal obesity limited visualization and exposure., Materials and Methods: We performed a retrospective review and identified 6 consecutive cases. No cases were excluded. A laparoscopic 33-cm Plasma Kinctic (PK) cutting forceps with a 5-mm diameter was applied transvaginally to coagulate and cut the uterosacral and cardinal ligaments, uterine vasculature, and ovarian ligaments. The uterus was delivered vaginally. Staging lymphadenectomy was not performed., Results: Median age was 51 years, median weight was 405 lbs, and median BMI was 66 kg/m². Five of 6 cases were successfully performed vaginally (83%). Median operative time was 1 hour 10 minutes, median blood loss was 500 mL, and pain was only discomforting. All patients were discharged the day after surgery. There were no complications. At median follow-up of 1 year, all patients were alive with no evidence of disease., Conclusion: It is our opinion that the transvaginal application of a laparoscopic bipolar cutting forceps can successfully assist vaginal hysterectomy in extremely obese endometrial cancer patients who cannot tolerate LAVH/BSO and lymphadenectomy and vaginal obesity limits visualization and exposure.

Removal of the fallopian tubes and ovaries at the time of vaginal hysterectomy is a skill that must be acquired if one is to be a competent vaginal surgeon. Various techniques have been described and will be reviewed in this chapter. A single technique or series of steps often must be modified depending on the descent of the adnexa, size and shape of the pelvis, and intraperitoneal pathology. The pelvic surgeon must adhere to the basic surgical principles and understand the anatomic relationships of the adnexa to other pelvic viscera, including the lower urinary tract. Preoperative discussion with all patients regardless of age is imperative in determining their desires for oophorectomy at the time of vaginal hysterectomy.

We prospectively collected data on all patients with stage IB1 cervical cancer, who underwent total laparoscopic radical hysterectomy with the use of a modified uterine manipulator. From January 2000 to December 2005, 54 patients met the study criteria. The mean age was 41.8 +/- 7.47 years. Average BMI (kg/m(2)) was 27.38 +/- 3.13. Squamous carcinoma and adenocarcinoma were found in 88.88% and 11.11% of the cases, respectively. The average surgical time was 265 +/- 70.8 min. The mean estimated blood loss was 276.11 +/- 123.03 ml. The average patient lymph node count was 19.64 +/- 5.08. Positive malignant lymph nodes were identified in 11.11% of the cases. Surgical margins were free of disease in all patients. The mean hospital stay was 1.5 +/- 1 days. There was no mortality. Total laparoscopic radical hysterectomy can be considered a safe alternative to laparotomy. The use of a uterine manipulator does not pose an increased surgical risk and allows for a simpler and more feasible procedure.

This was a review of 512 consecutive cases of laparoscopic-assisted vaginal hysterectomy (LAVH) for benign gynecologic conditions with the Biswas uterovaginal elevator (BUVE) from February 2003 through June 2008. A single operator, using the BUVE and a standard surgical protocol, performed all hysterectomies. Variables analysis included patient demographics, operative times, uterine weight, hospital stay, intraoperative blood loss, and intraoperative and postoperative complications. LAVH was successfully performed for all patients. The median operative time was 62 [corrected] minutes, range 35 to 250 minutes. The median uterine weight was 231 [corrected] g (range 43-1690 g). The median estimated blood loss was 100 [corrected] mL (range 5-1600 mL). The median length of hospital stay was 1 [corrected] days (range 1-6 days). [corrected] No case sustained injury to the ureter or major vessels or required conversion. LAVH with the BUVE eliminates the need for laparotomy in performing hysterectomies for benign gynecologic disorders. The BUVE can achieve a full range of uterine manipulation. It allows safe and easy dissection of the bladder and precise colpotomy through simultaneous uterine elevation and delineation of vaginal fornices. Prevention of ureteric injury is made possible by moving the surgical field away from the ureter. The technique described can be used to handle a wide variety of diseases and situations and has been shown to be safe, fast, easy to learn, and reproducible and carries few complications.

Removal of large uteri via minimally invasive methods propose a number of challenges that can be diminished by technique, instrumentation, and skill of the surgeon. We propose that the Alexis Wound Retraction System, initially designed for circumferential and atraumatic retraction during abdominal surgery, is a viable alternative to standard retraction techniques when large uteri are removed vaginally.

Objective: The aim of this study was to assess the feasibility and safety of vaginal removal of ovaries at the time of vaginal hysterectomy., Materials and Methods: All patients candidate to hystero-salpingo-oophorectomy by transvaginal approach, between 1 March 2004 and 28 February 2007, were admitted in the study., Results: Of the 472 women included in the study, 432 (91.5%) underwent hysterectomy and bilateral oophorectomy by vaginal approach. There was only one case of major vessel injury, but no patients required blood transfusion. All the operations were performed only by vaginal route and no conversion to the abdominal route was required., Conclusion: The need to perform oophorectomy should not be considered a contraindication to vaginal hysterectomy.

A reliable method of transvaginal access is needed for natural orifice transluminal endoscopic surgery. We introduce a new culdotomy procedure, using a technique for the creation of space in the cul-de-sac, transvaginal ultrasound, and a newly developed umbrella Hakko needle. An artificially developed, saline-containing space in the cul-de-sac was punctured by an umbrella Hakko needle from the vagina under the guidance of ultrasound. The vaginal walls on both sides of the needle were incised with an electric scalpel. In five cases with benign gynecological tumors, culdotomy was successfully performed. Operating time was less than 10 minutes and blood loss was less than 10 mL. There were no culdotomy-associated complications. This procedure, named Culdotomy FourS Two U, is a simple, safe, and reliable method for entry into the cul-de-sac in transvaginal gynecological surgeries and may have future applications in transluminal endoscopic surgery through the vagina.

Background: Robotic gynecologic procedures were FDA-approved in March 2005. Published average times for robotic hysterectomies vary from 192 minutes to 242 minutes and one report indicated operative times ranging from 4.5 to ten hours. Many critics cite learning curves and increased operative times as a deterrent to performing robotic hysterectomies., Methods: This is a retrospective review of surgical times (learning curve) for the first 100 consecutive extrafascial hysterectomies with or without salpingo-oophorectomy for a single surgeon. Operating times were recorded by operating room nursing staff for each case. The times reported are from "skin to skin," which is defined as from when the surgeon started to place anything vaginally until the last suture was placed to close the trocar sites. We report average times for hysterectomy per 20 cases., Results: The average time for hysterectomies was as follows: First 20 cases--124 minutes, second 20 cases--94 minutes, third 20 cases--85 minutes, fourth 20 cases--88 minutes, fifth 20 cases--81 minutes. Age, body mass index and uterine weights were comparable between groups. Complications were highest in the first 20 at 15 percent, compared with 5 percent for the remaining groups, but this did not reach statistical significance., Conclusions: The learning curve for da Vinci hysterectomies is steep, with the maximum improvement in surgical times in the first 20 cases. Minimal improvement was demonstrated after this.

Background: The purpose of this pilot study was to evaluate the impact of RealHand instruments on laparoscopic-assisted vaginal hysterectomy (LAVH) for the treatment of stage I uterine cancer., Methods: This was a single-center, nonrandomized, consecutive patient pilot study. Patient status was evaluated in terms of operative morbidity, length of surgery, anesthesia time, body mass index (BMI), estimated blood loss, uterine weight, and hospital stay., Results: In the group of 10 patients, mean operative time was 1.7 hours, and anesthesia time was 2.3 hours. Mean estimated blood loss was 70mL, and patient hospital stay was 31.8 hours. No intra- or postoperative complications occurred. Blood loss, anesthesia time, BMI, and uterine weight were significant predictors of operative time. In one patient, LAVH using the RealHand instruments was canceled because of deep pelvic visualization difficulties, resulting in a conversion to laparotomy., Conclusion: We present the first reported individual physician LAVH experience using RealHand instruments for the treatment of clinical stage I uterine cancer. The reported operative time, reasonable patient complication rates, and acceptable postoperative stay suggest that these innovative surgical instruments may have significant promise in the treatment of patients diagnosed with this gynecologic disease.

At present, there is no standard technique that allows surgeons performing total laparoscopic radical hysterectomy to complete the colpotomy and remove an adequate (2-cm) margin of upper vaginal tissue while maintaining adequate pneumoperitoneum. We evaluated the feasibility and safety of using a modified uterine manipulator for total laparoscopic radical hysterectomy in patients with cervical or endometrial cancer. A retrospective review was performed in all patients who underwent total laparoscopic radical hysterectomy using a modified uterine manipulator at our institution during the period April 2004 to December 2006. This analysis included 30 patients who underwent surgery with the modified uterine manipulator. There were no reports of difficulty with placement of the instrument, multiple attempts at placement, difficulty with uterine manipulation, or uterine perforation. In no patient was a vaginal incision or episiotomy required to fit the instrument through the introitus. In no case was there loss of pneumoperitoneum during colpotomy. Additional upper vaginal tissue had to be removed after intraoperative assessment of the adequacy of the surgical specimen in five (16.7%) of 30 patients. Use of the modified uterine manipulator according to our technique is safe and feasible, allowing for adequate vaginal resection and maintenance of pneumoperitoneum.

Severe adhesions between uterus and bladder or rectum, especially caused by endometriosis and multiple cesarean sections, remain a great challenge to surgeons in laparoscopic-assisted vaginal hysterectomy. Dense adhesions and anatomic variations cause difficulty in dissecting tissue planes, significant bleeding, lengthy operative time, and visceral injuries, especially an unrecognized thermal injury leading to late-onset fistulae or abscess. A modified technique, the combination of vaginal and laparoscopic approach with assistance of a Deaver retractor, is introduced in this article, which can achieve several advantages, including easily and safely dissecting tissue planes as close to the edge of adhesions as possible, avoidance of bladder or rectum injuries, less bleeding, shortened operative time, and minimized possibility of conversion to exploratory laparotomy if the surgeon is experienced in this technique.

The ratio of vaginal hysterectomy to abdominal hysterectomy in the UK is 1:3. It is well known that patients who have had a vaginal hysterectomy recover better compared with abdominal hysterectomy. However, abdominal hysterectomy is the preferred method in most hospitals because it is deemed easier to do. With ERBE Biclamp diathermy forceps, vaginal hysterectomy could be safely and easily performed by gynaecologists. This study showed a different surgical technique for performing vaginal hysterectomy. It allowed easier and safer operations in patients with large uterus, fibroid uterus, where there was no uterine descent and narrow introitus. Also it allowed the adnexal appendages to be removed easily by the vaginal route. We compared 100 patients who had a vaginal hysterectomy performed using this method, with patients who had a vaginal hysterectomy performed by the conventional method using sutures. We found that we could safely perform vaginal hysterectomy with greater ease. Also, the need for postoperative analgesia was less and the patients were discharged earlier. Consequently, the patients' convalescence period was shorter and better.

Background: Vascular injury during laparoscopic surgery typically occurs with the blind insertion of either the Veress needle or the trocar. We report an aortic puncture from the use of a laparoscopic fascial closure device., Case: After a laparoscopic-assisted vaginal hysterectomy and during closure of the 10-mm umbilical port with a fascial closure device, attempted passage of the needle encountered unusual resistance in the abdominal wall. Application of increased force resulted in uncontrolled entry of the needle into the abdominal cavity and a 1-mm puncture of the aorta. After emergency laparotomy the puncture was successfully repaired by a vascular surgeon., Conclusion: A previously unreported complication of this laparoscopic fascial closure device is aortic injury. Unusual resistance to passage of the needle should engender extra caution. The use of assistive closure devices should be reserved for patients with difficult anatomy.