Division of Obstetrics and Gynecology, Department of Maternal, Neonatal and Infant Health, ASL Biella, Biella, Italy.
Department of Obstetrics and Gynecology, AOUI Verona, University of Verona, Verona, Italy.
Acta Obstet Gynecol Scand. 2021 Oct;100(10):1840-1848. doi: 10.1111/aogs.14238. Epub 2021 Aug 15.
The transfusion rate in hysterectomies for benign pathology is almost 3%. However, despite the strong interest in reducing intraoperative bleeding, limited evidence is available regarding the technical aspects concerning uterine vessel management during a total laparoscopic hysterectomy (TLH). Uterine artery (UA) closure in TLH can be performed at the origin from the internal iliac artery or at the uterus level (UL). However, low-quality evidence is available regarding the superiority of one method over the other.
We performed a single-blind randomized (1:1) controlled trial (NCT04156932) between December 2019 and August 2020. One hundred and eighty women undergoing TLH for benign gynecological diseases were randomized to TLH with UA closure at the origin from the internal iliac artery (n = 90), performed at the beginning of the procedure by putting two clips per side at the origin, vs closure at the UL (n = 90). Intraoperative blood loss estimated from suction devices was the primary outcome. Secondary end points were perioperative outcomes, the conversion rate from one technique to the other, and complication rates with 4 months of follow up.
Uterine artery closure at the origin was completed in all 90 patients (0%), whereas closure at the UL was converted to closure at the origin in 11 cases (12.2%; p < 0.001); failures were mainly associated with the presence of endometriosis (81.8% [9/11] vs 10.1% [8/79]; p < 0.001). In the intention-to-treat analysis, the intraoperative blood loss was higher in the group assigned to the closure at the UL (108.5 mL) than in the group with closure at the origin (69.3 mL); the mean difference was 39.2 mL (95% CI 13.47-64.93 mL; p = 0.003). Other perioperative outcomes and complications rates did not differ.
Uterine artery closure at the origin reduces intraoperative blood loss during a TLH and appears to be more reproducible than closure at the UL without higher complication rates. However, the absent translation in clinical benefits impedes the support of a clinical superiority in all women. Closure at the origin may provide clinical advantages in the presence of severe preoperative anemia or pelvic anatomic distortion.
良性病理行子宫切除术的输血率几乎为 3%。然而，尽管人们强烈关注减少术中出血，但关于全腹腔镜子宫切除术（TLH）期间子宫血管管理的技术方面，证据有限。TLH 中可在子宫动脉（UA）发自髂内动脉处或在子宫水平（UL）处进行 UA 结扎。然而，关于一种方法优于另一种方法的高质量证据有限。
我们于 2019 年 12 月至 2020 年 8 月期间进行了一项单盲随机（1:1）对照试验（NCT04156932）。180 名因良性妇科疾病行 TLH 的女性被随机分为 UA 在髂内动脉起源处结扎的 TLH 组（n=90），该组在手术开始时每侧放置两个夹在起源处，与 UL 结扎组（n=90）。通过吸引装置估计的术中失血量为主要结局。次要终点是围手术期结局、从一种技术转为另一种技术的转化率以及 4 个月随访时的并发症发生率。
90 例患者（0%）完成了 UA 在起源处的结扎，而 90 例 UL 结扎中有 11 例（12.2%）转为起源处结扎（p<0.001）；失败主要与存在子宫内膜异位症有关（81.8%[9/11] vs. 10.1%[8/79]；p<0.001）。在意向治疗分析中，分配到 UL 结扎组的术中失血量（108.5ml）高于起源处结扎组（69.3ml）；平均差异为 39.2ml（95%CI 13.47-64.93ml；p=0.003）。其他围手术期结局和并发症发生率无差异。
UA 在起源处结扎可减少 TLH 中的术中失血，且似乎比 UL 结扎更具可重复性，而不会增加更高的并发症发生率。然而，缺乏临床获益的转化，限制了其在所有女性中具有临床优势的支持。在存在严重术前贫血或骨盆解剖结构扭曲的情况下，起源处结扎可能提供临床优势。
