Ginekologia Polska

2018, vol. 89, no. 5, 229–234

Copyright © 2018 Via Medica
O R G I N A L PA P ER / G Y NECO LO G Y ISSN 0017–0011

DOI: 10.5603/GP.a2018.0040

Single-layer versus double-layer closure of the vaginal

cuff with barbed sutures in laparoscopic hysterectomy
Dogukan Yildirim1, Sefik Eser Ozyurek2, Huseyin Kiyak1, Agahan Han1, Nadiye Koroglu1,
Aysegul Bestel1, Fitnat Topbas1
1Department of Obstetrics and Gynecology, Saglik Bilimleri University, Kanuni Sultan Suleyman Training and Research Hospital,

Istanbul, Turkey
2Department of Obstetrics and Gynecology, Saglik Bilimleri University, Bagcilar Training and Research Hospital, Istanbul, Turkey

ABSTRACT
Objectives: The utilization of barbed sutures in laparoscopic hysterectomy has become popular among gynecologic sur-
geons. Our aim was to compare the outcomes of two different techniques for closing the vaginal cuff with barbed sutures
in laparoscopic hysterectomies.
Material and methods: A retrospective study was completed on 202 patients who underwent laparoscopic hysterectomy
for benign diseases at Istanbul Kanuni Sultan Suleyman Training and Research Hospital from April 2014 through June
2016. In group 1 (n = 139), a single-layer continuous suturing method was used; each bite contained the pubocervical fascia
and vaginal mucosa anteriorly, and vaginal mucosa and rectovaginal fascia posteriorly. In group 2 (n = 63), a double-layer
continuous suturing method was used; only vaginal mucosa was included in the first layer, and a second layer incorporated
the pubocervical and rectovaginal fascias.
Results: Patient characteristics (age, body mass index, parity, previous abdominal surgery, smoking, comorbidity) were
similar between the two groups. There were also no differences in total operation time, length of hospitalization, intraop-
erative complications, and perioperative change in hemoglobin levels. There was no difference between the two groups
in terms of vaginal cuff dehiscence, which was the primary outcome measure of the study. Secondary outcome measures
(presence of granulation tissue, spotting, cuff cellulitis) were also similar between the two groups.
Conclusions: We observed no differences in outcomes between single- or double-layer vaginal closure techniques with
barbed sutures.
Key words: barbed suture, vaginal cuff dehiscence, laparoscopic hysterectomy, closure technique
Ginekologia Polska 2018; 89, 5: 229–234

INTRODUCTION Reich described the first LH in 1989 [3]. Since then, the
Hysterectomy is one of the most common gynecologic trend of using LH has steadily increased from 0.3% in 1990 to
operations in the world. Approximately 600,000 procedures 16.8–24.9% in 2010 [4, 5]. It has been associated with impro-
are executed each year in the United States compared with ved outcomes such as decreased morbidity, shorter hospital
1,000,000 cases in China [1]. It can be performed abdomi- stay, and quicker return to normal activities when compared
nally, vaginally or endoscopically. The American Congress with the abdominal approach [6]. However, LH has not been
of Obstetricians and Gynecologist recommends using a mi- widely used because of its technical difficulties such as in-
nimally invasive approach for the benefit of the patients tracorporeal suturing of the vaginal vault. With the recent
and the associated reduced health care costs [2]. Today, introduction of barbed suture technology, more surgeons are
laparoscopic hysterectomy (LH) is considered as a minimally performing laparoscopic cuff suturing without tying knots.
invasive procedure when vaginal hysterectomy is not feasi- Vaginal cuff dehiscence (VCD) is a partial or total se-
ble because of anatomic difficulties. paration of the edges of the vaginal cuff with or without

Corresponding author:
Dogukan Yildirim
Department of Obstetrics and Gynecology, Saglik Bilimleri University, Kanuni Sultan Suleyman Training and Research Hospital, Istanbul, Turkey
e-mail: [email protected]

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bowel evisceration [7]. This complication is more common (Clermont-Ferrand, Karl Storz, Tuttlingen, Germany) was
with LH when compared with both abdominal and vaginal inserted into the uterus. After pneumoperitoneum was
approaches [8]. The use of barbed sutures decreases the created, a 10 mm umbilical trocar port for the camera and
rate of VCD in endoscopic surgery [9, 10]. These results three ancillary 5 mm trocar ports were inserted for instru-
suggest that barbed sutures are a safe and valuable for mentation. Advanced bipolar devices (LigaSure; Valleylab,
vaginal cuff closure. To date, all previous studies compared Inc., Boulder, CO or Enseal; Ethicon Endo-Surgery, Blue Ash,
the results of barbed sutures with conventional sutures. In Ohio) were used to seal and transect the ligaments and
this retrospective cohort study, however, we only focused pedicles. Colpotomy was performed by using monopolar
on barbed sutures. We compared two different techniques energy with a pure cutting current. If necessary, uterine
for closing the vaginal vault using barbed sutures among morcellation was performed vaginally or laparoscopically.
women who underwent LH in our institution; single-layer After removal of the uterus from the vagina, bipolar energy
closure in group 1 and double-layer closure in group 2. was used to achieve cuff hemostasis at the lowest level.
Unidirectional barbed sutures (3–0, 15 cm length, 26 mm
MATERIAL AND METHODS half circle taper point needle, V-LocTM; Covidien, Mansfield,
Local ethics board approval was granted for the study MA) were used laparoscopically for vaginal cuff closure in
(Decree no: 624). We performed a retrospective study of all patients. Two surgeons (HK, AH) used a single-layer con-
patients who underwent laparoscopic hysterectomy for be- tinuous suturing method in group 1; starting from the left
nign indications by a single group of gynecologic surgeons corner, each bite contained the pubocervical fascia and
in Istanbul Kanuni Sultan Suleyman Training and Research vaginal mucosa anteriorly, and vaginal mucosa and rectova-
Hospital between April 2014 and June 2016. All three gy- ginal fascia posteriorly. The running suture was cut without
necologists (DY, HK, AH) were experienced in laparoscopic tying a knot at the right corner (Fig. 1). The other surgeon
surgery at the beginning of the study. All patient files, which (DY) used a double-layer continuous suturing method in
contain operative reports, clinic notes, anesthesia records, group 2; only vaginal mucosa was included in the first lay-
discharge summaries, and telephone contacts, were collec- er, and a second layer incorporated the pubocervical and
ted from the hospital archive and reviewed. Additional data rectovaginal fascias (not vaginal mucosa) to run the suture.
were retrieved from the electronic medical database system. The barbed suture was cut without tying a knot at the right
Patient characteristics (age, body mass index [BMI], obstetric corner (Fig. 2). The patients were instructed to abstain from
history, surgical history, indication for surgery, comorbidi-
ties), operation characteristics (operating time, perioperati-
ve blood parameter changes, postoperative hospital stay),
and intraoperative and postoperative complications were A
obtained. All of patients were reexamined between Sep-
tember 2016 and July 2017 to detect any existing vaginal
cuff granuloma. During this visit, we also questioned the
presence of postoperative complications that might have
been managed by another hospital because some patients
were not residing in the city where the study was conducted.
In the event that such a condition was detected, the rela-
ted documents and reports were provided and recorded.
Patients who could not be contacted or were not willing to
participate were excluded from the study. Subjects were B
also excluded from the analysis if they had an additional
urogynecologic procedure, cuff closure by vaginal route or
conversion to laparotomy. The primary outcome measure
was dehiscence of the vaginal cuff. Secondary outcome
parameters were the presence of granulation tissue, posto-
perative vaginal bleeding (or spotting), and cuff cellulitis.
All patients underwent the same routine preparation
before surgery including administration of prophylactic anti-
biotics. All laparoscopic hysterectomies (LH) were performed Figure 1. Single-layer suturing method in group 1. A. Suturing was
started from the left corner B. Each bite contained the pubocervical
in a standard fashion. In brief, our laparoscopic hysterecto-
fascia and vaginal mucosa anteriorly, and vaginal mucosa and
my technique was as follows. An intrauterine manipulator rectovaginal fascia posteriorly

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 Dogukan Yildirim et al., Barbed suture for vaginal cuff closure

A RESULTS
The records of 285 patients who underwent total lapa-
roscopic hysterectomy performed by the three surgeons
within the annotated time were retrieved from the data-
base system. Among 83 patients who were excluded from
the study: 37 had additional urogynecologic procedures,
29 had been sutured with conventional materials, 5 were
converted to laparotomy, 9 could not be contacted, and
3 were not willing to participate in the study. A total number
of 202 patients were analyzed; 139 (69%) comprised the
B single-layer group (group 1), and 63 (31%) were included
in the double-layer group (group 2).
Indications for surgery in group 1 included symptomatic
uterine leiomyoma (n = 71), adenomyosis-endometriosis
(n = 23), abnormal uterine bleeding resistant to medical tre-
atment (n = 42), and persistent adnexal mass after menopau-
se (n = 3). In group 2, surgical indications were symptomatic
uterine leiomyoma (n = 34), adenomyosis-endometriosis
Figure 2. Double-layer suturing method in group 2. A. Suturing was (n = 9), and abnormal uterine bleeding resistant to medical
started from the right corner including only the vaginal mucosa in treatment (n = 20). Overall, the most frequent indication
the first layer. B. A second layer incorporated the pubocervical and for surgery was uterine leiomyoma (51%) and there was no
rectovaginal fascias (not vaginal mucosa)
statistically significant difference between the two groups.
Six intraoperative complications occurred; three bladder
intercourse and deep bathing for at least eight weeks after injuries and two sigmoid serosal lacerations were repaired
the surgery. laparoscopically during the same operation. One omental
The demographic factors and outcome variables were injury related to the direct primary trocar entry was locali-
compared among groups 1 and 2 using univariate tests. Pa- zed and sealed to stop bleeding. These patients were not
rametric tests were used when equal variances and normal excluded from the study because these complications did
distribution could be confirmed. Otherwise, nonparametric not relate to the study outcomes.
tests were used to compare the parameters of the two gro- The results of the comparison performed with univa-
ups. Significance was considered when P values were lower riate analysis stratified by closure technique are shown in
than 0.05. The data entry and statistical tests were perfor- Tables 1 and 2. The mean age of the study population was
med using Microsoft Office 2010 and SPSS 22.0 software. 49.7 years (range, 35–82 years), and there were no statistical-

Table 1. Clinical features of the groups

Group 1 Group 2
(Single Layer) (Double Layer) P
n = 139 n = 63
Age mean ± SEM 49.3 (0.63) 50.4 (0.66) 0.34
BMI mean ± SEM 30.8 (0.46) 29.8 (0.42) 0.19
Parity mean ± SEM 2.97 (0.12) 2.79 (0.15) 0.37
Duration of the operation (min) mean ± SEM 138.9 (3.5) 141.1 (5) 0.74
∆Hb (g/dL) Mean ± SEM 1.46 (0.72) 1.43 (0.73) 0.80
Any previous abdominal surgery n (%) 32 (23) 19 (30.2) 0.30
Diabetes n (%) 11 (7.9) 6 (9.5) 0.79
Hypertension n (%) 34 (24.5) 12 (19) 0.47
Smoking n (%) 7 (5) 7 (11.1) 0.14
Peripheral vascular disease n (%) 3 (2.2) 1 (1.6) 0.99
Intraoperative complication n (%) 4 (2.9) 2 (3.2) 0.82
SEM — standart error of the mean; BMI — body mass index; Hb — haemoglobin

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Ginekologia Polska 2018, vol. 89, no. 5

Table 2. Outcome measures of the study groups

Group 1 Group 2
(single layer) (double layer) P
n = 139 n = 63
Vaginal cuff dehiscence n (%) 1 (0.7) 0 (0) 0.99
Granuloma tissue n (%) 24 (17.3) 6 (9.5) 0.20
Spotting n (%) 22 (15.8) 9 (14.3) 0.83
Cuff cellulitis n (%) 7 (5) 3 (4.8) 0.99

ly significant differences between the two groups. Twenty- and faster recovery [5]. Along with the rapid boost in the
-three percent of the patients in the single-layer group had rate of LH, an increased incidence of vaginal cuff dehiscence
a previous abdominal surgery, as did 30.2% of patients in (VCD) has been noted. The incidence of this rare complica-
the double-layer group; the difference was not statistically tion is not clear and varies between 0% and 5% [11, 12]. In
significant. The mean duration of the operation was 139 mi- a review, the rate of VCD increased from 0.1% with abdomi-
nutes (± 2.86 minutes) in the entire study population and nal hysterectomy to 5% with LH [8]. When VCD is associated
similar between the two groups. No statistically significant with bowel evisceration, some complications could occur
differences were found with respect to BMI, parity, change in the absence of proper management including bowel
in hemoglobin levels (∆Hb), length of hospital stay, smoking perforation, peritonitis, and sepsis [13].
and comorbidities (Tab. 1). Smoking, diabetes, advanced age, immunosuppres-
The primary outcome measure, VCD, was seen in only sion, early coital activity, postoperative infections, and cuff
one patient in the single-layer group. There was no sta- hematoma have been associated with an increased risk of
tistically significant difference between the two groups VCD [14, 15]. Nevertheless, the majority of VCD is seen wi-
(Tab. 2). The patient with VCD was aged 40 years with a BMI thout any detectable cause [8]. It has been postulated that
of 32.9 who underwent total laparoscopic hysterectomy for laparoscopic colpotomies using monopolar energy may be
a symptomatic leiomyoma. Her operation was unevent- an underlying factor due to tissue necrosis and prolonged
ful and took 90 minutes to perform. She presented with devascularization [8]. Also, some histopathology studies
vaginal bleeding 9 days after surgery and reported not suggested that the amount and the type of energy used
having antecedent intercourse. No bowel evisceration was for colpotomy could predispose to VCD [16, 17]. However,
associated; accordingly, she was started on antibiotics and several studies failed to reveal an association between mo-
treated expectantly. nopolar energy and an increased risk of VCD in laparoscopic
The rates of vaginal spotting were similar between the hysterectomies [12, 18]. Given all these considerations, per-
two groups: 15.8% in the single-layer group and 14.3% in haps the causes of VCD dwell in surgical technique, espe-
the double-layer group. No major bleeding occurred in cially in the closing process of the vaginal cuff.
either group apart from in the patient with VCD. Although Suturing of the vaginal cuff is a critical component of LH
vaginal cuff granuloma rates were lower in the double-layer with many variations in surgical technique and materials. In-
group (17.3% in group 1 vs. 9.5% in group 2), the difference sufficient suture placement, decreased knot security and
did not reach a statistically significant level (p = 0.15). Seven suture fraying may have an impact on the development of
cases (5%) in single layer group and 3 cases (4.8%) in double VCD [7]. In 2007, a revolutionary suture design, the barbed
layer group with cuff cellulitis were treated medically; the suture, was introduced to the market to facilitate laparo-
difference was not statistically significant. scopic suturing. Barbed sutures do not require an assistant
to apply tension to the suture thread, unlike continuous
DISCUSSION suturing with conventional materials. Moreover, they close
The findings of this retrospective analysis suggest that the tissue without the use of surgical knots, which is the
single- or double-layer vaginal cuff closure in LH using bar- weakest point of the suture line [19]. In this study, we focu-
bed sutures provide similar results with respect to VCD and sed on the performance of barbed sutures by not including
also granulation tissue generation, postoperative vaginal cases of vaginal closure with conventional sutures. However,
bleeding (i.e., spotting) or cuff cellulitis. several studies in the literature compared traditional suture
With advances in technology, the laparoscopic approach materials to barbed sutures.
is being increasingly used for total hysterectomy. Several Only two studies found that barbed sutures decreased
studies demonstrated that laparoscopic hysterectomy (LH) the rate of VCD compared with standard suture materials
associates with shorter hospital stay, less surgical infection, [9, 10]. On the other hand, many studies could not find any

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 Dogukan Yildirim et al., Barbed suture for vaginal cuff closure

association between the two groups for VCD [20–27]. In being at different points in their learning curves in LH. The
a meta-analysis, Bogliogo et al. [28] reported that the rate retrospective design was a limitation of our study. Therefore,
of minor bleeding, major bleeding, and VCD was similar in the allocation of cases to the two groups was not randomi-
minimally invasive hysterectomy with or without the use of zed due to which the group sizes were uneven. Moreover, it
barbed sutures. They found that barbed sutures reduced the was possible to have recall bias because some patients may
time for vaginal cuff suturing. In a review, Smith et al. [29] not have remembered all the potential symptoms during
also found that barbed sutures decreased the average total the early postoperative period (e.g., spotting). Another limi-
procedure time by 15.6 minutes and 5.4 minutes for vaginal tation was the rarity of the primary outcome (VCD), which
cuff suturing. This shortened surgical time may theoretically makes it difficult to demonstrate a decrease in the incidence
compensate for the elevated cost of barbed sutures [25]. of this event in a relatively small study population.
We did not measure the time for cuff suturing in our study;
however, the total operation time was similar in both groups. CONCLUSIONS
Jeung et al. [30] compared the double-layer continuous We observed no differences in outcomes between sin-
method with interrupted figure-of-eight sutures using Vicryl gle- or double-layer vaginal closure techniques with barbed
in both groups and found no benefits for the double-layer sutures. The preferred method, whether single- or double-
suturing group. Several studies that compared barbed sutures -layer closure of the vaginal cuff in LH, should be founded
(with double-layer cuff closure) with conventional sutures on the surgeon’s choice. This issue merits randomized con-
reported similar results with regard to spotting and cellulitis trolled prospective trials.
[20, 21, 23, 25]. In contrast, two studies performing a similar
comparison found a decrease in the proportion of patients Conflict of interest
with vaginal bleeding (spotting) using double- layer barbed The authors declare that they have no conflict of interest.
sutures [9, 22]. Regarding granuloma, two studies reported
that there was no advantage of double-layer closure with Acknowledgements
barbed sutures [20, 22]. Another two studies, however, found We thank Dr Seyma Yesiralioglu for the illustrations.
less granuloma tissue formation with double-layer barbed su-
tures [9, 24]. Our study is the first to compare the double-layer REFERENCES
technique with single-layer closure using barbed sutures in 1. Cong L, Li C, Wei B, et al. V-Loc™ 180 suture in total laparoscopic hyste-
rectomy: a retrospective study comparing Polysorb to barbed suture
both groups. We found no difference between the two groups
used for vaginal cuff closure. Eur J Obstet Gynecol Reprod Biol. 2016; 207:
regarding VCD, cuff granuloma, spotting or cellulitis. 18–22, doi: 10.1016/j.ejogrb.2016.09.012, indexed in Pubmed: 27816737.
Cuff complications after hysterectomy other than VCD 2. ACOG Committee Opinion No. 444: choosing the route of hysterec-
tomy for benign disease. Obstet Gynecol. 2009; 114(5): 1156–1158,
are not rare and can cause discomfort for patients. Bleeding doi: 10.1097/AOG.0b013e3181c33c72, indexed in Pubmed: 20168127.
(spotting) is the main reason for repeat consultations in the 3. REICH H, DeCAPRIO J, McGLYNN F. Laparoscopic Hysterectomy. Journal of
Gynecologic Surgery. 1989; 5(2): 213–216, doi: 10.1089/gyn.1989.5.213.
postoperative period after LH [22]. We found that 15.3% of 4. Cohen SL, Vitonis AF, Einarsson JI. Updated hysterectomy surveillance
the entire patient population experienced spotting; it was and factors associated with minimally invasive hysterectomy. JSLS. 2014;
18(3), doi: 10.4293/JSLS.2014.00096, indexed in Pubmed: 25392662.
the most common complication of our study. We could not 5. Jacoby VL, Autry A, Jacobson G, et al. Nationwide use of lapa-
measure the duration of spotting due to the retrospective roscopic hysterectomy compared with abdominal and vagi-
nal approaches. Obstet Gynecol. 2009; 114(5): 1041–1048, doi:
design of our study. We observed that some patients reported
10.1097/AOG.0b013e3181b9d222, indexed in Pubmed: 20168105.
prolonged periods of spotting of up to two months. Vaginal 6. Desai VB, Guo XM, Fan L, et al. Inpatient Laparoscopic Hysterectomy in
cuff granuloma was also frequent (14.8%) in our patient popu- the United States: Trends and Factors Associated With Approach Selec-
tion. J Minim Invasive Gynecol. 2017; 24(1): 151–158.e1, doi: 10.1016/j.
lation and was even defined beyond two years following the jmig.2016.08.830, indexed in Pubmed: 27614151.
operation in individual cases. One could presume that there 7. Fanning J, Kesterson J, Davies M, et al. Effects of electrosurgery and
vaginal closure technique on postoperative vaginal cuff dehiscence.
might be an association between spotting and granuloma. JSLS. 2013; 17(3): 414–417, doi: 10.4293/10860813X1369342251851,
However, only 7 of 30 patients (23.3%) with cuff granuloma indexed in Pubmed: 24018078.
8. Hur HC, Guido RS, Mansuria SM, et al. Incidence and patient characte-
reported spotting in our study, with no significant association. ristics of vaginal cuff dehiscence after different modes of hysterecto-
Our institution has been using barbed sutures for vaginal mies. J Minim Invasive Gynecol. 2007; 14(3): 311–317, doi: 10.1016/j.
jmig.2006.11.005, indexed in Pubmed: 17478361.
cuff closure in laparoscopic hysterectomies since 2013. Al-
9. Siedhoff MT, Yunker AC, Steege JF. Decreased incidence of vaginal
though some surgeons still prefer to use conventional bra- cuff dehiscence after laparoscopic closure with bidirectional barbed
ided sutures, barbed sutures became quite popular in our suture. J Minim Invasive Gynecol. 2011; 18(2): 218–223, doi: 10.1016/j.
jmig.2011.01.002, indexed in Pubmed: 21354068.
hospital. We only included the patients of three surgeons 10. Rettenmaier MA, Abaid LN, Brown JV, et al. Dramatically reduced inci-
because these surgeons performed a high volume of LH dence of vaginal cuff dehiscence in gynecologic patients undergoing
endoscopic closure with barbed sutures: A retrospective cohort study.
within the defined period, thereby eliminating the influence Int J Surg. 2015; 19: 27–30, doi: 10.1016/j.ijsu.2015.05.007, indexed in
of experience variability originating from different surgeons Pubmed: 25980394.

www. journals.viamedica.pl/ginekologia_polska 233

Ginekologia Polska 2018, vol. 89, no. 5

11. Nieboer TE, Johnson N, Lethaby A, et al. Surgical approach to hysterec- endometrial cancer: technical evaluation and 1-year follow-up of 61
tomy for benign gynaecological disease. Cochrane Database Syst Rev. patients. J Laparoendosc Adv Surg Tech A. 2013; 23(4): 347–350, doi:
2009(3): CD003677, doi: 10.1002/14651858.CD003677.pub4, indexed 10.1089/lap.2012.0079, indexed in Pubmed: 23573880.
in Pubmed: 19588344. 22. Medina BC, Giraldo CH, Riaño G, et al. Barbed suture for vaginal cuff
12. Uccella S, Ceccaroni M, Cromi A, et al. Vaginal cuff dehiscence in a se- closure in laparoscopic hysterectomy. JSLS. 2014; 18(1): 83–88, doi: 10.
ries of 12,398 hysterectomies: effect of different types of colpotomy 4293/108680813X13693422518795, indexed in Pubmed: 24680149.
and vaginal closure. Obstet Gynecol. 2012; 120(3): 516–523, doi: 23. Kim JH, Byun SW, Song JY, et al. Barbed versus conventional 2-layer con-
10.1097/AOG.0b013e318264f848, indexed in Pubmed: 22914459. tinuous running sutures for laparoscopic vaginal cuff closure. Medicine
13. Ceccaroni M, Berretta R, Malzoni M, et al. Vaginal cuff dehiscence after (Baltimore). 2016; 95(39): e4981, doi: 10.1097/MD.0000000000004981,
hysterectomy: a multicenter retrospective study. Eur J Obstet Gynecol indexed in Pubmed: 27684850.
Reprod Biol. 2011; 158(2): 308–313, doi: 10.1016/j.ejogrb.2011.05.013, 24. Cong L, Li C, Wei B, et al. V-Loc™ 180 suture in total laparoscopic hyste-
indexed in Pubmed: 21723030. rectomy: a retrospective study comparing Polysorb to barbed suture
14. Hur HC, Donnellan N, Mansuria S, et al. Vaginal cuff dehiscence after used for vaginal cuff closure. Eur J Obstet Gynecol Reprod Biol. 2016; 207:
different modes of hysterectomy. Obstet Gynecol. 2011; 118(4): 794–801, 18–22, doi: 10.1016/j.ejogrb.2016.09.012, indexed in Pubmed: 27816737.
doi: 10.1097/AOG.0b013e31822f1c92, indexed in Pubmed: 21934442. 25. Tsafrir Z, Palmer M, Dahlman M, et al. Long-term outcomes for different
15. Somkuti SG, Vieta PA, Daugherty JF, et al. Transvaginal evisceration vaginal cuff closure techniques in robotic-assisted laparoscopic hyste-
after hysterectomy in premenopausal women: a presentation of three rectomy: A randomized controlled trial. Eur J Obstet Gynecol Reprod
cases. Am J Obstet Gynecol. 1994; 171(2): 567–568, indexed in Pubmed: Biol. 2017; 210: 7–12, doi: 10.1016/j.ejogrb.2016.11.018, indexed in
8059847. Pubmed: 27923167.
16. Tulikangas PK, Smith T, Falcone T, et al. Gross and histologic characte- 26. Blikkendaal MD, Twijnstra ARH, Pacquee SCL, et al. Vaginal cuff dehi-
ristics of laparoscopic injuries with four different energy sources. Fertil scence in laparoscopic hysterectomy: influence of various suturing
Steril. 2001; 75(4): 806–810, indexed in Pubmed: 11287039. methods of the vaginal vault. Gynecol Surg. 2012; 9(4): 393–400, doi:
17. Gruber DD, Warner WB, Lombardini ED, et al. Laparoscopic hysterectomy 10.1007/s10397-012-0745-5, indexed in Pubmed: 23144640.
using various energy sources in swine: a histopathologic assessment. 27. Einarsson JI, Cohen SL, Gobern JM, et al. Barbed versus standard suture:
Am J Obstet Gynecol. 2011; 205(5): 494.e1–494.e6, doi: 10.1016/j. a randomized trial for laparoscopic vaginal cuff closure. J Minim Invasive
ajog.2011.07.009, indexed in Pubmed: 21924395. Gynecol. 2013; 20(4): 492–498, doi: 10.1016/j.jmig.2013.02.015, indexed
18. Uccella S, Ghezzi F, Mariani A, et al. Vaginal cuff closure after minimally in Pubmed: 23680517.
invasive hysterectomy: our experience and systematic review of the lite- 28. Bogliolo S, Nadalini C, Iacobone AD, et al. Vaginal cuff closure with
rature. Am J Obstet Gynecol. 2011; 205(2): 119.e1–119.12, doi: 10.1016/j. absorbable bidirectional barbed suture during total laparoscopic hyste-
ajog.2011.03.024, indexed in Pubmed: 21620360. rectomy. Eur J Obstet Gynecol Reprod Biol. 2013; 170(1): 219–221, doi:
19. Greenberg JA. The use of barbed sutures in obstetrics and gynecology. 10.1016/j.ejogrb.2013.06.006, indexed in Pubmed: 23820139.
Rev Obstet Gynecol. 2010; 3(3): 82–91, indexed in Pubmed: 21364859. 29. Smith K, Caceres A. Vaginal Cuff Closure in Minimally Invasive Hyste-
20. Nawfal AK, Eisenstein D, Theoharis E, et al. Vaginal cuff closure during rectomy: A Review of Training, Techniques, and Materials. Cureus. 2017;
robotic-assisted total laparoscopic hysterectomy: comparing vicryl to 9(10): e1766, doi: 10.7759/cureus.1766, indexed in Pubmed: 29234570.
barbed sutures. JSLS. 2012; 16(4): 525–529, doi: 10.4293/108680812X1 30. Jeung InC, Baek JM, Park EK, et al. A prospective comparison of vaginal
3462882736772, indexed in Pubmed: 23484558. stump suturing techniques during total laparoscopic hysterectomy. Arch
21. Ardovino M, Castaldi MA, Fraternali F, et al. Bidirectional barbed suture Gynecol Obstet. 2010; 282(6): 631–638, doi: 10.1007/s00404-009-1300-0,
in total laparoscopic hysterectomy and lymph node dissection for indexed in Pubmed: 19943055.

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