A clinical study of vault hematomas after different types of ...

Hemant Deshpande et al, Int J Pharm Biomed Sci 2013, 4(3), 91-95
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Table 1
Indications for abdominal and vaginal hysterectomies
Abdominal hysterectomy
Vaginal hysterectomy
Indication No. of cases No. of hematoma case (%) Indication No. of cases No. of hematoma case (%)
Large multiple fibroids 10 2(20) UV prolapse 70 5(7.14)
Fibroids 15 1(6.67) Fibroid 10 2(20)
DUB 45 0(0) DUB 15 2(13.33)
PID 21 3(14.29) Adenomyosis 5 2(40)
Chronic cervicitis 5 1(20)
Endometriosis 4 0(0)
Total 100 7(7) 100 11(11)
and laparoscopically assisted vaginal hysterectomies
(LAVH), for different benign uterine diseases.
Ethical committee permission was obtained for the study.
All patients were clinically evaluated by detail history,
thorough clinical examination, and needful investigations
along with pre-operative ultrasound assessment.
Preoperative assessment was done for high risk factors like
hypertension, chronic intake of aspirin, ischemic heart
disease, anticoagulant therapy, diabetes mellitus and
coagulopathy for increased bleeding tendencies. After final
diagnosis and indication for hysterectomy, decision regarding
route of hysterectomy was decided, to group the patients.
Hysterectomies were performed by different experienced
gynaecologists. A single dose of intravenous antibiotic,
Injection Cefixime 1 gm was given one hour pre-operatively.
Suture material and suturing technique used for vault closure
was recorded. Amount of blood loss, units of blood
transfused and operative time were recorded for every
patient. Type of haemorrhage, if present, was recorded as per
type - primary, reactionary or secondary.
Postoperative morbidity was assessed by complains like
abdominal pain and distension, fever, weakness, bleeding and
foul smelling discharge per vaginum. Postoperative vitals
were noted twice a day in the form of pulse rate, temperature
and blood pressure. Daily abdominal examination was
performed for distension, tenderness, guarding and rigidity.
Inspection of vulva was done daily for presence of any
vaginal discharge. Per speculum examination under aseptic
precautions was performed for the patients complaining of
bleeding per vaginum.
Transabdominal and transvaginal ultrasound was
performed in each case on 3 rd , 7 th and postoperative days
and if required on subsequent follow up after 4 weeks.
The size of any vault collection (non peristaltic complex
echogenic mass) was noted and classified according to its
mean diameter, i.e. small = 5cm. Patients with a detected pelvic
hematoma were subjected to a follow up ultrasound scan
after 7 days and onwards. Patients with large hematoma were
subjected to the evacuation of hematoma, in a lithotomy
position, with all aseptic precautions under anaesthesia.
Procedure for draining hematoma was removal of central two
sutures of the vaginal vault and if needed digital exploration
and evacuation. Insertion of Penrose drain was considered if
required. Patients with small hematomas were treated
conservatively for spontaneous resolution and observed for
any complications. Medium sized hematomas were treated
with antifibrinolytic agents like tranaxemic acid with a dose
of 500mg eight hourly intravenously or orally. Injectable
antibiotics were added to prevent any superseded infection.
The results were subjected to Chi-square test and Proportion
test for significance.
3. RESULTS
Table 1 shows indications for abdominal and vaginal
hysterectomies. Commonest indication for hysterectomy in
group A was DUB, fibroid uterus and in group B was genital
prolapse.
Incidence of vault hematoma in our study was 11%
following vaginal hysterectomy (VH). Maximum i.e. 45 out
of 100 cases of abdominal hysterectomies were performed for
DUB, none of them developed vault hematoma. Incidence of
vault hematoma was 7% after abdominal hysterectomy and
it was more in patients who underwent total abdominal
hysterectomies (TAH) for large multiple fibroids. Tyrone
Carpenter reported in his study, in around 5% of patients,
vault haematoma occured following abdominal hysterectomy
[14]. Total laparoscopic hysterectomies (TLH) were
performed in 20 patients, out them, two performed for fibroid
and PID developed hematoma. Incidence of hematoma
formation was 7.14% in patients with VH for uterine or
uterovaginal prolapse.
Table 2
Incidence of Vault haematoma and granuloma in relation to type of VH
Type of surgery
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No. of
cases
Vault
hematoma
Vault
granuloma
Abdominal procedures TAH 80 05(6.25%) 13(16.25%)
TLH 20 02(10%) 02(10%)
Total 100 07(7%) 15(15%)
Vaginal procedures VH 20 02(10%) 02(10%)
VH with repair 50 03(6%) 01(10%)
LAVH 10 02(5%) 01(10%)
NDVH 20 04(20%) 01(10%)
Total 100 11(11%) 05(5%)