I think the greatest advantage is to improve your laparoscopic skills suturing. Si when you will perform myomectomy o need to suture laparoscopically it will be easier.

Dear Muthukumaran,

When we started with laparoscopic hysterectomy some 10 years ago we also felt that vaginal suturing was easier to accomplish the procedure. However, we found that the vaginal part of the surgery was more difficult due to the improper position. of the legs And therefore, we lost a lot of time. for the vaginal part of the LAVH.

Now we accomplish the procedure by laparoscopic approach exclusively through two small abdominal wall incisions. The way we do seems to be very easy. We use a long thread and put first two sutures on both edges of the vaginal stump. After sutures in place we pull the ends of the threads out through trocars and then reinsert the trocars and lift the vagina by pulling the ends of the threads with peans/small forceps (first or second assistant). When the vaginal cuff is lifted it is easy to perform two additional sutures.

Regards,

Igor

Thanks for your prespectives, both Dr. Igor & Dr. Sole

Every time i put stiches vaginally. Its more easier to do and quickly as well.

It is better to suture laparoscopicaly, as better exposure , easier and less time consuming .

Good debate,I feel more comfortable in transvaginal approach,

Dear Muthukumaran,

In my department, some prefer to complete the suture vaginally, some would like to choose the laparoscopic approach. The critical step of laparoscopic suture of vaginal cuff is the identification of the part of ureter inlets into the bladder before performing sutures on both edges. No matter which procedure you preformed, previously meticulous dissection of the ureter from the paracervical tissue is necessary. Regarding to better exposure the ureter, I feel more comfortable in laparoscopic view.

Best regards from China

Dr. Chen

Intracorporeal suturing of the vaginal cuff is directly under laparoscopic vision and so is technically safer. The introduction of new sutures like Stratfix and V-lock sutures have revolutionised laparoscopic intracorporeal suturing with minimal morbidity .

After more than 10 years and more hundreds of laparoscopic hysterectomies in our department, we still use both types of approach. Some of my colleagues use more the vaginal suture considering easier to put some stitches under direct vision with classic instruments. I generally use laparoscopic closure of the vagina for some reasons I will detail next.

1.even if it is somehow difficult to maintain intra-abdominal CO2 pressure after opening the vaginal dome, a sponge in a glove inserted in vagina is usually enough to have a good exposure of the tissues to be sutured, including uterosacral ligaments. This exposure seems to me better that the vaginal approach.

2. as other surgeons have already mentioned, suturing in laparoscopy can be difficult without proper training. So, I think that it is mandatory to have a very good training in suturing and making knots by laparoscopic approach.

In my personal experience, I prefer laparoscopic intracorporeal suturing, and I agree with the colleague Solé about to Improve Your laparoscopic suturing skills, also from recently used as suture V-lock like Disu colleague says and this facilitates and enhances the action time knotted, preferably do it continuously, some tips for suturing in the vertical plane of the literature I read on the cover that attached, belonging to Dr. Koh

Thanks everyone for their valuable comments. My opinion:

1. To say 'laparoscopic suturing is recommended because it improves your skills' is

not a justification for doing it; what's best for the patient should be recommended

2. Dr. Disu stated 'introduction of new sutures like Stratfix and V-lock sutures'; but

how expensive are these? And are they necessary, especially when suturing can

easily be done trasvaginally?

The disadvantage of suturing vaginally is that this increases the potential to damage the ureters and increases the tensile strength on tissue close to the ureters. This inadvertently can cause kinking of the ureters towards the trigone at the level of the cardinal ligaments.

It doesn't make sense to perform the procedure under vision laparoscopically with careful dissection and then finish the procedure (due to the time factor alone) vaginally and risk injuries to structures above the vaginal cuff. The surgeon will then go above laparoscopically again to re-insufflate and check for bleeding points as well as re-check for ureteric damage.

V Lock suture has made the life easier for intra corporeal suturing under direct vision laparoscopically.

Thanks everyone - for making valid points in this lively discussion