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Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."
Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011
Dr. Shankar P.R.
"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."
Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011 Anuradha
Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.
Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020
Original article / research
Full Version
Vaginal Cuff Closure by Endosuturing in Total Laparoscopic Hysterectomy as Compared to Transvaginal Route of Suturing
Correspondence Address :
Dr. Pooja S Singh,
B 31, Shantam Tower, Shahibaug, Ahmedabad-380004, Gujarat, India.
E-mail: drpsomesh03@yahoo.co.in
Introduction: In present times, Total Laparoscopic Hysterectomy (TLH) is one of the commonly performed gynaecological procedure. Vaginal vault or cuff closure is crucial and critical in performance of TLH. During TLH, vaginal vault or cuff closure is done using a variety of available sutures. The techniques of suturing and approaches, either endoscopic or transvaginal, can vary. The skill, experience and preference of the surgeon counts in the final outcome of the surgery.
Aim: To compare and study the frequency of minor and major complication rates of intracorporeal (endosuturing) cuff closure technique and routinely used transvaginal route of suturing vaginal vault in TLH.
Materials and Methods: This prospective cohort research was conducted in the GCS Medical College and Hospital, Ahmedabad, India, from May 2018 to December 2019. A total of 102 TLH were studied. In 51 cases (50%), vault was sutured endoscopically and in other 51 cases (50%), vault was sutured transvaginal, using single continuous interlocking suturing of vaginal vault with Vicryl 1-0 in all cases. Statistical analysis was done using Statistical Package for the Social Sciences (SPSS) software version 24.0.
Results: In the follow-up of three months period, there were no cases of Vaginal Cuff Dehiscence (VCD). In present study, 21 cases (20.6%) out of 102 presented with vaginal cuff complications. A 15.7% cases with minor vaginal cuff complications were noted in laparoscopic endosuturing group and 25.5% cases of vaginal suturing group presented with minor vaginal cuff complications.
Conclusion: Both the techniques of suturing the vaginal vault following laparoscopic hysterectomy delivered the desired results. The laparoscopic route of suturing vaginal cuff following TLH had lesser complication rate though not statistically significant over vaginal route and none of the two groups had any major complication (VCD).
Endometrial hyperplasia, Minimally invasive gynaecologic surgeries, Vaginal vault or cuff dehiscence
In National Family Health Survey-IV (2015–2016) of India, the prevalence of hysterectomy ranged between 3-7% in majority of the districts (1). Hysterectomy meaning ‘surgical removal of uterus’ is being performed since long through different routes i.e., abdominal, vaginal and laparoscopic for all benign, premalignant and malignant indications. With an inclination towards minimal invasive procedures, laparoscopic route for hysterectomy is being preferred by both the patients and surgeons (2). In this era of minimal access surgeries, laparoscopy is the most important tool. In gynaecology, hysterectomy is the most common surgical procedure performed and TLH are being preferred over other routes of hysterectomies, with the readily available minimally invasive techniques (2).
Laparoscopy has a long learning curve as compared to abdominal or vaginal route of surgery, owing to its complexities of using endoscopic instruments and performing surgery over a virtual screen. The task becomes more tough with the endosuturing of vault after removal of hysterectomy specimen. Suturing laparoscopically is even more challenging compared to conventional transvaginal suturing of vault or cuff, which the gynaecologist is well versed with (3). In TLH, vaginal vault can be closed using different approaches, either laparoscopically or vaginally. Various suture materials can be used in different techniques of vault closure either continuous or interrupted sutures, with or without knotting and in single or more layers (4),(5). The main advantage of transvaginal suturing is its ease and less operating time as compared to endosuturing which is time consuming and technically demanding. The advantage of endosuturing is that the vaginal edges are inverted after suturing associated with lesser infection rate (4).
With this background, present study aimed at comparing whether laparoscopic endosuturing techniques have an edge over conventional transvaginal route of vault suturing in cases of TLH. Of all the complications, VCD remains the dreaded complication of hysterectomy operation. Present study also aimed at evaluating frequency of vaginal cuff complications including VCD. There is an ongoing need to study the superiority of one vaginal vault suturing technique over another as the available data is limited.
This prospective cohort study was conducted in the GCS Medical College and Hospital, Ahmedabad, Gujarat, India, from May 2018 to December 2019 after Ethical Committee (EC) approval (GCSMC/EC/TRIAL/APPROVE/2018/1090) and informed consent of the patients for the same.
Inclusion criteria: Patients with benign indications for TLH, which includes uterine fibroid, adenomyosis, dysfunctional uterine bleeding including endometrial hyperplasia.
Exclusion criteria: Laparoscopic hysterectomies for malignant indications or those having suspicion of malignancy and those who are unfit for pneumo peritoneum or trendelenberg position.
Sample size calculation: The sample size was calculated using Cochran’s formula (95% CI) and total 102 cases (51 cases of endosuturing group and 51 cases of transvaginal suturing group) were enrolled in present study with similar demographic and clinical factors.
Study Procedure
Total laparoscopic hysterectomy was performed in all cases. Monopolar energy using 60 W was used to perform colpotomy in all cases. The suturing of vaginal vault or cuff was performed with single continuous interlocking manner using Vicryl 1-0 suture, half of the cases undergoing endosuturing with intracorporeal knots and half undergoing transvaginal suturing of vaginal vault in 1:1 ratio. Intraoperatively, the time consumed from starting the first stitch and ending of last stitch of vault was noted. The performing surgeons were equally experienced in laparoscopic surgeries and used the same endoscopic instruments over the period of study. Preoperative and postoperative broadspectrum antibiotics are administered round the clock to take care of infections. All cases were followed at three weeks and three months after surgery.
Vaginal vault or cuff complications, which included minor complications like vaginal spotting or bleeding, vaginal discharge, vault granulation tissue and major complications like vault haematoma, cuff cellulitis and VCD were studied, compared and statistically analysed.
Statistical Analysis
The statistical analysis was done using SPSS software (version 24.0.) to compare the effectiveness between endosuturing and vaginal suturing of vaginal cuff following TLH. The statistical tests, Chi-quare test, Yates correction were used and the value of p<0.05 was considered significant.
Total 102 cases were studied, 51 cases (50%) underwent laparoscopic endosuturing of vaginal (cuff) vault and rest 51 cases (50%) underwent transvaginal suturing of vaginal vault.
The (Table/Fig 1) shows demographic and clinical characteristics in both the groups. Out of the total 102 studied cases, most common medical co-morbidity noted was hypertension (17 cases), followed by diabetes (4 cases) and hypothyroidism (4 cases).
The commonest indication for TLH in the present study was uterine fibroids in both the groups (47% vs 49%), followed by adenomyosis accounting for 31.4% of the cases (Table/Fig 2).
This study revealed that in laparoscopic endosuturing of vaginal cuff, average suturing time was 21.2±4.08 minutes. In transvaginal vault suturing approach, average suturing time was 12.7±1.79 minutes. On statistical analysis using Chi-square test with Yates correction, p-value=0.0007 which indicates that comparison is statistically significant.
Out of 102 total cases, 21 (20.6%) cases presented with vaginal cuff complications (Table/Fig 3). A total of 8 (15.7%) cases with minor vaginal cuff complications were noted in laparoscopic endosuturing group and 13 (25.5%) cases of vaginal suturing group presented with minor vaginal cuff complications. No statistical significance was noted between the two groups in terms of vaginal cuff complications.
Laparoscopic hysterectomy is the preferred route of hysterectomy in recent times because of its inherent advantages of cosmesis, short hospital stay and quicker return to routine activities, despite having a long learning graph (6). In present study, mean age in laparoscopic endosuturing group was 42.78±3.69 years and in transvaginal suturing group, 43.45±3.86 years. Also, mean BMI was 26.42±0.63 kg/m2 in endosuturing group and 26.57±0.57 kg/m2 in transvaginal suturing group. Uterine fibroids formed the commonest indication for TLH followed by adenomyosis in both the groups. Aydogmus H et al., study showed average age was 48.1 years and average parity being 2.6. TLH was performed mostly for abnormal uterine bleeding and symptomatic leiomyoma. The mean time of closing cuff vaginally was 6 (minimum 2- maximum 17) minutes. There were no cases of VCD reported in follow-up period (7).
In the present study, though vaginal cuff complications were slightly higher in transvaginal suturing group but not statistically significant. There was not a single case of VCD noted in present study in either groups. Hwang JH et al., observed the same findings in his study that there was no difference in the vaginal cuff complications in laparoscopic or vaginal approach (8). Hur HC et al., noted the rise in VCD cases after TLH in the 10 year study period. (9). Uccella S et al., reported a three-fold increase in VCD cases following endosuturing of vault in TLH as compared to transvaginal route based on their own study data and a review of literature (10). Uccella S et al., in their randomised controlled trial, suggested lower rates of vaginal cuff complications following endosuturing of vault in TLH. There was increased incidence of VCD in TLH cases closed vaginally (11). In the present study, laparoscopic route of suturing vaginal cuff following TLH had lesser complication rate though not statistically significant over vaginal route and none of the two groups had any major complication (VCD). Though, the laparoscopic route took a little longer suturing time as compared to transvaginal rote, but this can be attributed to the skill of the individual surgeons involved in the study. Fanning J et al., suggested that the incidence of VCD was higher in TLH who underwent endosuturing as compared to laparoscopic assisted vaginal hysterectomy group (12). Bastu E et al., reported that cuff closure done transvaginally, finished in significantly shorter time as compared to laparoscopic closure. But, postoperative vaginal length was longer in laparoscopic closure group (13).
Many gynaecologists prefer transvaginal suturing approach as it is technically easier to perform and has a shorter learning curve as compared to laparoscopic endosuturing approach, which is technically challenging and requires extensive training to become competent (3). In the present study, suturing time was relatively less in transvaginal group as compared to endosuturing group. Intracorporeal knot-tying is considered as the most difficult, challenging and time consuming laparoscopic skill even for expert laparoscopists (14). A good bite of the tissue including serosal layer needs to be grabbed with proper technique while suturing the vaginal cuff after laparoscopic hysterectomy (15). O’Hanlan KA et al., standardised the technique of laparoscopic vault closure and found a low rate of vaginal cuff complications of 2.29% (16).
Limitation(s)
In this research, multiple surgeons were involved having different levels of expertise in suturing. In the present study, colpotomy was limited to monopolar energy using 60 W. Other sources of energy being used for colpotomy were not studied. Also, hysterectomies are usually elective procedures, which were the scenario in this study as well, and performed mostly when the patient is clear of active infections including vaginal infections along with pre and postoperative antibiotic administration, which explains less complication rate.
The study concluded that both the suturing techniques in TLH had comparable outcomes. The minor vaginal cuff complications were slightly more with transvaginal route of suturing but statistically non significant as compared to endosuturing technique. Either of the vaginal cuff closure technique, be it endosuturing or transvaginal, can be used following TLH depending on surgeon’s experience and adaptability to a specific technique.
The future research needs to focus on the use of various energies used for colpotomy step in TLH as the efficacy of vaginal vault closure depends not only on the suturing route and technique but also on the effect of electrocoagulation.
DOI: 10.7860/JCDR/2022/53257.15951
Date of Submission: Nov 11, 2021
Date of Peer Review: Dec 10, 2021
Date of Acceptance: Jan 03, 2022
Date of Publishing: Feb 01, 2022
AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. NA
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