Abstract:

Vaginal cuff dehiscence represents a serious, but infrequent complication after hysterectomy, with a reported increased incidence following a laparoscopic approach. Various risk factors have been proposed including laparoscopically placed suture, surgical experience, use of electrosurgery, surgical indication, and obesity. Technical aspects of the procedure itself have also been questioned such as the variable use of monopolar electrosurgery during colpotomy and the suture type or number of layers chosen to reapproximate the vaginal cuff. Nothwithstanding the tendency for cuff dehiscence to occur following laparoscopic approach, there remains a paucity of high-quality data that supports or refutes this finding or clearly defines the mechanism(s) by which this event occurs allowing for the proposal of objective guidelines for reducing risk. Various techniques have been proposed to decrease the risk of vaginal cuff dehiscence during endoscopic hysterectomy, including use of monopolar current on cutting mode, achievement of cuff hemostasis with sutures rather than electrocoagulation, use of a two-layer cuff closure with polydioxanone suture, and use of bidirectional barbed suture for cuff closure. The authors experience at three university-based minimally invasive gynecologic surgery programs showed a low rate of vaginal cuff dehiscence in their own practices. Large randomized controlled trials are needed to truly determine whether there is a difference in vaginal cuff dehiscence between surgical modalities for hysterectomy as well as to determine the true risk factors.

Authors:

Emad Mikhail, MD, Fellow of Minimally Invasive Gynecologic Surgery, Department of Obstetrics and Gynecology, University of South Florida/Morsani College of Medicine, Tampa, Florida, Mary Ashley Cain, MD, Assistant Professor, Department of Obstetrics and Gynecology, University of South Florida/, Morsani College of Medicine, Tampa, Florida, Madhvi Shah, Medical Student, Marshall University Joan C. Edwards School of Medicine , Huntington, West Virginia, M. Jonathon Solnik, MD, FACOG, FACS , Associate Professor, Head of Gynecology and MIS, Department of Obstetrics and Gynecology , Faculty of Medicine, University of Toronto , Mt. Sinai Hospital, Toronto, Canada, Craig J. Sobolewski, MD , Assistant Professor, Department of Obstetrics and Gynecology Division , Chief, Minimally Invasive Gynecologic Surgery, Duke University School of Medicine, Durham, North Carolina , Stuart Hart, MD, MBA, MS, FACOG, FACS, Associate Professor, Division of Female Pelvic Medicine and , Reconstructive Surgery , Department of Obstetrics and Gynecology, Chief Medical Officer of Innovation, USF Health Center for Advanced Medical Learning and Simulation (CAMLS), University of South Florida Morsani College of Medicine, Tampa, Florida

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