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      Vaginal cuff dehiscence in laparoscopic hysterectomy: influence of various suturing methods of the vaginal vault

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          Abstract

          Vaginal cuff dehiscence (VCD) is a severe adverse event and occurs more frequently after total laparoscopic hysterectomy (TLH) compared with abdominal and vaginal hysterectomy. The aim of this study is to compare the incidence of VCD after various suturing methods to close the vaginal vault. We conducted a retrospective cohort study. Patients who underwent TLH between January 2004 and May 2011 were enrolled. We compared the incidence of VCD after closure with transvaginal interrupted sutures versus laparoscopic interrupted sutures versus a laparoscopic single-layer running suture. The latter was either bidirectional barbed or a running vicryl suture with clips placed at each end commonly used in transanal endoscopic microsurgery. Three hundred thirty-one TLHs were included. In 75 (22.7 %), the vaginal vault was closed by transvaginal approach; in 90 (27.2 %), by laparoscopic interrupted sutures; and in 166 (50.2 %), by a laparoscopic running suture. Eight VCDs occurred: one (1.3 %) after transvaginal interrupted closure, three (3.3 %) after laparoscopic interrupted suturing and four (2.4 %) after a laparoscopic running suture was used ( p = .707). With regard to the incidence of VCD, based on our data, neither a superiority of single-layer laparoscopic closure of the vaginal cuff with an unknotted running suture nor of the transvaginal and the laparoscopic interrupted suturing techniques could be demonstrated. We hypothesise that besides the suturing technique, other causes, such as the type and amount of coagulation used for colpotomy, may play a role in the increased risk of VCD after TLH.

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          Most cited references23

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          Incidence and patient characteristics of vaginal cuff dehiscence after different modes of hysterectomies.

          The purposes of this study were to estimate and compare the incidence of vaginal cuff dehiscence after different modes of hysterectomies (abdominal, vaginal, laparoscopic-assisted vaginal and laparoscopic) and to review the characteristics of hysterectomies complicated by vaginal dehiscences. Observational case series (Canadian Task Force classification II-3). Large, urban, university teaching hospital. All patients undergoing a total hysterectomy or vaginal dehiscence repair at Magee-Womens Hospital (MWH) from January 2000 through March 2006 were analyzed. Vaginal repair of vaginal cuff separation with reduction of eviscerating organ when appropriate. From January 2000 through March 2006, 7286 hysterectomies (7039 total and 247 supracervical) were performed at MWH by abdominal, vaginal, laparoscopic-assisted vaginal, or laparoscopic approach. Ten of these hysterectomies were complicated by vaginal cuff dehiscences and were repaired during this time period. The resulting overall cumulative incidence of vaginal cuff dehiscence after total hysterectomy at MWH was 0.14%. The annual cumulative incidence of vaginal dehiscences after total hysterectomy was 0%, 0%, 0%, 0%, 0.09%, 0.70%, and 0.31% from January 2000 to March 2006, respectively. There was a notable increase in the cumulative incidence of dehiscence in 2005 and thereafter. From January 2005 through March 2006, the cumulative incidence of vaginal dehiscence by mode of hysterectomy was 4.93% among total laparoscopic hysterectomies (TLH), 0.29% among total vaginal hysterectomies (TVH), and 0.12% among total abdominal hysterectomies (TAH). The relative risks of a vaginal cuff dehiscence complication after TLH compared with TVH and TAH were 21.0 and 53.2, respectively. Both were statistically significant, with 95% CIs of 2.6 to 166.9 and 6.7 to 423.4, respectively. Among the 10 dehiscences repaired, 8 (80%) were complications of TLHs, 1 (10%) was associated with TAH, and 1 (10%) followed a TVH. The median age at time of dehiscence was 39 years, and the median time between initial hysterectomy to vaginal dehiscence was 11 weeks. Six of the 10 patients presented with both cuff dehiscence and bowel evisceration. Six patients reported first postoperative intercourse as the trigger event. Half the patients with dehiscence report smoking cigarettes. All patients with dehiscence received preoperative prophylactic antibiotics at the time of hysterectomy. Until October 2006, there have been no reported recurrent dehiscences at MWH. Total laparoscopic hysterectomies may be associated with an increased risk of vaginal cuff dehiscence compared with other modes of total hysterectomy. We postulate that the use of thermal energy in addition to other factors unique to laparoscopic surgery may be responsible; however, prospective randomized trials are needed to support this hypothesis. When performing laparoscopic hysterectomies, a supracervical approach should be considered unless a clear indication for a TLH is present.
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            Characteristics of patients with vaginal rupture and evisceration.

            To characterize vaginal rupture and evisceration. We reviewed medical records (1970-2001) for use of the diagnostic terms "vaginal rupture," "vaginal evisceration," and "ruptured enterocele." Twelve clinical cases were identified. Patients usually presented with pain, vaginal bleeding, and abdominal pressure. In 9 of 12 women, rupture was primarily associated with postmenopausal prolapse and a history of pelvic surgery. Women with a history of abdominal hysterectomy tended to rupture through the vaginal cuff, and those with a history of vaginal hysterectomy tended to rupture through a posterior enterocele. Premenopausal rupture in 1 woman occurred postcoitally and involved the posterior fornix. Prolapse recurrence after repair was limited to 1 woman. Vaginal rupture and evisceration should be considered in women presenting with acute vaginal bleeding and pelvic pain. Evaluation is especially important in postmenopausal women with a history of pelvic surgery. In some cases, surveillance after pelvic surgery may prevent rupture, evisceration, and incarceration. II-3
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              Vaginal cuff closure after minimally invasive hysterectomy: our experience and systematic review of the literature.

              To determine the incidence of vaginal cuff dehiscence after minimally invasive hysterectomy, we reported our series of total laparoscopic hysterectomies with transvaginal colporraphy. We then conducted a systematic search of PubMed to retrieve published series of laparoscopic and robotic hysterectomies, in which different techniques for vaginal cuff closure were used. In our study group, vaginal cuff dehiscence occurred in 2 of 665 (0.3%) patients. Our literature search identified 57 articles, for a total of 13,030 endoscopic hysterectomies. Ninety-one postoperative vaginal separations were reported (0.66%). The pooled incidence of vaginal dehiscence was lower for transvaginal cuff closure (0.18%) than for both laparoscopic (0.64%; odds ratio [OR], 0.28; 95% confidence interval [CI], 0.12-0.65) and robotic (1.64%; OR, 0.11; 95% CI, 0.04-0.26) colporraphy. Laparoscopic cuff closure was associated with a lower risk of dehiscence than robotic closure (OR, 0.38; 95% CI, 0.28-0.6). Current evidence indicates that transvaginal colporraphy after total laparoscopic hysterectomy is associated with a 3- and 9-fold reduction in risk of vaginal cuff dehiscence compared with laparoscopic and robotic suture, respectively. Copyright © 2011 Mosby, Inc. All rights reserved.
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                Author and article information

                Contributors
                +31-71-5262871 , +31-71-5248181 , f.w.jansen@lumc.nl
                Journal
                Gynecol Surg
                Gynecol Surg
                Gynecological Surgery
                Springer-Verlag (Berlin/Heidelberg )
                1613-2076
                1613-2084
                3 May 2012
                3 May 2012
                November 2012
                : 9
                : 4
                : 393-400
                Affiliations
                [1 ]Department of Gynaecology, Leiden University Medical Centre, PO Box 9600, 2300 RC Leiden, the Netherlands
                [2 ]Department of Gynaecology, Bronovo Hospital, PO Box 96900, 2509 JH The Hague, the Netherlands
                Article
                745
                10.1007/s10397-012-0745-5
                3491192
                23144640
                87f145e3-8f2d-4ae1-a88e-dae05da6fc9b
                © The Author(s) 2012
                History
                : 17 February 2012
                : 6 April 2012
                Categories
                Original Article
                Custom metadata
                © Springer-Verlag Berlin Heidelberg 2012

                Obstetrics & Gynecology
                laparoscopic hysterectomy,laparoscopic suturing,barbed suture,vaginal cuff dehiscence

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