New Frontiers in Knee Surgery l April 2, 2008 l 1

Closure of the Vaginal Cuff Following Hysterectomy: Prevention and Management of Dehiscence

January 31, 2016Michael L. Sprague, M.D.Associate Director, Fellowship in Minimally Invasive Gynecologic Surgery

Closure of the Vaginal Cuff: Prevention and Management of Dehiscence

• Covidien, Inc. (Consultant)

Disclosures

Learning Objectives

1. Review the proposed factors that may predispose a patient to have vaginal cuff dehiscence

2. Demonstrate technique for durable vaginal cuff closure

3. Define a strategy for optimal management of vaginal cuff dehiscence

Closure of the Vaginal Cuff: Prevention and Management of Dehiscence

Vaginal Cuff Dehiscence

Closure of the Vaginal Cuff: Prevention and Management of Dehiscence

How would you manage this patient?

1.Observation

2.Abdominal Repair

3.Vaginal Repair

4.Laparoscopic / Robotic Repair

Closure of the Vaginal Cuff: Prevention and Management of Dehiscence

Vaginal cuff dehiscence

• Rare complication of hysterectomy 1

• Mean time to occurrence (6.1 weeks – 1.6 years) 2

• Associated with high morbidity 1

• Life threatening if associated with intestinal ischemia or intra-abdominal infection 1

1. Koo, Y.J., et al., Vaginal cuff dehiscence after hysterectomy. Int J Gynaecol Obstet, 2013. 122(3): p. 248-52.2. Cronin, B., V.W. Sung, and K.A. Matteson, Vaginal cuff dehiscence: risk factors and management. Am J

Obstet Gynecol, 2012. 206(4): p. 284-8.

Cuff Dehiscence: Separation vs. Evisceration

Closure of the Vaginal Cuff: Prevention and Management of Dehiscence

EviscerationSeparation

Vaginal Cuff Dehiscence

Risk Factors 1, 2

• Infection

• Previous radiation

• Vaginal atrophy

• Poor wound healing

• Pelvic organ prolapse

• Surgical technique

Predicating Events 2

• Valsalva (16 – 30%)

• Coitus (8 – 48%)

• None (~ 70%)

1. Ceccaroni, M., et al., Vaginal cuff dehiscence after hysterectomy: a multicenter retrospective study. Eur J Obstet GynecolReprod Biol, 2011. 158(2): p. 308-13.

2. Cronin, B., V.W. Sung, and K.A. Matteson, Vaginal cuff dehiscence: risk factors and management. Am J Obstet Gynecol, 2012. 206(4): p. 284-8.

Presenting Symptoms

• Abdominal pain (58 – 100%)

• Vaginal bleeding or watery discharge (33 – 90%)

• Vaginal pressure (~ 30%)

• Evisceration (up to 70%)

Cronin, B., V.W. Sung, and K.A. Matteson, Vaginal cuff dehiscence: risk factors and management. Am J Obstet Gynecol, 2012. 206(4): p. 284-8.

Incidence of vaginal cuff dehiscence

1. Ceccaroni, M., et al., Vaginal cuff dehiscence after hysterectomy: a multicenter retrospective study. Eur J ObstetGynecol Reprod Biol, 2011. 158(2): p. 308-13.

2. Uccella, S., et al., Vaginal cuff dehiscence in a series of 12,398 hysterectomies: effect of different types of colpotomy and vaginal closure. Obstet Gynecol, 2012. 120(3): p. 516-23.

Design Patients(#)

VCD(n)

AH(n)

VH(n)

LH(n)

Ceccaroniet. al (2011)

4 CenterRetrospective 8635 34

(0.39%)8

(0.25%)4

(0.15%)22

(0.80%)

Uccellaet. al (2012)

6 CenterRetrospective 12,398 38

(0.30%)9

(0.21%)6

(0.13%)23

(0.64%)

Incidence of vaginal cuff dehiscence

TLH

Laparoscopic Closure

20 / 2332(0.86%)

Transvaginal Closure

3 / 1241(0.24%)

1. Uccella, S., et al., Vaginal cuff dehiscence in a series of 12,398 hysterectomies: effect of different types of colpotomy and vaginal closure. Obstet Gynecol, 2012. 120(3): p. 516-23.

Incidence of vaginal cuff dehiscence

TLH Transvaginal Closure

3 / 1241(0.24%)

TVH Transvaginal Closure

6 / 4534(0.13%)

1. Uccella, S., et al., Vaginal cuff dehiscence in a series of 12,398 hysterectomies: effect of different types of colpotomy and vaginal closure. Obstet Gynecol, 2012. 120(3): p. 516-23.

p = 0.38

Vaginal Cuff Dehiscence

• Highest incidence following laparoscopic hysterectomy

• Unclear role for energy use in promoting dehiscence

• Laparoscopic approach for cuff closure may be greater risk factor than technique employed for colpotomy

Closure of the Vaginal Cuff: Prevention and Management of Dehiscence

New Frontiers in Knee Surgery l April 2, 2008 l 14

Prevention of vaginal cuffdehiscence

Prevention of vaginal cuff dehiscence

VCD Prevention

Preoperative Considerations

Surgical Technique

Postoperative Considerations

Closure of the Vaginal Cuff: Prevention and Management of Dehiscence

Prevention of vaginal cuff dehiscence

Surgical Technique

OptimizeColpotomy

Optimize Closure Technique

Closure of the Vaginal Cuff: Prevention and Management of Dehiscence

Prevention of vaginal cuff dehiscence

Surgical Technique

OptimizeColpotomy

Optimize Closure Technique

Closure of the Vaginal Cuff: Prevention and Management of Dehiscence

Anatomy of vaginal apex

Closure of the Vaginal Cuff: Prevention and Management of Dehiscence

Technique for durable cuff closure

• Optimize your colpotomy

• Reconstruct the pericervical ring by approximating ––Pubocervical Fascia–Vaginal Epithelium–Rectovaginal Septum–Cardinal-uterosacral Ligament Complex

• Restore the vaginal apex to the level of the ischialspines

Closure of the Vaginal Cuff: Prevention and Management of Dehiscence

New Frontiers in Knee Surgery l April 2, 2008 l 20

Management of Vaginal Cuff Dehiscence

Cuff Dehiscence: Separation vs. Evisceration

Closure of the Vaginal Cuff: Prevention and Management of Dehiscence

EviscerationSeparation

Cuff Dehiscence: Separation vs Evisceration

Closure of the Vaginal Cuff: Prevention and Management of Dehiscence

Management of vaginal cuff evisceration

Transvaginal

Medically StablePeritonitis AbsentNo Bowel Injury

Abdominal / Laparoscopic

PeritonitisBowel Compromise

HematomaAbscess

Matthews, CA et. al “ Treatment of Vaginal Cuff Evisceration.” Obstet Gynecol 2014 Oct;124(4):705-8

How would you manage this patient?

1.Abdominal Repair

2.Vaginal Repair

3.Laparoscopic / Robotic Repair

Closure of the Vaginal Cuff: Prevention and Management of Dehiscence

How would you manage this patient?

Closure of the Vaginal Cuff: Prevention and Management of Dehiscence

How would you manage this patient?

1.Abdominal Repair

2.Vaginal Repair

3.Laparoscopic / Robotic Repair

Closure of the Vaginal Cuff: Prevention and Management of Dehiscence

1. Broad spectrum intravenous antibiotics

2. Irrigate intestine with warm saline

3. Reduce prolapsed intestine

4. Debride vaginal cuff sharply

5. Approximate cuff edges with 0 gauge, monofilament suture in interrupted fashion

6. Drain per clinical indications

7. Discharge following return of bowel function

Matthews, CA et. al “ Treatment of Vaginal Cuff Evisceration.” Obstet Gynecol 2014 Oct;124(4):705-8

Management of vaginal cuff evisceration

Vaginal Cuff Dehiscence

Closure of the Vaginal Cuff: Prevention and Management of Dehiscence

Management of vaginal cuff dehiscence

•Postoperative Care–Pelvic rest x 3 months–Tight management of conditions leading

to increased intra-abdominal pressure–Possible role for vaginal estrogen

supplementation

Closure of the Vaginal Cuff: Prevention and Management of Dehiscence

Vaginal cuff dehiscence

• Rare complication following hysterectomy

• Greater incidence following laparoscopic cuff closure

• Optimal management strategy dependent on the clinical picture

Closure of the Vaginal Cuff: Prevention and Management of Dehiscence

spragum2@ccf.org

https://www.youtube.com/playlist?list=PLwsHSC0paoJjjkIsrgxuJw6SHI_RJPXY9