ArticlePDF Available

Rate of Vaginal Cuff Dehiscence When Using Vicryl (Poliglactyn 910) Compared to PDS (Polydioxanone) for Vaginal Cuff Closure in Laparoscopic Hysterectomy

Authors:

Abstract and Figures

Objective: To compare the vaginal cuff dehiscence (VCD) rates using Vicryl (Poliglactyn 910) and Polydioxanone (PDS) in patients who underwent laparoscopic hysterectomy. Materials and methods: A retrospective, monocentric study was conducted, including all patients undergoing laparoscopic hysterectomy at the Department of Obstetrics and Gynaecology, Azienda di Rilievo Nazionale e di Alta Specializzazione (ARNAS) Garibaldi Nesima, Catania, between January 2014 and December 2021. Patients underwent hysterectomy for benign gynecologic pathologies (endometriosis, leiomyomas, or benign pelvic pathologies) or malignant gynecologic pathologies (endometrium cancer, complex endometrial hyperplasia, ovarian cancer, cervix cancer, or uterine carcinosarcoma). The Z-score calculation was performed to find eventual statistically significant differences between the two populations regarding VCD rates. Results: Laparoscopic vaginal cuff closure was performed, with Vicryl sutures in 202 patients and PDS sutures in 184 women. Demographic and baseline characteristics were not significantly different in the two groups. VCD occurred in three patients in the Vicryl group and did not occur in the PDS group. The three cases of VCD were precipitated by intercourses that occurred within 90 days of surgery. However, there was not a significant statistical difference between the two groups regarding VCD (p = 0.09). Conclusions: Vicryl and PDS sutures seem to be similar for vaginal cuff closure in laparoscopic hysterectomy. The VCD rate was low, and the observed differences between the Vicryl and PDS groups did not reach statistical significance. Further research through prospective studies is essential.
Content may be subject to copyright.
Citation: Cannone, F.G.; Cormaci, L.;
Ettore, C.; Gulino, F.A.; Incognito,
G.G.; Benvenuto, D.; Ettore, G. Rate of
Vaginal Cuff Dehiscence When Using
Vicryl (Poliglactyn 910) Compared to
PDS (Polydioxanone) for Vaginal Cuff
Closure in Laparoscopic
Hysterectomy. Medicina 2024,60, 90.
https://doi.org/10.3390/
medicina60010090
Academic Editors: Benito Chiofalo
and Simone Ferrero
Received: 13 November 2023
Revised: 19 December 2023
Accepted: 29 December 2023
Published: 3 January 2024
Copyright: © 2024 by the authors.
Licensee MDPI, Basel, Switzerland.
This article is an open access article
distributed under the terms and
conditions of the Creative Commons
Attribution (CC BY) license (https://
creativecommons.org/licenses/by/
4.0/).
medicina
Article
Rate of Vaginal Cuff Dehiscence When Using Vicryl (Poliglactyn
910) Compared to PDS (Polydioxanone) for Vaginal Cuff Closure
in Laparoscopic Hysterectomy
Francesco Giuseppe Cannone 1, Livia Cormaci 1, Carla Ettore 1, Ferdinando Antonio Gulino 1, * ,
GiosuèGiordano Incognito 1, Domenico Benvenuto 2and Giuseppe Ettore 1
1
Department of Obstetrics and Gynaecology, Azienda di Rilievo Nazionale e di Alta Specializzazione (ARNAS)
Garibaldi Nesima, 95122 Catania, Italy; francesco.cannone@hotmail.it (F.G.C.);
livia.cormaci23@gmail.com (L.C.); carla.ettore@hotmail.it (C.E.); giordanoincognito@gmail.com (G.G.I.);
giuseppe.ettore@gmail.com (G.E.)
2Unit of Medical Statistics and Molecular Epidemiology, University Campus Bio-Medico of Rome,
00128 Rome, Italy; domenicobenvenuto95@gmail.com
*Correspondence: docferdi@hotmail.it; Tel.: +39-338-111-1000
Abstract: Objective: To compare the vaginal cuff dehiscence (VCD) rates using Vicryl (Poliglactyn
910) and Polydioxanone (PDS) in patients who underwent laparoscopic hysterectomy. Materials
and methods: A retrospective, monocentric study was conducted, including all patients undergoing
laparoscopic hysterectomy at the Department of Obstetrics and Gynaecology, Azienda di Rilievo
Nazionale e di Alta Specializzazione (ARNAS) Garibaldi Nesima, Catania, between January 2014 and
December 2021. Patients underwent hysterectomy for benign gynecologic pathologies (endometriosis,
leiomyomas, or benign pelvic pathologies) or malignant gynecologic pathologies (endometrium
cancer, complex endometrial hyperplasia, ovarian cancer, cervix cancer, or uterine carcinosarcoma).
The Z-score calculation was performed to find eventual statistically significant differences between
the two populations regarding VCD rates. Results: Laparoscopic vaginal cuff closure was performed,
with Vicryl sutures in 202 patients and PDS sutures in 184 women. Demographic and baseline
characteristics were not significantly different in the two groups. VCD occurred in three patients in
the Vicryl group and did not occur in the PDS group. The three cases of VCD were precipitated by
intercourses that occurred within 90 days of surgery. However, there was not a significant statistical
difference between the two groups regarding VCD (p= 0.09). Conclusions: Vicryl and PDS sutures
seem to be similar for vaginal cuff closure in laparoscopic hysterectomy. The VCD rate was low, and
the observed differences between the Vicryl and PDS groups did not reach statistical significance.
Further research through prospective studies is essential.
Keywords: vaginal cuff dehiscence; Poliglactyn 910; Vicryl; Polydioxanone; laparoscopic hysterec-
tomy; vault closure
1. Introduction
Vaginal cuff dehiscence (VCD) is defined as the partial or complete reopening of a
vaginal cuff that was previously closed during a hysterectomy. This condition is considered
an uncommon yet serious postoperative complication, with its incidence estimated to be
between 0.10% and 1.14% [
1
]. The rarity of VCD contrasts with its significant clinical
implications, necessitating a deeper understanding of its pathophysiology, risk factors,
and management strategies. Patients with VCD may present with a range of symptoms
that can vary in severity. The most common presentation includes sudden and severe
abdominal pain, which can be distressing and debilitating. Dyspareunia, or painful sexual
intercourse, is another symptom that significantly affects the quality of life. Additionally,
patients may experience vaginal discharge or bleeding, which can be alarming and lead to
Medicina 2024,60, 90. https://doi.org/10.3390/medicina60010090 https://www.mdpi.com/journal/medicina
Medicina 2024,60, 90 2 of 9
further complications if not promptly addressed. Systemic symptoms such as fever and
nausea are also observed and can be indicative of more severe underlying issues [
2
4
].
In the most extreme cases, VCD can lead to partial or total evisceration of intrabdominal
organs, a condition that requires immediate medical attention due to its life-threatening
nature. The management of VCD can vary, based on the severity of the condition. Mild
cases may be amenable to conservative management, which includes close monitoring and
non-surgical interventions. However, due to the potential risks associated with VCD, such
as evisceration, bowel strangulation and necrosis, acute mesenteric ischemia, and sepsis,
many cases must be treated as surgical emergencies. Vaginal evisceration, characterized
by the complete protrusion of abdominal organs through a disrupted vaginal cuff, is a
particularly dire emergency that necessitates immediate comprehensive management. This
management typically involves patient assessment, stabilization, and surgical repair of
the defect [
2
4
]. The timing of VCD occurrence post-hysterectomy varies, based on the
surgical technique employed. A study reported a median interval of 11 weeks between the
initial hysterectomy and the onset of dehiscence, with cases occurring anywhere from 1 to
13 months post-surgery [
5
]. This variability underscores the need for prolonged vigilance
in the postoperative period.
In recent times, laparoscopic hysterectomy has emerged as the preferred method for
this procedure, given its numerous advantages. These benefits include reduced blood
loss, shorter recovery time, less postoperative pain, and enhanced patient satisfaction
compared to traditional methods. However, it is important to note that studies have
indicated a higher incidence of VCD in minimally invasive hysterectomy techniques, such
as laparoscopic and robot-assisted procedures. These techniques have been associated
with a VCD incidence rate of 1.14%, compared to 0.14% for transvaginal and 0.10% for
laparotomic hysterectomies [
4
6
]. A systematic review further corroborated these findings,
reporting a 5 to 10 times higher incidence of VCD in minimally invasive surgeries, compared
to vaginal or laparotomic methods [7].
Several surgical risk factors have been identified concerning VCD. These include the
type of surgery performed, the technique used for colpotomy, and the procedure for cuff
closure. These factors are crucial in understanding and mitigating the risk of VCD [
8
].
Additionally, the choice of suture material in vaginal cuff closure has been a topic of debate
in the scientific community. The impact of different suture materials on the incidence
of VCD remains an area requiring further investigation. Two commonly used suture
materials in vaginal cuff closure are Vicryl (Poliglactin 910) and Polydioxanone (PDS).
Vicryl is a braided, synthetic, absorbable suture material, effective for approximately two
to three weeks and fully absorbed within 8–10 weeks. On the other hand, Polydioxanone
is a monofilament suture that, while initially having less tensile strength than Vicryl,
retains its strength for a longer period and is fully absorbed in about six months. These
distinct properties have led to their differential use in surgical applications, with Vicryl
typically preferred for short-term tissue approximation and PDS for situations requiring
prolonged support.
The current study aimed to explore and compare the risk of cuff breakdown when
using Vicryl versus PDS in vaginal suturing following a laparoscopic hysterectomy. This
investigation offered a valuable opportunity to determine if there is a more effective type of
suture material in reducing complications after a laparoscopic hysterectomy. By analyzing
outcomes associated with these two suture materials, the study endeavored to contribute
to the optimization of surgical techniques and the improvement of patient outcomes in
hysterectomy procedures.
2. Material and Methods
2.1. Study Design
A retrospective, monocentric cohort study was conducted at the Unit of Obstetrics
and Gynaecology of the Maternal-Child Department of Azienda di Rilievo Nazionale e di
Alta Specializzazione (ARNAS) Garibaldi Nesima in Catania (Italy), including all patients
Medicina 2024,60, 90 3 of 9
who underwent a laparoscopic hysterectomy during the period between January 2014 and
December 2021. The study conformed to the standards contained in the Strengthening
the Reporting of Observational Studies in Epidemiology (STROBE) Statement, available
through the Enhancing the Quality and Transparency of Health Research (EQUATOR)
Network. In addition, all stages of the study respected the guidelines provided by the
Helsinki Declaration. Each woman signed an informed consent form for the surgical
procedure and data collection. The study was approved by the Ethics Committee of
ARNAS Garibaldi Nesima, Catania (Protocol Code 263/C.E approved on 11 May 2022)
(Report No. 69/2022/CECT2).
2.2. Study Population
All patients who underwent hysterectomy were evaluated. The inclusion criteria
included the following: laparoscopic hysterectomy due to benign gynecologic pathologies
(endometriosis, benign pelvic pathologies, or leiomyomas) or premalignant and malignant
gynecologic pathologies (complex endometrial hyperplasia, endometrial cancer, uterine
carcinosarcoma, cervix cancer, or ovarian cancer); age
18 years; and elective surgery.
Exclusion criteria were the following: laparotomic or vaginal hysterectomy; previous
vaginal surgery; conversion to laparotomy before the end of the procedure; emergency
surgery; and non-gynecological pathologies.
2.3. Methods
Retrospective data from the medical charts were collected through a checklist, re-
viewing demographic characteristics (age, body mass index, parity, premenopausal and
postmenopausal status, and prior surgeries), indications for surgery, operative notes (type
of hysterectomy and operative time), type of suture, and VCD rates. All laparoscopic hys-
terectomies were performed by the same surgeon and the respective team, with experience
in gynecological laparoscopy > 10 years. The surgeon operated using different techniques,
according to the type and gravity of pathology. For endometriosis, benign pelvic patholo-
gies, uterine leiomyomas, and complex endometrial hyperplasia, a total hysterectomy
and bilateral adnexectomy were performed. Women with endometrial cancer had radical
hysterectomy type A or B1 and bilateral adnexectomy. Uterine carcinosarcoma was treated
with radical hysterectomy type A. Cervical cancer was treated by radical hysterectomy
type B1, B2 or C1. Laparoscopic hysterectomy for ovarian cancer was performed only for
the restaging of cancer in patients without a clear peritoneal impairment. Transvaginal cuff
closure was performed using either absorbable Vicryl or PDS sutures. From January 2014
to December 2018, vaginal cuff closure was performed by Vicryl suture. After that period,
it was performed by PDS suture. Laparoscopic knots were tied intracorporeally. The same
route of hysterectomy and the same technique for cuff closure were performed, applied by
the laparoscopic expertise of the surgeon assessed according to the Gynecologic Endoscopic
Surgical Education and Assessment (GESEA) program: i.e., laparoscopic hysterectomy with
an ultrasonic scalpel device and laparoscopic cuff closure with suspension to the endopelvic
fascia and the uterosacral ligaments. Colpotomy was performed by THUNDERBEAT Open
Extended Jaw (Olympus
®
, Tokyo, Japan). Vaginal closure was performed with a single-
layer running suture. All patients received cefazolin 2 g iv 1 h before surgery, indwelling
urinary catheters, and low-molecular-weight heparin (enoxaparin sodium, 4000 UI/die)
as thromboembolism prophylaxis postoperatively for 7 days. All patients underwent
standardized follow-up at 6 weeks post-operation, including gynecological examination
and transvaginal sonography, and were interviewed by telephone about the occurrence of
VCD. Patients were instructed to abstain from intercourse for 8–12 weeks postoperatively.
All postoperative events, including VCD and evisceration, were recorded. Univariate and
multivariable analyses were performed to identify independent predictors of VCD after
laparoscopic hysterectomy. For each item of data collected within the study, the mean and
the standard deviation were calculated for continuous data, while prevalence percentage
was calculated for dummy variables. The sample size calculation was performed in order
Medicina 2024,60, 90 4 of 9
to verify the margin of error, imposing an alpha of 0.05, a power of 80%, and a prevalence of
the condition analyzed of 1%. The Z-score calculation and the chi-squared calculation were
carried out to determine eventual statistically significant differences between the two popu-
lations. The statistical analysis was performed using MedCalc
®
Statistical Software version
20.218 (MedCalc Software Ltd., Ostend, Belgium; https://www.medcalc.org; accessed on 1
September 2023).
3. Results
A total of 510 women underwent hysterectomy and were evaluated for eligibility
criteria. Sixty-two patients were excluded, as they had laparotomic surgery; 40 women
with a prolapse of pelvic organs that was treated by a vaginal approach were not considered;
12 patients had previous vaginal surgery; and 10 women were lost during follow-up because
they did not come back for gynecological follow-up after surgery or did not answer the
standard interview 6 weeks after surgery. Finally, 386 women fulfilled the inclusion criteria
and were included in the study. The sample-size calculation showed that the margin of
error estimated for this study was less than 0.01.
Transvaginal cuff closure was performed using absorbable Vicryl sutures in 202 women
and PDS sutures in 184 women.
Demographic and operative characteristics were comparable in the two populations,
as shown in Table 1.
Table 1. Patients and operative characteristics of the two groups.
Clinical Data Vicryl PDS p-Value
Patients (n, %) 202 184
Age (years) (mean ±SD) 65.3 ±8.5 64.9 ±7p= 0.96
BMI (kg/m2) (mean ±SD) 30.7 ±5.5 30.5 ±5.4 p= 0.98
Parity 2.0 (1.00–3.00) 2.0 (1.00–3.00) p= 0.99
Premenopausal status (n, %) 72 (35.6%) 78 (42.4%) p= 0.42
Postmenopausal status (n, %) 130 (65.4%) 106 (57.6%) p= 0.47
Prior laparotomy (n, %) 117 (57.9%) 79 (42.9%) p= 0.13
Prior laparoscopy (n, %) 85 (42.1%) 81 (44.0%) p= 0.92
Any prior surgical history (n, %) 87 (43.1%) 78 (42.4%) p= 0.91
Operative time (min) (mean ±SD) 110 ±10.5 106.5 ±12 p= 0.98
Benign pathology (n, %) 55 (27.2%) 47 (25.5%) p= 0.47
Malignant pathology (n, %) 147 (72.8%) 137 (74.4%) p= 0.86
Abbreviations: BMI, body mass index; n, number; %, percentage. Continuous variables are expressed as
mean ±standard
deviations (SD) and categorical variables were summarized as percentages. The parity is ex-
pressed as the median (Q1, Q3). p-value was calculated using the Z-score calculation and
chi-squared calculation.
The surgical procedures performed are detailed in Table 2. The most commonly exe-
cuted surgeries were total hysterectomy + bilateral adnexectomy and radical hysterectomy
type A + bilateral adnexectomy, comprising 292 cases (75.6%) of the interventions.
Postoperative VCD were classified according to the pathology treated and the type of
suture used, and the results are shown in Table 3.
The largest group was represented by women with endometrial cancer in both groups.
VCD occurred in three patients in the Vicryl group (1.5%) and no patients in the PDS group.
Specifically, one case of VCD was in a woman undergoing hysterectomy for endometrial
cancer and two cases of VCD were in women undergoing hysterectomy for cervical cancer;
each case was precipitated by intercourse that occurred at 61, 73, and 80 days post-surgery,
respectively. However, there was no significant statistical difference between the two
groups in terms of VCD incidence (p= 0.09).
Medicina 2024,60, 90 5 of 9
Table 2. Type of hysterectomy.
Type of Hysterectomy Patients (n, %)
Total hysterectomy + bilateral adnexectomy 155 (40.1%)
Radical hysterectomy type A + bilateral adnexectomy 137 (35.5%)
Radical hysterectomy type A + partial colpectomy 5 (1.3%)
Radical hysterectomy type B1 + bilateral adnexectomy 57 (14.8%)
Radical hysterectomy type B2 + bilateral adnexectomy 23 (6.0%)
Radical hysterectomy type C1 + bilateral adnexectomy 9 (2.3%)
Abbreviations: n, number; %, percentage.
Table 3. Postoperative VCD occurrence of the two groups for each gynecological pathology.
Gynecological Pathology Polyglactin 910
n(%)
VCD
n(%)
PDS
n(%)
VCD
n(%) p-Value
Endometriosis 3 (1.5%) - 1 (0.5%) - p= 0.96
Benign pelvic pathologies 21 (10.4%) - 19 (10.3%) - p= 0.99
Uterine leiomyomas 31 (15.3%) - 27 (14.6%) - p= 0.98
Complex endometrial hyperplasia 28 (13.9%) - 25 (13.6%) - p= 0.99
Endometrial cancer 73 (36.1%) 1 (0.5%) 70 (38%) - p= 0.87
Uterine carcinosarcoma 4 (2%) - 2 (1.5%) - p= 0.92
Cervix cancer 28 (13.9%) 2 (1%) 27 (14.5%) - p= 0.96
Ovarian cancer 14 (6.9%) - 13 (7%) - p= 0.99
Total 202 3 (1.5%) 184 0 (0%) p= 0.09
Abbreviations: n, number; PDS, polydioxanone; VCD, vaginal cuff dehiscence; %, percentage. p-value was
calculated using the chi-squared calculation.
4. Discussion
This study compared the incidence of VCD among patients undergoing laparoscopic
hysterectomy using two different suture materials, Vicryl and PDS, with the aim of identi-
fying the most effective method for reducing postoperative complications.
The authors emphasize that this is a crucial topic, considering that hysterectomy is
the second most common surgical procedure after cesarean section occurring in 20–30% of
women [
9
,
10
]. VCD, while uncommon, is a serious postoperative complication that can
occur after a hysterectomy or similar pelvic surgeries. This condition is characterized by
either a partial or full separation at the vaginal vault, sometimes leading to evisceration. The
earliest recorded case of VCD was documented by Hobbs in 1952 [
11
]. Further research in
1994 by Somkuti et al. [
12
] identified multiple factors that could contribute to the weakening
of the vaginal apex post-surgery, such as inadequate surgical methods, infection at the
surgical site or cuff, hematoma at the wound, premature resumption of sexual activities
before complete healing, older age, prior radiation therapy, ongoing steroid use, physical
trauma including rape, previous vaginoplasty procedures, and performing Valsalva’s
maneuver post-vaginal hysterectomy or during bowel movements. These factors are still
largely accepted as relevant today.
Understanding these risk factors is crucial, especially considering the increased preva-
lence of laparoscopic hysterectomies, which may elevate the incidence of VCD [
4
13
]. The
type of suturing material used is also thought to play a role in the likelihood of developing
VCD. This synthetic, often-braided suture is produced by Ethicon Inc.
®
, Somerville, NJ,
USA a part of the Johnson & Johnson
®
family, New Brunswick, NJ, USA. It is designed
for smooth passage through tissues, reducing drag, and is noted for its easy handling,
consistent tie-down smoothness, and excellent knot stability.
Medicina 2024,60, 90 6 of 9
The coated Vicryl suture is recommended for general soft tissue approximation and/or
ligation, including ophthalmic procedures, but it is not suitable for cardiovascular and
neurological tissue applications. In tissue, it maintains its tensile strength for about two to
three weeks and is completely absorbed through acid hydrolysis in 8 to 10 weeks.
PDS antibacterial surgical suture is a synthetic, absorbable, and sterile monofilament
made of polyester. The empirical molecular formula of the polymer is (C
4
H
6
O
3
)
n
. It
is a non-antigenic, pyrogenic polymer and causes only a slight tissue reaction during
absorption. PDS is composed of multiple ether-ester units, derived through the ring-
opening polymerization of p-dioxanone, a process that utilizes heat and an organometallic
catalyst, such as zirconium acetylacetone or zinc L-lactate. Notably, its glass transition
temperature ranges from 10 to 0 C, and it exhibits approximately 55% crystallinity. For
suture production, PDS is typically extruded into fibers, although it is crucial to process
the polymer at the lowest feasible temperature to prevent spontaneous depolymerization
back into its monomer form. The flexibility of this suture material is attributed to the
ether oxygen group within its polymer chain. PDS sutures undergo degradation via
hydrolysis, and their breakdown products are predominantly excreted in urine, with the
remainder processed through the digestive system or expelled as CO
2
. This biomaterial
is fully absorbed within six months, causing only a minimal foreign body reaction in
the surrounding tissue. Furthermore, PDS materials can be sterilized effectively using
ethylene oxide.
Introduced in 1982, PDS represented a pioneering development as the first monofil-
ament synthetic absorbable suture. The monofilament design of PDS offers several ad-
vantages, including easier tissue passage, reduced tissue reactivity, and a lower risk of
wound infection. This structure, however, leads to decreased handling and knot strength,
attributed to its lower coefficient of friction. In terms of tensile strength, PDS initially
shows less strength compared to Polyglactin 910 or Polyglycolic acid. However, its slower
resorption rate means that PDS maintains its tensile strength for a longer duration. Specif-
ically, it retains 70% of its original tensile strength at 2 weeks, 50% at 4 weeks, and 25%
at 6 weeks. Absorption of the suture is minimal until the 90th postoperative day, with
complete resorption occurring approximately after 6 months. This extended period of
support makes PDS particularly useful for wounds under greater tension or those requiring
prolonged dermal support. In fact, extended dermal support for a minimum of 6 months
has been linked to reduced scar spreading.
PDS has undergone improvements since its initial release, with the introduction of
PDS II. This newer version offers enhanced handling characteristics, further augmenting
its utility in surgical applications. Several research studies indicated that barbed sutures
may be associated with lower rates of vaginal cuff dehiscence (VCD) compared to braided
sutures [
14
] or to both braided and monofilament sutures [
15
]. Additionally, the use of
barbed sutures has been linked to benefits such as reduced operation time, lesser post-
operative blood loss, shorter hospital stays, and decreased vaginal cuff granulation six
months after the operation [
16
]. Unidirectional barbed sutures for vaginal cuff closure have
been reported as safe, without major complications noted. However, Weizman et al. [
17
]
found that while a continuous suture method was protective against VCD, there was no
significant difference between braided and barbed sutures, nor between suturing by hand
or laparoscopically. In contrast, Blikkendaal et al. [18] observed no statistical difference in
VCD rates when comparing various methods (vaginal or laparoscopic interrupted sutures
or laparoscopic running sutures) or types of sutures (braided and barbed).
In their research, MacKoul et al. [
19
] compared absorbable and non-absorbable sutures
without finding a significant difference in effectiveness, although non-absorbable sutures
required surgical removal after 90 days. Uccella et al. [
20
] conducted a meta-analysis
revealing that barbed sutures presented a lower risk of VCD, which was particularly signif-
icant when compared to total laparoscopic hysterectomies. This improved outcome might
be attributed to the superior tensile strength of barbed sutures compared to polyglactin
sutures. They also noted that barbed sutures took longer to lead to dehiscence, compared
Medicina 2024,60, 90 7 of 9
to polyglactin sutures (73 days vs. 29 days). However, animal studies have shown mixed
results. One study in ewes found no difference in adhesion formation between barbed
and polyglactin sutures [
21
], while a similar study in rats observed increased adhesion
formation and a greater presence of inflammatory cells with barbed sutures [22].
The risk of cuff dehiscence is increased in laparoscopic or robotic hysterectomies,
where tissues heal slowly due to the use of thermal energy for hemostasis [
5
]. Suture type
is also implicated in VCD, considering that the surgical knot and the knot’s area are most
vulnerable to knot slippage [
23
]. The absorption process of Vicryl sutures involves both a
reduction in tensile strength and mass loss. Studies conducted on rat implants revealed
that Vicryl sutures maintain about 75% of their original tensile strength two weeks after
implantation. By the third week, this retention drops to around 50% for suture sizes 6-0 and
larger, and about 40% for sizes 7-0 and smaller. By the fourth week, the strength retention is
approximately 25% for sizes 6-0 and larger. All original tensile strength is typically lost by
the fifth week post-implantation. The complete absorption of coated Vicryl sutures usually
occurs between 56 and 70 days.
Two key factors define the
in vivo
performance of absorbable sutures: tensile strength
retention and the rate of absorption (or mass loss). PDS II suture, in particular, has been
engineered to minimize the variability in these characteristics, thereby providing consistent
wound support over an extended period of healing. Synthetic polymers, such as Vicryl
and PDS suture, degrade by hydrolysis. The presence of aliphatic ester bonds in these
suture materials renders them hydrolytically unstable; they degrade by hydrolysis from
body fluids. Water molecules penetrate the polymer threads and break down the polymer
chains of the suture. Synthetic sutures have a predictable loss of tensile strength. Typically,
Vicryl suture is fully absorbed by 70 days and PDS II suture is essentially absorbed between
182 and 238 days post-implantation, although this can vary depending on many factors,
including the level of hydration. Behbehani et al. [
24
] evaluated VCD after laparoscopic
hysterectomy using absorbable PDS and V-loc sutures or absorbable Vicryl sutures. The
authors concluded that a delayed absorbable suture is preferable for vaginal cuff closure at
laparoscopic hysterectomy, compared to an absorbable suture.
Most of the cases of VCD cases occur in the first 90 days after surgery [
25
,
26
]. The
choice of suture material is related to the complication rate, although there is currently no
consensus about the best suture material to use. Therefore, based on the previous studies
and the fact that the PDS group did not prove to be inferior to the Vicryl group in terms of
VCD rate, the authors believe that using the latter suture, which is absorbed later than the
former, could represent a valid option.
In this study, all three cases of VCD were observed in the Vicryl group, with no patients
in the PDS group reporting this complication. Given previous research and the fact that the
PDS group did not prove to be inferior to the Vicryl one, the authors believe that the former
suture type offers a viable alternative. It is important to note that the only instances of VCD
occurred in the Vicryl group and were triggered by intercourse within 90 days post-surgery.
This would support the non-inferiority of the use of PDS, which has delayed absorption
and maintains its tensile strength for a more extended period.
The strengths of the present study include a substantial number of cases, uniformity
in the surgical procedure performed by the same surgeon, the same method of colpotomy
used in all patients, and consistency in the mode of vaginal cuff closure (performed with a
single-layer running suture). The study’s use of advanced surgical techniques and state-
of-the-art equipment provides an added layer of precision and reliability to the surgical
outcomes. The use of consistent surgical protocols across all cases minimizes intraoperative
variability, thus enhancing the study’s internal validity. This approach allowed for a direct
comparison between the two different types of suture materials. Moreover, the study’s
design minimized variations due to different surgical approaches or operative variables,
providing more reliable and replicable results.
However, the retrospective nature of the study was a limitation, influenced by the
accuracy of medical data and transcription errors. Additionally, the variety of physicians
Medicina 2024,60, 90 8 of 9
following up with the patients post-hysterectomy can introduce variability in outcomes
and follow-up practices. This factor makes it challenging to estimate the true incidence of
suture-related complications after laparoscopic hysterectomy. Other limitations include the
absence of randomization and control groups, which could provide stronger comparisons
and further reduce potential biases. The duration of follow-up may also be insufficient to
identify all long-term complications. Additionally, the sample’s representativeness might
not adequately reflect the general population, limiting the generalizability of the results.
5. Conclusions
In conclusion, this study investigated the use of Vicryl and PDS sutures for vaginal
cuff closure in laparoscopic hysterectomy, revealing similar outcomes with both materials.
Notably, all cases of VCD occurred exclusively with Vicryl sutures. This absence of VCD in
the PDS group may be attributed to its slower absorption rate and prolonged tensile strength
retention. However, it is important to emphasize that the overall rate of VCD was relatively
low, and the differences observed between the Vicryl and PDS groups did not reach
statistical significance. These findings suggest that while both suture types are effective
for vaginal cuff closure, PDS may offer some advantages in reducing VCD risk, likely
due to its longer duration and physical properties retention. This is particularly relevant
in a surgical context, where preventing postoperative complications is crucial for patient
well-being. Given the importance of suture material choice in surgical practice, further
research is needed to confirm these preliminary findings. Large-scale prospective studies
could provide more insights into the relationship between suture type and complications
like VCD in laparoscopic hysterectomy. Such research could not only help define best
surgical practices but also improve outcomes for patients undergoing this procedure.
Author Contributions: F.G.C.: conceptualization; F.A.G. and G.G.I.: investigation, writing—original
draft preparation; L.C. and C.E.: investigation, writing—review and editing; D.B.: data curation
and formal analysis; G.E.: supervision and writing—review and editing. All authors have read and
agreed to the published version of the manuscript.
Funding: This research received no external funding.
Institutional Review Board Statement: This study was conducted in accordance with the Declaration
of Helsinki and approved by the Institutional Review Board (or Ethics Committee) of Azienda di
Rilievo Nazionale e di Alta Specializzazione (ARNAS) Garibaldi Nesima, Catania (Protocol Code
263/C.E approved on 11 May 2022) (Report No. 69/2022/CECT2).
Informed Consent Statement: Informed consent was obtained from the patients involved in the study.
Data Availability Statement: Data are contained within the article.
Conflicts of Interest: The authors declare no conflicts of interest.
References
1.
Agdi, M.; Al-Ghafri, W.; Antolin, R.; Arrington, J.; O’Kelley, K.; Thomson, A.J.; Tulandi, T. Vaginal vault dehiscence after
hysterectomy. J. Minim. Invasive Gynecol. 2009,16, 313–317. [CrossRef] [PubMed]
2.
De Iaco, P.; Ceccaroni, M.; Alboni, C.; Roset, B.; Sansovini, M.; D’Alessandro, L.; Pignotti, E.; De Aloysio, D. Transvaginal
evisceration after hysterectomy: Is vaginal cuff closure associated with a reduced risk? Eur. J. Obstet. Gynecol. Reprod. Biol. 2006,
125, 134–138. [CrossRef] [PubMed]
3.
Mehasseb, M.K.; Aiken, C.E.M.; Baldwin, P.J.W.; Shafi, M.I. Delayed post-coital vaginal evisceration of intestines following
interval debulking surgery. J. Obstet. Gynaecol. 2012,32, 317–318. [CrossRef]
4.
Ala-Nissilä, S.; Laurikainen, E.; Mäkinen, J.; Jokimaa, V. Vaginal cuff dehiscence is observed in a higher rate after total laparoscopic
hysterectomy compared to other types of hysterectomy. Acta Obstet. Gynecol. Scand. 2019,98, 44–50. [CrossRef]
5.
Hur, H.-C.; Guido, R.S.; Mansuria, S.M.; Hacker, M.R.; Sanfilippo, J.S.; Lee, T.T. Incidence and patient characteristics of vaginal
cuff dehiscence after different modes of hysterectomies. J. Minim. Invasive Gynecol. 2007,14, 311–317. [CrossRef] [PubMed]
6.
Ma, X.; Cao, D.-Y.; Dai, Y.-X. Experience in the Management of Vaginal Cuff Dehiscence and Evisceration: A Retrospective 37-Year
Single-Center Study. Front. Surg. 2022,9, 880875. [CrossRef] [PubMed]
7.
Hada, T.; Andou, M.; Kanao, H.; Nagase, T.; Fujiwara, K. Vaginal cuff dehiscence after total laparoscopic hysterectomy:
Examination on 677 cases. Asian J. Endosc. Surg. 2011,4, 20–25. [CrossRef]
Medicina 2024,60, 90 9 of 9
8.
Nezhat, C.; Kennedy Burns, M.; Wood, M.; Nezhat, C.; Nezhat, A.; Nezhat, F. Vaginal cuff dehiscence and evisceration: A review.
Obstet. Gynecol. 2018,132, 972–985. [CrossRef]
9.
Lin, C.; Li, C.; Wei, B.; Zhan, L.; Wang, W.; Youjiang, X. V-LocTM 180 suture in total laparoscopic hysterectomy: A retrospective
study comparing Polysorb to barbed suture used for vaginal cuff closure. Eur. J. Obstet. Gynecol. Reprod. Bio. 2016,207, 18–22.
10.
Magaña, I.; Ángeles-Castellanos, M.; Ubaldo-Reyes, L.M. Midazolam reduction with pre-operative melatonin in abdominal
hysterectomy: Double-blind randomized clinical trial. Reducción de midazolam con melatonina preoperatoria en histerectomía
abdominal: Ensayo clínico aleatorizado doble ciego. Cir. Cir. 2022,90, 353–358. [CrossRef]
11. Hobbs, F.S. Spontaneous evisceration through vagina. Can. Med. Assoc. J. 1952,66, 68. [PubMed]
12.
Somkuti, S.G.; Vieta, P.A.; Daugherty, J.F.; Hartley, L.W.; Blackmon, E.B. Transvaginal evisceration after hysterectomy in
premenopausal women: A presentation of three cases. Am. J. Obstet. Gynecol. 1994,171, 567–568. [CrossRef] [PubMed]
13.
Kunc, V.; Pastor, J.; Haluza, A.; Kachlik, D. Main pitfalls of skin surgical suturing—Review for junior surgeons and medical
students. Cirugía Y Cir. 2022,90, 124–127. [CrossRef]
14.
Rettenmaier, M.A.; Abaid, L.N.; Brown, J.V.; Mendivil, A.A.; Lopez, K.L.; Goldstein, B.H. Dramatically reduced incidence of
vaginal cuff dehiscence in gynecologic patients undergoing endoscopic closure with barbed sutures: A retrospective cohort study.
Int. J. Surg. 2015,19, 27–30. [CrossRef] [PubMed]
15.
Siedhoff, M.T.; Yunker, A.C.; Steege, J.F. Decreased Incidence of Vaginal Cuff Dehiscence after Laparoscopic Closure with
Bidirectional Barbed Suture. J. Minim. Invasive Gynecol. 2011,18, 218–223. [CrossRef]
16.
Jaime Moens, B.; Buonomo, A.; De Sutter, P. Vaginal Cuff Dehiscence: Two Case Reports and a Review of the Literature. J. Clin.
Med. 2023,12, 4187. [CrossRef]
17.
Weizman, N.F.; Einarsson, J.I.; Wang, K.C.; Vitonis, A.F.; Cohen, S.L. Vaginal Cuff Dehiscence: Risk Factors and Associated
Morbidities. JSLS 2015,19, e2013.00351.
18.
Blikkendaal, M.D.; Twijnstra, A.R.H.; Pacquee, S.C.L.; Rhemrev, J.P.T.; Smeets, M.J.G.H.; de Kroon, C.D.; Jansen, F.W. Vaginal cuff
dehiscence in laparoscopic hysterectomy: Influence of various suturing methods of the vaginal vault. Gynecol. Surg. 2012,9,
393–400. [CrossRef]
19.
MacKoul, P.; Danilyants, N.; Sarfoh, V.; van der Does, L.; Kazi, N. A Retrospective Review of Vaginal Cuff Dehiscence: Comparing
Absorbable and Nonabsorbable Sutures. J. Minim. Invasive Gynecol. 2020,27, 122–128. [CrossRef]
20.
Uccella, S.; Zorzato, P.C.; Kho, R.M. Incidence and Prevention of Vaginal Cuff Dehiscence after Laparoscopic and Robotic
Hysterectomy: A Systematic Review and Meta-analysis. J. Minim. Invasive Gynecol. 2021,28, 710–720. [CrossRef]
21.
Einarsson, J.I.; Grazul-Bilska, A.T.; Vonnahme, K.A. Barbed vs standard suture: Randomized single-blinded comparison of
adhesion formation and ease of use in an animal model. J. Minim. Invasive Gynecol. 2011,18, 716–719. [CrossRef] [PubMed]
22.
Api, M.; Boza, A.; Cıkman, M.S.; Aker, F.V.; Onenerk, M. Comparison of barbed and conventional sutures in adhesion formation
and histological features in a rat myomectomy model: Randomized single blind controlled trial. Eur. J. Obstet. Gynecol. Reprod.
Biol. 2015,185, 121–125. [CrossRef] [PubMed]
23.
Lee, Y.H.; Chong, G.O.; Kim, M.J.; Gy Hong, D.; Lee, Y.S. Overcoming the learning curve of single-port total laparoscopic
hysterectomy with barbed suture: A single surgeon’s initial experience. Videosurgery Other Miniinvasive Tech. 2017,12, 264–270.
[CrossRef] [PubMed]
24.
Behbehani, S.; Yi, J. Vaginal Cuff Dehiscence Mimicking Pelvic Organ Prolapse. J. Minim. Invasive Gynecol. 2020,27, 13–14.
[CrossRef]
25.
Greenberg, J.A.; Clark, R.M. Advances in suture material for obstetric and gynecologic surgery. Rev. Obstet. Gynecol. 2009,2,
146–158.
26.
Ceccaroni, M.; Berretta, R.; Malzoni, M.; Scioscia, M.; Roviglione, G.; Spagnolo, E.; Rolla, M.; Farina, A.; Malzoni, C.; De Iaco, P.;
et al. Vaginal cuff dehiscence after hysterectomy: A multicenter retrospective study. Eur. J. Obstet. Gynecol. Reprod. Biol. 2011,158,
308–313. [CrossRef]
Disclaimer/Publisher’s Note: The statements, opinions and data contained in all publications are solely those of the individual
author(s) and contributor(s) and not of MDPI and/or the editor(s). MDPI and/or the editor(s) disclaim responsibility for any injury to
people or property resulting from any ideas, methods, instructions or products referred to in the content.
... 19 Cannone et al concentrated on the suture aspect by comparing Vicryl (Polyglycolic acid 910) and Polydioxanone (PDS) in terms of the occurrence of vaginal cuff dehiscence following suturing, and found no significant discrepancy between the two. 20 Similarly, other researchers have reported comparable results when examining unidirectional barbed sutures in 21 In a systematic review conducted by Hafermann et al, barbed sutures were found to be an effective method for reducing surgical time, suturing time, and blood loss. However, they seem to have no impact on the occurrence of postoperative complications. ...
Article
Full-text available
Objective Vaginal cuff rupture is a rare but serious postoperative complication predominantly occurring after hysterectomy. Given that it can lead to partial or total evisceration, bowel strangulation, sepsis, and acute mesenteric ischemia. Any instance of this complication should be treated as a surgical emergency. In this context, we report a case of a vaginal stump following regular use of pessaries. Case Report A 50-year-old woman was admitted to the hospital with sudden onset of bowel-like prolapse from the vagina. She had a 7-year history of vaginal prolapse and had previously undergone repair surgery and laparoscopic hysterectomy for uterine fibroids. Following her hysterectomy, she began using a pessary due to recurrent prolapse. Clinical assessment revealed vaginal evisceration of the intestines, necessitating emergency surgery. She was discharged smoothly on the eighth day post-operation. Three months later, she underwent a laparoscopic sacrocolpopexy. Conclusion The utilization of pessaries may heighten the risk of stump rupture in patients following hysterectomy, thereby demanding more vigilant attention from gynecologists.
... According to numerous studies, risk factors for pelvic organ prolapse (POP) encompass obesity, the number of deliveries, age, family history, the presence of constipation, and previous hysterectomy. Careful consideration of reproductive organ anatomy is crucial, as factors such as levator detachment, the preoperative stage of reproductive organ prolapse, and hiatus surface may elevate the risk of symptom recurrence following surgical treatment [2][3][4]. While vaginal delivery stands out as a significant and well-known risk factor for POP, the age at the last delivery and operative delivery do not appear to be associated with an increased risk. ...
Article
Full-text available
Background: The study aimed to evaluate the clinical effects of utilizing acellular dermal matrix (ADM) for treating pelvic organ prolapse. The motivation behind exploring a new treatment method stems from the limited efficacy of current surgical options, which are often associated with side effects. Methods: Ten patients with reproductive organ prolapse underwent surgery at the Chair and Department of Gynecology, Obstetrics, and Gynecological Oncology in Katowice. ADM was used as a support material, with eight patients receiving double TOT and two undergoing a six-point fixation mesh procedure. Pelvic organ prolapse was evaluated pre-operatively and one month post-surgery using the Pelvic Organ Prolapse Quantification (POP-Q) System. General medical history and complaints were assessed using the short form (PFDIQ-SF20). The study included ten patients aged 39 to 71 (mean: 63.6 years), all with a history of at least one vaginal delivery (mean of two). None had undergone a cesarean section. Four patients exhibited POP-Q 3, and five had POP-Q 2. Results: The mean PFDIQ-SF20 score before surgery was 70.6 points. No major complications occurred during or after surgery. One patient experienced a vaginal fungal infection and an allergic reaction to sutures. Post-operation, ailments reduced by an average of 60.76 points, with five patients reporting no complaints. Conclusions: ADM emerges as a material of interest for gynecological surgery, with initial reports highlighting its effectiveness and optimistic safety profile. Further research is warranted to explore its potential as a promising option in pelvic organ prolapse treatment.
Article
Full-text available
Vaginal cuff dehiscence (VCD) is a rare but serious condition associated with high morbidity, especially in the presence of an evisceration. It usually occurs as a complication of hysterectomy, but has also been reported after other pelvic surgeries. In this article, we will present two cases of vaginal cuff dehiscence with evisceration in post-menopausal patients. Both cases occurred post-operatively, the first after a laparoscopic radical hysterectomy and the other after a trachelectomy performed by robotic-assisted laparoscopy (with a prior history of subtotal hysterectomy). Both cases were treated surgically, the first by a combined laparoscopic and vaginal approach, and the second case only by laparoscopic approach. The main risk and protective factors are discussed in a narrative literature review which summarizes the available evidence on this rare condition, discussed by type of study designs and thus evidence level. A laparoscopic vaginal cuff closure is the most protective factor in preventing VCD, compared to a vaginal closure. Clinicians should be aware of this condition and of its risk factors and precipitating events in order to identify high-risk patients. Knowledge of these allows prompt recognition, which is crucial for adequate management, for which multiple approaches have been described.
Article
Full-text available
Introduction: Midazolam is a benzodiazepine used for sedation, however, can cause respiratory depression and increases morbidity in patients. Melatonin is an effective alternative to manage anxiety in the perioperative period and could help to reduce the use of benzodiazepines during surgery. The aim of this clinical trial was to determine the efficacy of pre-operative sedation with a single-dose melatonin to reduce intraoperative use of midazolam in women under total abdominal hysterectomy (TAH). Materials and methods: This is a double-blind randomized clinical trial conducted in women over 25 years, scheduled for TAH, with American Society of Anesthesiologists Grade I or II. Each patient was randomly assigned to receive 5 mg of melatonin prolonged-release oral capsules or placebo. Midazolam use for anesthetic management was the decision of the treating anesthesiologist and sedation status was determined using the observer's assessment of alertness/sedation scale. Results: In patients receiving melatonin, the use of midazolam during surgery was less than in patients receiving placebo. In addition, melatonin produces sedation 30 min after administration, the sedative effect was maintained at 60- and 90-min. Furthermore, hospital stay was shorter in patients who received melatonin (p = 0.006). Conclusion: Melatonin is effective for reduces intraoperative midazolam consumption and hospital stay in women undergoing TAH.
Article
Full-text available
Purpose Vaginal cuff dehiscence (and evisceration) (VCD(E)) is an extremely rare and late-onset complication of total hysterectomy (TH). Limited evidence is available to guide clinicians in managing VCD(E). This study aimed to summarize the clinical characteristics of patients with VCD(E) treated in our center and share our experience in managing VCD(E). Patients and methods From 1983 to 2020, a total of 14 cases of VCD(E), including 10 cases in our hospital and 4 cases in other hospitals, were included. Medical records were reviewed to summarize the clinical features and management of VCD(E). Results The incidence of VCD(E) in our hospital was 10/46,993 (0.02%), and all 10 patients underwent laparoscopic hysterectomy. The median TH-to-VCD(E) interval was 3.13 months (8 days–27.43 months), and 11/14 (78.57%) patients experienced VCD(E) after coitus. The 3 major symptoms included abdominal pain in 11 patients, irregular vaginal bleeding in 8, and sensation of bulging or prolapsed organs in 4. Except for 2, most patients presented to our hospital within 72 h since the onset of the discomfort. All 14 cases were diagnosed through speculum examination: 3 had simple VCD, and 11 had VCDE. The protruding bowels of 4 patients were immediately manually repositioned in the emergency department without anesthesia. Regarding the surgical approach, 11 patients underwent simple transvaginal, 2 patients underwent laparoscopic-vaginal combined (transvaginal cuff closures), and 1 patient underwent laparoscopic. All but 1 patient did not undergo resection of the eviscerated organs. The median follow-up period was 39.33 (7.9–159.33) months. No patients showed any evidence of recurrence to date. Conclusions Laparoscopic hysterectomy is a risk factor for VCD(E), and early initiation of sexual intercourse is the most common trigger of VCD(E). Clinicians should educate patients to postpone sexual intercourse for at least 3–6 months after TH. Immediate medical attention and patient-specific surgical management are crucial to avoid serious complications.
Article
Full-text available
Study objective: To compare the rate of spontaneous and complete vaginal cuff dehiscence (VCD) using absorbable versus nonabsorbable sutures for vaginal cuff closure. Design: Retrospective comparative cohort design. Setting: Freestanding ambulatory surgery center in suburban Maryland. Patients: Women age >18 years old who underwent hysterectomy for benign conditions between October 2013 and April 2018. Intervention: Laparoscopic retroperitoneal hysterectomy was performed by 2 gynecologic surgical specialists. Transvaginal cuff closure was performed using either absorbable Vicryl (polyglactin 910) sutures (n = 881) or nonabsorbable Ethibond (polyester) sutures (n = 574). The nonabsorbable sutures were surgically removed after 90 days. Measurements and main results: No statistically significant differences in age, race, weight, body mass index, parity, uterine weight, or number of comorbidities were noted between the nonabsorbable and absorbable suture groups. Spontaneous vaginal cuff dehiscence (VCD) occurred in 3 patients (0.52%) in the nonabsorbable group and in 12 patients (1.4%) in the absorbable group (p = .183). Eleven of the 12 cases of VCD in the absorbable group were precipitated by intercourse and occurred within 90 days of surgery. Conclusion: Our data suggest that use of a nonabsorbable suture may be an effective approach to prevent spontaneous VCD, but the benefits should be weighed against the inherent risk associated with a second procedure to remove sutures.
Article
Full-text available
Introduction: Recently, it has been suggested that the occurrence of posthysterectomy vaginal cuff dehiscence has increased. Consequently, we evaluated the incidence of vaginal cuff dehiscence after different types of hysterectomies. Our hypothesis is that vaginal cuff dehiscence is more often associated with total laparoscopic hysterectomy (TLH) than other types of uterine removal. Material and methods: A total of 13 645 hysterectomies from 1992 to 2015 were evaluated in the Turku University Hospital district, Finland. The primary outcome was occurrence of vaginal dehiscence after different types of hysterectomy. The hysterectomy and postoperative vaginal dehiscence trends were analyzed as the secondary outcome. In a subanalysis of dehiscence cases, women's characteristics and perioperative vaginal cuff opening and closure techniques were compared between conventional hysterectomies (vaginal, abdominal, and laparoscopic with vaginal closure) and TLH. Results: Altogether, 22 cases of vaginal cuff dehiscence were included. Most cases (n = 15) occurred after TLH (n = 1104), resulting in an incidence of 1.27%. After conventional laparoscopic hysterectomy with vaginal closure (n = 2853), vaginal (n = 4150), and abdominal (n = 5538) hysterectomies, the incidence rates were 0.11%, 0.05%, and 0.02%, respectively. Compared to abdominal hysterectomy, which was associated with the lowest incidence rate, vaginal dehiscence after TLH had an odds ratio (OR) 71.1 (9.34-541.38, P < 0.001). In the subanalysis of possible underlying factors, the technique of opening of the vaginal cuff with or without electrocoagulation, duration of operation, and occurrence of postoperative infection or hematoma prior to VCD were observed differences between TLH and conventional hysterectomies. Conclusions: Compared with other types of hysterectomies, vaginal dehiscence was observed at the highest rate after TLH. Studies are needed to define if vaginal opening technique contributes to the risk of dehiscence.
Article
Full-text available
Introduction: Single-port total laparoscopic hysterectomy (TLH) has not been widely used because of its technical difficulty and steep learning curve, especially the laparoscopic suturing of the vaginal stump. Barbed suturing is a new technology that has the potential to greatly facilitate laparoscopic suturing. Aim: To compare surgical outcomes and vaginal vault healing between barbed sutures and traditional sutures in the repair of the vaginal vault during single-port TLH. Material and methods: Between August 2013 and June 2015, we performed single-port TLH in 85 consecutive patients for benign or premalignant gynecological conditions. The first 48 patients underwent single-port TLH with traditional interrupted sutures, and the next 37 patients underwent single-port TLH with absorbable unidirectional knotless barbed sutures for repair of the vaginal vault. Results: The patient characteristics (age, body mass index), procedures performed, uterine weight, and uterine disease were similar between the groups. There were no differences in blood loss, hemoglobin change, length of hospital stay, or perioperative complications. Operative time and the time required for vaginal cuff suturing were significantly shorter in the barbed suture group than in the traditional suture group (57.8 ±13.5 vs. 80.1 ±18.7 min, p < 0.001; 5.5 ±1.7 vs. 12.9 ±3.5 min, p < 0.001). Moreover, the use of barbed sutures significantly reduced the incidence of vaginal granulation tissue formation (2.7% vs. 35.4%, p < 0.001). Conclusions: Use of barbed sutures in single-port TLH reduced the operative time, suturing time of the vaginal vault, and formation of vaginal granulation tissue. Barbed suturing may help overcome surgical difficulties and vaginal cuff complications.
Article
Objective Vaginal cuff dehiscence, a severe and potentially detrimental complication, has significantly increased after the introduction of endoscopic hysterectomy. The aim of this systematic review and meta-analysis of the available literature was to identify the incidence of, and possible strategies to prevent, this complication after total laparoscopic hysterectomy and total robotic hysterectomy. Data Sources PubMed, ClinicalTrials.gov, Scopus, and Web of Science databases were systematically queried to identify all articles reporting either laparoscopic or robot-assisted hysterectomies for benign indications in which vaginal dehiscence was reported as an outcome. Reference lists of the identified studies were manually searched. Only papers written in English were considered. Methods of Study Selection The Population, Intervention, Comparison, and Outcome framework for the review included (1) population of interest: women who underwent conventional and robot-assisted laparoscopic hysterectomy; (2) interventions: possible methods to prevent vaginal dehiscence; (3) comparison: experimental strategies vs standard treatment or alternative strategy for each item of intervention; and (4) outcome: rate of vaginal dehiscence. Series of subtotal hysterectomies and radical hysterectomies in addition to reports that combined both benign and malignant cases were excluded. The meta-analysis was performed using RevMan version 5.4.1 (Cochrane Training, London, United Kingdom). Two independent reviewers identified all reports comparing 2 or more possible strategies to prevent vaginal dehiscence. Tabulation, Integration, and Results A total of 460 articles were identified. Of these, 20 (6 randomized, 2 prospective, and 12 retrospective) studies were included in this review for a total of 19 392 patients. The incidence of vaginal dehiscence after total laparoscopic hysterectomy ranged between 0.64% and 1.35%. Robotic hysterectomy was associated with a risk of vaginal dehiscence of approximately 1.64%. No study compared early vs delayed resumption of coital activity nor analyzed the role of training in laparoscopic suturing. No study specifically assessed the impact of electrosurgery on the risk of vaginal dehiscence in endoscopic hysterectomies for benign indications. Double-layer and reinforced sutures did not decrease the risk of dehiscence. Barbed sutures reduced the risk of separation compared with nonbarbed closure (0.4% [4/1108] vs 2% [22/1097]; odds ratio [OR] 0.25; 95% confidence interval [CI], 0.11–0.57). However, these data came mainly from retrospective series. Excluding studies on the use of self-anchoring sutures during robotic hysterectomy, there was no significant difference in the risk of dehiscence between barbed and nonbarbed sutures (0.5% [4/890] vs 1.4% [181/776]; OR 0.38; 95% CI, 0.13–1.10). Transvaginal suture of the vault at the end of an endoscopic hysterectomy seemed to increase the risk of dehiscence when compared with laparoscopic closure (2.3% [23/1002] vs 1.16% [11/944]; OR 1.97; 95% CI, 1.00–3.88). Conclusion There is a paucity of high-quality papers evaluating vaginal dehiscence and possible prevention strategies in the current literature. Only 2 effective strategies have been identified in reducing the risk for this complication: the use of barbed sutures and the adoption of a laparoscopic approach to close the vaginal cuff. When restricting the analysis only to laparoscopic cases, the use of barbed sutures does not protect against vaginal cuff separation.
Article
Vaginal cuff dehiscence is an infrequent complication of hysterectomy, with the potential for evisceration and additional morbidity. This review aims to describe the incidence, risk factors, preventative measures, and management. Identification of specific risk factors is problematic because many studies either lack comparison groups or are underpowered as a result of the rarity of this complication. Good surgical technique to optimize vaginal cuff healing and minimize the risk of postoperative cuff infection are important as is avoidance of early intercourse, traumatic vaginal penetration, or excess strain on the vaginal cuff during the postoperative period. Judicious use of electrocautery or other thermal energy, use of delayed absorbable sutures, and adequate tissue bites can further decrease the risk of dehiscence. Prompt recognition and management are critical to achieve best outcomes.