Risk of Vaginal Cuff Dehiscence in Minimally Invasive Hysterectomy
Abstract & Commentary
By Frank W. Ling, MD, Clinical Professor, Departments of Obstetrics and Gynecology, Vanderbilt University School of Medicine, and Meharry Medical College, Nashville, is Associate Editor for OB/GYN Clinical Alert.
Dr. Ling reports no financial relationships relevant to this field of study.
Synopsis: Transvaginal cuff closure is associated with a three-fold reduction in the risk of dehiscence when compared to laparoscopic suturing and a nine-fold reduction when compared to robotic suturing.
Source: Uccella S, et al. Vaginal cuff closure after minimally invasive hysterectomy: Our experience and systematic review of the literature. Am J Obstet Gynecol2011 [Epub ahead of print].
In the initial phase of data collection, the authors identified two vaginal cuff dehiscences out of 665 total laparoscopic hysterectomies with transvaginal cuff closure (0.3%). An exhaustive literature search of 57 cohort studies reporting 13,030 endoscopic hysterectomies revealed a vaginal dehiscence rate of 0.18% when the cuff was closed transvaginally, which was significantly better than laparoscopic closure (0.64%; odds ratio [OR] 0.28; 95% confidence interval [CI] 0.12-0.65) as well as robotic closure (1.64%; OR 0.11; 95% CI 0.04-0.26). In addition, laparoscopic closure carried a lower risk of cuff disruption than robotic closure (OR 0.38; 95% CI 0.28-0.6).
Commentary
OK, I admit ... this is not great science. It's not a prospective, randomized trial. Cuff closure techniques were not standardized. There was no control over the experience of the surgeons. However, this is real clinical medicine. This is potentially what each of us is dealing with every time we go to the operating room. It addresses something that we have all talked about and even possibly experienced. The authors give us good food for thought.
First, it should be acknowledged that we're talking about an infrequent, even rare, occurrence. However, it is important to consider that the incidence of cuff dehiscence was significantly increased when it was performed laparoscopically and more so when it was done via the robot. As these new surgical techniques are embraced, we can't and shouldn't ignore this phenomenon, which apparently has come along with the new technology.
To fix the problem, we need to recognize what causes it. Therein is the dilemma ... the real cause is not well recognized. Several explanations have been offered, none of which has been studied in a systematic fashion. Since the authors performed the hysterectomies as total laparoscopic procedures (TLH) and only closed the cuff via the vagina, it seems that TLH is not the underlying risk factor. It appears to be the route and/or technique of closure.
Could it be the increased thermal tissue damage created by the electrocautery used for the colpotomy? Maybe.
Could it be that knots tied manually in a vaginal closure are more reliable than those tied via laparoscopic or robotic techniques? Maybe.
Could it be that the tension in the knots tied by hand is greater? Maybe.
Could it be that laparoscopic visualization magnifies the view such that there is insufficient tissue included in the suture? Maybe.
The authors point out an interesting offshoot of these findings. If one assumes that the laparoscopic knot-tying is a difficult skill to master, wouldn't it make sense to just routinely close with a vaginal approach? Maybe.
Some of you are already thinking to yourselves, "Hey, what about the newer approaches to cuff closure like barbed suture? Why not do a double layer closure?" Indeed, those are questions that should be considered, and hopefully answered.
Will those and other queries be addressed by gynecologic surgeons looking for a truly better mousetrap? Can Level I data be generated so that we can be guided in our clinical decision-making? Maybe.
Until the answers are forthcoming, each of us should commit to practicing evidence-based medicine by reading the best literature on newest developments, using techniques that maximize safety for the patient, and exercising caution in the surgical arena.
In the initial phase of data collection, the authors identified two vaginal cuff dehiscences out of 665 total laparoscopic hysterectomies with transvaginal cuff closure (0.3%).You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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