Learning Objectives:After participating in this continuing education activity, the provider should be better able to:

1. Identify the incidence, risk factors, and clinical presentation of vaginal cuff dehiscence and evisceration.

2. Choose appropriate closure techniques to repair vaginal cuff dehiscence with or without evisceration.

3. Assess modifiable risk factors and employ evidence-based intraoperative techniques to reduce the risk of vaginal cuff dehiscence.

Hysterectomy is the most frequently performed major gynecologic procedure in the United States.1,2 Although vaginal cuff dehiscence is an uncommon complication of hysterectomy, if not recognized and treated appropriately, it can be life-threatening or cause significant patient morbidity.2-4 Therefore, it is important to be comfortable not only with the diagnosis and management of vaginal cuff dehiscence, but also with the available measures to prevent its occurrence. Recent studies have identified preoperative, intraoperative and postoperative factors associated with an increased risk of vaginal cuff dehiscence. These factors and potential methods of reducing the risk of cuff dehiscence are reviewed in this article.

Definitions

Vaginal cuff dehiscence is defined as the full-thickness separation of the anterior and posterior edges of the vaginal cuff.2 A dehiscence can be partial, which involves only a portion of the vaginal cuff, or complete, which includes separation of the entire length of the initial incision.2 Vaginal cuff dehiscence with evisceration refers to expulsion of intraperitoneal contents through the separated vaginal cuff. This can lead to more serious complications including sepsis and bowel perforation.1,5

Incidence

Vaginal cuff dehiscence with or without evisceration is an uncommon event after hysterectomy; however, it can result in high morbidity and requires urgent evaluation and treatment.5 The overall incidence is reported to range from 0.14% to 4.1%.2-4 Evisceration may complicate 35% to 67% of vaginal cuff dehiscence cases, and as many as 20% of patients will require a bowel resection due to necrosis caused by obstructed blood flow.2,5,6

Clinical Presentation

The median time to presentation for vaginal cuff dehiscence has been reported at 6.1 weeks after surgery.3 However, other reports note dehiscence as early as 3 days postoperatively and as late as 30 years after surgery.7 Patients typically present with a combination of symptoms including pelvic or abdominal pain (58%-100%) or a combination of vaginal bleeding and a sudden gush of watery discharge (33%-90%).7,8 Patients with evisceration are more likely to describe a mass or vaginal pressure.7 The diagnosis of vaginal cuff dehiscence is made by performing a pelvic examination with visualization or palpation of a separation of the vaginal cuff. This can occur with or without prolapse of intra-abdominal contents through the defect.2 Although most patients present within 24 hours of symptom onset, not all patients with cuff dehiscence experience symptoms. A series of 21 patients reported 2 asymptomatic patients who were diagnosed on their routine 6-week postoperative examinations.7

Postoperative Causative Factors

An increase in intra-abdominal pressure during Valsalva, such as coughing, sneezing, or during defecation, accounts for 16% to 30% of reported cases.7 Intercourse is another commonly cited cause and is identified as the precipitating event in 8% to 48% of cases.2,7 Up to 70% of vaginal cuff dehiscence occurs spontaneously and without any identifiable cause.7-9 It is therefore important to have a high index of clinical suspicion when a patient presents with any symptom that may be consistent with dehiscence.7

Methods of Repair

Currently there is no consensus on the ideal method of surgical repair of a vaginal cuff dehiscence with or without evisceration. Surgical approaches include transvaginal, abdominal, laparoscopic (with or without robotic assistance), or a combination of these methods.2 In a literature review, Cronin et al7 identified 100 cases of vaginal cuff dehiscence. Of these cases, 51% were repaired vaginally, 32% abdominally, 2% laparoscopically, and 10% were repaired using a combined approach. Only 5% were expectantly managed and left to heal by secondary intention.

In cases involving evisceration, inspection of the entire bowel and mesentery and peritoneal lavage should be performed in addition to vaginal closure.5 Because transvaginal closure does not allow for inspection of the bowel, criteria used for transvaginal closure include stable vital signs, lack of bowel duskiness on examination, the ability to reduce the bowel transvaginally, and normal bowel peristalsis.2,8 The benefits of laparoscopic repair include the ability to survey the abdominal cavity and perform bowel resection as indicated, leading some surgeons to use a combined laparoscopic and transvaginal approach.2 Additionally, synthetic mesh or an omental flap can be used to support the repair.5

Regardless of the approach, all necrotic tissue should be excised so that healthy tissue edges may be reapproximated.2 Hur et al10 recommend that suture be placed at least 1 cm from the cuff edge to ensure that vaginal epithelium and rectovaginal fascia are incorporated into the closure. Pelvic rest including abstinence from intercourse is typically recommended for at least 8 to 12 weeks postoperatively.10

Patient Risk Factors

Patient factors affecting tissue quality and wound healing can have an impact on dehiscence rates.2 However, because vaginal cuff dehiscence is an uncommon complication, many studies evaluating patient risk factors are largely underpowered.10 Most studies looking at risk factors focus on demographics or patient factors associated with poor wound healing, including malignancy, tissue radiation, chronic corticosteroid administration, smoking, and diabetes.2,10

Age

The causes of vaginal cuff dehiscence differ by menopausal status. Premenopausal women often present with symptoms after intercourse, whereas vaginal cuff dehiscence in postmenopausal women is more often a spontaneous event.6 Some researchers have attributed this to hypoestrogenism and vaginal atrophy in older women.6

Obesity

Research suggests that obesity may be a protective factor. In one study, obese women were 86% less likely to have a vaginal cuff dehiscence compared with normal-weight women after laparoscopic hysterectomy.11 These authors postulate that positioning during intercourse may be different for obese women, resulting in a decrease in physical forces at the apex of the vagina. Additionally, an increase in adipose tissue may lead to the delivery of less energy to the vaginal tissue during colpotomy creation, resulting in less overall tissue desiccation and therefore improved healing.

Race

In the same study, black women were demonstrated to have a 4-fold increased risk of dehiscence compared with all other races after not only laparoscopic hysterectomy, but also total abdominal hysterectomy and laparoscopic-assisted vaginal hysterectomy.11 Other studies have demonstrated no difference in dehiscence rates by race.12

Corticosteroids

Multiple studies have suggested that chronic systemic corticosteroids impair wound healing and therefore may increase the risk of cuff dehiscence. One study demonstrated that patients taking corticosteroids for at least 30 days before surgery had a 5 times higher wound complication rate compared with patients not on corticosteroids.13

Cancer

Some studies suggest that hysterectomy for malignancy results in an increased risk of vaginal cuff dehiscence; however, the data are limited. For example, in one study hysterectomy for malignant indications was associated with a higher evisceration rate when compared with uterine prolapse (9/1153, 0.8% vs 4/2289, 0.2%); however, it was not significantly higher than hysterectomies performed for benign disease (21/5193, 0.4%).6

Another study evaluating risk factors of patients undergoing robotic-assisted hysterectomy with established gynecologic cancers demonstrated that postoperative chemotherapy and brachytherapy significantly increased the risk of vaginal cuff dehiscence.14 Although malignancy is often associated with poor wound healing, it is difficult to study as an independent risk factor, as these patients often have other attributable risks due to their older age and multiple medical comorbidities.

Smoking

It is thought that smoking may play a role in vaginal atrophy causing weakness in the vaginal vault and therefore contributing to dehiscence rates.6 In a study of 7039 patients who underwent hysterectomy, 10 patients experienced a vaginal cuff dehiscence, half of whom reported smoking cigarettes.4 In a smaller study of 263 patients who underwent robotic-assisted total laparoscopic hysterectomy, 4 patients had a vaginal cuff dehiscence. All 4 patients were current smokers.15 Other studies demonstrated no difference in tobacco use; however, they were underpowered to find such a difference.7,9

Diabetes

The impact of diabetes on wound healing has been well studied. Diabetes causes microvascular disease that can impair blood flow and lead to poor wound perfusion.16 Additionally, hyperglycemia can increase the risk of wound infection, further delaying wound healing.16 This increased risk of poor wound healing may lead to an increased risk of vaginal cuff dehiscence; however, studies have been underpowered to find a significant difference.9

Route of Hysterectomy

Recent studies have determined that the incidence of vaginal cuff dehiscence differs greatly depending on the route of hysterectomy. These studies show that laparoscopic and robotic hysterectomies are associated with higher rates of vaginal cuff dehiscence compared with open abdominal hysterectomies and vaginal hysterectomies.3,6,10 In a review of the literature in 2016, Hur et al10 reported that the highest rates of cuff dehiscence occur after robotic-assisted total laparoscopic hysterectomy (incidence 2.33%), followed by total laparoscopic hysterectomy (0.87%), total abdominal hysterectomy (0.28%), laparoscopic-assisted vaginal hysterectomy (0.20%), and total vaginal hysterectomy (0.15%). The possible causes for the increased risk of dehiscence is hypothesized to be the use of electrosurgery for colpotomy and the inclusion of less vaginal tissue into the cuff closure due to laparoscopic magnification.17

Use of Electrosurgery During Colpotomy

Colpotomy is usually accomplished with a scalpel or scissors during abdominal and vaginal hysterectomy.18 Various energy sources including ultrasonic, monopolar, and bipolar energy are usually used for colpotomy during laparoscopic hysterectomy. The use of electrosurgery for colpotomy causes tissue necrosis and prolonged devascularization, which can lead to suboptimal vaginal cuff healing.4 Due to the vascular nature of the vagina, long instrument activation times are often used to achieve hemostasis. This results in a wider area of adjacent tissue injury, which is thought to reduce suture holding strength and can lead to vaginal cuff separation. In a study using swine models to evaluate energy-induced damage on vaginal tissue, all energy sources demonstrated tissue damage, with ultrasonic energy showing the least and bipolar the greatest.18 A randomized controlled trial comparing the use of monopolar coagulation and cut modes during colpotomy demonstrated no significant difference in vaginal cuff dehiscence rates.19

Approach to Vaginal Cuff Closure at Time of Hysterectomy

Methods for closing the vaginal cuff after laparoscopic hysterectomy vary by hospital practice and surgeon preference. The vaginal cuff can be closed either transvaginally or laparoscopically. Multiple retrospective studies including a meta-analysis of 13,030 patients demonstrated a lower incidence of vaginal cuff dehiscence with transvaginal closure when compared with a laparoscopic closure.17 Studies have also suggested that robotic closures have the highest risk of dehiscence even when compared with laparoscopic closure, due to magnification of the tissue.20

However, Uccella et al1 published in 2018 a randomized controlled trial of 1395 patients, which demonstrated a significant reduction of vaginal cuff dehiscence with laparoscopic closure (1%) when compared with the transvaginal technique (2.7%). The study ended early based on the significant findings of decreased vaginal bleeding (2.7% vs 4.9%), vaginal cuff hematoma (1.0% vs 2.9%), postoperative infection (0.9% vs 2.3%), need for vaginal resuture (0.9% vs 2.3%), and any vaginal complication (4.7% vs 9.8%) with laparoscopic compared with transvaginal cuff closure. The reasons postulated for the contradictory outcomes in more recent studies compared with earlier published literature may be a result of the prospective study design and more importantly the refinement in current laparoscopic technology and technique over time.

Vaginal Cuff Closure Technique

There are multiple laparoscopic closure techniques including the use of interrupted figure of 8 stitches, continuous single-layer closure, and 2-layer closure. Some studies have compared an interrupted figure of 8 closure technique with a 2-layer continuous closure. The results of these studies have shown no significant difference in vaginal cuff complications.15,21,22 However, a randomized controlled trial of 263 patients comparing single-layer closure to double-layer closure demonstrated decreased rates of vaginal cuff dehiscence in patients who underwent a double-layer closure.15

Suture Material

In the past, most vaginal cuff closures were performed using polyglactin 910 (Vicryl). However, it has been recently argued that newer barbed sutures could have a "profound impact" on laparoscopic outcomes by helping to overcome technically challenging laparoscopic closure techniques.23 Multiple studies have compared various methods of closure using polyglactin 910 with the use of currently available barbed suture. Studies have demonstrated no difference in cuff complications with barbed suture compared with polyglactin 910.21 In fact, one study showed that in cases when barbed suture is used for vaginal cuff closure there is a decrease in hospital length of stay, estimated blood loss, and procedure time with no difference in the frequency of both major and minor complications.24 Another study comparing bidirectional barbed suture with all other methods of closure, including transvaginal and laparoscopic approaches, demonstrated a decrease in vaginal cuff dehiscence with barbed suture (0% vs 4.2%).25

Although these results are promising, it has been suggested that one potential infrequent complication of using barbed suture is small bowel obstruction (SBO). A review of the literature published in 2019 documented a total of 18 cases of SBO secondary to the use of barbed suture. One of the most common procedures identified was hysterectomy.26 There is debate about whether this number is clinically significant; however, surgeons should have a high index of suspicion in patients presenting with obstructive symptoms after a procedure in which barbed suture is used. To prevent the risk of SBO while using barbed suture, the authors recommend cutting the suture flush with the peritoneum after taking 1 to 2 bites back on the suture line, consistent with package insert instructions.26

Addressing Modifiable Risk Factors

Modifiable factors that increase a patient's risk for poor wound healing and therefore vaginal cuff dehiscence should be addressed with the patient preoperatively. Patients who use tobacco should be counseled on smoking cessation, and optimal glucose control should be discussed with diabetic patients.10 Preoperative anemia should also be evaluated and treated appropriately. Because estrogen status may play a role in vaginal wound healing for postmenopausal women, perioperative use of estrogen can also be considered. In a randomized controlled trial of 269 women who underwent vaginal hysterectomy, patients who were randomized to a 28-day course of transdermal estradiol before surgery showed fewer visible vaginal cuff wound openings at 4 weeks postoperatively than patients receiving vaginal estrogen.27

Preoperative Treatment of Infection

Some vaginal infections including bacterial vaginosis (BV) and trichomonas vaginitis increase the risk of vaginal cuff infections in patients undergoing hysterectomy and thus increase the risk for vaginal cuff dehiscence.2,4 Patients should therefore be appropriately screened and treated before surgery. In an analysis of 134 patients who underwent abdominal hysterectomy, patients with preoperative BV infections had a significantly higher rate of vaginal cuff cellulitis or abscess compared with those who did not (34% vs 11%).28

Preoperative Antibiotics and Antisepsis

The current recommendation for antibiotic prophylaxis for hysterectomy is 1 to 2 g of cefazolin IV. For obese patients, several authors recommend antibiotic dosing be increased to 3 g based on pharmacokinetic data.29 Alternatives for patients with severe penicillin allergies include gentamicin 1.5 mg/kg IV in addition to either clindamycin 600 mg IV or metronidazole 500 mg IV.29 To provide optimal infection prevention, antibiotics should be administered 30 to 60 minutes before incision.29 Redosing of antibiotics should be considered in cases with longer operation times (>3 hours) or excessive blood loss.10,29

For skin antisepsis, studies have demonstrated that chlorhexidine-alcohol is more effective than povidone-iodine scrub in preventing superficial and deep incisional infections in patients undergoing clean-contaminated procedures.30 Although chlorhexidine solutions have traditionally been avoided in vaginal preparation due to the potential for irritation, allergic reactions, and risk of burns, concentrations of 4% or less seem to be well tolerated.29 Chlorhexidine has been shown to more effectively reduce vaginal bacteria and, unlike povidone-iodine, is effective in the presence of blood.29 Although only povidone-iodine preparations are currently approved by the FDA for vaginal surgical site antisepsis, the use of chlorhexidine is supported by the American College of Obstetricians and Gynecologists in cases of allergy to iodine or surgeon preference.29

Conclusion

Although vaginal cuff dehiscence is a rare complication, it can cause significant morbidity, especially if evisceration occurs. Because hysterectomy is the most frequent major gynecologic procedure performed in the United States, even this rare complication can impact many women.1,9 If not recognized and managed appropriately, vaginal cuff dehiscence and evisceration may represent a significant burden to patients and the health care system.1 Surgeons should be prepared to promptly diagnose and treat patients with vaginal cuff dehiscence. It is important for surgeons to be aware of the potentially modifiable risk factors and varying surgical techniques that may decrease a patient's risk for this complication. Because high-quality data on the subject are limited, additional research is also needed to determine the best methods for prevention and management.

REFERENCES