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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
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