Original article
Incidence and patient characteristics of vaginal cuff dehiscence after different modes of hysterectomies

https://doi.org/10.1016/j.jmig.2006.11.005Get rights and content

Abstract

Study objective

The purposes of this study were to estimate and compare the incidence of vaginal cuff dehiscence after different modes of hysterectomies (abdominal, vaginal, laparoscopic-assisted vaginal and laparoscopic) and to review the characteristics of hysterectomies complicated by vaginal dehiscences.

Design

Observational case series (Canadian Task Force classification II-3).

Setting

Large, urban, university teaching hospital.

Patients

All patients undergoing a total hysterectomy or vaginal dehiscence repair at Magee-Womens Hospital (MWH) from January 2000 through March 2006 were analyzed.

Interventions

Vaginal repair of vaginal cuff separation with reduction of eviscerating organ when appropriate.

Measurements and main results

From January 2000 through March 2006, 7286 hysterectomies (7039 total and 247 supracervical) were performed at MWH by abdominal, vaginal, laparoscopic-assisted vaginal, or laparoscopic approach. Ten of these hysterectomies were complicated by vaginal cuff dehiscences and were repaired during this time period. The resulting overall cumulative incidence of vaginal cuff dehiscence after total hysterectomy at MWH was 0.14%. The annual cumulative incidence of vaginal dehiscences after total hysterectomy was 0%, 0%, 0%, 0%, 0.09%, 0.70%, and 0.31% from January 2000 to March 2006, respectively. There was a notable increase in the cumulative incidence of dehiscence in 2005 and thereafter. From January 2005 through March 2006, the cumulative incidence of vaginal dehiscence by mode of hysterectomy was 4.93% among total laparoscopic hysterectomies (TLH), 0.29% among total vaginal hysterectomies (TVH), and 0.12% among total abdominal hysterectomies (TAH). The relative risks of a vaginal cuff dehiscence complication after TLH compared with TVH and TAH were 21.0 and 53.2, respectively. Both were statistically significant, with 95% CIs of 2.6 to 166.9 and 6.7 to 423.4, respectively. Among the 10 dehiscences repaired, 8 (80%) were complications of TLHs, 1 (10%) was associated with TAH, and 1 (10%) followed a TVH. The median age at time of dehiscence was 39 years, and the median time between initial hysterectomy to vaginal dehiscence was 11 weeks. Six of the 10 patients presented with both cuff dehiscence and bowel evisceration. Six patients reported first postoperative intercourse as the trigger event. Half the patients with dehiscence report smoking cigarettes. All patients with dehiscence received preoperative prophylactic antibiotics at the time of hysterectomy. Until October 2006, there have been no reported recurrent dehiscences at MWH.

Conclusions

Total laparoscopic hysterectomies may be associated with an increased risk of vaginal cuff dehiscence compared with other modes of total hysterectomy. We postulate that the use of thermal energy in addition to other factors unique to laparoscopic surgery may be responsible; however, prospective randomized trials are needed to support this hypothesis. When performing laparoscopic hysterectomies, a supracervical approach should be considered unless a clear indication for a TLH is present.

Section snippets

Materials and methods

All women who underwent any type of hysterectomy or vaginal dehiscence repair at Magee-Womens Hospital (MWH) from January 2000 through March 2006 were identified by use of pertinent diagnostic codes and procedure codes. The medical records of the patients with dehiscence were reviewed to ensure that only those patients who had a vaginal cuff dehiscence as a complication of a hysterectomy were included in the study. Both the accuracy of the diagnosis and the location of the original hysterectomy

Results

A total of 7286 hysterectomies via all surgical modalities was performed at MWH from January 2000 through March 2006; 7039 of these were total hysterectomies, 244 were supracervical hysterectomies (excluded), and 3 were hysterectomies that were not classified. An average of 1126 total hysterectomies were performed annually, ranging from 1065 to 1143 total hysterectomies per year (Table 1). During the same time period, a total of 12 vaginal cuff dehiscences were repaired at MWH. Ten of these

Discussion

Vaginal cuff dehiscence after hysterectomy is a rare event. There are few published reports of the incidence of vaginal dehiscence after hysterectomy. Croak et al1 report a 0.032% incidence of vaginal evisceration, but this incidence includes all pelvic operations. We were specifically interested in the incidence of vaginal dehiscence after hysterectomy. Ramirez and Klemer10 provide a thorough review of the literature regarding vaginal eviscerations after hysterectomy but fail to calculate an

Conclusions

Total laparoscopic hysterectomies appear to have a statistically significant increased risk of vaginal cuff dehiscence compared with other modes of hysterectomy. We recommend laparoscopic hysterectomies over abdominal hysterectomies because of advantages such as less blood loss, fewer infections or fevers, shorter hospital stay and recovery time, earlier resumption of baseline activities,11 faster return to work, less postoperative pain,12, 13, 14 decreased pain medication requirements, and

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    2023, Journal of Minimally Invasive Gynecology
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