Vaginal cuff dehiscence, or separation of the vaginal incision, is a rare postoperative complication unique to hysterectomy. Morbidity related to evisceration of abdominal contents can be profound and prompt intervention is required.
A 10-year observational study of 11,000 patients described a 0.24% cumulative incidence after all modes of hysterectomy.1 Though data are varied, the mode of hysterectomy does have an impact on the risk of dehiscence.
Laparoscopic (0.64%-1.35%) and robotic (0.46%-1.5%) hysterectomy have a higher incidence than abdominal (0.15%-0.26%) and vaginal (0.08%-0.25%) approaches.2 The use of monopolar cautery for colpotomy and different closure techniques may account for these differences.
Cuff cellulitis, early sexual intercourse, cigarette smoking, poor nutrition, obesity, menopausal status, and corticosteroid use are all proposed risk factors that promote infection, pressure at the vaginal cuff, and poor wound healing. Although some are modifiable, the rarity of this complication has made establishing causality and promoting prevention challenging.
Prevention
• Preoperatively. Treating bacterial vaginosis, Trichomonas vaginalis, gonorrhea, and chlamydia can decrease the risk of cuff cellulitis and dehiscence.3 • Intraoperatively. Surgeons should ensure adequate vaginal margins (greater than 1 cm) with full-thickness cuff closures while avoiding excessive electrocautery.4 Retrospective data show that transvaginal cuff closure is associated with a decreased risk of dehiscence.5 However, given the lack of randomized data and the difficulty controlling for surgeon experience, gynecologists should use the approach that they are most comfortable with. Though the various laparoscopic cuff closure techniques have limited evidence regarding superiority, some experts propose using two-layer cuff closure and barbed sutures.6-8 Several retrospective studies have found an equivalent or a decreased incidence of cuff dehiscence with barbed sutures, compared with other methods (e.g., 0-Vicryl, Endo Stitch).9,10
• Postoperatively. Women should avoid intercourse and lifting more than 15 pounds for at least 6-8 weeks as the vaginal cuff gains tensile strength. Vaginal estrogen can promote healing in postmenopausal patients.11
Management
Patients with vaginal cuff dehiscence commonly present within the first several weeks to months after surgery with pelvic pain (60%-100%), vaginal bleeding (30%-60%), vaginal discharge (30%), or vaginal pressure/mass (30%).1,7 Posthysterectomy patients with these complaints warrant an urgent evaluation. The diagnosis is made during a pelvic exam.
Broad-spectrum antibiotics are necessary because all vaginal cuff separations or dehiscences expose the peritoneal cavity to vaginal flora. Nonsurgical management is reasonable for small separations – less than 25% of the cuff – if there is no evidence of evisceration.
However, surgically closing all recognized cuff dehiscences is reasonable, given the potential for further separation. A vaginal approach is preferred when possible. Women with vaginal cuff dehiscence, stable vital signs, and no evidence of bowel evisceration can be repaired vaginally without an abdominal survey.
In contrast, women with bowel evisceration have a surgical emergency because of the risk of peritonitis and bowel injury. If the eviscerated bowel is not reducible, it should be irrigated and wrapped in a warm moist towel or gauze in preparation for inspection and reduction in the operating room. If the bowel is reducible, the patient can be placed in Trendelenburg’s position. Her vagina should be packed to reduce the risk of re-evisceration as she moves toward operative cuff repair.
If the physician is concerned about bowel injury, inspection via laparoscopy or laparotomy would be reasonable. However, when bowel injury is not suspected, a vaginal technique for dehiscence repair has been described by Matthews et al.:12
1. Expose the cuff with a weighted speculum and Breisky-Navratil retractors.
2. Sharply debride the cuff edges back to viable tissue.
3. Dissect adherent bowel or omentum to allow for full-thickness closure.
4. Place full-thickness, interrupted delayed absorbable sutures to reapproximate the cuff edges.
Cuff dehiscence is a rare but potentially morbid complication of hysterectomy. Prevention, recognition, and appropriate management can avoid life-threatening sequelae.
References
1. Obstet Gynecol. 2011 Oct;118(4):794-801.
2. JSLS. 2012 Oct-Dec;16(4):530-6.
3. Am J Obstet Gynecol. 1990 Sep;163(3):1016-21; discussion 1021-3.
4. Obstet Gynecol. 2013 Mar;121(3):654-73.
5. Obstet Gynecol. 2012 Sep;120(3):516-23.
6. J Am Assoc Gynecol Laparosc. 2002 Nov;9(4):474-80.
7. Eur J Obstet Gynecol Reprod Biol. 2006 Mar 1;125(1):134-8.
8. Obstet Gynecol. 2009 Aug;114(2 Pt 1):231-5.
9. J Minim Invasive Gynecol. 2011 Mar-Apr;18(2):218-23.
10. Int J Surg. 2015 Jul;19:27-30.
11. Maturitas. 2006 Feb 20;53(3):282-98.
12. Obstet Gynecol. 2014 Oct;124(4):705-8.
Dr. Pierce is a gynecologic oncology fellow in the department of obstetrics and gynecology at the University of North Carolina at Chapel Hill. Dr. Clarke-Pearson is the chair and the Robert A. Ross Distinguished Professor of Obstetrics and Gynecology and professor in the division of gynecologic oncology at the university. They reported having no relevant financial disclosures.
