Vaginal cuff dehiscence after total laparoscopic hysterectomy: examination on 677 cases

Rate of Vaginal Cuff Dehiscence When Using Vicryl (Poliglactyn 910) Compared to PDS (Polydioxanone) for Vaginal Cuff Closure in Laparoscopic Hysterectomy

Objective: To compare the vaginal cuff dehiscence (VCD) rates using Vicryl (Poliglactyn 910) and Polydioxanone (PDS) in patients who underwent laparoscopic hysterectomy. Materials and methods: A retrospective, monocentric study was conducted, including all patients undergoing laparoscopic hysterectomy at the Department of Obstetrics and Gynaecology, Azienda di Rilievo Nazionale e di Alta Specializzazione (ARNAS) Garibaldi Nesima, Catania, between January 2014 and December 2021. Patients underwent hysterectomy for benign gynecologic pathologies (endometriosis, leiomyomas, or benign pelvic pathologies) or malignant gynecologic pathologies (endometrium cancer, complex endometrial hyperplasia, ovarian cancer, cervix cancer, or uterine carcinosarcoma). The Z-score calculation was performed to find eventual statistically significant differences between the two populations regarding VCD rates. Results: Laparoscopic vaginal cuff closure was performed, with Vicryl sutures in 202 patients and PDS sutures in 184 women. Demographic and baseline characteristics were not significantly different in the two groups. VCD occurred in three patients in the Vicryl group and did not occur in the PDS group. The three cases of VCD were precipitated by intercourses that occurred within 90 days of surgery. However, there was not a significant statistical difference between the two groups regarding VCD (p = 0.09). Conclusions: Vicryl and PDS sutures seem to be similar for vaginal cuff closure in laparoscopic hysterectomy. The VCD rate was low, and the observed differences between the Vicryl and PDS groups did not reach statistical significance. Further research through prospective studies is essential.

Vaginal Cuff Dehiscence: Two Case Reports and a Review of the Literature

Vaginal cuff dehiscence (VCD) is a rare but serious condition associated with high morbidity, especially in the presence of an evisceration. It usually occurs as a complication of hysterectomy, but has also been reported after other pelvic surgeries. In this article, we will present two cases of vaginal cuff dehiscence with evisceration in post-menopausal patients. Both cases occurred post-operatively, the first after a laparoscopic radical hysterectomy and the other after a trachelectomy performed by robotic-assisted laparoscopy (with a prior history of subtotal hysterectomy). Both cases were treated surgically, the first by a combined laparoscopic and vaginal approach, and the second case only by laparoscopic approach. The main risk and protective factors are discussed in a narrative literature review which summarizes the available evidence on this rare condition, discussed by type of study designs and thus evidence level. A laparoscopic vaginal cuff closure is the most protective factor in preventing VCD, compared to a vaginal closure. Clinicians should be aware of this condition and of its risk factors and precipitating events in order to identify high-risk patients. Knowledge of these allows prompt recognition, which is crucial for adequate management, for which multiple approaches have been described.

Preventive effect of metronidazole vaginal tablets on vaginal bacteria-related postoperative complications with total laparoscopic hysterectomy

BACKGROUND

The use of total laparoscopic hysterectomy is increasing. However, as with conventional abdominal hysterectomy, vaginal bacteria-related postoperative complications need to be managed in total laparoscopic hysterectomy. Therefore, we started to combine metronidazole vaginal tablets with intravenous administration of cephem antibiotics immediately before starting surgery to reduce complications. To evaluate the effect of this combination, and to determine the risk factors for these complications, we retrospectively collected medical records from our hospital and performed a multivariate analysis.

METHODS

We reviewed the medical records of 520 patients who underwent total laparoscopic hysterectomy from 1 January 2015 to 31 December 2021. Among these cases, we identified 16 cases as having vaginal bacteria-related postoperative complications, defined as needing more than one additional day for treatment of postoperative complications, namely postoperative infection (10 cases) and vaginal dehiscence (6 cases). First, we evaluate the effect of metronidazole vaginal tablets by dividing the patients into two groups according to whether metronidazole vaginal tablets were used, and comparing the vaginal bacteria-related postoperative complication rates and other indices. Second, we performed a multivariate logistic regression analysis to assess the influence of each of 17 representative factors, including patient characteristics and symptoms, uterus and leiomyoma sizes, concomitant procedures such as laparoscopic cystectomy and pelvic lymphadenectomy, and others.

RESULTS

In the multivariate analysis of the 520 cases, we confirmed that the use of metronidazole vaginal tablets could reduce the vaginal bacteria-related postoperative complications rate by more than half (odds ratio, 0.36). In addition to metronidazole vaginal tablets use, concomitant laparoscopic cystectomy and blood transfusion were associated with significant increases in the vaginal bacteria-related postoperative complication rate.

CONCLUSIONS

The effect of the addition of metronidazole vaginal tablets to pre- and postsurgical treatment on the reduction of vaginal bacteria-related postoperative complications was confirmed. This easy, safe, and low-cost method may improve the management of total laparoscopic hysterectomy.

Laparoscopic assessment and transvaginal reparation of post-coital vaginal cuff dehiscence with bowel evisceration: a case report

Vaginal cuff dehiscence (VCD) is a rare postoperative complication of total hysterectomy. Presenting symptom is acute pelvic or abdominal pain accompanied by nausea and vomiting. Immediate recognition and surgical repair are crucial for successful management. A 40-year-old para 1+0 presented with complaints of pelvic pain associated with sexual activity, three months after a total laparoscopic hysterectomy. Speculum examination revealed the presence of bowel into the vagina. Diagnostic laparoscopic assessment combined with VCD repair through the transvaginal route. The occurrence of VCD after laparoscopic hysterectomy has been linked to overuse of electrocautery, prolonged inflammatory response and suturing methods. Laparoscopic, abdominal and vaginal approaches are the routes for repairing VCD. However, it depends on the clinical presentation and surgeon expertise. Careful history, and physical examination are vital factors in guiding clinicians to diagnose and treat VCD. Nevertheless, an ideal modality remains variable to each case.

Vaginal Cuff Dehiscence After Endometriosis Surgery

Background and Objectives

Laparoscopic hysterectomy is one of the surgical treatment options for endometriosis. A rare complication of this surgical procedure is vaginal cuff dehiscence, with an incidence of 0.03% to 0.30%. Sexual intercourse may be the main triggering event. It is unclear if patients with endometriosis are more prone to develop vaginal cuff dehiscence than other women undergoing laparoscopic hysterectomy.

Methods

We present the cases of women aged 35 to 46 years who underwent laparoscopic endometriosis surgery. In all patients the vaginal cuff was opened with a high-energy surgical device and closed with an absorbable suture. After 60 to 194 d, the patients developed symptoms including acute abdominal pain and fever shortly after or during coitus and were diagnosed with vaginal cuff dehiscence.

Results

Patients undergoing surgical treatment for endometriosis may experience poor wound healing of the vaginal cuff due to the frequent use of gonadotrophin-releasing hormone analogues before surgery. Contributing to this may be the use of a high-energy surgical device when opening the vaginal cuff. Resuming sexual activities before proper healing of the wound has occurred may then trigger vaginal cuff dehiscence.

Conclusion

Women with endometriosis might be prone to develop vaginal cuff dehiscence, not because of the endometriosis itself but because of a combination of patient-specific factors present in women with endometriosis. Surgeons treating women with endometriosis should be aware of this.

Exploration of assistive technology for uniform laparoscopic surgery

INTRODUCTION

Laparoscopic surgery is less invasive than open surgery and is now common in various medical fields. However, laparoscopic surgery is more difficult than open surgery and often requires additional time for the operator to achieve mastery. Therefore, we investigated the use of assistive technology for uniform laparoscopic surgery.

METHODS

We used the OpenCV2 library for augmented reality with an ArUco marker to detect and estimate forceps positioning. We used Sense HAT as the gyro sensor. The development platforms used were Mac OS X 10.11.3 and Raspberry Pi 3, model B.

RESULTS

By attaching the ArUco marker to the needle holder, we could draw a line vertically to the marker. When the needle was held, a cube could be imagined, and both the needle and lines could be used to determine the appropriate position. By attaching the gyro sensor to the camera, we could detect its angle of rotation. We obtained stabilized images by rotating the image by the detected degrees; this was possible for any camera position.

CONCLUSIONS

Assistive technology allowed us to obtain consecutive converted images in real time and may be readily applicable to clinical practice.

Surgical outcomes of total laparoscopic hysterectomy with 2-dimensional versus 3-dimensional laparoscopic surgical systems

Three-dimensional (3D) laparoscopic surgical systems have been developed to account for the lack of depth perception, a known disadvantage of conventional 2-dimensional (2D) laparoscopy. In this study, we retrospectively compared the outcomes of total laparoscopic hysterectomy (TLH) with 3D versus conventional 2D laparoscopy. From November 2014, when we began using a 3D laparoscopic system at our hospital, to December 2015, 47 TLH procedures were performed using a 3D laparoscopic system (3D-TLH). The outcomes of 3D-TLH were compared with the outcomes of TLH using the conventional 2D laparoscopic system (2D-TLH) performed just before the introduction of the 3D system. The 3D-TLH group had a statistically significantly shorter mean operative time than the 2D-TLH group (119±20 vs. 137±20 min), whereas the mean weight of the resected uterus and mean intraoperative blood loss were not statistically different. When we compared the outcomes for 20 cases in each group, using the same energy sealing device in a short period of time, only mean operative time was statistically different between the 3D-TLH and 2D-TLH groups (113±19 vs. 133±21 min). During the observation period, there was one occurrence of postoperative peritonitis in the 2D-TLH group and one occurrence of vaginal cuff dehiscence in each group, which was not statistically different. The surgeon and assistant surgeons did not report any symptoms attributable to the 3D imaging system such as dizziness, eyestrain, nausea, and headache. Therefore, we conclude that the 3D laparoscopic system could be used safely and efficiently for TLH.

Effects of Hysterectomy on Sexual Function

Hysterectomy remains the most common major gynecological surgery. Postoperative sexual function is a concern for many women and their partners. In this respect, a beneficial effect of hysterectomy for benign disease independent of surgical techniques or removal of the cervix has been demonstrated in the past decade by the majority of studies. For about 20 % of women, deteriorated sexual function has been reported and current research is attempting to identify mechanisms and predictive factors explaining these postoperative changes. Alternative treatments of benign uterine disorders or uterus preserving surgery for genital prolapse appeared to have similar outcomes in terms of sexual function. Concomitant oophorectomy had negative effects on sexual function and long-term health, particularly in premenopausal women. This may not be reversed by estrogen replacement. Hysterectomy performed for malignancy had a detrimental effect on sexual function. Individualized risk assessment and information should be aimed at during preoperative decision making.