Vaginal cuff dehiscence after hysterectomy
- Hye-Chun Hur, MD
Hye-Chun Hur, MD
- Division Director
- Minimally Invasive Gynecologic Surgery
- Beth Israel Deaconess Medical Center
- Assistant Professor of Obstetrics, Gynecology and Reproductive Biology
- Harvard Medical School
- Section Editors
- Tommaso Falcone, MD, FRCSC, FACOG
Tommaso Falcone, MD, FRCSC, FACOG
- Section Editor — Minimally Invasive Gynecologic Surgery
- Professor of Obstetrics and Gynecology
- Cleveland Clinic Lerner College of Medicine
- Howard T Sharp, MD
Howard T Sharp, MD
- Section Editor — Gynecologic Surgery
- Professor and Vice Chair for Clinical Activities
- Department of Obstetrics and Gynecology
- University of Utah Health Sciences Center
Vaginal cuff dehiscence is a rare, but potentially morbid, complication of total hysterectomy (surgical removal of the uterus and cervix). After removal of the uterine specimen, the vaginal incision (vaginal cuff) or the peritoneal defect is closed. Vaginal cuff dehiscence refers to separation of the vaginal incision. The term vaginal cuff dehiscence is frequently interchanged with the terms cuff separation or cuff rupture. All denote the separation of a vaginal incision that was previously closed at time of initial hysterectomy.
After dehiscence of the vaginal cuff, abdominal or pelvic contents may be expelled through the vaginal opening. Bowel evisceration can lead to serious sequelae, including peritonitis, bowel injury and necrosis, and sepsis. Prompt surgical and medical intervention is required.
Incidence, risk factors, and management recommendations for vaginal dehiscence that occurs after total hysterectomy will be reviewed here. Other complications of gynecologic surgery are discussed separately. (See "Complications of gynecologic surgery".)
Vaginal cuff dehiscence following hysterectomy is a rare event with an estimated incidence of 0.24 to 0.31 percent [1-4]. In a large case series, there were 28 cases of vaginal cuff dehiscence among 11,606 patients (0.24 percent) who underwent total hysterectomy at one institution . Another large multi-institutional study with 12,398 patients reported 38 cases (0.31 percent) of dehiscence after hysterectomy . Both studies included patients undergoing hysterectomy for benign and malignant indications. The incidence of vaginal cuff dehiscence after any type of pelvic surgery is 0.03 percent and varies by surgical approach .
The rate of vaginal cuff dehiscence is higher after laparoscopic hysterectomy (0.64 to 0.75 percent) compared with abdominal (0.15 to 0.26 percent) or vaginal (0.08 to 0.25 percent) approaches [1-4,6-8]. Among laparoscopic hysterectomies, those with vaginal closure of the cuff have a lower reported incidence of dehiscence (0.18 to 0.30 percent) than laparoscopic hysterectomies with laparoscopic closure of the cuff (0.64 percent) . While there have been concerns about a markedly high rate of cuff dehiscence following laparoscopic hysterectomy (4.93 percent) , a follow-up study suggests a lower dehiscence rate of 0.75 percent .
- Hur HC, Guido RS, Mansuria SM, et al. Incidence and patient characteristics of vaginal cuff dehiscence after different modes of hysterectomies. J Minim Invasive Gynecol 2007; 14:311.
- Iaco PD, Ceccaroni M, Alboni C, et al. Transvaginal evisceration after hysterectomy: is vaginal cuff closure associated with a reduced risk? Eur J Obstet Gynecol Reprod Biol 2006; 125:134.
- Hur HC, Donnellan N, Mansuria S, et al. Vaginal cuff dehiscence after different modes of hysterectomy. Obstet Gynecol 2011; 118:794.
- Uccella S, Ceccaroni M, Cromi A, et al. Vaginal cuff dehiscence in a series of 12,398 hysterectomies: effect of different types of colpotomy and vaginal closure. Obstet Gynecol 2012; 120:516.
- Croak AJ, Gebhart JB, Klingele CJ, et al. Characteristics of patients with vaginal rupture and evisceration. Obstet Gynecol 2004; 103:572.
- Robinson BL, Liao JB, Adams SF, Randall TC. Vaginal cuff dehiscence after robotic total laparoscopic hysterectomy. Obstet Gynecol 2009; 114:369.
- Agdi M, Al-Ghafri W, Antolin R, et al. Vaginal vault dehiscence after hysterectomy. J Minim Invasive Gynecol 2009; 16:313.
- Uccella S, Ghezzi F, Mariani A, et al. Vaginal cuff closure after minimally invasive hysterectomy: our experience and systematic review of the literature. Am J Obstet Gynecol 2011; 205:119.e1.
- Kho RM, Akl MN, Cornella JL, et al. Incidence and characteristics of patients with vaginal cuff dehiscence after robotic procedures. Obstet Gynecol 2009; 114:231.
- Kashani S, Gallo T, Sargent A, et al. Vaginal cuff dehiscence in robotic-assisted total hysterectomy. JSLS 2012; 16:530.
- Drudi L, Press JZ, Lau S, et al. Vaginal vault dehiscence after robotic hysterectomy for gynecologic cancers: search for risk factors and literature review. Int J Gynecol Cancer 2013; 23:943.
- Ramirez PT, Klemer DP. Vaginal evisceration after hysterectomy: a literature review. Obstet Gynecol Surv 2002; 57:462.
- Kowalski LD, Seski JC, Timmins PF, et al. Vaginal evisceration: presentation and management in postmenopausal women. J Am Coll Surg 1996; 183:225.
- Soper DE, Bump RC, Hurt WG. Bacterial vaginosis and trichomoniasis vaginitis are risk factors for cuff cellulitis after abdominal hysterectomy. Am J Obstet Gynecol 1990; 163:1016.
- Cardosi RJ, Hoffman MS, Roberts WS, Spellacy WN. Vaginal evisceration after hysterectomy in premenopausal women. Obstet Gynecol 1999; 94:859.
- Walsh CA, Sherwin JR, Slack M. Vaginal evisceration following total laparoscopic hysterectomy: case report and review of the literature. Aust N Z J Obstet Gynaecol 2007; 47:516.
- Yüce K, Dursun P, Gültekin M. Posthysterectomy intestinal prolapse after coitus and vaginal repair. Arch Gynecol Obstet 2005; 272:80.
- Purakal J, Moyer G, Burke W. Vaginal cuff dehiscence after hysterectomy in a woman with systemic lupus erythematosus: a case report. J Reprod Med 2008; 53:305.
- Zambrano D. Clindamycin in the treatment of obstetric and gynecologic infections: a review. Clin Ther 1991; 13:58.
- Shen CC, Hsu TY, Huang FJ, et al. Comparison of one- and two-layer vaginal cuff closure and open vaginal cuff during laparoscopic-assisted vaginal hysterectomy. J Am Assoc Gynecol Laparosc 2002; 9:474.
- Siedhoff MT, Yunker AC, Steege JF. Decreased incidence of vaginal cuff dehiscence after laparoscopic closure with bidirectional barbed suture. J Minim Invasive Gynecol 2011; 18:218.
- Kirsner RS, Eaglstein WH. The wound healing process. Dermatol Clin 1993; 11:629.
- Vesna A, Neli B. Benefit and safety of 28-day transdermal estrogen regimen during vaginal hysterectomy (a controlled trial). Maturitas 2006; 53:282.
- Pushkar' DIu, D'iakov VV, Godunov BN, Gvozdev MIu. [Ovestin in preparation for transvaginal surgeries]. Urologiia 2002; :34.
- Nezhat CH, Nezhat F, Seidman DS, Nezhat C. Vaginal vault evisceration after total laparoscopic hysterectomy. Obstet Gynecol 1996; 87:868.
- Joy SD, Phelan M, McNeill HW. Postcoital vaginal cuff rupture 10 months after a total vaginal hysterectomy. A case report. J Reprod Med 2002; 47:238.
- Nasr AO, Tormey S, Aziz MA, Lane B. Vaginal herniation: case report and review of the literature. Am J Obstet Gynecol 2005; 193:95.
- Kambouris AA, Drukker BH, Barron J. Vaginal evisceration. A case report and brief review of the literature. Arch Surg 1981; 116:949.
- RISK FACTORS
- Role of laparoscopic hysterectomy
- Preoperative preparation
- Surgical technique
- Postoperative period
- CLINICAL MANIFESTATIONS
- DIAGNOSIS AND EVALUATION
- Choosing a surgical approach
- Postoperative care and follow-up
- SUMMARY AND RECOMMENDATIONS