Recognition, Evaluation and Treatment of Vaginal Cuff Separation
Learning Objectives and CME/Disclosure Information
This activity is intended for healthcare providers delivering care to women and their families.
After completing this activity, the participant should be better able to:
1. List the steps in evaluating a patient with suspected cuff separation 2. Discuss procedures that have been associated with vaginal cuff separation
Estimated time to complete activity: 0.25 hours
Susan J. Gross, MD, FRCSC, FACOG, FACMG
President and CEO, The ObG Project
Disclosure of Conflicts of Interest
Postgraduate Institute for Medicine (PIM) requires faculty, planners, and others in control of educational content to disclose all their financial relationships with ineligible companies. All identified conflicts of interest (COI) are thoroughly vetted and mitigated according to PIM policy. PIM is committed to providing its learners with high quality accredited continuing education activities and related materials that promote improvements or quality in healthcare and not a specific proprietary business interest of an ineligible company.
The PIM planners and others have nothing to disclose. The OBG Project planners and others have nothing to disclose.
Faculty: Susan J. Gross, MD, receives consulting fees from Cradle Genomics, and has financial interest in The ObG Project, Inc.
Planners and Managers: The PIM planners and managers, Trace Hutchison, PharmD, Samantha Mattiucci, PharmD, CHCP, Judi Smelker-Mitchek, MBA, MSN, RN, and Jan Schultz, MSN, RN, CHCP have nothing to disclose.
Method of Participation and Request for Credit
Fees for participating and receiving CME credit for this activity are as posted on The ObG Project website. During the period from Dec 31 2017 through Jan 25 2023, participants must read the learning objectives and faculty disclosures and study the educational activity.
If you wish to receive acknowledgment for completing this activity, please complete the post-test and evaluation. Upon registering and successfully completing the post-test with a score of 100% and the activity evaluation, your certificate will be made available immediately.
For Pharmacists: Upon successfully completing the post-test with a score of 100% and the activity evaluation form, transcript information will be sent to the NABP CPE Monitor Service within 4 weeks.
Joint Accreditation Statement
In support of improving patient care, this activity has been planned and implemented by the Postgraduate Institute for Medicine and The ObG Project. Postgraduate Institute for Medicine is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.
Physician Continuing Medical Education
Postgraduate Institute for Medicine designates this enduring material for a maximum of 0.25 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Continuing Nursing Education
The maximum number of hours awarded for this Continuing Nursing Education activity is 0.2 contact hours.
Vaginal cuff separation remains a rare but serious complication of total hysterectomy, and evisceration is a surgical emergency. It is imperative to maintain a high index of suspicion in patients following pelvic surgery, particularly those presenting after laparoscopic or robotic hysterectomy. If a patient presents with complaints of pelvic pain, bulge or watery/bloody vaginal discharge following these procedures
Urgently perform a physical exam assessing for signs of peritonitis
If no intestines are at the introitus, perform a careful speculum exam of cuff to evaluate separation, hematoma, abscess
Manually palpate the cuff to assess integrity
Wrap any exposed bowel in moist towels while awaiting operating room (OR) transfer
Obtain metabolic panel and complete blood count
Imaging not necessary for evisceration
Start IV and administer broad spectrum antibiotics
Close vaginally if patient is stable and no evidence of bowel injury; irrigate exposed bowel and reintroduce into the peritoneal cavity
Debride vaginal edges until bleeding indicates healthy tissue; close with interrupted delayed absorbable monofilament
Place a drain if concerned about pelvic abscess/hematoma
Continue antibiotics x 24 hours and observe as an inpatient; discharge if afebrile with normal bowel function
Recognition and prompt treatment often allows a vaginal repair, although traditionally laparotomy has been mandated to fully assess bowel integrity. An accurate clinical assessment of the extent of separation, the health of the peritoneal tissues, and the presence/absence of peritonitis dictates whether a patient can be safely repaired vaginally.
Symptoms of dehiscence include
Sudden onset pelvic pain, vaginal bleeding/discharge or bulge
Symptoms of evisceration include feeling a mass or pressure
May occur from 3 days to 30 years postoperatively
Risk factors include number of vaginal surgeries, atrophy, poor wound healing, chronic cough, vaginal cuff hematoma/abscess
Association in the literature with total laparoscopic or robotic hysterectomy has been reported
Quality prospective data are lacking
Dehiscence does not appear to be more frequent when procedures are performed by experienced, minimally invasive surgeons
Increased risk may be due to use of energy for colpotomy, shallow tissue bites and poor knot integrity at closure
Transvaginal suturing reduces the incidence of cuff separations for laparoscopic and robotic hysterectomies
OBG Project CME requires a modern web browser (Internet Explorer 10+, Mozilla Firefox, Apple Safari, Google Chrome, Microsoft Edge). Certain educational activities may require additional software to view multimedia, presentation, or printable versions of their content. These activities will be marked as such and will provide links to the required software. That software may be: Adobe Flash, Apple QuickTime, Adobe Acrobat, Microsoft PowerPoint, Windows Media Player, or Real Networks Real One Player.
Disclosure of Unlabeled Use
This educational activity may contain discussion of published and/or investigational uses of agents that are not indicated by the FDA. The planners of this activity do not recommend the use of any agent outside of the labeled indications.
The opinions expressed in the educational activity are those of the faculty and do not necessarily represent the views of the planners. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings.
Participants have an implied responsibility to use the newly acquired information to enhance patient outcomes and their own professional development. The information
presented in this activity is not meant to serve as a guideline for patient management. Any procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this activity should not be used by clinicians without evaluation of their patient’s conditions and possible contraindications and/or dangers in use, review of any applicable manufacturer’s product information, and comparison with recommendations of other authorities.
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