#Grand Rounds

Transvaginal vs Laparoscopic Cuff Closure to Prevent Dehiscence

BACKGROUND AND PURPOSE:

Vaginal cuff dehiscence is estimated to be between 0.1-0.2% following open or vaginal hysterectomy
Some reports have suggested that minimally invasive procedures may result in increased risk for dehiscence
Previous literature has reported that a transvaginal approach to vaginal cuff closure at the end of an otherwise totally endoscopic hysterectomy reduces the risk of postoperative vaginal breakdown
Uccella et al. (AJOG, 2018) undertook an RCT to compare laparoscopic vs TV closure of the vaginal vault following laparoscopic hysterectomy

Multicentered randomized study
Participants: Patients undergoing total laparoscopic hysterectomy for benign indications
Patients received vaginal closure through either:
- Transvaginal approach
  - Vaginal closures had a single-layer running braided and coated 0-polyglactic suture
- Laparoscopic approach
Monopolar energy for colpotomy was set at 60W
In all cases an attempt was performed to include the posterior peritoneum in the suture
Laparoscopic knots were tied intracorporeally
3 month follow up to identify possible vaginal cuff complications
Univariate and multivariable analyses were performed to identify independent predictors of vaginal cuff dehiscence after total laparoscopic hysterectomy
Primary outcome
- Rate of vaginal cuff dehiscence
- Secondary outcomes were
  - Vaginal bleeding, vaginal cuff hematoma, postoperative infection, vaginal resuturing, any reoperation, and a combined outcome defined as “any cuff complication,” including any patient with at least 1 vaginal dehiscence, vaginal hematoma, vaginal bleeding, postoperative infection, or vaginal resuturing

Study was stopped early following interim analysis
1,408 patients were enrolled in a prespecified interim analysis
- 13 (0.9%) women did not undergo the postoperative assessment and were excluded
Baseline characteristics of the 1395 patients included (695 in the transvaginal group and 700 in the laparoscopic group) were similar
Patients in the transvaginal group had significantly higher rates of the following
- Vaginal dehiscence: 2.7% vs 1%; odds ratio (OR) 2.78; 95% CI, 1.16–6.63 (P=.01)
- Cuff complications: 9.8% vs 4.7%; OR 2.19; 95% CI, 1.43–3.37 (P=.0003)
After multivariable analysis, transvaginal closure of the vault was independently associated with higher rates of vaginal dehiscence and vaginal complications
Higher risk of dehiscence was also associated with premenopausal status and smoking habit

Laparoscopic closure is associated with reduced risk for vaginal dehiscence, any cuff complication, vaginal bleeding, vaginal cuff hematoma, postoperative infection, need for vaginal resuture, and reintervention
Possible explanations for laparoscopic closure being a superior approach are
- Performing the suture intraabdominally allows the surgeon to incorporate the peritoneum
- Closing the gap between the vaginal mucosa and the pouch of Douglas may decrease postoperative oozing reducing hematoma risk
- Magnification capability using laparoscopy

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