Delayed Presentation of Vaginal Cuff Dehiscence after Robotic Hysterectomy for Gynecologic Cancer: A Case Series and Review of the Literature

Abstract

Background. Vaginal cuff dehiscence after hysterectomy has varying incidence according to surgical approach, with highest rates associated with laparoscopic surgery. Comparative data on timing of diagnosis describe a wide range of clinical presentation from weeks to years after hysterectomy. Limited reports have focused specifically on delayed presentation of vaginal cuff dehiscence. Cases. All cases of vaginal cuff dehiscence at our institution between 2005 and 2015 were collectively reviewed and three cases were identified of women who presented with cuff dehiscence greater than 180 days from index surgery. Diagnosis occurred at 342 to 461 days after operation. One patient presented with abdominal pain, a second case presented with vaginal discharge, and the third case lacked clinical symptoms altogether. Prior to diagnosis, one case received chemotherapy and external beam radiation for Stage IB1 cervical cancer and another case received external beam radiation alone for Stage II endometrioid adenocarcinoma. All cuffs were repaired vaginally with interrupted, early absorbable suture. Conclusion. Robotic total laparoscopic hysterectomy may be associated with increased risk of vaginal cuff dehiscence. Further studies are needed to determine risk factors and patient characteristics associated with delayed presentation of vaginal cuff dehiscence in robotic total hysterectomy as well as all surgical approaches.

The Effect on Performance Time and Quality of the Knots after Mono or Bimanual Training of Laparoscopic Intracorporeal Knot Tying according to the Gladiator Rule Technique

“…This is corroborated by studies that demonstrate a lower rate of surgical complications according to the surgical technique used and previous training. 23,24 It is also important to stress that the data herein demonstrated reflects specifically the studied population in a specific condition of knowledge and training. Although we personally agree that the bimanual knot tying technique seems safer and may be faster, it could be true that with a longer training or larger sample size this concept would change.…”

Post-coital vaginal cuff dehiscence with small bowel evisceration after laparoscopic type II radical hysterectomy: A case report

“…A recent in vitro study evaluating the effect of electrode size on the depth of coagulation showed that use of a sharp point electrode is associated with more superficial coagulation [7] . As in our clinic, electrocautery is commonly used for colpotomy during laparoscopic hysterectomy, which may lead to poor blood supply to the wound [8] . The cutting mode has been thought to cause less harm than the coagulation mode; however, both can be used during colpotomy if more bleeding than expected occurs.…”

Vaginal cuff dehiscence following transvaginal oocyte retrieval: a case report

“…For both patients, dehiscence occurred following minimally invasive hysterectomies (robotic-assisted laparoscopic in the Peyser case and laparoscopic in our case). Additionally, both women underwent hysterectomy for malignant indications, that can predispose to wound healing complications [2]. In contrast, the patient described in the Peyser case was 25 years old and obese while our patient was 35 years old with a BMI of 20.5.…”

“…VCD with evisceration occurs in the majority of reported cases with an estimated incidence of 0.032 to 1.2% [1]. VCD can present with a range of symptoms including abdominal and pelvic pain or pressure, leaking of vaginal fluid, vaginal bleeding, or sometimes no symptoms with identification on clinical examination [2]. Identification of VCD requires immediate surgical management to prevent additional complications including bowel prolapse/ necrosis and sepsis.…”

“…As originally outlined by Nezhat et al, these risk factors can be categorized as those that interrupt healthy wound healing (malignancy, diabetes, local infection, etc), increase intra-abdominal pressure (gynecologic intervention, sexual activity, chronic cough or constipation, etc), or are related to surgical methods (mode of hysterectomy with higher dehiscence rates seen for minimally invasive cases, cuff closure techniques, etc) [3]. In case reports, clear precipitating factors are often cited as those causing the dehiscence, but more often the source cannot be clearly identified [2,4]. It is likely that VCD is multifactorial in etiology.…”