Incidence and Prevention of Vaginal Cuff Dehiscence after Laparoscopic and Robotic Hysterectomy: A Systematic Review and Meta-analysis

Abstract

Vaginal cuff dehiscence, a severe and potentially detrimental complication, has significantly increased after the introduction of endoscopic hysterectomy. The aim of this systematic review and meta-analysis of the available literature was to identify the incidence of, and possible strategies to prevent, this complication after total laparoscopic hysterectomy and total robotic hysterectomy. Data Sources: PubMed, ClinicalTrials.gov, Scopus, and Web of Science databases were systematically queried to identify all articles reporting either laparoscopic or robot-assisted hysterectomies for benign indications in which vaginal dehiscence was reported as an outcome. Reference lists of the identified studies were manually searched. Only papers written in English were considered. Methods of Study Selection: The Population, Intervention, Comparison, and Outcome framework for the review included (1) population of interest: women who underwent conventional and robot-assisted laparoscopic hysterectomy; (2) interventions: possible methods to prevent vaginal dehiscence; (3) comparison: experimental strategies vs standard treatment or alternative strategy for each item of intervention; and (4) outcome: rate of vaginal dehiscence. Series of subtotal hysterectomies and radical hysterectomies in addition to reports that combined both benign and malignant cases were excluded. The meta-analysis was performed using RevMan version 5.4.1 (Cochrane Training, London, United Kingdom). Two independent reviewers identified all reports comparing 2 or more possible strategies to prevent vaginal dehiscence. Tabulation, Integration, and Results: A total of 460 articles were identified. Of these, 20 (6 randomized, 2 prospective, and 12 retrospective) studies were included in this review for a total of 19 392 patients. The incidence of vaginal dehiscence after total laparoscopic hysterectomy ranged between 0.64% and 1.35%. Robotic hysterectomy was associated with a risk of vaginal dehiscence of approximately 1.64%. No study compared early vs delayed resumption of coital activity nor analyzed the role of training in laparoscopic suturing. No study specifically assessed the impact of electrosurgery on the risk of vaginal dehiscence in endoscopic hysterectomies for benign indications. Double-layer and reinforced sutures did not decrease the risk of dehiscence. Barbed sutures reduced the risk of separation compared with nonbarbed closure (0.4% [4/1108] vs 2% [22/1097]; odds ratio [OR] 0.25; 95% confidence interval [CI], 0.11−0.57). However, these data came mainly from retrospective series. Excluding studies on the use of self-anchoring sutures during robotic hysterectomy, there was no significant difference in the risk of dehiscence between barbed and nonbarbed sutures (0.5% [4/890] vs 1.4% [181/776]; OR 0.38; 95% CI, 0.13−1.10). Transvaginal suture of the vault at the end of an endoscopic hysterectomy seemed to increase the risk of dehiscence when compared with laparoscopic closure (2.3% [23/1002] vs 1.16% [11/944]; OR 1.97; 95% CI, 1.00−3.88). Conclu...

Complications in laparoscopic and robotic-assisted surgery: definitions, classifications, incidence and risk factors - an up-to-date review.

“…Contemporarily, VCD is noted after 0.11–1.27% of laparoscopic, 0.45–1.64% of robotic-assisted, 0.05–0.13% of vaginal, and 0.02–0.38% of open hysterectomies [ 103 – 107 ]. As of 2021, the occurrence of VCD following total LH (TLH) can be expected in 0.64–1.35% of cases, and after robotic hysterectomy in approximately 1.6% of cases [ 108 , 109 ]. The manifestations of VCD are: pelvic pain, abnormal vaginal discharge and bleeding, peritonitis, and – in 30–68% of cases – omentum or bowel protruding from the vagina [ 101 – 103 , 107 ].…”

“…The manifestations of VCD are: pelvic pain, abnormal vaginal discharge and bleeding, peritonitis, and – in 30–68% of cases – omentum or bowel protruding from the vagina [ 101 – 103 , 107 ]. Sexual intercourse earlier than 8 weeks after LH is the main risk factor for VCD, regardless of how (CLS or RALS) and why (benign or oncologic indications) the hysterectomy was performed [ 101 – 104 , 108 , 109 ]. In oncological patients, vaginal brachytherapy and chemotherapy have been identified as further risk factors for VCD [ 103 , 109 , 110 ].…”

“…Surgical risks include extensive or inadequate application of electrosurgical technique (e.g. coagulation instead of cutting mode for vaginal incision [ 111 ]), transvaginal closure of the vault, use of single instead of continuous stiches, postoperative infection and supravaginal hematoma [ 106 , 108 ]. Patient-related risks for developing VCD are: premenopausal status, smoking habit, and preexistent endometriosis [ 103 , 105 – 113 ].…”

Uterine artery closure at the origin vs at the uterus level in total laparoscopic hysterectomy: A randomized controlled trial

“…[3][4][5][6][7] Nevertheless, despite the extensive use, evidence on the technique to perform the procedure is limited to only some steps. 8,9 An efficient closure of uterine arteries (UAs) is crucial during a total laparoscopic hysterectomy (TLH). The two main options consist of closing UAs at the origin from the internal iliac artery or at the uterus level (UL).…”

“…Among minimally invasive options, 2 laparoscopic hysterectomy has gained increasing popularity for treating benign pathologies, becoming the most common approach with progressively fewer limitations and more comprehensive applications 3–7 . Nevertheless, despite the extensive use, evidence on the technique to perform the procedure is limited to only some steps 8,9 …”