Closure of the Vaginal Cuff Following Hysterectomy: Prevention · PDF fileNew Frontiers in...

New Frontiers in Knee Surgery l April 2, 2008 l 1

Closure of the Vaginal Cuff Following Hysterectomy: Prevention and Management of Dehiscence

January 31, 2016Michael L. Sprague, M.D.Associate Director, Fellowship in Minimally Invasive Gynecologic Surgery

Closure of the Vaginal Cuff: Prevention and Management of Dehiscence

• Covidien, Inc. (Consultant)

Disclosures

Learning Objectives

1. Review the proposed factors that may predispose a patient to have vaginal cuff dehiscence

2. Demonstrate technique for durable vaginal cuff closure

3. Define a strategy for optimal management of vaginal cuff dehiscence


Vaginal Cuff Dehiscence


How would you manage this patient?

1.Observation

2.Abdominal Repair

3.Vaginal Repair

4.Laparoscopic / Robotic Repair


Vaginal cuff dehiscence

• Rare complication of hysterectomy 1

• Mean time to occurrence (6.1 weeks – 1.6 years) 2

• Associated with high morbidity 1

• Life threatening if associated with intestinal ischemia or intra-abdominal infection 1

1. Koo, Y.J., et al., Vaginal cuff dehiscence after hysterectomy. Int J Gynaecol Obstet, 2013. 122(3): p. 248-52.2. Cronin, B., V.W. Sung, and K.A. Matteson, Vaginal cuff dehiscence: risk factors and management. Am J

Obstet Gynecol, 2012. 206(4): p. 284-8.

Cuff Dehiscence: Separation vs. Evisceration


EviscerationSeparation


Risk Factors 1, 2

• Infection

• Previous radiation

• Vaginal atrophy

• Poor wound healing

• Pelvic organ prolapse

• Surgical technique

Predicating Events 2

• Valsalva (16 – 30%)

• Coitus (8 – 48%)

• None (~ 70%)

1. Ceccaroni, M., et al., Vaginal cuff dehiscence after hysterectomy: a multicenter retrospective study. Eur J Obstet GynecolReprod Biol, 2011. 158(2): p. 308-13.

2. Cronin, B., V.W. Sung, and K.A. Matteson, Vaginal cuff dehiscence: risk factors and management. Am J Obstet Gynecol, 2012. 206(4): p. 284-8.

Presenting Symptoms

• Abdominal pain (58 – 100%)

• Vaginal bleeding or watery discharge (33 – 90%)

• Vaginal pressure (~ 30%)

• Evisceration (up to 70%)

Cronin, B., V.W. Sung, and K.A. Matteson, Vaginal cuff dehiscence: risk factors and management. Am J Obstet Gynecol, 2012. 206(4): p. 284-8.

Incidence of vaginal cuff dehiscence

1. Ceccaroni, M., et al., Vaginal cuff dehiscence after hysterectomy: a multicenter retrospective study. Eur J ObstetGynecol Reprod Biol, 2011. 158(2): p. 308-13.

2. Uccella, S., 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(3): p. 516-23.

Design Patients(#)

VCD(n)

AH(n)

VH(n)

LH(n)

Ceccaroniet. al (2011)

4 CenterRetrospective 8635 34

(0.39%)8

(0.25%)4

(0.15%)22

(0.80%)

Uccellaet. al (2012)

6 CenterRetrospective 12,398 38

(0.30%)9

(0.21%)6

(0.13%)23

(0.64%)


TLH

Laparoscopic Closure

20 / 2332(0.86%)

Transvaginal Closure

3 / 1241(0.24%)



TLH Transvaginal Closure

3 / 1241(0.24%)

TVH Transvaginal Closure

6 / 4534(0.13%)


p = 0.38


• Highest incidence following laparoscopic hysterectomy

• Unclear role for energy use in promoting dehiscence

• Laparoscopic approach for cuff closure may be greater risk factor than technique employed for colpotomy



Prevention of vaginal cuffdehiscence

Prevention of vaginal cuff dehiscence

VCD Prevention

Preoperative Considerations

Surgical Technique

Postoperative Considerations


Prevention of vaginal cuff dehiscence

Surgical Technique

OptimizeColpotomy

Optimize Closure Technique


Anatomy of vaginal apex


Technique for durable cuff closure

• Optimize your colpotomy

• Reconstruct the pericervical ring by approximating ––Pubocervical Fascia–Vaginal Epithelium–Rectovaginal Septum–Cardinal-uterosacral Ligament Complex

• Restore the vaginal apex to the level of the ischialspines



Management of Vaginal Cuff Dehiscence

Cuff Dehiscence: Separation vs. Evisceration


EviscerationSeparation

Cuff Dehiscence: Separation vs Evisceration


Management of vaginal cuff evisceration

Transvaginal

Medically StablePeritonitis AbsentNo Bowel Injury

Abdominal / Laparoscopic

PeritonitisBowel Compromise

HematomaAbscess

Matthews, CA et. al “ Treatment of Vaginal Cuff Evisceration.” Obstet Gynecol 2014 Oct;124(4):705-8


1.Abdominal Repair

2.Vaginal Repair



1. Broad spectrum intravenous antibiotics

2. Irrigate intestine with warm saline

3. Reduce prolapsed intestine

4. Debride vaginal cuff sharply

5. Approximate cuff edges with 0 gauge, monofilament suture in interrupted fashion

6. Drain per clinical indications

7. Discharge following return of bowel function

Matthews, CA et. al “ Treatment of Vaginal Cuff Evisceration.” Obstet Gynecol 2014 Oct;124(4):705-8

Management of vaginal cuff evisceration

Management of vaginal cuff dehiscence

•Postoperative Care–Pelvic rest x 3 months–Tight management of conditions leading

to increased intra-abdominal pressure–Possible role for vaginal estrogen

supplementation


Vaginal cuff dehiscence

• Rare complication following hysterectomy

• Greater incidence following laparoscopic cuff closure

• Optimal management strategy dependent on the clinical picture


[email protected]

https://www.youtube.com/playlist?list=PLwsHSC0paoJjjkIsrgxuJw6SHI_RJPXY9

Closure of the Vaginal Cuff Following Hysterectomy: Prevention · PDF fileNew Frontiers in...

Documents

Transcript of Closure of the Vaginal Cuff Following Hysterectomy: Prevention · PDF fileNew Frontiers in...