Two-Layer Compared With One-Layer Vaginal Cuff Closure at the Time of Total Laparoscopic Hysterectomy to Reduce Complications

Abstract

OBJECTIVE: To explore whether two-layer laparoscopic vaginal cuff closure at the time of laparoscopic hysterectomy is associated with a lower rate of postoperative complications compared with a standard one-layer cuff closure. METHODS: A retrospective cohort study of total laparoscopic hysterectomies performed by fellowship-trained minimally invasive gynecologic surgeons between 2011 and 2017 was performed. Surgeons sutured the vaginal cuff laparoscopically, either in a two- or one-layer closure. The primary outcome was a composite of total postoperative complications, including all medical and surgical complications within 30 days and vaginal cuff complications within 180 days. Factors known to influence laparoscopic vaginal cuff complications including age, postmenopausal status, body mass index, tobacco use, and immunosuppressant medications were examined and controlled for, while surgeon skill, colpotomy technique, and suture material remained standardized. We conducted statistical analyses including χ2, Fisher exact test, logistic regression, and post hoc power calculations. RESULTS: Of the 2,973 women who underwent total laparoscopic hysterectomies, 40.8% (n=1,213) of vaginal cuffs were closed with a two-layer closure and 59.2% (n=1,760) with a one-layer technique. Two-layer vaginal cuff closure was associated with decreased numbers of total postoperative complications (3.5% vs 5.7%; P<.01). The primary difference stemmed from lower vaginal cuff complications within 180 days (0.9% vs 2.6%; P<.01); no differences in 30-day medical and surgical postoperative complications were observed between the two groups (2.6% vs 3.1%; P=.77). No patients in the two-layer vaginal cuff closure cohort experienced a vaginal cuff dehiscence or mucosal separation compared with 1.0% in the one-layer group (P<.01). Compared with a one-layer closure, a two-layer closure was protective from postoperative complications (adjusted odds ratio 0.38, 95% CI 0.19–0.74). CONCLUSION: Although postoperative complications with laparoscopic hysterectomies are rare, two-layer laparoscopic vaginal cuff closure is associated with lower total postoperative complications compared with a one-layer closure. The difference was primary driven by cuff complications.

Prevention and management of vaginal cuff dehiscence: an updated review

“…There are patient factors that may impede wound healing and lead to VCD. Postmenopausal status, prior gynecologic surgeries, malignancy, and prior pelvic radiation are some nonmodifiable risk factors that can contribute to VCD [2,11,17 ▪ ]. In order to decrease the risk of VCD in the hypoestrogenic postmenopausal population, some surgeons have used vaginal estrogen application postoperatively to minimize the risk of VCD; however, studies have not demonstrated conclusive benefits [4].…”

“…These studies seem to validate that two-layer closure is optimal compared with one-layer closure. However, the first study is retrospective and has limited external validity as the vast majority of cases were performed by the same four surgeons [17 ▪ ]. Likewise, the significance in the second study may not solely be related to the double layer closure as different suture materials were used in each group [19].…”

“…In order to decrease the risk of VCD in the hypoestrogenic postmenopausal population, some surgeons have used vaginal estrogen application postoperatively to minimize the risk of VCD; however, studies have not demonstrated conclusive benefits [4]. Immunosuppression, steroid use, diabetes mellitus, tobacco use, and conditions that increase intraabdominal pressure (chronic cough and chronic constipation) have all been associated with VCD [2,11,17 ▪ ,18]. For example, patients taking prednisone doses of 40 mg per day or higher have a two-to-five-fold increase of wound complications [4].…”

“…Postoperative risk factors for VCD are infection and hematoma. The presence of either can prevent proper wound healing and complete closure of the cuff [1,7,17 ▪ ]. Thus, proper preoperative antibiotic administration, use of proper antiseptic preparation, and good intraoperative hemostasis are important [4].…”

“…The most common reason for VCD is postoperative resumption of penetrative vaginal intercourse [1,4,7,17 ▪ ]. There are no exact recommendations of when patients should be cleared to resume intercourse; commonly patients are instructed on complete pelvic rest for 6–12 weeks postoperatively depending on surgeon preference and patient risk factors [3 ▪▪ ,4].…”