Presentation and Management of Vaginal Cuff Dehiscence Following Hysterectomy

INTRODUCTION: Vaginal cuff dehiscence (VCD) is a rare but potentially serious complication following total hysterectomy, with a reported incidence ranging from 0.14% to 4.1%. Given its uncommon nature, data on its presentation and specifically optimal management remain extremely limited. OBJECTIVE: To evaluate the clinical presentation of VCD after hysterectomy, describe management strategies, and report associated complications. METHODS: We conducted a retrospective cohort study of hysterectomies performed for benign or malignant indications at two hospitals within a single academic institution between 2013 and 2021 over 9 years. Supracervical and cesarean hysterectomies were excluded. Electronic medical records were reviewed comprehensively to identify all cases of VCD. Data were collected on baseline patient characteristics, route and intraoperative details of the hysterectomy, clinical presentation of VCD, management strategies employed, and the complications associated with VCD. RESULTS: Among 11,163 hysterectomies, 110 (1.0%) cases of VCD were identified. VCD occurred after 59 robotic (53.6%), 36 laparoscopic (32.7%), 9 abdominal (8.2%), and 6 vaginal or laparoscopically assisted vaginal hysterectomies (5.4%). Most cuff closures had been performed with barbed absorbable sutures (68, 61.8%), followed by polyglactin sutures (35, 31.8%) at the time of hysterectomy (Table 1). The median time to diagnosis was 6 weeks (interquartile range IQR, 3.0–9.8) post-hysterectomy. 25 patients (22.7%) were diagnosed at or beyond 12 weeks after the surgery, and 12 patients (10.9%) had a prior postoperative visit during which no dehiscence was identified. VCD was recognized incidentally in 18 patients (16.4%) at routine follow-up, whereas it was triggered or exacerbated by coital activity in 17 patients (15.4%). Vaginal bleeding was the most common presenting complaint, reported by 44 patients (40.0%). Evisceration through the cuff occurred in 16 patients (14.5%), none of whom developed strangulation, ileus, or required bowel resection. Of the 110 VCD cases, 92 (83.6%) were classified as incomplete and 18 (16.3%) as complete. Conservative management was effective in 33 (30.0%) cases, all of which were in the incomplete group, whereas the remaining 77 patients (70.0%) underwent surgical repair. Among those who had surgery, 41 (53.2%) had vaginal, and 32 (41.6%) laparoscopic exploration and closure. There were 2 (2.6%) abdominal and 2 (2.6%) robotic repairs. No recurrent dehiscences were observed in the entire series within our median follow-up of 6.0 months (IQR, 3.8–12.0) after VCD diagnosis. Among surgically repaired cases, polyglactin was the predominant suture material (68/77, 85.7%) for VCD closure, whereas barbed sutures were used in 7 cases (9.1%). After VCD repairs, 5 minor complications (Table 2) were noted with no significant difference between conservative, vaginal and laparoscopic approaches (p=0.20). CONCLUSIONS: In this largest reported series of VCD to date, the rate was 1.0%, consistent with existing literature. Careful examination of the vaginal cuff during postoperative visit is essential, as many patients present late and with subtle symptoms. Select cases of incomplete dehiscence can be safely managed conservatively. Although hysterectomies were predominantly performed laparoscopically or robotically with barbed absorbable sutures to close the cuff, surgeons chose the vaginal approach and used polyglactin for VCD repairs.Table 1Table 2