Page 24 - Peer Reviewed Laparoscopic Jornal

WJOLS

Vaginal Cuff Dehiscence after Minimal Invasive Hysterectomy: Laparoscopic Surgical Techniques

The safety and effectiveness of barded sutures, in closure electrosurgery, which may yield thermal damage at the cuff
of the vaginal cuff, has already been demonstrated in two site, weakening the tissue and increasing the risk of
studies. 16,22 However, one was noncomparative and, in the dehiscence. 8
other, a more time-consuming double-layer suturing method It is known that monopolar energy in the coagulation
was used. In both, the use of this suture reduced the mode, is frequently used, for the colpotomy in THL.
incidence of the VCD. Furthermore, the barbed suture Coagulation mode is an interrupted, high-voltage current
proved to be relatively easy to learn dehiscence while not dispersed over a large surface area, while cutting mode is a
increasing the rate of postoperative bleeding, cuff cellulitis continuous, low-voltage current concentrating the energy
or granulation tissue. Some concern is expressed regarding in a small area, resulting in more rapid tissue heating and
adhesion formation of the intestine to the tail of the barbed less thermal spread. Coagulation mode may result in more
suture, which in turn potentially could cause bowel tissue damage, although is better at sealing vessels in
obstruction. 23 vascular areas like the vaginal cuff. 8
A recent study, conducted in swines, analyzed energy-
Suture Material
induced damage (ultrasonic, monopolar and bipolar), to the
Several studies did address the type and class of suture vagina during laparoscopic hysterectomy, using the distal
material as a possible cause for VCD. 3,24,25 Up-to-date review scalpel-cut margin was used as reference. All energy sources
suggests the use of a delayed absorbable monofilament demonstrated tissue damage, with ultrasonic showing the
suture [e.g. polydioxanone (PDS II™)]: Preferred for the least and bipolar the greatest. 27
theoretical advantage of lower infectious risks. 7 Further study of tissue damage relative to cuff closure
However, there is neither data demonstrating evidence at laparoscopic hysterectomy is warranted, as also its
nor consensus on the preferred suture material, concerning possible association with vaginal dehiscence.
monofilament vs multifilament and delayed absorbability of
the thread. CONCLUSION
According to the data, there is no superiority of one of VCD is a potentially severe adverse event and is still a matter
the suturing method over the others. of concern to those who perform minimal invasive
hysterectomy. Its exact etiology remains unclear.
ELECTROSURGERY
Data on additional risk factors for cuff dehiscence are
Some authors state that electrosurgical colpotomy, limited and conflicting. Although one study reported no
2
often used in TLH, is responsible for suboptimal vaginal difference in age, tobacco use or diabetes mellitus between
cuff healing, due to tissue necrosis and prolonged women with and without cuff dehiscence, it likely was
devascularization. 14,25-27 underpowered to detect a clinically meaningful difference. 28
Colpotomy technique may account for the observed Although it seems biologically plausible that any condition
increased risk of VCD associated with TLH as compared that could compromise wound healing would increase the
with TVH and TAH. In the latter procedures, the colpotomy risk of VCD, the data on such risk factors are sparse. The
is often made sharply using heavy scissors or a knife. inconsistency of the reporting of risk factors in studies and
However, during TLH, the colpotomy is often made using case reports, the rarity of the VCD, and the lack of
comparison of risk factors between women with and without
dehiscence in most retrospective studies makes it impossible
to assess the significance of each of these potential risk
factors.
Some questions remain are as follows:
1. If in the abdominal hysterectomy, VCD is not increased
in patients who had an unclosed cuff closure technique,
why would be the suture method, the cause of this
complication in the laparoscopic procedure?
2. If electrosurgical colpotomy, overused in laparoscopic
hysterectomy, is the cause of damage and wound
healing complications, why these exist a superiority
of transvaginal closure compared with laparoscopic
Fig. 1: Bidirectional barbed suture with barbs that change closure (concerning VCD), in the same electrosurgical
direction in the middle 17 damaged tissues?
World Journal of Laparoscopic Surgery, May-August 2013;6(2):81-85 83