We read the article from Cronin et al, “Vaginal cuff dehiscence: risk factors and management,” with great interest. With the increasing rates of video-assisted laparoscopic and robot-assisted hysterectomy, the prevention of vaginal dehiscence and evisceration with minimally invasive techniques is of utmost importance. Because the authors have recommended that other institutions continue to report their experiences with video-assisted laparoscopic hysterectomy and vaginal cuff outcomes, we offer the observation that Nezhat et al have been reporting on laparoscopic hysterectomy since 1990, and in 1996, they reported the first known case series of vaginal vault evisceration following video-assisted laparoscopic hysterectomy in 3 patients. This citation was overlooked in the current article. In their report, the authors make many similar points to the authors of the current study. They state that overuse of electrocautery may contribute to evisceration and that adequate purchase of healthy tissue is necessary for healing. Additionally, in this early report, the authors insightfully discuss the rapid recovery associated with a minimally invasive approach, which may contribute to a quick return to regular activity and increased risk of dehiscence.

Whether monopolar, bipolar, laser, plasma, or ultrasonic energy is used in excising the uterus and cervix, the vaginal cuff requires adequate perfusion to facilitate healing. While hemostasis is necessary, a completely “dry” cuff should not be the surgical goal. Regardless of the suture used (barbed or otherwise), single- or double-layer closure, or vaginal or laparoscopic closure, the vaginal cuff edges need to be hemostatic but well perfused with a substantial tissue purchase that will prevent tissue necrosis and allow continued healing of the surgical site.

We look forward to the continued expansion of minimally invasive approaches to hysterectomy and appreciate the authors’ encouragement among surgeons to share thoughts and ideas on how best to prevent these complications in our patients.