Our experience

The study population consists of all women who underwent laparoscopic hysterectomy at our institution between Jan. 1, 2002, and May 31, 2010. For purposes of the current study, we performed a retrospective analysis of prospectively collected data, with appropriate Research Ethics Board approval. Information concerning the surgical procedures, intra- and postoperative details, adjuvant therapy as well as follow-up evaluations is entered directly into the computerized surgical database, a research-quality database maintained by trained residents and updated on a regular basis. At our institution, minimally invasive hysterectomy was introduced in 2002, and since then it has been our policy to avoid an open approach to hysterectomies whenever possible, to the extent that in the last 5 years more than 95% of procedures have been performed vaginally or laparoscopically. When indication for hysterectomy was a benign condition, the choice between laparoscopy and vaginal surgery was left to the surgeon’s discretion, based on clinical judgment (with parity, previous abdominal surgery, signs and symptoms of endometriosis, size of the uterus, and anesthesiologic contraindications to laparoscopy entering into the decision-making process). After incorporation of laparoscopy into the surgical practice of our gynecologic oncology service, no patient with an apparently early-stage malignacy was refused laparoscopic surgery for reasons of tumor size, obesity, prior surgical history, and anticipated difficulty of resection.

Our technique for laparoscopic hysterectomy can be classified as a type IVE procedure (in which all the steps, including colpotomy, are completed by laparoscopy), according to the American Association of Gynecologic Laparoscopists classification. Procedures with any vaginal component other than vaginal vault suture (ie, laparoscopic-assisted vaginal hysterectomy) and radical hysterectomies were excluded from this study. All procedures were performed by 2 advanced gynecologic laparoscopists.

The details of the surgical technique have been previously described elsewhere. Briefly, an intrauterine manipulator (RUMI System; CooperSurgical, Trumbull, CT), in conjunction with a Koh cup (Koh Colpotomizer System; CooperSurgical), was inserted. After pneumoperitoneum was created, a 10- or 5-mm 0° laparoscope was introduced at the umbilical site. Under direct visualization, 3 ancillary trocars were inserted, 1 suprapubically and 2 laterally to the epigastric arteries, in the left and right lower abdominal quadrants, respectively. Three- or 5-mm instruments were used, including: 1 atraumatic and 2 traumatic graspers, 1 bipolar coagulation forceps, scissors, 1 suction/irrigation device, and 1 monopolar hook or spatula. Hysterectomy was started with coagulation and section of the round ligaments and the infundibulopelvic ligaments. The broad ligament was opened up to the uterovescical fold that was then incised with caudal reflection of the bladder. Afterward, the uterine arteries, the cardinal ligaments, and the uterosacral ligaments were coagulated and transected. Hysterectomy was completed performing a laparoscopic circular colpotomy with a monopolar hook set at 60 W. The uterus was then extracted from the vagina. Vaginal cuff closure was always performed transvaginally with a single-layer technique, using a running braided and coated 0 polyglactin suture on a half-circle HR26 needle (loss of tensile strength by 35 days and complete absorption by about 60-70 days).

After hysterectomy, women were advised to delay first intercourse at least 1 month postoperatively. A follow-up visit was scheduled between 1 and 3 months after hysterectomy, and all patients were strongly advised to return to our department in case of any symptom possibly related to the operation, such as fever, vaginal discharge, vaginal bleeding, pelvic discomfort, abdominal pain, or constipation.

Literature review

The PubMed database was systematically searched for records from Jan. 1, 1989, to May 31, 2010, using the terms “laparosc*” and “hysterectomy”, and “robot*” and “hysterectomy.” We sought to identify all articles reporting series of laparoscopic- or robotic-assisted hysterectomies. Only papers written in English have been considered. Abstracts presented at meetings were not considered if no indexed full-length article followed. We also excluded case reports, reviews of previous studies, articles enrolling cases that were included in subsequent larger studies, series of subtotal hysterectomies and radical hysterectomies, studies including procedures with a vaginal component other than vaginal cuff suture, studies that did not detail postoperative complications and did not report adequate follow-up information, and those in which cervical or vaginal cancer were indication for hysterectomy. We cross-checked the references of all selected papers to identify other potentially relevant reports. Finally, we selected only cohort studies including at least 30 minimally invasive hysterectomies.

If relevant data were unavailable in a manuscript, the corresponding author was contacted by e-mail and asked to supply the missing information. If no answer was received, a solicitation e-mail was sent after 2 months, then the requested information was considered as “not available.”

For each paper that met our inclusion criteria, we abstracted a standard set of information: (1) the number of hysterectomies included, (2) indication for hysterectomy (benign vs malignant disease), (3) the rate of vaginal cuff dehiscences, (4) the incidence of vaginal bleeding, (5) the rate of vaginal cuff infection/abscess, (6) vaginal cuff complications requiring surgical reintervention, (7) the method of cuff closure (laparoscopic, robotic, or vaginal), (8) the type of suture used for cuff closure, (9) if laparoscopic cuff closure was performed, the technique of knot tying (intra- or extracorporeal), and (10) the technique and energy source used for colpotomy.

All studies were reviewed by 2 independent reviewers to verify inclusion and exclusion criteria. Differences of opinion were resolved by consensus after consultation between the 2 reviewers. The terms “vaginal separation” and “vaginal dehiscence” were considered as interchangeable. Wherever specified, we distinguished vaginal cuff dehiscences requiring surgical repair from those allowed to heal by secondary intention. If not otherwise specified, we considered that no surgical repair was needed. “Vaginal bleeding” and “vaginal cuff dehiscence” were considered as separate entities.

Metaanalysis of published cohort studies was performed with GraphPad Prism version 5.00 for Windows (GraphPad Software, San Diego, CA). A χ ² test for heterogeneity among proportions was used to determine the presence of statistical heterogeneity when we combined the results of studies grouped by technique of cuff closure (laparoscopic, transvaginal, and robotic suturing). Pooled estimates of incidence of vaginal cuff dehiscence, vaginal bleeding, bleeding plus dehiscence, need for vaginal resuture, and vaginal infection/abscess were calculated and compared among groups using the χ ² test. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated for each comparison. Statistical significance was considered achieved when P was less than .05.

Our experience

During the study period, a total of 671 TLHs have been performed at our institution. Of these, 530 were performed for benign indications and 141 for endometrial cancer. Three (0.57%) cases in the benign disease group and 3 (2.13%) in the malignancy group were converted to laparotomy, leaving 665 patients for inclusion in the study. In the entire cohort, median (range) age and body mass index (BMI) were 47 (31-86) years and 24.6 (16–46.9) kg/m ² , respectively. Median (range) age and BMI were 46 (31–86) years and 24.4 (16–46.9) kg/m ² , respectively, in the benign disease group and 64 (41–78) years and 26 (19–46) kg/m ² , respectively, in the malignancy group. Uterine fibromas were the most common benign indication for hysterectomy (71.9%). Fifty-two percent of women undergoing hysterectomy for a benign condition and 55.8% of those with a malignancy had previously undergone open abdominal surgery. Four women (0.6%) did not return for the postoperative assessment and were considered lost to follow-up. The first follow-up visit was performed after a median follow-up time of 58 (32-91) days. Two cases (0.3%, 95% CI, 0.04–1.1%) of vaginal cuff dehiscence occurred, one after TLH for uterine myomas, and the other after surgical staging of endometrial cancer. In the former case, cuff separation occurred 18 days after surgery and in the latter on postoperative day 7. Neither trigger events (such as resumption of sexual intercourse) nor predisposing conditions for a difficult wound healing (such as diabetes, smoking habit, or corticosteroid therapy) were identified. Both patients underwent vaginal vault resuturing with interrupted stitches of a 0 polyglycolic acid suture and neither of them recurred after a follow-up of 61 and 91 days. Two (0.3%, 95% CI, 0.04–1.1%) cases of postoperative vaginal bleeding occurred; one was managed conservatively and the other required resuturing to achieve hemostasis. No other cases of vaginal cuff complications occurred.

Literature review

Our search identified a total of 57 cohort studies on minimally invasive hysterectomy that met our inclusion criteria. Of these, 47 were series of laparoscopic hysterectomies, 10 were series of robotic hysterectomies, and 1 was a series including both robotic and laparoscopic hysterectomies. These studies included a total of 13,030 women, of which 8481 underwent TLH with laparoscopic cuff closure, 2672 had TLH with transvaginal cuff suturing (3337 including our 665 cases), and 1887 had robotic hysterectomy. Overall, 89 cases of vaginal cuff dehiscence were reported (91 if considering patients operated at our Institution).

When results from our series and those from the medical literature on minimally invasive hysterectomies were combined, the pooled incidence of vaginal cuff dehiscence was 0.64% (54/8481, 95% CI, 0.47–0.79), 0.18% (6/3337, 95% CI, 0.09–0.44), and 1.64% (31/1887, 95% CI, 1.16–2.32) after laparoscopic, transvaginal, and robotic cuff closure, respectively. The rates of vaginal cuff dehiscence, bleeding, and infection reported in clinical studies are displayed in Tables 1 and 2 (laparoscopic closure), Table 3 (vaginal closure), and Table 4 (robotic closure).

TABLE 1

TLH with laparoscopic vaginal cuff closure and knots

Author (year of publication)	Study design	No. of patients a	Method for colpotomy	Indication for hysterectomy	Type of suture for cuff closure	Type of laparoscopic knots	Vaginal cuff dehiscence	Vaginal bleeding	Reintervention	Vaginal vault infection
Boggess et al (2008)	RS	77	NA	Malignancy	NA	Extracorporeal	1 (1.2%)	0	NA	0
Canis et al (2008)	RS	618	Monopolar	Benign pathology	Polyglactin or polyglecaprone; interrupted stitches	Extracorporeal	6 (0.9%)	0	4 (0.6%)	8 (1.2%)
Candiani et al (2009)	RCT	30	NA	Benign pathology	NA	Intracorporeal	0	0	0	0
Cipullo et al (2009)	RS	158	Monopolar	Benign pathology	NA	Intracorporeal	0	1 (0.6%)	0	1 (0.6%)
Iaco et al (2006)	RS	127	NA	Both	Polyglycolic; running suture	Intracorporeal	2 (1.5%)	0	2 (1.5%)	0
De Lapasse et al (2008)	PS	35	Monopolar	Benign pathology	Polyglactin or polyglecaprone; interrupted stitches	Extracorporeal	0	0	0	1 (2.9%)
Drahonovsky et al (2010)	RCT	40	NA	Benign pathology	NA	NA	3 (7.5%)	0	0	0
Donnez O and Donnez J (2010)	RS	252	NA	Benign pathology	Running suture	Intracorporeal	2 (0.7%)	0	2 (0.7%)	0
Fader et al (2009)	RS	70	Monopolar	Malignancy	NA	Extracorporeal	2 (2.8%)	0	2 (2.8%)	2 (%)
Fiaccavento et al (2007)	RS	247	Monopolar	Benign pathology	NA	NA	1 (0.4%)	4 (1.6%)	0	0
O’Gorman et al (2009)	RS	32	Harmonic scalpel	Malignancy	NA	NA	0	0	0	0
Harmanli et al (2009)	RS	450	NA	Benign pathology	NA	Both	6 (1.3%)	0	6 (1.3%)	0
Heinberg et al (2004)	RS	253	Monopolar	Both	Polyglycolic acid	Extracorporeal	5 (1.9%)	0	1 (0.3%)	7 (2.7%)
Hoffman et al (2005)	RS	108	Monopolar (80W)/harmonic scalpel/PK bipolar ZIP	Benign pathology	Synthetic reabsorbable	Extracorporeal	0	4 (3.7%)	4 (3.7%)	1 (0.9%)
Hur et al (2007)	CS	234	Monopolar	Both	Polysorb	NA	8 (3.4%)	0	8 (3.4%)	0
Jaenisch and Junior (1999)	PS	100	Monopolar	Benign pathology	Polyglactin	NA	0	0	0	1 (1%)
Jeung et al (2010)	RCT	248	Monopolar	Benign pathology	Polysorb; running suture or Interrupted stitches	Extracorporeal	3 (1.2%)	1 (0.4%)	4 (1.6%)	0
Kavallaris et al (2010)	RS	67	Scissors/Sonosurgical/PKS cutting forceps	Benign pathology	Polyglactin	Intracorporeal	0	0	0	0
Kim et al (1998)	RS	102	Scissors and bipolar forceps	Benign pathology	NA	Intracorporeal	4 (3.9%)	4 (3.9%)	NA	0
Kriplani et al (2008)	RS	103	Monopolar	Both (1 case of malignancy)	Polyglactin; intermittent mattress suture	Extracorporeal	0	0	0	0
Malzoni et al (2004)	RS	620	Monopolar	Benign pathology	Polyglactin; running suture	Extracorporeal	0	2 (0.1%)	1 (0.1%)	0
Malzoni et al (2009)	RS	81	Monopolar	Malignancy	Polyglactin; running suture	Extracorporeal	2 (2.4%)	0	2 (2.4%)	0

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