Vaginal cuff closure during total laparoscopic hysterectomy




A concern of vaginal cuff dehiscence and other complications after total laparoscopic hysterectomy has been voiced by numerous surgeons. We have developed a simple and easy to learn technique for cuff closure that is associated with no cases of cuff dehiscence and a low complication rate. Our technique is described with an accompanying video.





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Problem: laparoscopic closure of the vaginal cuff can be tricky


Minimally invasive hysterectomy (MIH), including total laparoscopic hysterectomy (TLH), has become a popular procedure over the past 5 years. Advantages over traditional abdominal hysterectomy include reduced postoperative infection and quicker recovery times. However, many surgeons performing MIH worry about postoperative vaginal cuff dehiscence, an uncommon but serious complication.


In addition, surgeons have commented on the difficulty in obtaining adequate vaginal cuff closure. Concerns over knot integrity, bladder injury, and increased operative time have resulted in many practitioners performing a laparoscopic hysterectomy only to close the cuff vaginally. Other surgeons have refrained from incorporating MIH into their practice or rely on robotic MIH, which–when compared with TLH–adds considerable cost and time to a procedure.


In one small survey (response rate, 25.8%), 83.9% of 376 surgeons said abdominal hysterectomy was the most common hysterectomy procedure they had performed in the previous year; 75.8% said vaginal hysterectomy was the second most common. Yet, 46.5% wanted to decrease their rates of total abdominal hysterectomy, and 52.5% said they would like to increase their rates of TLH. Respondents most often said that their training during residency, technical difficulty, personal surgical experience, and operating time were barriers to performing TLH.




Our solution


We have developed a simple and easy-to-learn technique for vaginal cuff closure in TLH ( Video Clip ). From June 2009 through December 2011, we performed 100 TLHs using this method. The procedures were done by 2 primary surgeons in southwestern Pennsylvania. Of patients, 15% had a prior cesarean section. All patients were followed up for a minimum of 6 months postoperatively, and to date, none have experienced cuff dehiscence.


In fact, the overall complication rate was low, consisting of 4 urinary tract infections and 1 case of cuff cellulitis. The average operative time was 95.6 minutes, and the average blood loss was 65 mL. One patient’s surgery was converted from attempted TLH to abdominal hysterectomy because significant dense adhesions from endometriosis obliterated the pelvic cul-de-sac. No ureteral or bladder injuries occurred, and no fistula formation was identified. Using our cuff-closure technique, the average closure time was 5-8 minutes. The average uterine weight was 140 g; median weight was 116 g.


Our method begins with the patient in a lithotomy position, her hips extended. A variable Trendelenburg position facilitates exposure and optimizes anesthesia ventilation. The uterus is amputated with cutting current and morcellated or removed vaginally. To minimize necrosis, care is taken to avoid excessive cautery, which can cause subsequent tissue damage to the vaginal cuff.


Next, a glove packed with sponges is inserted midway into the vagina to maintain a pneumoperitoneum while allowing adequate mobility of the vaginal apex. This positioning also minimizes the risk of incorporating the glove into the closure. Liberal irrigation throughout the procedure helps identify relevant anatomical landmarks.


Using an 11-mm left-lower-quadrant port, the operating surgeon begins at the left vaginal angle. The assisting surgeon, using a 5-mm right-lower-quadrant port, grasps the posterior vagina with smooth grasping forceps to accentuate the insertion of the uterosacral ligament. An automated suturing device (Endo Stitch; Covidien Surgical, Mansfield, MA) is loaded with a cartridge of 48-in undyed Polysorb sutures (Covidien Surgical) in size 0 and located to incorporate the left uterosacral ligament into the lateral posterior vagina. The assistant then grasps the anterior vagina while the operating surgeon completes the angle suture. Lateral placement of the suture is avoided to minimize the possibility of ureteral injury. To ensure adequate closure of the cuff, bites with the automated suture device must go through the full thickness of the vagina, anteriorly and posteriorly ( Figure ). The automated suture device is removed, and a knot is tied extracorporeally and cinched with a knot-throwing tool (Marlow knot-pusher; Cooper Surgical Inc, Trumbull, CT).


May 13, 2017 | Posted by in GYNECOLOGY | Comments Off on Vaginal cuff closure during total laparoscopic hysterectomy

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