We read with interest the recent article entitled “Vaginal cuff dehiscence: risk factors and management” by Cronin et al. The authors correctly point out that minimally invasive hysterectomy seems associated with a strong increase in the risk of vaginal cuff dehiscence. They suggest some possible strategies to try to reduce the incidence of this complication after endoscopic interventions, such as the use of bidirectional barbed sutures, 2-layer closures, and monopolar rather than bipolar cautery.

A recent study from our group has underlined that the route chosen to suture the vaginal vault also is crucial in the genesis of vaginal dehiscence: in a systematic review of more than 13,000 patients from 57 series of endoscopic hysterectomies, we observed that transvaginal colporraphy is associated with a 3- and 9-fold reduction in the risk of vaginal cuff dehiscence compared with laparoscopic and robotic suture, respectively. In particular, the percentage of dehiscences was 0.18%, 0.64%, and 1.64% for transvaginal, laparoscopic, and robotic closure, respectively. Also, the incidence of vaginal bleeding and the need for reintervention was lower when the transvaginal approach to colporraphy was adopted, whereas the incidence of postoperative vaginal infection was similar among groups.

Traditionally, the purists of minimally invasive surgery require that each surgical step of an endoscopic hysterectomy is performed laparoscopically or robotically. However, transvaginal colporraphy appears as a simple, quick, not highly technically demanding modality to perform vaginal closure at the end of endoscopic hysterectomy. We believe that this aspect should be emphasized to try to refine and optimize the technique of laparoscopic and robotic hysterectomy.