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5/1/2014

Management of Dehiscence of the Vaginal Cuff

Vaginal cuff dehiscence, a rare complication of hysterectomy, is the full or partial separation of the edges of the vaginal cuff.  Evisceration is dehiscence with prolapse of abdominal contents. These complications typically happen within days, but may occur up to months or years following hysterectomy.  The incidence has recently increased, with estimates ranging from 0.14% to 4.1% of hysterectomies. Minimally invasive approaches have higher rates of dehiscence than vaginal or abdominal approaches, although there are no consistent differences in vaginal vs. abdominal approach.

The increased risk in laparoscopic and robotic procedures likely arises from differences in either laparoscopic suturing technique or the use of electrosurgical energy for colpotomy.  Excessive energy application for colpotomy may lead to devascularization and poorer wound healing.  The risk appears reduced when the cuff is closed vaginally, regardless of hysterectomy approach.  

Although cuff dehiscence can occur after defecation or sexual intercourse, most cases occur spontaneously.  Other risk factors include prior or current radiation therapy, immunosuppressive medications, corticosteroid use, tobacco use, increased intra-abdominal pressure, vaginal atrophy, and cancer.

Symptoms of cuff dehiscence include vaginal bleeding or discharge, pain, pressure, and changed bowel habits.  The presence of these symptoms in a recent post-operative hysterectomy patient warrants immediate evaluation.  The speculum and bimanual exams must be performed carefully as evisceration of bowel may occur in up to two-thirds of patients with cuff dehiscence.

Small partial vaginal cuff dehiscence may be managed conservatively, but the patient is at risk for full thickness separation. Surgical examination with repair should be performed if there is doubt for integrity of the closure.

Vaginal cuff dehiscence with evisceration is a surgical emergency.  Patients should be taken to the operating room immediately for repair.  A moist sterile towel should be placed on prolapsed bowel or omentum. Intravenous fluid hydration and broad-spectrum antibiotics should be started immediately.  Traditionally, patients with evisceration were managed via laparotomy and abdominal closure of the cuff.  Experience is growing with minimally invasive and vaginal replacement and closure.  Protruding contents must be carefully inspected for injury.  If there is evidence of trauma or ischemia, or if bowel contents cannot be easily reduced, an abdominal or laparoscopic procedure is appropriate and consultation with a surgeon with experience in bowel repair should be obtained to determine if bowel repair or resection is necessary.  The vaginal cuff can be closed either abdominally or vaginally, with interrupted or figure-of-8 delayed absorbable sutures incorporating the full thickness of the vagina.  No large series exist to guide management, but use of a vaginal drain is reasonable, particularly if infection is present at the time of the procedure.  Given the high risk of subclinical infection, continuation of broad-spectrum antibiotics for at least 24 hours postoperatively is reasonable.  Antibiotics should be continued until any clinically apparent infection has been fully treated.

Further Reading:

Matthews CA, Kenton K.; Treatment of vagina cuff evisceration.   Obstet Gynecol. 2014 Oct;124(4):705-8. doi: 10.1097/AOG.0000000000000463.

Nezhat C, Kennedy Burns M, Wood M, Nezhat C, et. al. Vaginal Cuff Dehiscence and Evisceration: A Review. Obstet Gynecol. 2018 Oct;132(4):972-985. doi: 10.1097/AOG.0000000000002852. PMID: 30204700.

Initial Approval November 2014; Originally named “Management of Evisceration of the Vaginal Cuff”. Reaffirmed 5/1/16, 9/5/17; Reaffirmed and renamed October 2020; Minor Revision May 2022; Minor revision March 2024

 

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