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Vaginal Cuff Dehiscence After Hysterectomy: a Multicenter Retrospective Study

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Vaginal Cuff Dehiscence After Hysterectomy: a Multicenter Retrospective Study European Journal of Obstetrics & Gynecology and Reproductive Biology 158 (2011) 308–313 Contents lists available at ScienceDirect European Journal of Obstetrics & Gynecology and Reproductive Biology jou rnal homepage: www.elsevier.com/locate/ejogrb Vaginal cuff dehiscence after hysterectomy: a multicenter retrospective study a,b c, d b a,b Marcello Ceccaroni , Roberto Berretta *, Mario Malzoni , Marco Scioscia , Giovanni Roviglione , e c e d e Emanuela Spagnolo , Martino Rolla , Antonio Farina , Carmine Malzoni , Pierandrea De Iaco , b e Luca Minelli , Luciano Bovicelli a Gynecologic Oncology Division, International School of Surgical Anatomy, Sacred Heart Hospital, Negrar, Verona, Italy b Department of Obstetrics and Gynecology, European Gynecology Endoscopy School, Sacred Heart Hospital, Negrar, Verona, Italy c Department of Gynecology, Obstetrics and Neonatology, Division of Gynaecology Oncology, University of Parma, Via Gramsci 14, 43100 Parma, Italy d Advanced Gynecological Endoscopy Center, Malzoni Medical Center, Avellino, Italy e Department of Obstetrics and Gynecology, Bologna University Hospital, Bologna, Italy A R T I C L E I N F O A B S T R A C T Article history: Objective: This study estimates the incidence of vaginal cuff dehiscence resulting from different Received 20 January 2011 approaches to hysterectomy. Received in revised form 1 May 2011 Study design: This multicentric study was carried out retrospectively. We retrospectively analyzed 8635 Accepted 13 May 2011 patients; 37% underwent abdominal hysterectomy, 31.2% vaginal hysterectomy, and 31.8% laparoscopic hysterectomy. All the hysterectomies were considered, vaginal evisceration was registered and analyzed Keywords: for time of onset, trigger event, presenting symptoms, details of prolapsed organs and type of repair Vaginal cuff dehiscence surgery. Continuous variables were compared using the one-way analysis of variance between groups as Laparoscopic-vaginal-abdominal all data followed a Gaussian distribution, as confirmed by the Kolmogorov–Smirnov test. Differences hysterectomy among subgroups were assessed using the Tukey–Kramer multiple comparisons test. Categorical Vaginal cuff closure variables were compared with two tailed Chi-square tests with Yates correction or Fisher’s exact test, as appropriate. Pearson’s linear correlation was used to verify linear relationships between the dehiscence interval and patient’s age at surgery. Results: Thirty-four patients (0.39%) experienced vaginal evisceration. The laparoscopic route was associated with a significantly higher incidence of dehiscence (p < 0.05). No differences were found between the 6027 patients (69.8%) who had closure of the vaginal cuff and the 2608 (30.2%) who had an unclosed cuff closure technique. Conclusion: Vaginal evisceration after hysterectomy is a rare gynecological surgical complication. Sexual intercourse before the complete healing of the vaginal cuff is the main trigger event in young patients, while evisceration presents as a spontaneous event in elderly patients. Surgical repair can be performed either vaginally or laparoscopically with similar outcomes. ß 2011 Elsevier Ireland Ltd. All rights reserved. 1. Introduction Vaginal evisceration was associated with chronic pelvic prolapse, atrophic vagina was a serious risk factor for postmenopausal Vaginal cuff dehiscence is a rare event which can lead to severe women, regardless of whether the patient had prior surgery, atrophy complications when it is associated with bowel evisceration. It has coincided with the triad of hypoestrogenism, chronic tissue been defined as a full thickness separation, partial or total, of the devascularization, and pelvic floor weakness. Other factors such anterior and posterior edges of the vaginal cuff with or without as collagen disease, radiation, and smoking also play a role in vaginal bowel evisceration [1]. A large 30 year survey at the Rochester Mayo atrophy. In affected patients, rupture occurred at the weakest point Clinic revealed a substantially low incidence (0.032%) of vaginal of the vaginal vault or posterior fornix and was associated frequently evisceration after abdominal or vaginal approaches to pelvic surgery with a posterior enterocele. Somkuti described 10 risk factors for [2]. Several factors have been described by Somkuti et al. [3] and apical vaginal rupture after an abdominal or vaginal hysterectomy: Kowalski et al. [4].The causes of vaginal rupture and evisceration (1) poor technique, (2) postoperative infection, (3) hematoma, (4) differ between premenopausal and postmenopausal women. coitus before healing, (5) age, (6) radiotherapy, (7) corticosteroid therapy, (8) trauma or rape, (9) previous vaginoplasty, and (10) use of the Valsalva maneuver. There are many other factors worthy of mention, e.g., lifestyle, organic disease (hypothyroidism), and poor * Corresponding author. Tel.: +39 0521 702430; fax: +39 0521 702513. E-mail address: [email protected] (R. Berretta). collagen structure. 0301-2115/$ – see front matter ß 2011 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ejogrb.2011.05.013 M. Ceccaroni et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 158 (2011) 308–313 309 The distal ileum is the most frequent eviscerating organ when Each vaginal evisceration was analyzed for time of onset, trigger vaginal evisceration is observed although prolapse of the event, presenting symptoms, details of prolapsed organs and type omentum, appendix and fallopian tubes have also been reported. of surgery needed to repair the problem. [5,6]. Several authors have reported different surgical approaches Classical surgical techniques were performed for abdominal such as abdominal, vaginal and laparoscopic, without substantial and vaginal hysterectomies (Groups 1 and 2, respectively) [13], differences [2–7]. Based on the large number of hysterectomies while laparoscopic hysterectomies (Group 3) were carried out performed yearly, there is a dearth of well-conducted studies on according to the classical Type-3 and Type-4 hysterectomies, as per vaginal evisceration after hysterectomy making the overall Clermont Ferrand’s technique [9], which consists in the perfor- incidence of this complication inconsistent in the literature mance of all the classical surgical steps by laparoscopy with [7,8]. We have recently reported a review of 3593 hysterectomies vaginal and, respectively, laparoscopic closure of the vaginal cuff. performed with an overall incidence of evisceration at 0.28% [7]. Colpotomy is routinely carried out this way: after identification of This study estimates the incidence of vaginal cuff dehiscence cervico-vaginal fascia anteriorly and section of utero-sacral resulting from different approaches to hysterectomy and describes ligament posteriorly, cranial traction of the uterus by the third the patient characteristics of those with vaginal cuff dehiscence surgeon is performed with the uterine manipulator and exposure after hysterectomy in an attempt to identify potential risk factors of the anterior vaginal fornix is obtained by ventral rotation of the for this complication. vaginal valve; then monopolar section is performed along the vaginal valve, in the usual order: anterior, left, left half of posterior 2. Materials and methods fornix, then right and finally posterior vaginal fornix. In patients undergoing abdominal and vaginal hysterectomies, This study was carried out retrospectively in four Italian general two methods for vaginal cuff closure were used, either closed 7337 hospitals, namely the Sacred Heart Hospital of Negrar (Verona), the (85%) or unclosed cuff 1295 (15%), according to the surgeon’s S. Orsola University Hospital of Bologna, the University Hospital of preference. The former was obtained through interrupted 0 Parma and the Malzoni Medical Centre of Avellino. The local ethics polyglicolic sutures placed in each lateral angle, with the committees in each hospital authorized the publication of the remaining cuff closed in running sutures. The peritoneum was study. All patients who underwent abdominal (Group 1), vaginal unclosed with application of closed suction drainage in the (Group 2) or laparoscopic (Group 3) total hysterectomies from abdominal cavity in case of inadequate hemostasis. In the unclosed January 1994 to December 2008 were considered. Medical records cuff technique, the cuff’s margins were sutured with a running were retrieved to collect clinical and surgical data. The main details interlocking suture, leaving the cuff open, before peritoneal considered for the analysis were age, BMI, obstetrical history, running suture. surgical route, indication for surgery (fibroids, uterine prolapse or The peritoneum was closed with a running suture and open cancer), Table 1, administration of prophylactic antibiotics at time trans-cuff drainage was used in case of inadequate hemostasis. of hysterectomy, type of vaginal cuff closure, postoperative Laparoscopic single-layer semi-continuous running suture was complications, postoperative adjuvant therapy, time interval performed in 2332 (87%) patients of Group 3 (Clermont-Ferrand between hysterectomy and vaginal cuff dehiscence, trigger events, type 4), while single-layer running suture was performed by presenting symptoms, presence of evisceration and type of vaginal route in 413 (13%) patients (Clermont Ferrand type 3). The prolapsing organ, and type of repair. laparoscopic technique consisted of two running sutures with 0 All patients were evaluated by clinical
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