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What to do with the vaginal apex at the time of hysterectomy: optimal technique, tips, and tricks for successful vaginal closure of the cuff.

Management of the vaginal cuff during hysterectomy remains an important consideration for gynecologists. In the short term, the main objective of cuff closure is to decrease bleeding and prevent cuff dehiscence and resultant evisceration. In the long term, the technique used for cuff closure may have implications for development of new or recurrent apical prolapse.

In this article, we review various techniques of vaginal cuff closure during open, laparoscopic, and vaginal hysterectomy, with particular focus on tips and tricks for successful closure of the cuff vaginally.

Choosing suture type and technique: Does it matter?

Prior to the advent of perioperative antibiotic prophylaxis, it was routine practice to leave the vaginal cuff partially open to allow for drainage. This is no longer necessary, and it is standard procedure to close the vaginal epithelium. Separate peritoneal closure is not necessary.

There is no evidence that a specific method of suture closure is superior to the others. The options for closure include continuous running, running-locked, or interrupted absorbable sutures.

Tips for suturing. During running cuff closure--particularly if it is being completed vaginally--we find it helpful to elevate the corners with long Allis clamps or stay sutures. This prevents "rolling in" of the vaginal epithelium and helps to ensure that the edges are correctly opposed during closure.

An inadequate purchase of the cuff during closure may increase the risk of vaginal cuff hematoma and resultant abscess; ensure full-thickness bites of the epithelium. If using a smaller caliber needle (such as an SH needle), it generally should be reloaded between the upper and lower edges of the incision to ensure an adequate purchase and to prevent bending of the needle.

To close from above or below during laparoscopic hysterectomy

Cuff dehiscence rates consistently are reported to be lower for vaginal and abdominal hysterectomy than for laparoscopic and robotic hysterectomy. (1-3) A recent review of reports of cuff dehiscence and vaginal evisceration over 30 years found ranges of cuff dehiscence of 0.14% to 0.27% for all types of hysterectomy, and 1% to 4.1% after laparoscopic or robotic hysterectomy. (4) Authors of a recent meta-analysis of nearly 13,000 patients found a 3-fold and 9-fold reduction in cuff dehiscence with vaginal closure versus laparoscopic and robotic closure, respectively. (5)

Differences in surgical technique may account for the higher rates of cuff dehiscence with laparoscopic and robotic hysterectomy. Electrosurgery typically is used for creation of the colpotomy in laparoscopic and robotic hysterectomy, and thermal damage at the cuff could lead to poor healing. Experts generally recommend that cutting current, rather than coagulation current, be used for the colpotomy to minimize thermal spread.

One study attempted to address the impact of electrosurgery and laparoscopic suturing on the rate of vaginal cuff dehiscence by comparing the incidence of dehiscence in 463 patients undergoing total laparoscopic hysterectomy (TLH) for benign disease and 147 patients undergoing laparoscopic-assisted vaginal hysterectomy (LAVH) for cancer. In the TLH group, the colpotomy was created with an ultrasonically activated scalpel and closed with No. 2-0 polyglactin laparoscopically. In the LAVH group, the colpotomy was made with a monopolar electrosurgical pencil and closed with No. 0 polyglactin. There were no (0%) cases of cuff dehiscence in the LAVH group and 17 (4%) in the TLH group, suggesting that the increased magnification or laparoscopic suture technique, not electrosurgery, accounted for the increased incidence of dehiscence. (6)

Surgical tip: Avoid incorporating too little tissue when suturing. Increased magnification of the operative field during laparoscopic and robotic hysterectomy may result in unintentional incorporation of less tissue with each suture pass. When closing the cuff robotically or laparoscopically, we recommend reloading the needle between purchases of each cuff edge to ensure full incorporation of the tissue edges, especially since larger needles (CT-1) may not fit down the laparoscopic/robotic ports and are not usually utilized.

Barbed versus conventional sutures.

Barbed suture material is purported to decrease the risk of cuff dehiscence with laparoscopic and robotic hysterectomy. In a retrospective analysis involving 387 women who underwent laparoscopic and robotic surgery, there were no cuff dehiscences in the 149 patients with laparoscopic barbed-suture cuff closure, compared with 10 of 238 (4%) with laparoscopic cuff closure with polyglactin, poliglecaprone 25, or an automated endoscopic suturing device. (7)

Authors of other studies, including a randomized controlled trial of 64 women undergoing TLH and a meta-analysis of 1,031 hysterectomies, have not found a difference in the rate of cuff dehiscence with barbed versus conventional suture. (8,9) Closure with barbed suture generally is faster compared with conventional suture material, (9) and is designed to result in equal distribution of tension across the vaginal cuff (though this is unlikely to be clinically significant). Barbed suture obviates the need to tie knots laparoscopically, a challenging and time-consuming skill, and is therefore appealing to many surgeons.

At present, there is insufficient evidence to claim the superiority of barbed suture over conventional suture, and the choice of which to use remains a matter of surgeon preference. If barbed suture is being used, however, patients should be counseled about the possibility of feeling the barbs, which may be palpable for several weeks.

Our bottom-line suture recommendations

Laparoscopic suturing is a highly advanced skill that many gynecologists do not master during residency training. In light of the current evidence, never hesitate to close the cuff from a vaginal approach, especially if you have any misgivings about laparoscopic suturing. If choosing to close the cuff laparoscopically, we recommend judicious use of electrocautery and care to incorporate at least 1 cm of tissue on each side of the vaginal cuff.

Preventing apical prolapse

Hysterectomy's impact on the development of subsequent apical prolapse remains a subject of debate. Hysterectomy has been found to be a risk factor for pelvic organ prolapse, (10,11) but some studies have found similar rates of prolapse in women with and without previous hysterectomy. (12,13) Women with prolapse at the time of their hysterectomy appear to be at increased risk for future prolapse surgery, (14,15) but few trials have evaluated surgical techniques for prevention of future prolapse in women without existing prolapse at the time of their hysterectomy. Techniques that have been evaluated for prolapse prevention typically have involved fixation of the cuff to the uterosacral ligaments.

McCall culdoplasty: The standard for women without prolapse at hysterectomy

The McCall culdoplasty is the most commonly performed technique for prevention of prolapse at the time of vaginal hysterectomy; it also may be performed from an abdominal approach. The McCall culdoplasty involves midline plication of the uterosacral ligaments with incorporation of the peritoneum and posterior vaginal cuff. Technique. Traditionally, several rows of internal nonabsorbable sutures are placed, starting at the left uterosacral ligament, then incorporating the peritoneum of the cul-desac, and ending in the right uterosacral ligament (FIGURE 1). These sutures obliterate the cul-de-sac and help prevent future enterocele formation.

External sutures are also placed; these incorporate the vaginal epithelium, muscularis, and uterosacral ligament on one side, then travel across the cul-de-sac peritoneum, and exit through the contralateral uterosacral ligament and vaginal cuff. The external sutures elevate the posterior vagina to the uterosacral ligaments and thereby add vaginal length. Some surgeons simplify this technique by omitting the internal sutures.

See the video, "McCall culdoplasty technique," by Mickey Karram, MD, that accompanies this supplement at http:// obgmanagement.com.

The evidence. To date, there is only 1 trial comparing techniques of cuff closure during vaginal hysterectomy to prevent future prolapse in women without preexisting prolapse. This trial compared McCall culdoplasty, simple purse-string closure of the peritoneum, and vaginal Moschcowitz-type closure (which involves purse-string closure of the posterior peritoneum with fixation to the distal uterosacral and cardinal ligaments) in 100 women undergoing hysterectomy. (16) The investigators found a significantly lower incidence of stage 2 pelvic organ prolapse (descent to within 1 cm of the hymen) at 3 years after hysterectomy for McCall culdoplasty (2/32 [6%]) versus peritoneal closure (13/33 [39%]) and vaginal Moschowitz procedure (10/33 [30%]) (P = .004).

Our recommendation. Given the safety and ease of McCall culdoplasty, we recommend that this procedure be performed as part of all hysterectomies in women without prolapse.

Modify the McCall if there is prolapse at hysterectomy

In women with uterovaginal prolapse, modification of the McCall culdoplasty with fixation to a higher portion of the uterosacral ligament improves the durability and success of apical suspension.

In this procedure, the proximal uterosacral ligaments are identified by placing traction on the distal portion of the ligaments at their insertion into the vaginal cuff. The proximal ligament is grasped with an Allis clamp and deviated away from the pelvic sidewall. Two or 3 nonabsorbable or delayed-absorbable sutures are placed through the ligament and then affixed to the anterior and posterior vaginal cuff (FIGURE 2). These sutures affix the uterosacral ligaments to the pubocervical and rectovaginal muscularis, thereby reestablishing the connections between upper vaginal supports. If using permanent sutures, the vaginal epithelium is excluded. The sutures are tied down, elevating the cuff to the proximal uterosacral ligaments.

The success rate for this technique is approximately 80%. (17) The main concern with this procedure is ureteral injury, due to the close proximity of the ureters to the uterosacral ligaments. Ureteral kinking by the uterosacral suspension suture, rather than ligation or transection, may occur in up to 1% to 11% of cases, (18,19) and is easily corrected by simple release of the suture. While not the focus of this article, we suggest cystoscopy to ensure ureteral patency when any vault suspension technique is utilized.

Surgical tip. It can be quite challenging to close the cuff after it has been suspended. You may find it helpful to partially close the cuff by placing a few running sutures from each angle and holding them prior to tying down the suspension sutures, then complete the cuff closure with the held sutures after tying the suspension sutures.

Final takeaways, from evidence and experience

Though it is often overlooked, the technique for closure of the vaginal cuff can have a major impact on the outcome of hysterectomy. Performing a McCall culdoplasty at the time of vaginal hysterectomy has been shown to prevent future apical prolapse and adds minimal time to the procedure. It is reasonable to presume that reattaching the vaginal cuff to the uterosacral ligaments during other routes of hysterectomy would have a similar protective effect. In addition, data indicate that closure of the cuff from a vaginal approach results in less cuff dehiscence than laparoscopic and robotic approaches. Surgeons should strongly consider a vaginal approach to cuff closure, especially if they have any misgivings about laparoscopic suturing.

Andrew I. Sokol, MD, and Katelyn R. Smithling, MD

Dr. Sokol is Associate Professor of Obstetrics and Gynecology and Urology at Georgetown University School of Medicine and Associate Director, Minimally Invasive Surgery, Section of Female Pelvic Medicine and Reconstructive Surgery at MedStar Washington Hospital Center in Washington, DC.

Dr. Smithling is Clinical Fellow in Female Pelvic Medicine and Reconstructive Surgery at MedStar Washington Hospital Center.

The authors report no financial relationships relevant to this article.

References

(1.) Hur H-C, Guido RS, Mansuria SM, Hacker MR, Sanfilippo IS, Lee TT. Incidence and patient characteristics of vaginal cuff dehiscence after different modes of hysterectomies. I Minim Invasive Gynecol. 2007;14(3):311-317.

(2.) Kho RM, Akl MN, Cornelia JL, Magtibay PM, Wechter ME, Magrina JF. Incidence and characteristics of patients with vaginal cuff dehiscence after robotic procedures. Obstet Gynecol. 2009;114(2 pt l):231-235.

(3.) Uccella S, Ghezzi F, Mariani A, et al. Vaginal cuff closure after minimally invasive hysterectomy: our experience and systematic review of the literature. Am J Obstet Gynecol. 2011;205(2):119.e1-e12.

(4.) Cronin B, Sung VW, Matteson KA. Vaginal cuff dehiscence: risk factors and management. Am J Obstet Gynecol. 2012;206(4):284-288.

(5.) Uccella S, Ceccaroni M, Cromi A, et al. Vaginal cuff dehiscence in a series of 12,398 hysterectomies: effect of different types of colpotomy and vaginal closure. Obstet Gynecol. 2012;120(3):516-523.

(6.) Fanning J, Kesterson J, Davies M, et al. Effects of electrosurgery and vaginal closure technique on postoperative vaginal cuff dehiscence. JSLS. 2013;17(3):414-417.

(7.) Siedhoff MT, Yunker AC, Steege JF Decreased incidence of vaginal cuff dehiscence after laparoscopic closure with bidirectional barbed suture. I Minim invasive Gynecol. 2011; 18(2):218-223.

(8.) Einarsson JI, Cohen SL, Gobern JM, et al. Barbed versus standard suture: a randomized trial for laparoscopic vaginal cuff closure. I Minim Invasive Gynecol. 2013;20(4): 492-498.

(9.) lavazzo C, Mamais I, Gkegkes ID. The role of knotless barbed suture in gynecologic surgery: systematic review and meta-analysis [published online ahead of print October 15, 2014], Surg Innov. pii:1553350614554235.

(10.) Aigmueller T, Dungl A, Hinterholzer S, Geiss I, Riss P. An estimation of the frequency of surgery for posthysterectomy vault prolapse. Int Urogynecology 1.2009;21(3):299-302.

(11.) Altman D, Falconer C, Cnattingius S, Granath F. Pelvic organ prolapse surgery following hysterectomy on benign indications. Am I Obstet Gynecol. 2008;198(5):572.el-e6.

(12.) Hendrix SL, Clark A, Nygaard I, Aragaki A, Barnabei V, McTieman A. Pelvic organ prolapse in the Women's Health Initiative: gravity and gravidity. Am J Obstet Gynecol. 2002:186(6): 1160-1166.

(13.) Hendrix SL, Cochrane BB, Nygaard IE, et al. Effects of estrogen with and without progestin on urinary incontinence. JAMA. 2005;293(8):935-948.

(14.) Blandon RE, Bharucha AE, Melton III LJ, et al. Incidence of pelvic floor repair after hysterectomy: a population-based cohort study. Am J Obstet Gynecol. 2007;197(6):664.el-e7.

(15.) Mant J, Painter R, Vessey M. Epidemiology of genital prolapse: observations from the Oxford Family Planning Association study. BJOG. 1997;104(5):579-585.

(16.) Cruikshank SH, Kovac SR. Randomized comparison of three surgical methods used at the time of vaginal hysterectomy to prevent posterior enterocele. Am I Obstet Gynecol. 1999;180(4):859-865.

(17.) Maher C, Feiner B, Baessler K, Schmid C. Surgical management of pelvic organ prolapse in women. Cochrane Database Syst Rev. 2013;4:CD004014. doi:10.1002/14651858. CD004014.pub5.

(18.) Barber MD, Visco AG, Weidner AC, Amundsen CL, Bump RC. Bilateral uterosacral ligament vaginal vault suspension with site-specific endopelvic fascia defect repair for treatment of pelvic organ prolapse. Am J Obstet Gynecol. 2000; 183(6): 1402-1410.

(19.) Margulies RU, Rogers MA, Morgan DM. Outcomes of transvaginal uterosacral ligament suspension: systematic review and metaanalysis. Am J Obstet Gynecol. 2010;202(2): 124-134.

McCall culdoplasty technique

Mickey Karram, MD View the video with this supplement posting in the Education Center at obgmanagement.com

Courtesy of Mickey Karram, MD, International Academy of Pelvic Surgery
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Author:Sokol, Andrew I.; Smithling, Katelyn R.
Publication:OBG Management
Date:Oct 1, 2015
Words:2432
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