Vaginal cuff dehiscence after total hysterectomy

INTRODUCTION — Vaginal cuff dehiscence is a rare, but potentially morbid, complication of total hysterectomy (surgical removal of the uterus and cervix). When vaginal cuff dehiscence occurs, abdominal or pelvic contents are at risk of evisceration (expulsion) through the vaginal opening. Cuff dehiscence can lead to serious sequelae, including peritonitis, bowel injury, necrosis, sepsis, and if untreated, death. Prompt surgical and medical intervention are required.

This topic will review the incidence, risk factors, diagnosis, and management of vaginal dehiscence that occurs after total hysterectomy. Potential steps for risk reduction will also be presented. Other complications of gynecologic surgery are discussed separately. (See "Complications of gynecologic surgery".)

In this topic, when discussing study results, we will use the terms "woman/en" or "patient(s)" as they are used in the studies presented. However, we encourage the reader to consider the specific counseling and treatment needs of transgender and gender expansive individuals.

DEFINITION — After removal of the uterus, the vaginal incision (vaginal cuff) is typically closed by suturing the anterior and posterior edges together. Vaginal cuff dehiscence refers to separation of the vaginal edges; other terms include "cuff separation" or "cuff rupture." Complete cuff dehiscence involves full-thickness separation of the entire length of the vaginal incision, whereas partial cuff dehiscence involves full-thickness separation of only a portion of the vaginal incision. Partial-thickness cuff separation refers to a partial separation of the cuff thickness (ie, the vaginal mucosa is disrupted, but the muscularis and peritoneum are intact) without a full-thickness separation; thus, the cuff does not have an actual opening on the vaginal incision. Vaginal cuff dehiscence with evisceration indicates expulsion of intraperitoneal contents through the separated vaginal incision.

INCIDENCE

Overall — The largest studies report an overall incidence of posthysterectomy cuff abscess of 0.14 to 0.37 percent (all surgery types), although dehiscence rates up to nearly 5 percent have been reported [1-11]. In a large single-center study in the United States, 28 cases of vaginal cuff dehiscence (partial or complete) were reported among 11,606 patients who underwent total hysterectomy between 2000 and 2009 (0.24 percent incidence) [2]. Another large single-institution study in Finland reported 26 dehiscences among 13,645 hysterectomy patients from 1992 to 2015 (0.19 percent incidence; author performed calculation from study data) [7]. The largest multi-institution study conducted in Italy that included 12,398 hysterectomy patients from 1994 to 2008 reported 38 cases of dehiscence (0.31 percent incidence) [3]. The incidence of cuff dehiscence with evisceration is even lower, ranging from 0.03 to 0.40 percent [1,3,12,13]. All of these calculations included patients undergoing hysterectomy for both benign and malignant indications.

The true incidence of vaginal cuff dehiscence after hysterectomy is challenging to determine since this complication is likely underreported. Patients may have their initial hysterectomy at one hospital and then present to a different hospital with the cuff complication, making it difficult to accurately capture the data. In addition, many cases of vaginal cuff dehiscence in the literature were reported as individual case reports. As a result, there is a lack of comprehensive information regarding the numbers for all hysterectomies that were and were not associated with a dehiscence complication, making it impossible to calculate an incidence from these reports.

Mode of surgery

●All types of hysterectomy – The growing body of medical literature suggests the rate of dehiscence after hysterectomy varies by mode of surgery, with an increased risk after traditional laparoscopic hysterectomy and robot-assisted laparoscopic hysterectomy as opposed to vaginal or abdominal approaches.

•Total vaginal hysterectomy – 0.12 percent (range 0.05 to 0.32 percent)

•Total abdominal hysterectomy – 0.3 percent (range 0.02 to 0.60 percent)

•Total laparoscopic hysterectomy – 0.7 percent (range 0.64 to 1.27 percent)

•Robot-assisted total laparoscopic hysterectomy – 2.3 percent (range 0.4 to 4.1 percent)

●Laparoscopic hysterectomy – The rate of vaginal cuff dehiscence is higher after total laparoscopic hysterectomy compared with abdominal or vaginal total hysterectomy [1-5,7,8]. While there have been concerns about a markedly higher rate of cuff dehiscence following laparoscopic hysterectomy (4.93 percent) [8], a follow-up of that study suggested a lower dehiscence rate of 0.75 percent [2]. This lower rate of dehiscence after laparoscopic hysterectomy is consistent with subsequent large studies [2,3,7].

●Robot-assisted hysterectomy – Robot-assisted total laparoscopic hysterectomy appears to have the highest incidence of dehiscence compared with all other modes of hysterectomy [4,9,14-16]. However, conclusions are limited because of the small number and size of the studies and lack of data directly comparing robotic hysterectomy with other surgical approaches. The largest cohort study reported a 4.1 percent incidence (21 of 510 robotic hysterectomies) but had no comparison groups [9]. The largest study (2382 patients undergoing hysterectomy) that did compare the robotic approach with different routes of hysterectomy reported a 3.3 percent incidence of dehiscence for robot-assisted, 1.1 percent for laparoscopic, 0.6 percent for abdominal, and 0.3 percent for vaginal hysterectomy [4]. However, this was a small study for this rare outcome with only 184 robotic hysterectomies among the total cohort of 2382 patients undergoing hysterectomy, which limits final conclusions.

RISK FACTORS

Established and suspected risk factors

●Established risk factors and data limitations – As vaginal dehiscence is rare, it is difficult to identify predisposing factors. Many studies have attempted to evaluate risk factors for dehiscence, but these studies are limited by the infrequency of the outcome and are primarily retrospective. Thus, most studies are underpowered and lack comparison groups. Prior studies have attempted to identify risk factors for dehiscence and examined age, hormonal status premenopausal versus postmenopausal status, sexual activity, and existence of concomitant pelvic organ prolapse [1,8,12,17-22]. Although menopausal status itself may be a theoretical risk factor for dehiscence, increasing age does not appear to be related [4,23]. A case-controlled study identified older age and obesity (body mass index [BMI] >30 kg/m²) to be protective factors for cuff dehiscence [23].

While some instances of vaginal cuff dehiscence occur spontaneously [1,8,12,18], the following appear to be independent factors that increase dehiscence risk [2-5,7,8,13,23]:

•Mode of surgery (eg, total laparoscopic hysterectomy, robot-assisted total laparoscopic hysterectomy).

•Vaginal closure of the cuff after laparoscopic hysterectomy (as compared with laparoscopic cuff closure).

•Smoking.

•Low BMI.

●Proposed but unproven risk factors – In general, cuff dehiscence is associated with risk factors for infection, poor wound healing, excessive pressure at the vaginal incision site, or pelvic floor defects. The following factors have been proposed, but have not been proven, as risk factors for vaginal cuff dehiscence [1,2,4,5,8-10,12,18,19,23-26]:

•Factors resulting in poor wound healing:

-Vaginal cuff infection (cellulitis or abscess).

-Vaginal cuff hematoma.

-Pelvic radiation therapy.

-Chronic medical conditions (eg, malnutrition, anemia, diabetes, HIV, connective tissue disorders).

-Medications that result in immunosuppression (eg, chronic steroid intake).

•Factors resulting in pressure on the vaginal incision:

-Vaginal trauma (eg, vaginal intercourse during the immediate postoperative period, vaginal instrumentation).

-Pelvic organ prolapse.

-Conditions that increase intraabdominal pressure, such as constipation or chronic cough (eg, chronic obstructive pulmonary disease, asthma, gastroesophageal reflux disease, or chronic constipation).

•Jobs requiring excessive heavy lifting or constant Valsalva (eg, professional movers, athletes, opera singers, etc).

In the author's experience, early detection of vaginal cuff infection and avoidance of excessive strain on the vaginal incision (eg, premature coitus or excessive Valsalva with severe constipation) are key modifiable risk factors that surgeons can address with patients. (See 'Risk modification' below.)

•(See 'Risk modification' below.)

•(See "Overview of preoperative evaluation and preparation for gynecologic surgery", section on 'Antibiotic prophylaxis'.)

•(See "Bacterial vaginosis: Initial treatment", section on 'Individuals undergoing gynecologic procedures'.)

Surgical techniques and materials — Surgical techniques have been evaluated as contributing factors for cuff dehiscence. The role of electrosurgery and different energy sources [3,4,27], different suture materials [4,15,28-34], one- versus two-layer vaginal cuff closures [35-37], and closure technique (continuous versus interrupted sutures for cuff closure) [4,10,27] have all been evaluated as dehiscence risk factors without conclusive results. Most studies are retrospective, underpowered, and lack a comparison group. Given the dearth of quality data, it is impossible to draw any definitive conclusions on the best surgical techniques for vaginal cuff closure to minimize the risk of dehiscence. Below, we review the limited data and offer our surgical practices.

Principles for cuff closure — Regardless of how the colpotomy is made, the same surgical principles should be applied to cuff closure, which include preserving vaginal length, optimizing tissue quality, limiting use of energy for cuff hemostasis (to minimize tissue necrosis), and using a cuff closure technique that reapproximates tissue without strangulating it. The author performs a full-thickness closure that incorporates both the vaginal mucosa and pubocervical fascial ring, with sutures placed roughly 1 cm apart from one another and at least 1 cm deep and distal from the cut edge. The author avoids cuff closure devices that incorporate a fixed volume or distance of tissue (eg, Endo Stitch device) that may fail to incorporate a full-thickness closure that extends 1 cm or more beyond the cuff edge. In particular, patients with a thick vaginal cuff, such as patients with adhesions or endometriosis, may be at greater risk for a compromised cuff closure with such devices. (See "Hysterectomy: Laparoscopic", section on 'Vaginal cuff'.)

Energy devices — Unfortunately, there are limited data regarding the impact of different energy sources used for colpotomy on wound healing, cuff complications, and risk of dehiscence. Therefore, there is no standard approach to colpotomy to minimize the dehiscence risk. Use of energy sources to make the vaginal colpotomy (picture 1) may provide more hemostasis, but may also cause more tissue damage, potentially resulting in tissue destruction beyond the incision [38-40]. Compared with cold-cut colpotomy techniques using a scalpel or scissors, using energy devices for colpotomy may lead to increased tissue necrosis and subsequent poor healing of the cuff (figure 1). Different electrosurgical instruments (eg, bipolar and monopolar devices) or ultrasonic devices produce varying amounts of tissue destruction. (See "Overview of electrosurgery".)

●Author approach – The author performs colpotomy with an electrosurgical monopolar device on pure cut waveform. Every effort is made to minimize tissue necrosis and optimize surgical cutting effect by using an on-tension, noncontact cutting technique with focused current density. This can be achieved by selecting a pointed monopolar device (eg, micro-shear scissors or L-hook) and pushing hard on the uterine manipulator to apply tension on the vaginal cuff and distance the ureters. When using monopolar devices, special care must be taken to minimize the risk of stray current injuries.

●Available data – There are no studies comparing outcomes between total hysterectomies using cold-cut colpotomies versus colpotomies made with energy sources such as electrosurgical monopolar devices. In one trial comparing monopolar coagulation with monopolar cut waveforms for colpotomy at the time of laparoscopic hysterectomy, the dehiscence rates were statistically similar (1 versus 0 percent), but the relatively small number of study subjects (199 total) made it difficult to determine whether the lack of significance reflected a lack of power to detect a difference versus a true lack of difference between groups. In addition, this study is of limited generalizability as there are multiple different power settings for cut and coagulation waveforms for monopolar electrosurgery; this study used a 35 watt power setting for both waveforms.

Additional discussions of surgical energy sources and wound healing can be found separately.

●(See "Overview of electrosurgery".)

●(See "Basic principles of wound healing".)

Suture selection — Quality data to guide suture selection for cuff closure that minimizes dehiscence risks are lacking. The overwhelming majority of the existing literature consists of small retrospective studies, which all show a lack of difference between different types of suture and dehiscence risk. In addition, the studies may be underpowered, have collinearity within their model's variables, and/or lack a comparator group. The author's preference is to use a delayed absorbable monofilament suture, such as polydioxanone (PDS II) (table 1). The clinical rationale is that monofilament suture theoretically poses less risk of infection than polyfilament suture in an area such as the vagina, and a delayed absorbable suture offers more suture strength postoperatively in case of postoperative cuff cellulitis or excessive stress on the vaginal incision with premature vaginal intercourse or excessive heavy lifting.

A variety of different sutures is available for cuff closure after hysterectomy. The surgeon must consider the following suture characteristics when selecting the suture to minimize dehiscence risks:

●Absorbable, delayed absorbable, and nonabsorbable suture – Sparse data exist to inform suture selection based on rate of suture absorption (table 1 and table 2). One study that compared absorbable with permanent suture at the time of laparoscopic hysterectomy reported nonsignificant differences in dehiscence rates between the two groups (absorbable: 1.4 percent [12 out of 881] versus permanent: 0.52 percent [3 out of 574]) [26]. However, patients in the permanent suture group required a second surgery for removal of the permanent suture. Based on lack of the significant difference between the study groups in dehiscence rate, the author avoids permanent suture for cuff closure to skip the need for subsequent removal.

●Monofilament versus polyfilament suture – A significant difference between type of suture and risk of dehiscence has not been established. Most studies comparing monofilament versus polyfilament suture assess monofilament barbed suture with polyfilament Vicryl suture (see bullet below).

●Traditional versus barbed suture – Most studies that compare barbed suture versus traditional suture for cuff closure report similar dehiscence outcomes [29-34]. One trial that evaluated three different cuff closure methods in 90 patients undergoing robot-assisted hysterectomy for benign disease reported no dehiscences in any of the three groups and similar one-year outcomes for vaginal bleeding, cuff infection, and dyspareunia [29]. However, after accounting for patients lost to follow-up, the study groups were small (22 patients in the running 2.0 V-lock continuous running suture group, 19 patients in the 0 Vicryl figure-of-eight suture group, and 13 patients in the running 0 Vicryl suture with Lapra-Ty group) and underpowered for definitive conclusion. The patients in whom running 0 Vicryl with Lapra-Ty were used reported more vaginal pain compared with those receiving running 2.0 V-Lock and 0 Vicryl figure-of-eight sutures (23, 0, and 0 percent, respectively). A meta-analysis comparing cuff closure with barbed suture versus traditional suture concluded there was no difference in the risk of dehiscence between the groups [41]. Retrospective studies published after the meta-analysis continued to support the conclusions [30-34].

Suture placement — A variety of suturing methods have been evaluated with regard to dehiscence risk:

●Continuous running versus figure-of-eight versus interrupted suture.

●Single-layer versus multilayer closure.

●Vaginal versus laparoscopic approach for cuff closure after total laparoscopic hysterectomy. (See 'Impact of laparoscopic and robot-assisted hysterectomy' below.)

Like the other variables above, there are insufficient data regarding the best suturing method for closing the cuff to decrease dehiscence risks. After laparoscopic hysterectomy, the author performs cuff closure with a continuous running suture using laparoscopic suturing and intracorporeal knot tying technique.

Impact of laparoscopic and robot-assisted hysterectomy — There are several studies that suggest laparoscopic and robot-assisted hysterectomies have a higher incidence of vaginal cuff dehiscence compared with other modes of surgery. The highest rates of cuff dehiscence are cited for robot-assisted hysterectomy, followed by laparoscopic, abdominal, and vaginal hysterectomy. (See 'Incidence' above.)

Unique features of laparoscopic surgery that potentially increase the risk of vaginal dehiscence include [8]:

●Route of cuff closure – The best route of cuff closure has been long debated. Data suggest vaginal closure of the cuff poses a greater risk of dehiscence compared with laparoscopic cuff closure (picture 2) at the time of total laparoscopic hysterectomy. Initially, a review of retrospective studies of laparoscopic hysterectomy reported vaginal cuff closure was associated with a lower incidence of dehiscence compared with laparoscopic closure (0.18 to 0.30 percent versus 0.64 percent [38]). A subsequent randomly assigned trial comparing vaginal and laparoscopic cuff closure at the time of laparoscopic hysterectomy was stopped early because the prespecified interim analysis reported vaginal closure was associated with both a higher risk of cuff dehiscence (2.7 versus 1 percent, odds ratio [OR] 2.78, 95% CI 1.16-6.63) and any cuff complication (9.8 versus 4.7 percent, OR 2.19, 95% CI 1.43-3.37) [13]. Consistent with prior studies, in this study, other independent risk factors for cuff dehiscence included smoking and premenopausal status.

Route of cuff closure does not appear to affect sexual function. A follow-up study of a subgroup of patients from the trial reported similar postoperative sexual outcomes for both laparoscopic and vaginal closure groups [42].

●Surgical skill – Laparoscopic closure of the vaginal cuff requires specific surgical training to master laparoscopic suturing. With the increasing use of barbed suture, there is less surgical training for laparoscopic knot tying using extracorporeal or intracorporeal techniques. Inappropriate use of the laparoscopic knot pusher or poor intracorporeal knot tying technique may compromise suture integrity and cuff strength.

●Visual field distortion – Laparoscopic magnification of the surgical field may distort the view and cause the surgeon to place shallow sutures too close to the vaginal cuff edge (<1 cm) or not achieve full-thickness closure.

RISK MODIFICATION — Interventions to minimize the risk of vaginal cuff dehiscence after hysterectomy are uncertain since the causes are not well-established. Diagnosis and treatment of identified modifiable risk factors during the preoperative, intraoperative, and postoperative phases of care can help minimize the risk of cuff dehiscence. Strategies based on existing data are described below. Routine interventions for benign gynecologic surgery are presented separately. (See "Overview of preoperative evaluation and preparation for gynecologic surgery".)

Vaginal and/or cervical infections — To minimize the risk of cuff cellulitis or abscess, the data support evaluating patients preoperatively for evidence of vaginitis and/or cervicitis. Such infections can include bacterial vaginosis, Trichomonas vaginalis, gonorrhea, and chlamydia [20,43].

●(See "Bacterial vaginosis: Clinical manifestations and diagnosis", section on 'Clinical consequences of BV'.)

●(See "Prevention of sexually transmitted infections", section on 'Factors associated with STI acquisition'.)

●(See "Vaginitis in adults: Initial evaluation".)

Pelvic rest — In general, scar tissue attains approximately 40 percent of its final strength in the first postoperative month, and strength continues to increase for as long as one year after injury [44]. Therefore, after total hysterectomy, patients should maintain pelvic rest (eg, defer vaginal intercourse and avoid placing objects into the vagina) and refrain from heavy lifting. In our practice, we advise patients to avoid these activities for 8 weeks after hysterectomy and up to 12 weeks for higher risk individuals (eg, patients undergoing robotic or laparoscopic hysterectomy). The highest risk patients have multiple risk factors for dehiscence (such as smokers; those with prior pelvic radiation; medical comorbidities such as poorly controlled diabetes, HIV infection, or renal failure; chemotherapy; and/or steroids or other immunosuppressant medications, etc). These individuals may be counseled to avoid intravaginal activities for an extended period, although supporting data for this approach are lacking. (See "Hysterectomy: Abdominal (open) route", section on 'Follow-up'.)

Vaginal atrophy — The role of pre- and postoperative estrogen therapy, both systemic and low-dose vaginal, to prevent complications at the time of hysterectomy has been debated. Among postmenopausal individuals, some studies have suggested perioperative estrogen therapy may promote vaginal wound healing after gynecologic surgery [45-47]. Data specific to the use of estrogen therapy for reduction of cuff dehiscence are limited. A trial randomly assigned 315 postmenopausal patients undergoing vaginal hysterectomy for benign indications to transdermal estrogen therapy (ie, systemic) for 14 days before and after surgery or vaginal estrogen therapy for 14 days before surgery and no postoperative estrogen therapy [45]. At four weeks after surgery, individuals in the transdermal estrogen therapy group had a reduced incidence of incomplete reepithelialization of vaginal suture sites (5 versus 17 percent) and visible wound opening (0 versus 2 percent); cuff dehiscence was not reported. However, some postmenopausal individuals are not candidates for systemic estrogen therapy, and the benefit of low-dose vaginal estrogen therapy versus placebo was not assessed, which makes uniform treatment recommendations challenging.

CLINICAL PRESENTATION

Presenting symptoms — The most common presenting symptoms associated with vaginal dehiscence are [1,8,12,17,18,24,48-50]:

●Pelvic or abdominal pain – 60 to 100 percent

●Vaginal bleeding – 23.5 to 90 percent

●Vaginal discharge or gush of fluid – 55 percent

●Vaginal pressure or mass – 30 percent

Timing — Individuals have presented with cuff dehiscence as early as three days and as remotely as 30 years from the index surgery [21,51].

●For premenopausal patients, dehiscence tends to occur early in the postoperative course (two to five months), and the most common trigger is coitus [1,8,18,21,24,48,49].

●For postmenopausal patients, vaginal cuff rupture may occur months to years after surgery and is commonly associated with pelvic organ prolapse [1,12,18,19,52]. One hypothesis is that later rupture results from progressive weakening of the vaginal scar [18]. However, many postoperative dehiscences can occur spontaneously [12].

DIAGNOSTIC EVALUATION

Diagnosis — Vaginal cuff dehiscence with or without evisceration is a clinical diagnosis made during pelvic examination, typically with the speculum examination. The vaginal cuff defect and/or eviscerating structure may be visualized on speculum examination or palpated on bimanual pelvic examination.

Clinical suspicion and evaluation — The possibility of dehiscence should be suspected in an individual who has had a hysterectomy at any point in the past and reports sudden onset of pain, vaginal bleeding, and/or a gush or "pop" of fluid from the vagina. In such patients, our evaluation focuses on the following:

●Exclude alarm findings – Alarm findings include hemodynamic instability and organ evisceration. Individuals who are hemodynamically unstable are immediately resuscitated and evaluated, typically in an emergency care or operating room setting. Patients with organ evisceration are best assessed in the operating room. Since evisceration of bowel or other pelvic organs (eg, ovary, fallopian tube) can lead to peritonitis and sepsis, all patients with eviscerations are considered to have a surgical emergency, and surgery should not be delayed for imaging. (See 'Management of dehiscence' below.)

●Focused history – A focused history is essential in triaging patients who call with potential symptoms of dehiscence to determine the clinical acuity and need for an in-person examination. The author finds the following helpful in evaluating patients with suspected vaginal cuff dehiscence:

•Assess symptoms:

-Pain (location and severity)

-Vaginal bulge

-Fever

-Vaginal bleeding

-Vaginal pressure

-Nausea

-Vaginal gush of fluid

-Vomiting

•Assess triggers:

-Recent coitus

-Heavy lifting

-Difficult bowel movement

-Vaginal instrumentation

•Assess for risk factors:

-Smoking

-Medications (steroids, immunosuppressants)

-Chronic obstructive pulmonary disease, chronic cough

-Low body mass index (BMI)

-Chronic constipation

Upon screening the patient, if there are any concerns for dehiscence, the patient should be instructed to come in for an examination. Definitive diagnosis of vaginal cuff dehiscence is made at the time of pelvic examination.

●Examination

•Abdominal examination – For the abdominal examination, the clinician particularly evaluates for suprapubic tenderness, peritoneal signs, and masses. (See "Evaluation of the adult with abdominal pain", section on 'Physical examination'.)

•Pelvic examination – The speculum examination is the key portion of the pelvic examination. The examiner assesses for vaginal discharge (purulent or physiologic); pelvic floor defects (eg, apical prolapse); and vaginal cuff abnormalities, including hematoma, cellulitis, abscess, gap, and dehiscence. If present, dehiscence appears as a full-thickness separation of the previously closed vaginal edges. Peritoneal contents may be visible or actively prolapsed through the separation. (See "The gynecologic history and pelvic examination", section on 'Speculum examination'.)

●Assess for contributing risk factors – Once the vaginal cuff dehiscence is diagnosed, the clinician should evaluate the patient for risk factors that may have predisposed her to dehiscence or potential sequelae of dehiscence, including:

•Vaginal cuff infection or abscess.

•Vaginal cuff hematoma.

•Abdominal or pelvic mass, malignancy, or foreign body.

•Bowel obstruction or perforation. (See "Etiologies, clinical manifestations, and diagnosis of mechanical small bowel obstruction in adults".)

●Determine partial or complete dehiscence – Patients may present with partial or complete dehiscence of the vaginal cuff. Complete dehiscence involves separation of the entire length of the vaginal incision whereas partial dehiscence involves separation of only a portion of the length of the vaginal incision.

●Identify pelvic organ evisceration – Vaginal cuff dehiscence with evisceration indicates expulsion of intraperitoneal contents through the separated vaginal incision. The larger the vaginal cuff dehiscence, the greater the risk of evisceration of an organ through the vaginal cuff defect. The bowel is the organ most likely to eviscerate through the separated vaginal cuff; the distal ileum is the most common bowel segment. Other reported structures include omentum, fallopian tube, appendix, and bowel epiploica [1,8,12,18,21,24,48,53].

Organ evisceration, while rare, is a surgical emergency. Bowel evisceration may lead to bowel injury, including incarceration with subsequent strangulation, necrosis, perforation, peritonitis, or sepsis. In cases of frank organ evisceration, we advise wrapping the exposed tissue in laparotomy packs that have been moistened with normal saline as the patient is prepared for further surgical management. Prompt surgical management often allows for a minimally invasive assessment and repair through a vaginal or laparoscopic route. (See 'Management of dehiscence' below.)

●Laboratory evaluation and imaging studies – Laboratory evaluation and imaging studies do not contribute to the diagnosis of vaginal cuff dehiscence. However, patients who are hemodynamically unstable, have concern for preceding infection or sepsis, have organ evisceration, or require surgical correction may require laboratory and/or imaging studies for management of those scenarios. Minimum testing with complete blood count with differential and blood type and screen are typically useful for these patients. (See 'Management of dehiscence' below.)

Differential diagnosis — A variety of different conditions can mimic symptoms of dehiscence. The differential diagnosis includes:

●Cuff cellulitis.

●Cuff hematoma.

●Vaginal prolapse.

●Cuff abscess.

●Cuff granulation tissue.

●Cuff gap or cuff space. It is important to differentiate a vaginal cuff dehiscence (separation of the vaginal incision that was previously closed) from a vaginal cuff gap (ie, an opening on the vaginal incision due to poor suture placement during closure leaving a large gap or space between sutures, or failure to reapproximate the vaginal mucosa). A gap in the vaginal cuff closure may be managed expectantly unless it is sufficiently large to pose evisceration risks.

●Cuff complications without dehiscence. Some individuals who present with posthysterectomy pelvic pain, bleeding, and/or vaginal discharge may have cuff cellulitis, which is a potential risk factor for cuff dehiscence. Since cuff cellulitis is typically a clinical diagnosis, it is important to include a pelvic examination (speculum examination and bimanual examination) at the routine postoperative visit and quickly evaluate any patient with new onset of symptoms. Other cuff complications, such as cuff abscess or hematoma (intact or draining) and granulation tissue on the vaginal incision, can also present with symptoms similar to dehiscence. If the diagnosis is not apparent on examination and there are ongoing symptoms, laboratory tests and imaging may be required for further evaluation.

Stable patients with cuff cellulitis or abscess without dehiscence should be started on antibiotics. Given the polymicrobial nature of vaginal/pelvic infections, the author typically uses broad coverage antibiotics for two weeks (eg, levofloxacin and metronidazole). Antibiotic selection should reflect resistance based on the local hospital environment. Since cuff complications, such as cuff cellulitis, abscess, and hematoma, can increase the risk of dehiscence, dehiscence precautions, including pelvic rest, should be carefully reviewed with the patient. (See 'Postoperative care and follow-up' below.)

MANAGEMENT OF DEHISCENCE — Management of vaginal cuff dehiscence depends on the patient's hemodynamic status, presence of organ evisceration, and the surgeon's training.

General approach

●All patients – Most patients receive intravenous access for fluid and possible antibiotic therapy. The author gives all patients, regardless of organ evisceration, broad spectrum combination antibiotic therapy for 24 hours (eg, ampicillin plus gentamicin plus clindamycin or levofloxacin plus metronidazole). The rationale is that vaginal cuff dehiscence exposes the peritoneal cavity to contamination from vaginal bacteria, with subsequent risk of peritonitis and sepsis. This is particularly true for patients with evisceration. However, administration of broad-spectrum antibiotics is not a universal approach, and the final decision for antibiotic therapy is based on the patient history and physical examination findings. (See "Antimicrobial approach to intra-abdominal infections in adults".)

●Dehiscence without evisceration – For patients with cuff dehiscence without evisceration, expectant or surgical management may be employed, depending on the size of the cuff separation. For patients who present with partial-thickness separation of the vaginal cuff, where the full thickness of the cuff has not entirely separated, it is important to thoroughly assess the entirety of the vaginal incision as these defects may by the "tip of the iceberg" of impaired healing of the rest of the incision. As there is no existing standard of care, each patient is individually assessed. Although some clinicians manage small dehiscences (ie, less than 1 cm separation) expectantly, in the author's practice, all recognized dehiscences are surgically closed because a partial separation (either partial-thickness separation without an actual opening on the incision or partial cuff dehiscence with a full-thickness opening on the cuff involving only a portion of the cuff length) may separate further and place the patient at risk for organ evisceration or peritonitis.

When surgical closure is elected, it is ideal to proceed with a minimally invasive approach (laparoscopic or vaginal). Patients with vaginal cuff dehiscence, stable vital signs, and no evidence of significant bowel evisceration with injury can be repaired vaginally without an abdominal survey. (See 'Route of surgical repair' below.)

●Dehiscence with organ evisceration – Patients with bowel evisceration have a surgical emergency. The bowel should be wrapped with moist laparotomy sponges, the patient placed in Trendelenburg position, and a bladder catheter inserted. Broad spectrum antibiotics that include anaerobic coverage should be initiated. Prior to surgery, the visible organ is inspected for injury, marked if possible (eg, with surgical marking pen or a suture), and then gently reduced if possible. If the surgical team does not have appropriate training in bowel resection, they should coordinate with an appropriately trained surgeon (eg, general surgery or colorectal surgery) specialists if there are any concerns for bowel injury requiring bowel resection or repair.

Patient factors for evaluation — Factors to consider for surgical planning include:

●Hemodynamic status. Unstable patients require emergency resuscitation and surgical evaluation.

●Bowel evisceration and the condition of the bowel contents (ie, viability, reducibility).

●Suspicion of other injuries (eg, bladder injury).

●Presence of pelvic floor defects that require concomitant surgical repair.

●Vaginal cuff abscess or hematoma that may require drainage and/or irrigation.

Route of surgical repair — Various surgical approaches (vaginal, open abdominal, laparoscopic, robotic, or a combination) have been described in the literature, but no standard exists [8,12,48,54].

●Vaginal repair only – Hemodynamically stable patients without bowel evisceration or evidence of infection are candidates for transvaginal repair without abdominal exploration. For highly select, stable patients with a bowel evisceration, vaginal reduction of the eviscerated bowel and vaginal cuff repair are an option if there are no signs of peritonitis or bowel injury, the bowel can be fully evaluated vaginally, and the bowel appears healthy. If there is any clinical concern for a bowel injury, or the bowel cannot be fully evaluated, abdominal exploration is performed as described in the next bullet.

●Abdominal exploration and cuff repair – Patients with hemodynamic instability, organ evisceration, and/or possible intraabdominal visceral injury or infection undergo abdominal exploration at the time of cuff repair. Other potential indications for abdominal exploration include concern for bladder injury or adhesions to the vaginal cuff. Abdominal exploration may be performed via laparoscopy or laparotomy. The mode of exploration is based on the patient's hemodynamic status, the individual surgeon's skill set, availability of equipment, and ability of the surgical approach to provide the required visualization. The author prefers a laparoscopic repair since it enables one to survey the intraperitoneal cavity for potential complications, such as bowel injuries, abscess, and hematoma, while maintaining a minimally invasive approach for cuff closure. Upon surveying the abdomen, if there is significant bowel injury requiring repair, a surgeon with expertise in intestinal surgery should be consulted, and the patient may require laparotomy.

For patients with organ injury, complete evaluation and repair may require cystoscopy and bladder repair, small bowel or colon resection, laparoscopy, and/or laparotomy. Consultation with additional surgical specialists should be obtained as indicated.

Cuff closure technique — For both abdominal and vaginal approaches, the author takes the following steps:

●Survey – Perform a full abdominal and pelvic survey for a comprehensive assessment. Call for help from other surgical specialties (eg, colorectal, general surgery, urology) if indicated. If there is purulent fluid draining from the cuff or within the pelvic cavity, obtain a culture to include both aerobic and anaerobic testing.

●Inspection for hematoma or abscess – Stable hematomas may be observed; however, hematomas that limit surgical access should be drained. Intraperitoneal expanding hematomas are opened to identify and control the bleeding source, if possible. If there is a vaginal cuff abscess, it is drained. For either hematoma or abscess, a drain may be indicated.

●Irrigation – Prior to cuff closure, the author copiously irrigates the vaginal dehiscence site.

●Removal of necrotic tissue – The author excises any areas of necrotic cuff tissue using scalpel or scissors (ie, cold cutting dissection techniques) until at least 1 cm of healthy viable tissue edges are exposed. It is important to avoid making the cuff edge overly hemostatic as excessive desiccation of the vaginal cuff may interfere with healing. Bleeding from the tissue edges is typically a sign of healthy tissue. Before trimming the cuff edges, one should identify the bladder anatomy anteriorly and bowel posteriorly to ensure these structures are at a safe distance from the cuff edge. Frequently, bladder and/or bowel adhesions must be lysed to free enough of the vaginal cuff for a safe trim and secure closure.

●Cuff closure – To close the vaginal cuff, the author uses a delayed absorbable monofilament suture (eg, polydioxanone [PDS II]) rather than catgut or short-acting synthetic suture) (table 1). Although some surgeons use a delayed absorbable braided suture, the author prefers a monofilament suture for the theoretical advantage of lower infection risk. Though there are no prospective study data examining suture placement in vaginal closures, data from abdominal closure studies suggest that sutures should be small and <1 cm in distance [55]. The closure should be full thickness, including the vaginal epithelium, vaginal musculature, and the pubocervical fascial ring. The goal is to reapproximate but not strangulate the vaginal cuff tissue. There are no conclusive data to suggest one method of cuff closure is superior. Suture type, one- versus two-layer closures, and continuous versus interrupted sutures have all been studied with no specific conclusions [15]. (See 'Suture selection' above.)

POSTOPERATIVE CARE AND FOLLOW-UP — Studies to support a data-informed approach to postoperative care are lacking. We monitor patients who have undergone vaginal dehiscence repair frequently, with routine visits scheduled at 2, 6, and 12 weeks postoperatively. At each visit, we perform a vaginal speculum examination to confirm cuff closure and absence of infection or hematoma. Vaginal discharge detected on speculum examination is sent for vaginal culture and treated if indicated. A wet prep may help identify yeast or bacterial vaginosis more quickly.

We advise patients to maintain pelvic rest for at least three months after vaginal dehiscence repair. The appropriate timing for resumption of vaginal intercourse should be based on a reassuring pelvic examination at the 12-week postoperative visit. (See 'Pelvic rest' above.)

Any underlying medical conditions that chronically increase abdominal pressures (eg, chronic cough, asthma, reflux, constipation, emesis) should be treated aggressively to minimize recurrent stress on the healing vaginal cuff.

SUMMARY AND RECOMMENDATIONS

●Definition – Vaginal cuff dehiscence is partial or complete separation of the vaginal incision after hysterectomy. It is an uncommon complication of total hysterectomy (<1 percent). (See 'Definition' above.)

●Clinical presentation – Sudden onset of pelvic or abdominal pain and vaginal discharge/bleeding are the most common clinical symptoms. The onset can range from days to years from the index surgery. (See 'Clinical presentation' above.)

●Diagnosis and management– Vaginal cuff dehiscence is diagnosed by physical examination. (See 'Diagnostic evaluation' above.)

•For patients with cuff dehiscence, we suggest surgical repair (Grade 2C). Surgical repair prevents further cuff separation and reduces the risk of future organ evisceration and peritonitis. (See 'General approach' above.)

•When surgical repair is chosen, we suggest a vaginal approach for patients with stable vital signs and no evidence of peritonitis (Grade 2C). However, we also recognize that each patient must be individually assessed, and treatment selection is based on patient and surgeon factors. (See 'Route of surgical repair' above.)

•For surgical closure of the cuff, the author uses a delayed absorbable monofilament suture that is placed at least 1 cm deep from the vaginal edge securing a full-thickness closure that incorporates the vaginal epithelium, musculature, and pubocervical ring. (See 'Cuff closure technique' above.)

●Surgical emergency – Evisceration of the bowel or other structures is a less common but much more serious sequelae of dehiscence; this constitutes a surgical emergency. Bowel evisceration can lead to bowel necrosis and subsequent peritonitis and sepsis. (See 'Clinical suspicion and evaluation' above.)

Vaginal cuff dehiscence complicated by organ evisceration, injury, or incarceration is a surgical emergency and typically requires abdominal exploration. Both laparoscopy (conventional laparoscopy or robot-assisted laparoscopy) and laparotomy are options; selection depends on the hemodynamic stability of the patient, the surgeon's training, and equipment availability. For stable patients without evidence of bowel ischemia or necrosis, the bowel may be reduced intraoperatively, and the cuff dehiscence may be repaired vaginally. (See 'Route of surgical repair' above.)

●Role of antibiotics – Patients with cuff dehiscence and cellulitis are started on broad-spectrum antibiotics (ie, coverage of gram negative and anaerobic organisms) and undergo cuff closure as outlined above. The author continues oral antibiotics with levofloxacin and metronidazole for two weeks, although other regimens are reasonable. (See 'General approach' above.)

●Postoperative care – After cuff dehiscence repair, the author evaluates patients at 2, 6, and 12 weeks postoperatively. At each visit, the author performs a vaginal speculum examination to evaluate the integrity of the closure and identify hematoma, cellulitis, or abscess, if present. (See 'Postoperative care and follow-up' above.)

●Risk factors – Vaginal cuff dehiscence is rare. Major risk factors are total robotic or laparoscopic hysterectomy, low body mass index (BMI), and cigarette smoking. Suspected but unproven risk factors include vaginal cuff infection and trauma (eg, coitus). The most common trigger for dehiscence among premenopausal individuals is coitus. (See 'Risk Factors' above.)

●Risk reduction – Strategies to minimize the risk of dehiscence include optimizing vaginal cuff tissue quality by avoiding excessive hemostasis (eg, avoiding excessive use of electrosurgery on the cuff), securing a reliable cuff closure (full-thickness closure with sutures placed 1 cm apart and more than 1 cm deep from cut edge), and avoidance of vaginal intercourse or excessive Valsalva for 8 to 12 weeks after surgery. (See 'Risk modification' above.)