European Journal of Obstetrics & Gynecology and Reproductive Biology 234 (2019) 38–42

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European Journal of Obstetrics & Gynecology and

Reproductive Biology
journal homepage: www.elsevier.com/locate/ejogrb

Full length article

Vaginal cuff dehiscence following total laparoscopic hysterectomy by

monopolar cut vs coagulation mode during colpotomy: A randomized
controlled trial
Salih Taşkın* , Yavuz Emre Şükür, Batuhan Turgay, Duygu Altin, Fırat Ortaç
Ankara University School of Medicine, Department of Obstetrics and Gynecology, Ankara, Turkey

A R T I C L E I N F O A B S T R A C T

Article history: Objectives: To assess the effect of monopolar coagulation vs cut mode during colpotomy at total
Received 18 October 2018 laparoscopic hysterectomy on vaginal cuff dehiscence.
Received in revised form 17 December 2018 Study design: We conducted this randomized controlled trial at a university hospital’s department of
Accepted 23 December 2018
obstetrics and gynecology from September 2016 through January 2018. Enrolled women were
Available online xxx
randomized 1:1 to monopolar coagulation or cut modes during colpotomy. We followed up 100
participants in the coagulation arm and 99 in the cut arm for ongoing data collection for 12 weeks after
Keywords:
surgery. Exclusion criteria were suspicion of pregnancy, previous radiation therapy, uterine size
Coagulation
Cut
exceeding 20 weeks’ gestation, contraindication for high intraabdominal pressure, clinical advanced
Monopolar energy stage malignant disease, and conversion to laparotomy before completion of colpotomy. Differences
Total laparoscopic hysterectomy between groups for categorical variables were analyzed by chi-square test and the comparisons of
Vaginal cuff dehiscence continuous variables between groups were analyzed by Student’s t-test
Results: The study groups were comparable regarding demographics and perioperative parameters. The
rate of vaginal cuff dehiscence in coagulation group (1%) was similar to that of cut group (0%) (p = 0.995).
The other vaginal cuff related complication rates were also similar.
Conclusion: Monopolar coagulation and cut modes during colpotomy at total laparoscopic hysterectomy
have similar vaginal cuff dehiscence rates and both energy modes seem acceptable for colpotomy.
© 2019 Published by Elsevier B.V.

Introduction of 17.2 (95% CI 3.9–75.9) compared with total vaginal hysterectomy,

and risk ratio of 4.9 (95% CI 1.1–21.5) compared with laparoscopy
Vaginal cuff dehiscence (VCD) after hysterectomy is characterized assisted vaginal hysterectomy [2].
by partial or complete separation of the vaginal cuff. It’s a rare event The most commonly proposed risk factors other than mode of
but may result in major morbidities like prolapse of intraabdominal surgery are previous pelvic radiation, vaginal atrophy, chronic
content and intestines. Intestinal evisceration can lead to serious steroid use, sexual intercourse, cigarette smoking, pelvic organ
sequelae such as peritonitis, intestinal injury and/or necrosis, and prolapse, postmenopausal status, low body mass index, chronic
sepsis. The overall incidence of VCD has been reported less than 1% in conditions increasing intraabdominal pressure, and other factors
large series [1–5]. However, the incidence of VCD was highest in affecting wound healing.
women who had total laparoscopic hysterectomy (TLH). In a 15-year Thermal damage induced by electrosurgical instruments during
retrospective analysis, VCD rates were reported as 0.64% after TLH, colpotomy, inappropriate suturing technique of vaginal cuff due to
0.2% after abdominal hysterectomy, and 0.13% after vaginal inexperience in laparoscopic suturing and deceptive effect of
hysterectomy [1]. Total laparoscopic hysterectomy-related enlarged view may increase risk of VCD after TLH. In addition,
dehiscence was significantly increased compared with other modes several risk factors such as suture materials used, learning curve,
of hysterectomy, with a risk ratio of dehiscence after TLH of 9.1 (95% local antiseptics and antibiotics during surgery, suture technique
CI 4.1–20.3) compared with total abdominal hysterectomy, risk ratio (one or two layer), and closure technique (continuous or
interrupted) have also been proposed as risk factors [3,6,7].
However, there’s still no consensus on the exact impacts of those
possible risk factors.
* Corresponding author at: Ankara University School of Medicine, Cebeci
Hospital, Department of Obstetrics and Gynecology, Dikimevi, Ankara, Turkey. Electrosurgery induced thermal injury during colpotomy and
E-mail address: [email protected] (S. Taşkın). the mode of energy were proposed as the main reasons for higher

https://doi.org/10.1016/j.ejogrb.2018.12.034
0301-2115/© 2019 Published by Elsevier B.V.
 S. Taşkın et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 234 (2019) 38–42 39

rates of VCD after TLH [2,8]. However, there is no exact data to laparoscopic bipolar forceps was used to stop brisk arterial
prove whether using energy or mode of energy increase the risk of bleeding from the vaginal cuff. The uterus was removed vaginally
VCD. Our hypothesis was that using cut or coagulation currents for in all of the operations. If the uterus was too big to remove vaginal
colpotomy during TLH are not associated with increased risk of morcellation was performed by using a scalpel.
VCD. This randomized controlled trial investigates the effects of The vaginal cuff was closed using barbed size 0 suture with
two monopolar current modes, coagulation and cut, during unlocked fashion (V-Loc, Covidien, USA). Vaginal cuff suturing was
colpotomy on postoperative vaginal cuff complication rates. The initiated from the right side and attachment of uterosacral ligament
primary outcome was VCD detected by vaginal examination. to upper posterior vagina was included to the first bite. Full
thicknesses of posterior and anterior vaginal walls were also
Materials and methods included and suturing was continued to the left uterosacral ligament
and then the suture was turned back (towards the medial part of
The present study, a randomized controlled trial (Clinicaltrials. vaginal cuff) with 2 additional bites. Barbed suture was cut at the level
gov registry number NCT02879487), was conducted at a university of vaginal cuff to avoid suture related complications (Movie clip S1).
hospital’s department of obstetrics and gynecology, from Septem- Patients were informed about sexual intercourse abstinence for
ber 2016 through January 2018. The institutional Ethical Commit- 6 weeks after surgery. All participants were examined twice during
tee approved the study (approval number: 12-562-16) and the the follow-up period, at 6 and 12 weeks. Patients were asked for
paper is written according to the CONSORT statement. their complaints; vaginal cuff was visualized by speculum
We assessed eligibility of potential participants who were examination and transvaginal ultrasound was performed to detect
scheduled for hysterectomy either for benign or malignant any cuff related lesions such as hematomas or abscesses.
conditions prior to surgery. Potential participants received The primary end point of our study was to compare the rate of
standardized counseling about the coagulation and cut modes VCD between two study groups. Secondary end points were
for colpotomy at TLH. Written informed consent was obtained from postoperative vaginal cuff abscess, hematoma, blood loss, postop-
each patient. The inclusion criteria were women scheduled for erative hemoglobin drop and duration of hospital stay.
hysterectomy due to benign or malignant gynecologic reasons, and This study was performed as a non-inferiority trial, designating
agreed to randomization for the present study. Exclusion criteria cut, the commonly used method for cuff opening, as the
were as follows: suspicion for a pregnancy, uterine size exceeded comparison for the effects of coagulation toward vaginal cuff
20 weeks’ gestation to constitute a more standardized cohort, dehiscence. The incidence of vaginal cuff dehiscence was
previous radiation therapy, contraindication for Trendelenburg calculated as 0.2% according to the data obtained from our
position and/or high intraabdominal pressure, clinical advanced previous surgeries. The number of patients required for each group
stage malignant disease, conversion to laparotomy before comple- was determined on the basis of the non-inferiority hypothesis. For
tion of colpotomy incision and detachment of uterus from the non-inferiority of the coagulation group versus cut group, a
vagina. Demographic data, indications for surgery, intra- and post- maximum difference of 1.5% (margin of non-inferiority) on the
operative data were recorded were recorded along with primary incidence of vaginal cuff dehiscence was considered as acceptable.
and other outcome parameters. Therefore, we calculated that a study with 95 patients per group
Following application of inclusion and exclusion criteria the would have at least 80% power, with one-sided type I error of 0.05.
enrolled participants were randomized to one of the following two Taking into consideration of the 10% dropout rate, we decided to
groups: monopolar coagulation mode vs monopolar cut mode at the enroll 105 patients in each group.
stage of colpotomy. Randomization was performed using sealed Data analyses were performed by using SPSS Version 21.0 (IBM
envelopes. At the beginning of the study 210 envelopes were Corporation, Armonk, NYC, USA). Shapiro-Wilk test was used to
prepared,105 for each group, according to the sample size calculation. test distribution of normality. Differences between groups for
The envelopes were kept in the operating room and an envelope was categorical variables were analyzed by chi-square test and the
selected randomly at the stage of colpotomy and the surgeon was comparisons of continuous variables between groups were
notified of the randomization assignment. All surgeries were analyzed by Student’s t-test according to results of their normality
performed by the same surgeon (S.T.) with assistance of a fellow. tests. P value less than 0.05 was considered statistically significant.
The participants were blinded to the technique performed. In
addition, the outcome adjudicator was blinded to the colpotomy Results
technique. All patients were evaluated by the same author (S.T.) at
6 and 12 weeks following surgery. From September 2016 through January 2018 we assessed a total
All patients underwent TLH using a standardized approach. The of 217 women for eligibility. Seven of them excluded from the
operation was performed under general anesthesia in lithotomy study because of clinical advanced stage malignancy (n = 3),
position and a single dose of prophylactic antibiotic was given. extremely large uterus (n = 3) and lung disease preventing high
After perineal and vaginal disinfection with polyvinylpyrrolidone intraabdominal pressure (n = 1). Then, 210 participants were
iodine 10% (Batticon1, Adeka, Samsun, Turkey) the cervix is enrolled and randomized during the study period, 105 to each
grasped with Pozzi tenaculum forceps and a uterine manipulator group (Fig. 1). During the post-operative follow-up period five from
was inserted to assist the surgery. A 10-mm, 0-degree laparoscope coagulation arm and six from cut arm were lost to follow-up within
was used in all cases. Vessel sealing was performed using the first 12 weeks. All patients who could not be followed-up
conventional bipolar graspers (RoBi rotating bipolar forceps, indicated that they lived in another city at a long distance. Finally,
Karl Storz, Tuttlingen, Germany) or advanced bipolar devices we analyzed results of 100 participant in coagulation arm and 99
(e.g., LigaSure, Covidien-Medtronic, Dublin, Ireland). participants in cut arm. The mean age and BMI of the trial
Colpotomy was performed by circumferential vaginal incision population were 52.1  9.0 years and 29.1  4.0 kg/m2, respectively.
with monopolar hook using a 35 W pure cut or coagulation current Patient characteristics and indications for surgeries are shown in
(ForceTriad Energy Platform, Medtronic, MN) according to Table 1. There were no statistically significant differences between
randomization. While 30–40 W is the most commonly used the study groups regarding demographics. The indications for
setting for gynecologic laparoscopy worldwide, we preferred surgery were similar between the groups. The rate of premalignant
35 W for all participants for standardization. Bipolar energy set at or malignant indications were similar between the groups (48% vs
40 W (ForceTriad Energy Platform, Medtronic, MN) applied with 44.4%, P = 0.670). Fifty-eight patients had previous abdominal or
40 S. Taşkın et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 234 (2019) 38–42

Fig. 1. Flowchart of the study.

Table 1 pelvic surgery including cesarean section (n = 24), cholecystectomy

Baseline characteristics of the study groups. (n = 12), appendectomy (n = 11), cesarean section and cholecystec-
Coagulation Cut P value
tomy (n = 3), cholecystectomy and appendectomy (n = 3), diagnos-
(n = 100) (n = 99) tic laparoscopy (n = 2), myomectomy (n = 1), endometriosis surgery
Age, years 51.9  9.2 52.3  8.8 0.723
(n = 1) and laparoscopic tubal ligation (n = 1).
BMI, kg/m2 28.7  3.9 29.6  4.1 0.136 Perioperative data and follow-up outcomes are presented in
Postmenopausal, n (%) 45 (45) 47 (47.4) 0.309 Table 2. The rate of participants who underwent bilateral pelvic
Previous abdominal surgery, n (%) 30 (30) 28 (28.3) 0.229 (paraaortic) lymph node dissection in addition to TLH were
Systemic diseases, n (%) 50 (50) 47 (47.5) 0.722
comparable between the groups (32% vs 32.4%, P = 0.123). The
Smoking, n (%) 14 (14) 11 (11.1) 0.669
Indications for surgery, n (%) 0.670 number of adjuvant radiotherapies were also similar between
Benign Disorders 52 (52) 55 (55.5) the groups. In addition, the groups were comparable regarding the
Fibroid 32 34 duration of operation, estimated blood loss, and duration of
Ovarian cyst / Adnexal mass 4 3 hospitalization. The rate of VCD in the coagulation group (1%) was
Abnormal uterine bleeding 10 11
Endometriosis 6 5
similar to that of the cut group (0%). The only VCD was a partial one
Tuboovarian abscess 1 0 and it was a 1 cm defect at the left corner of the cuff. It was
Premalignant or Malignant Disorders 48 (48) 44 (44.4) vaginally sutured by local anesthesia. There was no complete
Endometrial cancer 33 31 separation. The other vaginal cuff related complication rates were
Endometrial hyperplasia 10 9
also similar between the groups.
Uterine leiomyosarcoma 1 0
Placental site trophoblastic tumor 0 1
Cervical cancer stage Ia1 2 1 Comment
Cervical carcinoma in situ 1 1
Borderline ovarian tumor 1 1 This randomized controlled trial demonstrated that the
Note: BMI: body mass index. coagulation and cut modes during colpotomy were similar to
 S. Taşkın et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 234 (2019) 38–42 41

Table 2 may decrease or avoid VCD. Minimally invasive surgeons should

Perioperative factors and outcome parameters.
improve their laparoscopic suture skills. Until gaining enough skill,
Coagulation Cut P value vaginal visualization of the cuff and when necessary additional
(n = 100) (n = 99) suture through vagina might be feasible.
Surgical intervention, n (%) 0.123 In addition to experience, the suturing technique was also
TLH + salpingectomy 8 (8) 9 (9.1) assessed for VCD risk. Recently, Zhou et al. reported that vaginal
TLH + BSO 60 (60) 58 (58.5)
cuff closure by unidirectional barbed suture had some advantages
TLH + BSO + BP(P)LND 32 (32) 32 (32.4)
Antibiotic prophylaxis, n (%) 0.658
over interrupted vicryl suturing such as less granulation tissue,
Cefazoline 97 (97) 97 (98) shorter operation time, and lower estimated blood loss [14].
Metronidazole and Ciprofloxacine 3 (3) 2 (2) However, they could not show a statistical difference in cuff
Radiation therapy within 3 months, n (%) 0.679 healing time, VCD or cellulitis [14]. On the other hand, continuous
Vaginal radiotherapy 12 10
suturing of the cuff was reported to have a lower risk of VCD [3].
External pelvic and vaginal radiotherapy 2 1
Chemotherapy and vaginal radiotherapy 0 1 Another important factor studied was the type of suture material.
First intercourse postoperatively, n (%) 0.870 Although barbed sutures have been associated with shorter
<6th week 3 (3) 2 (2) operation time and less intraoperative blood loss, the overall
6th -12th weeks 55 (55) 53 (53.5)
postoperative complication rates seem to be similar with
Abstinence within 12 weeks 42 (42) 44 (44.4)
Duration of operation, min. 94  30 92  31 0.702
conventional suturing [15]. However, two recent studies reported
Estimated blood loss, ml 188  95 174  92 0.322 a dramatic decrease of VCD by using barbed sutures [16,17].
Hemoglobin drop after surgery, g/dL 0.8  0.4 0.7  0.5 0.349 Although there are concerns about increased risk of VCD by
Bipolar energy during colpotomy, n (%) 17 (17) 24 (24.2) 0.224 using coagulation mode for colpotomy, less bleeding during
Blood transfusion, n (%) 2 (2) 3 (3) 0.682
colpotomy incision may provide clearer laparoscopic view and
Duration of hospitalization, days 1.7  1.6 1.9  0.9 0.389
Vaginal cuff dehiscence, n (%) 1 (1) 0 (0) 0.995 can make vaginal cuff closure easier. Also, according to our clinical
Vaginal cuff hematoma, n (%) 0 (0) 1 (1) 0.996 observations, less smoke by coagulation mode may be advanta-
Vaginal cuff abscess, n (%) 1 (1) 0 (0) 0.995 geous during colpotomy. As mentioned above there were no
Note: TLH: total laparoscopic hysterectomy; BSO: bilateral salphingo-oophorecto- unfavorable effects of these two methods on VCD and our results
my; BP(P)LND: bilateral pelvic (para-aortic) lymph node dissection. also showed that there were no significant adverse effects in terms
of other intra- and post-operative outcomes.
The standardization of all surgical steps by a single surgeon,
each other regarding VCD. The incidences of VCD were similar in except using cut or coagulation current for colpotomy, was the
the study arms and it does not support the thoughts that using most important strength of our study. As a limitation of our study,
monopolar energy, particularly coagulation current, is associated effects of different powers of monopolar energy was not evaluated.
with increased VCD risk after TLH. In addition, we also failed to In addition, although VCD mostly occurs within three months
show any effect of monopolar energy mode on other vaginal cuff postoperatively, the follow-up period of 12 weeks might be short
related complications. and VCD incidence could have change with longer follow-up as it
One third of our patients underwent lymphadenectomy and can occur even years after hysterectomy [8,13,18]. Another
some of them received postoperative radiotherapy. Although limitation was the design of monocentric survey with only one
intraabdominal lymphatic leakage and radiotherapy suggested as surgeon. Performing a multicentric study could possibly be more
predisposing factors for VCD, there were no vaginal cuff related advantageous.
complications even in those cases in our study population [9]. In conclusion, using cut or coagulation mode during colpotomy
Furthermore, while the ratio of malignant cases and adjuvant at TLH does not seem to be a risk factor for VCD. We suppose that
therapies were similar between the two study groups, this VCD can be avoided by proper and standardized vaginal cuff
situation could not affect the results. closure technique regardless of the energy mode used for
There were no randomized trials comparing monopolar cut and colpotomy. Future studies should focus on the quality of
coagulation for VCD risk. In a retrospective study, VCD rate was laparoscopic closure as a variable in VCD occurrence.
reported 4.1% and 0.4% by using coagulation or cut modes,
respectively, after robotic hysterectomy [10]. The median thermal
Conflicts of interest
damage distance from colpotomy border was reported as 0.7 mm
(range: 0.2 to 1.6 mm) with monopolar currents and there were no
The authors have no conflicts of interest.
differences for thermal damage distance and vaginal cuff
complications including VCD for monopolar v-mod and cut/
Acknowledgements
coagulation arms [11]. We believe in that suturing of vaginal cuff
from few millimeters from vaginal edge including full thickness of
None.
vaginal wall and mucosa, as described, could be enough to
overcome the risk of thermal damage on VCD after TLH.
Appendix A. Supplementary data
Vaginal cuff dehiscence risk was reported 3–17 times higher after
TLH [1]. However, this risk become equal to other hysterectomy types
Supplementary material related to this article can be
if vaginal cuff was closed vaginally [12]. These results suggest that
found, in the online version, at doi:https://doi.org/10.1016/j.
inexperience in laparoscopic vaginal cuff suturing may lead to higher
ejogrb.2018.12.034.
VCD rates after TLH. Hur et al. reported 2.76% VCD rate after TLH
between 2001 and 2005 and this rate was decreased to 0.76%
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