Vaginal Cuff Complications

Objectives: Vaginal cuff dehiscence is a serious and rare complication in gynecologic surgery. Clinical presentation includes abdominal or pelvic pain, vaginal pressure, vaginal bleeding, or persistent vaginal discharge. Vaginal cuff evisceration is identified 35-67% of the time. It involves the protrusion of the small bowel contents into the vagina and represents a surgical emergency. Early recognition and management are warranted. To improve learners’ awareness and preparedness in managing this surgical complication, we created a surgical video to discuss the management and techniques used for this surgical complication.

Methods: Our patient presented with persistent vaginal discharge associated with pelvic pain four weeks from a robotic hysterectomy. Physical examination demonstrated a complete vaginal cuff dehiscence with bowel content at the vaginal cuff edges. The small bowel was reduced intraperitoneally after examining the viability of the tissue. She underwent a transvaginal cuff repair using interrupted delayed absorbable sutures. The patient was followed up 6 weeks after surgery and no complications were noted. When vaginal cuff complications are encountered, several considerations should be taken including (1) physician preparedness and comfort in managing this complication, (2) ensuring proper help is available in cases when an abdominal exploration of the bowel is needed, (3) administration of intraprocedural antibiotic prophylaxis and evaluate the need of continuing these, (4) dissection and replacement of the bowel contents intraperitoneally, (5) evaluate vaginal cuff edges and secure healthy tissue edges, (6) secure suture placement to allow a one-centimeter distance from the vaginal cuff edges and (7) suture placement in an interrupted manner to allow drainage of fluid through the vaginal canal. Postoperative counseling emphasizing pelvic rest for up to 12 weeks is needed to ensure proper healing and prevent a recurrence.

Clinical Relevance: Most of the time, a vaginal approach for vaginal cuff dehiscence and evisceration is a feasible option, especially if the bowel is viable and easily reduced. When managing this complication, technical considerations and the availability of support services should be considered. Given the rarity of vaginal cuff dehiscence, discussion of surgical techniques and management is essential between providers to aid in handling this complication.