Vaginal cuff dehiscence associated with laparoscopic hysterectomy

To the editors: I would like to congratulate Dr Blikkendaal and colleagues for their article on the incidence of vaginal cuff dehiscence (VCD) associated with laparoscopic hysterectomy [1]. VCD is a potentially severe adverse event occurring in between 1 and 3 % of patients following a laparoscopic hysterectomy. Risk factors for VCD are largely unknown.

The authors analyze their series of 331 total laparoscopic hysterectomy cases. Vaginal vault closure was achieved transvaginally, laparoscopically interrupted, and with a laparoscopic running suture. The authors conclude that a total of eight VCDs occurred without an association between baseline patient, surgical factors, or the suture technique with the incidents of VCD.

We also observed a couple of VCDs using the V-Loc barbed suture [2]. Both patients had a total laparoscopic hysterectomy for prophylactic reasons. Surgery was uncomplicated, and blood loss was minimal. VCD occurred after 2 and 4 months, respectively. The common factor in both patients was a history of breast cancer and chemotherapy. Using identical surgical and suturing technique, it may well be that patient characteristics such as a history of previous chemotherapy rather than suture technique and material will impact on the risk of VCD.

Due to the low incidence of VCD, large perspective randomized trials may be infeasible. However, and very concerning, governing bodies approve sutures and other surgical devices, such as meshes, without prior clinical testing. Not a single prospective evaluation of the V-Loc barbed suture is available in a PubMed literature search (PubMed 2000 till 2013).

As an alternative, outcomes of surgery using novel devices should be recorded prospectively within a clinical trial setting prior to accreditation and registration. At least nonrandomized data that inform about incidence rates should be made available to surgeons prior to using those devices on live patients. In addition, surgeons should be aware about the outcomes from their surgery. Audit tools will assist to provide feedback and comparative outcomes from peers for benchmarking [3].