The wide application of laparoscopic total hysterectomy in the clinic has brought many benefits to patients but also brought many complications, such as subcutaneous emphysema, abdominal wall vascular injury, various organ injuries, epigastric and scapular pain, etc. Vaginal cuff dehiscence is a rare but serious complication following laparoscopic total hysterectomy. There are many risk factors for vaginal cuff dehiscence, such as menopause, anemia, diabetes, constipation, and cough leading to increased abdominal pressure, poor prognosis of the vaginal cuff, premature sexual life after operation, etc. The total incidence of vaginal cuff dehiscence after hysterectomy was 0.14%-0.28%; compared with a transabdominal hysterectomy and transvaginal hysterectomy, the incidence of vaginal cuff rupture after laparoscopic total hysterectomy is higher, with an incidence rate of 0.6%-1.14%. Due to laparoscopic operation with energy instruments, the increased incidence rate may also be damaged by thermal instruments, and the width and strength of sutures are not enough. As a minimally invasive operation, early recovery of daily activities and increase of abdominal pressure may, in turn, affect the healing of vaginal fornix.
There were 1459 cases with laparoscopic total hysterectomy in our hospital, 9 cases with vaginal cuff dehiscence after the operation, the incidence rate was 0.617%, of which 2 cases were due to intestinal prolapse through the vagina. Emergency exploratory laparotomy was performed without incarceration and necrosis of the intestinal canal.4 cases were sutured through the vagina, 3 cases of conservative treatment. All patients recovered well, there was no peritonitis or other complications, and the prognosis was good. Univariate analysis showed that preoperative hemoglobin < 90g/L, intermittent suture, and the first sexual lifetime < 3 months after the operation are related to the occurrence of vaginal cuff dehiscence after laparoscopic total hysterectomy. Multivariate Logistic regression analysis showed that preoperative hemoglobin < 90g/L and the first sexual lifetime < 3 months after the operation are independent risk factors for the occurrence of vaginal cuff dehiscence after laparoscopic total hysterectomy. After surgical trauma, the patient's resistance decreased, coupled with preoperative anemia, which affected postoperative recovery and wound healing, resulting in poor healing of the vaginal cuff. Premature sexual life and frequent sexual life following surgery impose direct external force on the vaginal cuff, resulting in vaginal cuff dehiscence. At the same time, vaginal PH increases after sexual life, vaginal microecology is destroyed, and flora imbalance is easy to cause vaginitis, thus affecting the healing of the vaginal cuff. Multiple factors interact and the incidence rate of vaginal cuff dehiscence increases[8, 9]. Therefore, correcting anemia before operation and prohibiting sexual life within 3 months after the operation can reduce the occurrence of vaginal cuff dehiscence. Follow-up of patients should be strengthened after the operation, and timely treatment of vaginal cuff bleeding, inflammation, and poor healing should be carried out to reduce the occurrence of vaginal cuff dehiscence.
Laparoscopic hysterectomy has high surgical difficulty, with a long learning curve for surgical methods. The operation of instruments under the microscope, the proficiency of suture techniques, and the choice of suture methods may all have an impact on the occurrence of complications[10, 11]. Laparoscopy is characterized by the expansion of the field of vision. Surgeons are easy to misidentify the distance during suture, resulting in insufficient suture width and affecting later healing. Therefore, special attention should be given to the suture width of the vaginal cuff. At the same time, clinicians should improve the operation skills under a microscope, be familiar with pelvic anatomy, avoid damaging periodic tissues and organs, reduce intraoperative bleeding and shorten the operation time, which will play a certain role in reducing the occurrence of complications of vaginal cuff dehiscence[12, 13]. In our hospital, the risk of thermal injury caused by ultrasonic scalpel incision of the vaginal wall is low in comparison to unipolar and bipolar. However, due to the unique characteristics of laparoscopic energy instrument operation, thermal injury remains a risk factor that must be overlooked.
Other possible influencing factors, such as postoperative measures to reduce intraperitoneal pressure, may also be conducive to vaginal cuff healing, in theory, proper exercise, attention to diet structure, keeping stool unobstructed, using stool softener when necessary, preventing constipation, and treating chronic long-term cough and vomiting. Postmenopausal women are prone to flora imbalance and vaginal inflammation due to the decrease of estrogen level and vaginal resistance, which will also affect the healing of the cuff. Appropriate estrogen supplement therapy for postmenopausal women may also contribute to the healing of the cuff.
The benefits of laparoscopic total hysterectomy are numerous; yet, the complications associated with this operation need our attention. This research reveals the related factors that may cause this complication through more than 1,000 operations in our hospital over the last 7 years, and established corresponding preventive measures to limit the occurrence of complications. However, there are still many deficiencies and more cases need to be accumulated and conducted further research.