Issues around vaginal vault closure

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Issues Around Vaginal Vault Closure Moustafa M et al. Issues around vaginal vault closure. TOG 2019;21:203–208. doi:10.1111/tog.12573

4.9% / 0.29% / 0.12% 1.8–11.6% 25–59% VCD: LAPAROSCOPIC / ABDOMINAL / VAGINAL INCIDENCE OF POST-HYSTERECTOMY VAULT VAULT HAEMATOMA AFTER VAGINAL ROUTE PROLAPSE HYSTERECTOMY

DO N' T-M IS S FA C TS

  1. VCD by route: laparoscopic 4.9% > abdominal 0.29% > vaginal 0.12%

  2. VCD = surgical emergency – Trendelenburg, moist exposed bowel, antibiotics/hydration, then ACOG lavage/debridement/re-suture

  3. Early absorbable sutures → VCD 2.5%; delayed absorbable (PDS) → VCD 0.7%

  4. Barbed vs polyglycolic acid suture: time to VCD 73 vs 29 days; 4-week tensile strength 80% vs 25%

  5. VVP incidence 1.8–11.6% (post-hysterectomy vault prolapse ~36/10,000); McCall culdoplasty best evidence for vault support

  6. RCOG: do not use subtotal hysterectomy to prevent post-hysterectomy vault prolapse

  7. Vault haematoma after vaginal hysterectomy: 25–59% incidence, usually asymptomatic

  8. Sacrocolpopexy success 78–100%; higher mesh erosion with Mersilene vs Prolene

EVIDENCE TIERS AT A GLANCE

Reduce VCD risk: monopolar cutting colpotomy, sutures > electrocoagulation, full-thickness 2-layer PDS ≥1cm from edge, barbed sutures

No proven benefit: subtotal hysterectomy for PHVP prevention, routine vault drainage

ABBREVIATION KEY

VCD — vaginal cuff dehiscence PDS — polydiaxone (delayed absorbable suture)

VVP — vaginal vault prolapse ACOG — American College of Obstetricians and Gynecologists

PHVP — post-hysterectomy vault prolapse RCOG — Royal College of Obstetricians and Gynaecologists

Source: The Obstetrician & Gynaecologist (TOG), RCOG journal — Moustafa M et al. Issues around vaginal vault closure. TOG 2019;21:203–208. doi:10.1111/tog.12573

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