Re: JSLS. 2013;17:414-417. Effects of electrosurgery and vaginal closure technique on postoperative vaginal cuff dehiscence.

Dear Editor,

We read with much interest the article by Fanning et al[1] entitled “Effects of Electrosurgery and Vaginal Closure Technique on Postoperative Vaginal Cuff Dehiscence,” regarding the rate of vaginal cuff dehiscence after laparoscopic hysterectomy. The issue is extremely important because vaginal cuff breakdown can cause severe postoperative morbidity and impair patients' quality of life.

In their article Fanning et al[1] compare 2 different modalities of vaginal cuff closure at the end of an otherwise totally laparoscopic procedure: transvaginal versus laparoscopic suturing of the vault. The results of their investigation showed that the rate of vaginal cuff dehiscence is significantly higher when closure is accomplished laparoscopically.

The study by Fanning et al[1] adds further evidence to the results of a recent meta-analysis published by our group and including >13 000 patients who underwent endoscopic hysterectomy.[2] Our data clearly showed that endoscopic closure of the vaginal cuff (whether performed by laparoscopy or by robotics) is significantly associated with postoperative vaginal cuff complications (including dehiscence) compared with transvaginal suturing. These findings were confirmed and reinforced in a subsequent publication on >12 000 hysterectomies performed in 6 Italian centers.[3]

Although a vast number of gynecologic surgeons still prefer laparoscopic closure, we believe that data are rapidly accumulating in support of the use of a transvaginal approach to suture the vaginal stump at the end of a hysterectomy. This modality not only seems less time-consuming and more easily accomplished but also appears safer compared with the laparoscopic approach.

We now wonder whether it is time to clearly define transvaginal closure as the gold standard at the end of a totally endoscopic hysterectomy. Reducing the incidence of vaginal cuff dehiscence would overall reduce one of the worst postoperative complications of this procedure. Women who have vaginal breakdown after hysterectomy have a non-negligible risk of sepsis, peritonitis, and intestinal obstruction, with the potential need for bowel resection. We are convinced that every factor that may aid in decreasing the rate of such a threatening condition improves the level of assistance delivered to the patient.