Factors influencing vaginal cuff dehiscence after laparoscopic hysterectomy and the psychological state of the patients

Abstract

BACKGROUND

Despite laparoscopic total hysterectomy provided more benefits to patients and has become one of the most commonly used surgical methods for total hysterectomy. However, vaginal cuff dehiscence is a serious complication after laparoscopic total hysterectomy and so far, there are limited studies on vaginal cuff dehiscence after a total hysterectomy.

AIM

To investigate the factors influencing vaginal cuff dehiscence after laparoscopic hysterectomy and the psychological state of the patients.

METHODS

This study retrospectively, univariately, and multivariately analyzed the clinical data of patients who experienced vaginal cuff dehiscence after laparoscopic hysterectomy in Yuyao People’s Hospital from January 2015 to December 2021. Logistic regression was utilized to analyze the high-risk factors of vaginal cuff dehiscence.

RESULTS

Among 1459 cases with laparoscopic hysterectomy, 9 reported vaginal cuff dehiscence postoperatively, with an incidence of 0.617%. Univariate logistic regression analysis revealed that preoperative hemoglobin value [odds ratio (OR) = 5.12, P = 0.016], vaginal cuff suture method (OR = 0.26, P = 0.048), and postoperative first sexual lifetime (OR = 15.86, P = 0.002) were associated with vaginal cuff dehiscence following laparoscopic hysterectomy. Multivariate logistic regression analysis revealed that preoperative hemoglobin value of < 90 g/L (OR = 5.17, P = 0.015) and time interval between postoperative first sexual life and operation of < 3 months (OR = 54.00, P = 0.004) are independent risk factors for vaginal cuff dehiscence after laparoscopic hysterectomy.

CONCLUSION

Postoperative hemoglobin and the time interval between postoperative first sexual life and operation were the independent factors of developing vaginal cuff dehiscence after laparoscopic hysterectomy.

Key Words: Laparoscopy; Hysterectomy; Vaginal cuff dehiscence; Hemoglobin value; First sex time

Core Tip: Laparoscopic total hysterectomy has been widely utilized in the clinic, which has the advantages of minimally invasive techniques. However, vaginal cuff dehiscence is a serious complication after laparoscopic total hysterectomy. This study aims to investigate the factors influencing vaginal cuff dehiscence after laparoscopic hysterectomy and the psychological state of the patients.

INTRODUCTION

Laparoscopic total hysterectomy has been widely utilized in the clinic, which has the advantages of minimally invasive techniques, such as fewer traumas, less pain, quick recovery, a short length of stay, etc., with the development of minimally invasive surgery in gynecology. It has provided more benefits to patients and has become one of the most predominantly used surgical methods for total hysterectomy. Therefore, it has gradually become the first choice by an increasing number of doctors and patients. However, some complications intra- and postoperatively have a greater effect on the prognosis of patients[1]. Vaginal cuff dehiscence is a serious complication following laparoscopic total hysterectomy[2]. So far, studies on vaginal cuff dehiscence following a total hysterectomy are limited, because only a few papers are related to such events. A few papers emphasized the very low overall incidence of dehiscence[3], ranging from 0.14% to 0.28%, with the incidence of dehiscence following laparoscopic total hysterectomy as the highest (1.35%), and once it occurs, it may be a fatal event due to its uncertain incidence. The majority of the reports in the literature involve a single case. Therefore, related case data for the serious complication of vaginal cuff dehiscence must be collected to identify the relevant factors, reduce the aforementioned risk factors, improve surgical techniques and instruments, and prevent the occurrence of such complications. The analysis involved the medical records of 1459 patients who underwent a laparoscopic total hysterectomy in our hospital in the past 7 years. This study understands the factors related to vaginal cuff dehiscence, actively prevents the corresponding possible causes, guides our clinical work, and reduces the occurrence of vaginal cuff dehiscence after laparoscopic total hysterectomy.

MATERIALS AND METHODS

Clinical data

A total of 1459 patients aged 31–79 years (50.70 ± 6.39) years, with body mass index (BMI) of 23.73 ± 3.24, underwent a laparoscopic total hysterectomy at our hospital from January 2015 to December 2021. Table 1 shows the baseline information of the patients.

Table 1 Baseline data of the patients, n (%)/mean ± SD.

Characteristic	Patients (n = 1459)
Age (years old)	50.70 ± 6.39
BMI (kg/m2)	23.73 ± 3.24
Menopausal	411 (28.2)
Disease type
Uterine fibroids	756
Adenomyosis	265
Adenomyosis combined with uterine fibroids	66
Cervical intraepithelial neoplasia grade III and carcinoma in situ	230
Mixed endometriosis	28
Benign ovarian tumor	32
Atypical hyperplasia of endometrium	80
Placental site trophoblastic tumor	2

BMI: Body mass index.

Operative methods

Preoperatively, all patients were well prepared for vaginal cleaning. The procedure was conducted under general anesthesia with endotracheal intubation. The bladder lithotomy position was maintained, with the head low and the buttocks high. The vital signs of patients, including blood pressure, heart rate, oxygen saturation, and airway pressure, were monitored intraoperatively. Conventional disinfection, drape application, indwelling catheterization and placement of uterine lifting cup, umbilical air abdominal needle, pneumoperitoneum pressure maintained at 12–14 mmHg, 10 mm trocar puncture, endoscope, a 10 mm trocar, and a 5 mm trocar in the left lower abdomen, and a 5 mm trocar in the right lower abdomen. Ultrasonic scalpel cutting, bipolar electrocoagulation, and sutures were used throughout the operation steps of laparoscopic total hysterectomy. Postoperatively, infection was prevented and catheterization was indwelled for 72 hours, and the patient was discharged approximately 5 days later.

Analytical indicators

The related data of patients who underwent laparoscopic total hysterectomy, including age, BMI, menopause, surgical reasons, complications, preoperative hemoglobin, length of surgery, suture method, postoperative hemoglobin, postoperative body temperature, and postoperative sexual lifetime, were analyzed.

Psychological resilience, coping style, and social support were evaluated 1 week postoperatively in all patients: (1) Psychological resilience: The patient was assessed with the Connor–Davidson Resilience Scale (CD-RISC), consisting of three dimensions, namely, strength (8 items), optimism (4 items), and resilience (13 items). Each item is scored from 0 to 4, indicating never, rarely, sometimes, often, and almost always, respectively, with a total score of 100 points. The higher the score, the better the psychological resilience of the patient. The retest validity of the scale was 0.837, with a Cronbach’s alpha coefficient of 0.861; and (2) Coping style: The Simplified Coping Style Questionnaire (SCSQ) was utilized to evaluate the coping style of the patients. The questionnaire was categorized into positive coping (12 items) and negative coping (8 items), with a total of 2 dimensions and 20 items. Each item was scored as 0–3 points, indicating non-adoption, occasional adoption, sometimes adoption, and frequent adoption, respectively, with a total score of 60 points, consisting of 24 and 36 points for negative and positive coping, respectively. The coping tendency was equal to the standardized score for positive coping minus the standardized score for negative coping, with scores of ≥ 0 and < 0 points indicating positive and negative in the patient. The scale retest validity is 0.827, with Cronbach’s alpha coefficient of 0.859.

Statistical analysis

Statistical Package for the Social Sciences version 23.0 statistical software was used for data analyses. The measurement data was presented as the mean and SD. Univariate and multivariate logistic regression analyses were used for multiple factors. P values of < 0.05 indicate a statistically significant difference.

RESULTS

General condition

A total of 1459 cases underwent laparoscopic total hysterectomy, among which 9 experienced vaginal cuff dehiscence postoperatively. The incidence rate was 0.617%. Additionally, 1 case was menopausal and 6 cases had sexual life within 3 months postoperatively. Further, 5 cases were uterine fibroids, 2 were adenomyosis, 2 were cervical intraepithelial neoplasia grade III, and 4 were hemoglobin of < 90 g/L (Table 2).

Table 2 Relevant data of 9 patients.

Case	Disease	Preoperative hemoglobin value (g/L)	Review 1 month after surgery	Clinical symptoms	Vaginal cuff rupture time after surgery (days)	Reason	Treat
1	Uterine fibroids	118	-	Vaginal bleeding	15	Infect	Conservative treatment
2	Uterine fibroids	115	-	Asymptomatic	24	Infect	Conservative treatment
3	Uterine fibroids	145	-	Asymptomatic	30	Sex	Transvaginal repair
4	Adenomyosis	68	Basic healed	Vaginal bleeding	48	Infect and sex	Transvaginal repair
5	Uterine fibroids	82	Basic healed	Vaginal bleeding	55	Infect and sex	Transvaginal repair
6	Cervical intraepithelial neoplasia	125	Fully healed	Asymptomatic	75	Sex	Exploratory laparotomy
7	Adenomyosis	80	Fully healed	Asymptomatic	98	Sex	Exploratory laparotomy
8	Uterine fibroids	78	Fully healed	Asymptomatic	102	Sex	Transvaginal repair
9	Cervical intraepithelial neoplasia	133	-	Vaginal bleeding	130	Infect	Conservative treatment

Univariate regression analysis results of vaginal cuff dehiscence after laparoscopic total hysterectomy

Among 1459 patients who underwent the laparoscopic total hysterectomy, 9 experienced vaginal cuff dehiscence and were analyzed in terms of age, BMI, menopause, surgical reasons, complications, preoperative hemoglobin value, length of surgery, vaginal cuff suture method, postoperative hemoglobin value, postoperative body temperature, and postoperative first sexual lifetime. The results revealed that the preoperative hemoglobin value, the vaginal cuff suture method, and the time of first sexual life postoperatively were correlated with the vaginal cuff dehiscence, which was statistically significant (P < 0.05) (Table 3).

Table 3 Single factor analysis of vaginal stump dehiscence after laparoscopic hysterectomy.

Univariate logistic regression analysis	OR (95%CI)	P values
Age (< 50/≥ 50)	2.20 (0.55-8.82)	0.267
BMI (< 25 kg/m2/≥ 25 kg/m2)	1.72 (0.36-8.32)	0.499
Menopause (No/Yes)	3.17 (0.40-25.38)	0.278
Reason for surgery (uterine leiomyoma/adenomyosis/adenomyosis with uterine leiomyoma/cervical high-grade intraepithelial neoplasia/endometriosis/benign ovarian tumor/atypical endometrial hyperplasia/placental site trophoblastic tumor)	1.16 (0.74-1.82)	0.516
Comorbidities (hypertension/diabetes/hypertension with diabetes/hyperthyroidism/cholecystitis, gallstones/without)	0.74 (0.39-1.43)	0.373
Operation time (< 120/≥ 120)	1.08 (0.27-4.34)	0.912
Preoperative hemoglobin (g/L) (< 90/≥ 90)	5.12 (1.36-19.23)	0.016
Suture method (interrupted suture/continuous suture)	0.26 (0.70-0.99)	0.048
Postoperative hemoglobin (g/L) (< 90/≥ 90)	2.38 (0.59-9.57)	0.223
Postoperative body temperature (< 38 °C/≥ 38 °C)	0.37 (1.00-1.38)	0.138
Sexuality (without/< 3 months/≥ 3 months)	15.86 (2.83-88.97)	0.002

BMI: Body mass index.

Multivariate logistic regression analysis results of vaginal cuff dehiscence after laparoscopic total hysterectomy

With vaginal cuff dehiscence occurrence as the dependent variable, each factor with a P-value of < 0.05 in Table 2 was assigned, and multivariate logistic regression analysis was conducted. The results indicated that preoperative hemoglobin value and postoperative first sexual lifetime of < 3 months from surgery were independent risk factors for vaginal cuff dehiscence after laparoscopic total hysterectomy (Table 4).

Table 4 Multivariate logistic regression analysis of vaginal stump dehiscence after laparoscopic hysterectomy.

Multivariate logistic regression analysis	OR (95%CI)	P values
Preoperative hemoglobin (g/L) (< 90/≥ 90)	5.17 (1.37-19.49)	0.015
Suture method (interrupted suture/continuous suture)	0.26 (0.70-0.98)	0.052
Sexuality (< 3 months/≥ 3 months)	54.00 (3.59-811.35)	0.004

Psychological resilience of patients undergoing laparoscopic hysterectomy

The average score of CD-RISC in 1459 patients undergoing laparoscopic total hysterectomy was 61.71 ± 6.10 points. Strength, optimism, and toughness scores were 21.06 ± 3.16, 9.55 ± 1.37, and 31.11 ± 5.07 points. Meanwhile, no significant difference was observed in the score of CD-RISC, strength, optimism, and toughness between the 9 patients and the rest (P > 0.05). The SCSQ scores demonstrated that most of the patients were in positive coping (97.2%) (Table 5).

Table 5 Psychological resilience of patients, mean ± SD.

Items	Number	Total (n = 1459)	With vaginal stump dehiscence (n = 9)	Without vaginal stump dehiscence (n = 1450)	t value	P value
CD-RISC	1459	61.71 ± 6.10	58.33 ± 9.42	61.73 ± 6.07	1.669	0.095
Strength	1459	21.06 ± 3.16	20.89 ± 5.30	21.06 ± 3.14	0.161	0.872
Optimism	1459	9.55 ± 1.37	10.00 ± 1.12	9.55 ± 1.37	0.983	0.326
Resilience	1459	31.11 ± 5.07	31.89 ± 4.31	31.10 ± 5.07	0.466	0.641
SCSQ	1459
Positive coping	1417	10.59 ± 3.51	-	-	-	-
Negative coping	42	-2.86 ± 1.96	-	-	-	-

SCSQ: Simplified Coping Style Questionnaire; CD-RISC: Connor–Davidson Resilience Scale.

DISCUSSION

The wide application of laparoscopic total hysterectomy in the clinic has exerted many benefits to patients but also exhibited many complications, including 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[4]. Vaginal cuff dehiscence indicated many risk factors, including menopause, anemia, diabetes, constipation, and cough, causing increased abdominal pressure, poor vaginal cuff prognosis, premature sexual life postoperatively, etc.[5]. The total incidence of vaginal cuff dehiscence after hysterectomy was 0.14%–0.28%. Additionally, 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%[6]. The increased incidence rate may also be damaged by thermal instruments due to laparoscopic operation with energy instruments, and the width and strength of sutures are insufficient. Early recovery from daily activities and an increase in abdominal pressure may, in turn, affect the healing of vaginal fornix, as a minimally invasive operation[7].

A total of 1459 cases underwent laparoscopic total hysterectomy in our hospital, of which 9 experienced vaginal cuff dehiscence postoperatively, indicating an incidence rate of 0.617%. Of the 9 cases, 2 were due to intestinal prolapse through the vagina. Emergency exploratory laparotomy was performed without intestinal canal incarceration and necrosis. Further, 4 cases were sutured through the vagina and 3 cases received conservative treatment. All patients recovered well, with no peritonitis or other complications, and with good prognoses. Univariate analysis revealed that preoperative hemoglobin of < 90 g/L, intermittent suture, and the first sexual lifetime of < 3 months postoperatively are associated with the occurrence of vaginal cuff dehiscence after laparoscopic total hysterectomy. Multivariate logistic regression analysis revealed that preoperative hemoglobin of < 90 g/L and the first sexual lifetime of < 3 months postoperatively are independent risk factors for the occurrence of vaginal cuff dehiscence following laparoscopic total hysterectomy. The results differ from other studies. In particular, Eoh et al[8,9] revealed no significant differences between patients who experienced vaginal cuff dehiscence and those who did not. Moreover, we thought that after surgical trauma, the patient’s resistance decreased, coupled with preoperative anemia, which affected postoperative recovery and wound healing, causing poor vaginal cuff healing. Differences in results may be caused by variations in sample size. Moreover, premature sexual life and frequent sexual life following surgery impose are considered mechanical injuries which will result in direct external force on the vaginal cuff, causing vaginal cuff dehiscence. Several studies demonstrated the findings[9,10]. Concurrently, vaginal pH increases after sexual life, vaginal microecology is destroyed, and flora imbalance is easy to cause vaginitis, thereby affecting vaginal cuff healing. Multiple factors interact, and the incidence rate of vaginal cuff dehiscence increases[11,12]. Therefore, correcting anemia preoperatively and prohibiting sexual life within 3 months postoperatively can reduce the occurrence of vaginal cuff dehiscence. Follow-up of patients should be strengthened postoperatively, and timely treatment of vaginal cuff bleeding, inflammation, and poor healing should be performed to reduce the occurrence of vaginal cuff dehiscence.

Other possible related factors, such as postoperative measures to reduce intraperitoneal pressure[13], may 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 caused by the decrease in estrogen level and vaginal resistance, which influence cuff healing[14]. Additionally, appropriate estrogen supplement therapy for postmenopausal women may contribute to cuff healing[15].

Limitations remain in this study, due to the limited cohort by retrospective analysis, some studies of the patient’s own, and surgical factors that may affect dehiscence. Additionally, this is a retrospective study. The incidence of cases remains relatively small although the sample size was large, considering the relative rarity of vaginal cuff rupture. Further, a type II error is possible in our study. In future studies, a multicenter, large case, and longer follow-up period are warranted to confirm the effectiveness of our proposal.

CONCLUSION

Laparoscopic total hysterectomy exerts numerous benefits. However, the complications associated with this operation need our attention. This research revealed the related factors that may cause this complication through more than 1000 operations in our hospital over the last seven years and established corresponding preventive measures to limit the occurrence of complications. However, many deficiencies remain, more cases need to be accumulated, and further research is warranted.