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BACKGROUND Hysterectomy is a gynecological procedure that can lead to complications arising from structural changes incurred during the surgical process. Vaginal nodules may appear at the vaginal cuff after hysterectomy, which could be indicative of recurring cancer, endometriosis, or formation of fistulae or granulation tissue. In rare instances, abdominal organ prolapse occurs after vaginal cuff dehiscence. Prolapse of the terminal ileum is the most common type of prolapse from vaginal cuff dehiscence, but prolapsed epiploica of colon after hysterectomy occurs in rare instances. Epiploic appendages are a type of fatty tissue attached to the colonic surface that can become inflamed or necrotic and detach from the colon. The purpose of this report is to describe a rare case of prolapsed epiploica of colon at the vaginal cuff. CASE REPORT A 55-year-old woman who had robot-assisted laparoscopic hysterectomy for endometrioid carcinoma presented with a vaginal polyp 2 months after surgery. Histological analysis of the excised polyp revealed adipose tissue with fat necrosis and calcification, indicative of prolapsed epiploica of colon. This is the first report of post-hysterectomy epiploica of colon at the vaginal cuff not associated with obvious dehiscence. CONCLUSIONS This case highlights the importance of thorough histological analysis of excised vaginal nodules and consideration of prolapsed epiploica of colon in the differential diagnoses in addition to benign and malignant vaginal neoplasms.

Objective: Vaginal cuff dehiscence, a severe and potentially detrimental complication, has significantly increased after the introduction of endoscopic hysterectomy. The aim of this systematic review and meta-analysis of the available literature was to identify the incidence of, and possible strategies to prevent, this complication after total laparoscopic hysterectomy and total robotic hysterectomy., Data Sources: PubMed, ClinicalTrials.gov, Scopus, and Web of Science databases were systematically queried to identify all articles reporting either laparoscopic or robot-assisted hysterectomies for benign indications in which vaginal dehiscence was reported as an outcome. Reference lists of the identified studies were manually searched. Only papers written in English were considered., Methods of Study Selection: The Population, Intervention, Comparison, and Outcome framework for the review included (1) population of interest: women who underwent conventional and robot-assisted laparoscopic hysterectomy; (2) interventions: possible methods to prevent vaginal dehiscence; (3) comparison: experimental strategies vs standard treatment or alternative strategy for each item of intervention; and (4) outcome: rate of vaginal dehiscence. Series of subtotal hysterectomies and radical hysterectomies in addition to reports that combined both benign and malignant cases were excluded. The meta-analysis was performed using RevMan version 5.4.1 (Cochrane Training, London, United Kingdom). Two independent reviewers identified all reports comparing 2 or more possible strategies to prevent vaginal dehiscence., Tabulation, Integration, and Results: A total of 460 articles were identified. Of these, 20 (6 randomized, 2 prospective, and 12 retrospective) studies were included in this review for a total of 19 392 patients. The incidence of vaginal dehiscence after total laparoscopic hysterectomy ranged between 0.64% and 1.35%. Robotic hysterectomy was associated with a risk of vaginal dehiscence of approximately 1.64%. No study compared early vs delayed resumption of coital activity nor analyzed the role of training in laparoscopic suturing. No study specifically assessed the impact of electrosurgery on the risk of vaginal dehiscence in endoscopic hysterectomies for benign indications. Double-layer and reinforced sutures did not decrease the risk of dehiscence. Barbed sutures reduced the risk of separation compared with nonbarbed closure (0.4% [4/1108] vs 2% [22/1097]; odds ratio [OR] 0.25; 95% confidence interval [CI], 0.11-0.57). However, these data came mainly from retrospective series. Excluding studies on the use of self-anchoring sutures during robotic hysterectomy, there was no significant difference in the risk of dehiscence between barbed and nonbarbed sutures (0.5% [4/890] vs 1.4% [181/776]; OR 0.38; 95% CI, 0.13-1.10). Transvaginal suture of the vault at the end of an endoscopic hysterectomy seemed to increase the risk of dehiscence when compared with laparoscopic closure (2.3% [23/1002] vs 1.16% [11/944]; OR 1.97; 95% CI, 1.00-3.88)., Conclusion: There is a paucity of high-quality papers evaluating vaginal dehiscence and possible prevention strategies in the current literature. Only 2 effective strategies have been identified in reducing the risk for this complication: the use of barbed sutures and the adoption of a laparoscopic approach to close the vaginal cuff. When restricting the analysis only to laparoscopic cases, the use of barbed sutures does not protect against vaginal cuff separation., (Copyright © 2020 AAGL. Published by Elsevier Inc. All rights reserved.)

Introduction: Recently, it has been suggested that the occurrence of posthysterectomy vaginal cuff dehiscence has increased. Consequently, we evaluated the incidence of vaginal cuff dehiscence after different types of hysterectomies. Our hypothesis is that vaginal cuff dehiscence is more often associated with total laparoscopic hysterectomy (TLH) than other types of uterine removal., Material and Methods: A total of 13 645 hysterectomies from 1992 to 2015 were evaluated in the Turku University Hospital district, Finland. The primary outcome was occurrence of vaginal dehiscence after different types of hysterectomy. The hysterectomy and postoperative vaginal dehiscence trends were analyzed as the secondary outcome. In a subanalysis of dehiscence cases, women's characteristics and perioperative vaginal cuff opening and closure techniques were compared between conventional hysterectomies (vaginal, abdominal, and laparoscopic with vaginal closure) and TLH., Results: Altogether, 22 cases of vaginal cuff dehiscence were included. Most cases (n = 15) occurred after TLH (n = 1104), resulting in an incidence of 1.27%. After conventional laparoscopic hysterectomy with vaginal closure (n = 2853), vaginal (n = 4150), and abdominal (n = 5538) hysterectomies, the incidence rates were 0.11%, 0.05%, and 0.02%, respectively. Compared to abdominal hysterectomy, which was associated with the lowest incidence rate, vaginal dehiscence after TLH had an odds ratio (OR) 71.1 (9.34-541.38, P < 0.001). In the subanalysis of possible underlying factors, the technique of opening of the vaginal cuff with or without electrocoagulation, duration of operation, and occurrence of postoperative infection or hematoma prior to VCD were observed differences between TLH and conventional hysterectomies., Conclusions: Compared with other types of hysterectomies, vaginal dehiscence was observed at the highest rate after TLH. Studies are needed to define if vaginal opening technique contributes to the risk of dehiscence., (© 2018 Nordic Federation of Societies of Obstetrics and Gynecology.)

Vaginal cuff dehiscence is a rare but serious complication that can develop after hysterectomy. Emergent surgical intervention is required for vaginal cuff dehiscence due to the potential subsequent vaginal evisceration, which may lead to necrosis of the small bowel. A 62-year-old nulliparous woman with a 30-year history of smoking, diabetes mellitus, and rheumatoid arthritis (treated with oral steroids) presented with a vaginal cuff dehiscence. Thirty-eight days before the admission, she had undergone a radical operation including total abdominal hysterectomy for uterine corpus cancer at another hospital. We performed emergent laparoscopic surgery to reduce the prolapsed small bowel into the abdominal cavity and repaired the vaginal cuff with a two-layer continuous closure using absorbable barbed sutures. The patient experienced no postoperative complications, and no recurrence of the vaginal cuff dehiscence occurred. Vaginal cuff dehiscence and evisceration can be surgically managed using an abdominal, vaginal, or laparoscopic approach, and the choice of method should be based on patient characteristics and the surgeon's skills. Laparoscopic vaginal cuff repair with a two-layer continuous closure using absorbable barbed sutures is a minimally invasive technique that is safe and effective for medically stable patients with no small bowel injury or vascular compromise and no pelvic abscess.

Objective: Sutures in laparoscopy have been extensively developed in recent years. In this study, we assessed differences between Polysorb™ braided absorbable suture (CL-914) and V-Loc™ barbed suture (V-Loc 180) used in vaginal cuff closure during laparoscopic hysterectomy from various aspects., Study Design: This paper presented a prospective cohort study of 490 consecutive women underwent total laparoscopic hysterectomy (TLH) performed between January 2013 and September 2015 applying identical procedure technique, with cuff closure approaches selected by surgeons. Data collected included operative time, estimated blood loss, postoperative changes in body temperature, perioperative routine blood parameters changes, total average hospital stay, and postoperative hospital stay. In addition, short-term (at least 6 months) outcomes of vaginal cuff granulomatous (VCG) between the two suture approaches were compared., Results: Between groups, statistical differences were detected in operative duration, estimated blood loss, total and postoperative hospital stay, WBC, neutrophil counts and Hb in postoperative routine blood parameters; while there were no significant differences in other data (all P>0.05). Postoperative routine blood parameters in each group: compared to preoperative baseline, in Group 1, WBC, N increased (P<0.05), while RBC, Hb decreased (P<0.05). In Group 2, same tendency in WBC, N and Hb was indicated, but RBC increased with no significant difference. In both groups, vaginal cuff healing was well, with no dehiscence. VCG occurred more often in women used CL-914 than women applied V-Loc 180., Conclusions: V-Loc barbed suture can be used for vaginal cuff closure during TLH due to advantages such as less operative duration and blood loss, shorter postoperative and total hospital stay, and reduced VCG formation six months after TLH., (Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.)

Although vaginal hysterectomy has long been championed by the American College of Obstetricians and Gynecologists as the preferred mode of uterine removal, nationwide vaginal hysterectomy utilization has steadily declined. This article reviews the evidence comparing vaginal with other modes of hysterectomy and highlights areas of ongoing controversy regarding contraindications to vaginal surgery, risk of subsequent prolapse development, and impacts of changing hysterectomy trends on resident education., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Purpose of Review: Vaginal cuff dehiscence and evisceration are rare but potentially serious complications of hysterectomy. In this article, we review the incidence, risk factors, management, and preventive measures for dehiscence based on available literature., Recent Findings: Identifying risk factors for dehiscence is challenging because studies lack comparison groups and most studies are largely underpowered to draw concrete conclusions., Summary: High-quality data on cuff dehiscence after hysterectomy are limited. Potentially modifiable risks that optimize vaginal wound healing, minimize vaginal cuff strain, and minimize cuff infection should be optimized.

Objective: To determine the incidence of vaginal cuff dehiscence (VCD) among women undergoing hysterectomy according to clinico-surgical factors including surgical route, and to describe patient characteristics associated with VCD., Methods: In a retrospective study, the medical records of all women who underwent hysterectomy between January 2005 and March 2011 at a university teaching hospital in Seoul, Republic of Korea, were reviewed. The incidence of VCD was determined in relation to the following factors: patient age, hysterectomy route, indication for hysterectomy, and extent of resection (either simple or radical hysterectomy)., Results: Among 9973 hysterectomies, 37 (0.37%) cases of VCD were identified. The incidence of VCD was significantly higher after abdominal hysterectomy (0.6%) than after laparoscopic (0.2%) or vaginal (0.4%) hysterectomy (P=0.016). Compared with laparoscopic approaches, abdominal hysterectomy was associated with a higher risk of VCD (odds ratio, 2.735; 95% confidence interval, 1.380-5.420). However, there was no significant difference in the incidence of VCD according to surgical indication or extent of resection., Conclusion: Laparoscopic hysterectomy was found to be associated with a lower risk of VCD compared with abdominal hysterectomy. The lower risk is probably related to the different techniques used for colpotomy and cuff closure., (Copyright © 2013 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.)

Vaginal evisceration is a rare condition most commonly associated with previous vaginal surgery. It usually presents with vaginal bleeding, lower abdominal pain and a protruding mass, and requires immediate assessment and surgical management to salvage the prolapsed bowel. Any delay in the treatment may result in bowel ischaemia and perforation which is associated with higher morbidity and mortality. We report a case of spontaneous vaginal evisceration during defaecation in a 56-year-old postmenopausal women 11 months post hysterectomy. This case highlights the benefits of a combined laparoscopic and transvaginal approach in the successful management of this surgical emergency.

Vaginal cuff dehiscence and evisceration are rare but serious complications of pelvic surgery, specifically hysterectomy. The data on risks of vaginal cuff dehiscence are variable, and there is no consensus on how to manage this complication. In our review, we present a summary of the risk factors, with symptoms, precipitating events, and treatment options for patients with vaginal cuff dehiscence after pelvic surgery. In addition, we provide a review of the current literature on this important surgical outcome and suggestions for future research on the incidence and prevention of vaginal cuff dehiscence., (Copyright © 2012 Mosby, Inc. All rights reserved.)

We report a patient with intracoital vaginal rupture two months after a hysterectomy. The case was managed successfully by simple suturing of the vaginal vault.

This report describes a case of a 55-year old woman presenting with evisceration of small bowel through the vagina, five years after a Total abdominal hysterectomy and bilateral salpingoopherectomy for irregular bleeding and a benign ovarian cyst. Examination under anesthesia revealed a 70 cm loop of bowel prolapsing through a 5 cm defect in the vaginal vault. She underwent an exploratory laparotomy and repair of vaginal vault defect. Small bowel prolapse through vaginal vault defect is a rare complication after abdominal hysterectomy. Appropriate management includes prompt recognition, thorough assessment of the herniated viscus and surgical repair of the vaginal defect. Combining abdominal and vaginal approaches as in our case may facilitate repair and avoid further morbidity.

Background: Vaginal cuff dehiscence is an uncommon but serious complication of hysterectomy. It has not previously been described in the setting of systemic lupus erythematosus (SLE) and total laparoscopic hysterectomy (TLH)., Case: A 43-year-old woman with SLE presented to the emergency department >7 weeks after TLH with severe abdominal pain resulting from a postoperative intercourse attempt. Examination under anesthesia revealed complete separation of the anterior and posterior vaginal cuff edges., Conclusion: A patient's medical profile, including comorbidities that affect wound healing, plays a role in vaginal cuff integrity after hysterectomy. For patients with SLE undergoing TLH, temporarily stopping immunosuppressive medications for several weeks preoperatively and postoperatively and allowing prolonged recovery with pelvic rest may improve postoperative outcomes.

Study Objective: The purposes of this study were to estimate and compare the incidence of vaginal cuff dehiscence after different modes of hysterectomies (abdominal, vaginal, laparoscopic-assisted vaginal and laparoscopic) and to review the characteristics of hysterectomies complicated by vaginal dehiscences., Design: Observational case series (Canadian Task Force classification II-3)., Setting: Large, urban, university teaching hospital., Patients: All patients undergoing a total hysterectomy or vaginal dehiscence repair at Magee-Womens Hospital (MWH) from January 2000 through March 2006 were analyzed., Interventions: Vaginal repair of vaginal cuff separation with reduction of eviscerating organ when appropriate., Measurements and Main Results: From January 2000 through March 2006, 7286 hysterectomies (7039 total and 247 supracervical) were performed at MWH by abdominal, vaginal, laparoscopic-assisted vaginal, or laparoscopic approach. Ten of these hysterectomies were complicated by vaginal cuff dehiscences and were repaired during this time period. The resulting overall cumulative incidence of vaginal cuff dehiscence after total hysterectomy at MWH was 0.14%. The annual cumulative incidence of vaginal dehiscences after total hysterectomy was 0%, 0%, 0%, 0%, 0.09%, 0.70%, and 0.31% from January 2000 to March 2006, respectively. There was a notable increase in the cumulative incidence of dehiscence in 2005 and thereafter. From January 2005 through March 2006, the cumulative incidence of vaginal dehiscence by mode of hysterectomy was 4.93% among total laparoscopic hysterectomies (TLH), 0.29% among total vaginal hysterectomies (TVH), and 0.12% among total abdominal hysterectomies (TAH). The relative risks of a vaginal cuff dehiscence complication after TLH compared with TVH and TAH were 21.0 and 53.2, respectively. Both were statistically significant, with 95% CIs of 2.6 to 166.9 and 6.7 to 423.4, respectively. Among the 10 dehiscences repaired, 8 (80%) were complications of TLHs, 1 (10%) was associated with TAH, and 1 (10%) followed a TVH. The median age at time of dehiscence was 39 years, and the median time between initial hysterectomy to vaginal dehiscence was 11 weeks. Six of the 10 patients presented with both cuff dehiscence and bowel evisceration. Six patients reported first postoperative intercourse as the trigger event. Half the patients with dehiscence report smoking cigarettes. All patients with dehiscence received preoperative prophylactic antibiotics at the time of hysterectomy. Until October 2006, there have been no reported recurrent dehiscences at MWH., Conclusions: Total laparoscopic hysterectomies may be associated with an increased risk of vaginal cuff dehiscence compared with other modes of total hysterectomy. We postulate that the use of thermal energy in addition to other factors unique to laparoscopic surgery may be responsible; however, prospective randomized trials are needed to support this hypothesis. When performing laparoscopic hysterectomies, a supracervical approach should be considered unless a clear indication for a TLH is present.

Introduction: Our aim was to investigate the prevalence of sonographically detectable vault fluid collection after hysterectomy and its relation to post-operative morbidity., Materials and Methods: We studied a group of 103 women below 60 years of age who had undergone abdominal or vaginal hysterectomy for benign causes apart from uterovaginal prolapse. A transvaginal ultrasound examination was carried out 24 to 72 hours after surgery. A telephone follow-up and a record review were done six to eight weeks later to determine the morbidity rate., Results: Of the 103 women scanned, 39 (38%) had sonographically detected vaginal vault fluid collection. A haemoglobin concentration drop was observed in a significant number of patients (33% vs. 13%) who had fluid collection in the immediate post-operative period. At follow-up, a significant increase in the complaints of post-operative pain (15% vs. 42%) and re-presentation (32% vs. 55%) was seen in the fluid collection group. The increased risk of re-presentation was not accompanied by an increased risk of needing additional treatment., Conclusion: Sonographic detection of vaginal vault fluid collection is common after hysterectomy, but such a finding rarely indicates additional treatment. Vaginal ultrasound examination should not be performed routinely after hysterectomy.

Aims: To identify self-reported urogynaecological dysfunctions in women treated by radical hysterectomy, and predict risk factors., Methods: A survey using questionnaires. Questionnaires were mailed to 396 patients., Results: Symptoms of urinary incontinence and urinary retention were reported by more than one-third, respectively. One-third of the patients reported cystitis and dysuria. However, 78% of the women did not consider their symptoms as a problem. Analyses identified body mass index, at least one delivery, pre-operative urinary incontinence, and pulmonary disease as predictors for development of post-operative urinary incontinence. Predictive variables for urinary retention symptoms were age, cystitis and/or dysuria, previous rupture of the anal sphincter, fetal weight at delivery > or =4000 g, sensation of vaginal dryness, and pre-operative urinary retention symptoms. Considering post-operative cystitis and/or dysuria, fetal weight > or =4000 g, sensation of vaginal dryness, cystitis and/or dysuria before the operation, and physical activity were predictive variables., Conclusions: Patients can be informed and advised about possible urinary tract symptoms. Special attention in the pre- and post-operative period can be paid to a subgroup of patients at high risk of later urogynaecological problems.

Objective: To evaluate the overall incidence of transvaginal evisceration following hysterectomy and to assess the risk associated with indication, route of surgery, age and vaginal cuff closure technique., Materials and Methods: A database was used to identify all patients undergoing hysterectomy from 1995 to 2001 at our institution and all the patients admitted for vaginal evisceration during the same period. Each vaginal evisceration was analyzed for time of onset, trigger event, presenting symptoms, details of prolapsed organs and type of repair surgery., Results: Of the 3593 patients enrolled in the study, 63.5% underwent abdominal hysterectomy, 33.0% vaginal hysterectomy, and 3.5% laparoscopic hysterectomy. Ten patients (0.28%) presented to the emergency room with vaginal evisceration. No statistical differences in evisceration rates were seen according to the route of surgery. No differences were found between the 1440 patients who had closure of the vaginal cuff and the 2153 who had an unclosed cuff closure technique., Conclusions: Our data suggest that, in young patients, sexual intercourse is to be considered the main trigger event before the complete healing of the vaginal cuff while, in elderly patients, the evisceration is a spontaneous event. Uterine prolapse was not associated with a higher rate and the route of surgery or vaginal cuff closure technique did not influence the dehiscence rate.

Background: Intestinal evisceration through the vagina is rare and transvaginal evisceration after transabdominal surgery is far more rare., Case: We present an unusual case of a postmenopausal woman who presented with transvaginal evisceration of the small bowel after radical abdominal hysterectomy and pelvic lymphadenectomy., Conclusion: This was a rare case of terminal ileal evisceration through a ruptured vaginal cuff after radical hysterectomy and bilateral pelvic lymphadenectomy. We performed a delayed closure of the vaginal defect through the vagina after manual reduction of the eviscerated small bowel, and the outcome was satisfactory.

The purpose of this study was to determine the incidence of vaginal vault granulation after total abdominal hysterectomy using polyglactin (Vicryl) for vault closure. Fifty women who underwent total abdominal hysterectomy for benign and elective conditions were included into the study. Standard surgical technique of total abdominal hysterectomy was employed except for closure of the vaginal vault performed by interrupted figure-of-eight sutures using No. 1 polyglactin. All patients were prospectively followed-up at approximately 6 weeks postoperatively and vaginal vault granulation was diagnosed as present or absent. It was found that 5 patients had vaginal vault granulation without any symptoms, giving the incidence of 10 per cent. One patient who developed vault granulation had postoperative morbidity from cuff cellulitis. The remaining 49 patients had no immediate postoperative complications.

We describe a surgical procedure and post-operative management for the prevention of vaginal shortening following radical hysterectomy. A total of 452 patients who underwent hysterectomies were examined prospectively depending on the operation method. This study showed that our procedure was effective in the prevention of vaginal shortening following radical hysterectomy. Preservation of the ovaries appeared to be important in preventing vaginal shortening, and post-operative hormone replacement therapy was not as effective as the preservation of the ovaries. The effect of external irradiation on vaginal shortening was not conspicuous in the case that the ovaries were preserved.

Background: Fallopian tube prolapse is reported to most commonly occur after vaginal hysterectomy. Both diagnosis and management have varied, resulting in differing efficacies of treatment., Methods: We reviewed the presentation, diagnosis, management, and outcomes of 18 cases of tubal prolapse in 17 women., Results: Most cases (65%) occurred after abdominal hysterectomy. The post-hysterectomy course was complicated by cuff cellulitis in three women, an infected cuff hematoma in one, and post-extubation pulmonary edema in one; four were observed for elevated temperature only. At presentation, 44% complained of dyspareunia, 39% vaginal bleeding, 33% vaginal discharge, 28% abdominal pain, and 28% were asymptomatic. Seven women had vaginal excision (one requiring an additional abdominal procedure), three had laparotomy with salpingectomy, and seven (41%) had spontaneous disappearance of prolapsed fallopian tube without treatment., Conclusions: In our series, tubal prolapse most commonly occurred after abdominal hysterectomy. Moreover, women with tubal prolapse may be asymptomatic, and observation alone may lead to resolution.

Objective: To assess whether ultrasound detection of vault haematoma can be used as a predictor of post-operative morbidity following vaginal hysterectomy., Design: Prospective observational study of consecutive cases of vaginal hysterectomy performed between 1991 and 1994., Sample: Two hundred and twenty-three women having undergone vaginal hysterectomy., Methods: All women had transvaginal ultrasound examination by an independent observer on the third post-operative day. Routine observations and clinical assessments were made by established management protocol, by staff blinded to the ultrasound findings., Main Outcome Measures: Febrile morbidity; haemoglobin drop; need for blood transfusion; length of stay in hospital; re-admission rate and length of stay., Results: Of the 223 scanned women, 55 (25%) had a vault haematoma. This group was compared with the 168 women with no haematoma. Significant increases in febrile morbidity (31% vs 7%), post-operative haemoglobin drop (2.5 g/dL vs 1.6 g/dL), need for blood transfusion (14.5% vs 1.2%), representation to hospital (25.5% vs 5.4%) and length of hospital stay (8.87 days vs 6.25 days) were seen in the haematoma group., Conclusion: Ultrasound detection of vault haematoma following vaginal hysterectomy is a common finding associated with increased febrile morbidity, need for blood transfusion, longer hospital stay and higher re-admission rate. In view of increasing demand for early discharge, driven by purchasers and patients, post-operative ultrasound identifies a high risk population and is both convenient and noninvasive. To further reduce morbidity, it also offers the opportunity to perform a controlled trial of prophylactic antibiotics in this identified subset.

Objective: This report describes a technique for total colpocleisis performed on women with posthysterectomy vaginal eversion and presents the outcome of this surgery., Study Design: Thirty-three women, aged 51 to 94 years (78.1 +/- 8.8, average +/- SD) with vaginal eversion were treated with total colpocleisis. Twenty-four women had previously undergone a total of 40 operations for prolapse, and many had a massive prolapse with scarring and ulceration. Five women had stress incontinence, and an additional 12 had poor urethral support without stress incontinence. In association with colpocleisis, 14 had suburethral plication of the endopelvic fascia; two, needle suspensions; and one, a pubovaginal sling. Three had a perineorrhaphy., Results: Operations lasted from 30 to 205 minutes (101 +/- 33.4, average +/- SD), and the estimated blood loss ranged from 20 to 750 ml (206 +/- 171, average +/- SD). No operative complications occurred. Postoperatively, congestive heart failure developed in two women and one had pneumonia; all illnesses resolved with appropriate therapy. There were no complications at the operative site. Average follow-up was 35 (+/-48) months. All women were initially cured of the vaginal eversion. Recurrent eversion developed in one woman 1 year after surgery and was successfully treated with repeat colpocleisis. Of five women with preoperative stress incontinence, four were cured and one lost to follow-up. No new stress incontinence occurred., Conclusion: Total colpocleisis is an effective operation for the treatment of vaginal eversion in selected situations. When defective urethral support is corrected at the time of the operation, postoperative incontinence is not usually a problem.

Thirty consecutive patients underwent transabdominal ultrasound scanning on day 2 postoperatively in order to provide data on the incidence of vaginal vault haematoma following laparoscopic hysterectomy. Details of postoperative morbidity, both inpatient and after discharge, were recorded. Results support the view that there is no significant association between the presence of vaginal vault haematoma (73%) and the incidence of posthysterectomy febrile morbidity (16.7%). Furthermore the incidence of vault haematoma after laparoscopic hysterectomy is comparable to literature figures for both abdominal and vaginal hysterectomy, whilst that of febrile morbidity is at least equivalent if not reduced for the laparoscopic approach. We believe this provides further evidence confirming the safety of the laparoscopic approach to hysterectomy.

We describe the case histories of five women who developed a severe ulcerating and constricting condition of the vagina following hysterectomy. Three of these women had other classic ulcerative conditions of skin, mouth or colon. One of these women has been described previously.

Background: Vaginal vault rupture with intestinal herniation, although rare, is a recognized postoperative complication of vaginal and abdominal hysterectomies. The incidence after laparoscopic hysterectomy is unknown., Cases: Three women, ages 40-43 years, presented to the emergency room with bleeding and pain 2-5 months after total laparoscopic hysterectomy. The small bowel was visible through the introitus or protruding into the vagina. Inspection of the bowel revealed no evidence of trauma. Two vaginal cuff repairs were completed transvaginally and one laparoscopically, all with interrupted sutures of no. 0 polydioxanone or polyglactin. In follow-up period of 12-17 months, the patients were doing well., Conclusion: Total laparoscopic hysterectomy may be associated with an increased risk of vaginal vault evisceration. Because laparoscopy increasingly is used to replace abdominal hysterectomy, it is important to be aware of this complication and its management.

Objective: This study was undertaken to compare the effectiveness of fixation of the vaginal apex to the coccygeus fascia with fixation to the sacrospinous ligament during surgical repair of vaginal vault eversion with enterocele., Study Design: The records of 121 patients with posthysterectomy vaginal vault eversion with enterocele treated by the author between 1983 and 1994 were reviewed. Preoperative and postoperative symptoms and findings on pelvic examination and postoperative recovery were compared in patients undergoing sacrospinous ligament suspension and coccygeus fascial suspension. Statistical analysis was performed with chi 2 analysis and Kaplan-Meier life tables., Results: Eighty-one patients underwent fixation to the coccygeus fascia and 30 underwent sacrospinous ligament suspension. The two groups are similar for clinical history, symptoms, and findings on pelvic examination. Ten patients underwent an abdominal sacral colpopexy for specific indications and are not comparable. The incidence of postoperative complications and length of hospital stay were similar for the two vaginal procedures. Patients with coccygeus fascial suspension have a projected 96% cure rate at 2 years compared with an 80% cure rate for patients with a sacrospinous ligament suspension., Conclusion: Bilateral vaginal vault suspension to the coccygeus fascia is a safe, simple, and effective technique in the management of vaginal vault eversion with enterocele.

Three premenopausal women had transvaginal evisceration after hysterectomy; the original approach was abdominal in two and vaginal in one. Postoperative cuff infection may contribute to evisceration, and symptoms vary with the length of time after evisceration. Prompt recognition and surgical repair resulted in a good outcome for the three women.

Ovariohysterectomy was performed in 20 mares at three stages of estrus. An ecraseur was used to severe the ovarian branch of the ovarian artery and vein and the ovarian suspensory ligament en masse. All other vessels supplying the ovaries and uterus were doubly ligated and transected. All mares survived. Complications were intraoperative hemorrhage in three mares, postoperative vaginal bleeding in two mares, and a hematoma in the remnant of the broad ligament in one mare. No adhesions between the uterine stump or remnants of the broad ligament and abdominal structures were detected by palpation per rectum.

Objective: A review of the results of surgery for vaginal vault prolapse following hysterectomy., Design: A retrospective review of all patients treated surgically for vaginal vault prolapse between 1981 and 1990 in one hospital., Setting: St George's Hospital, London., Subjects: 28 women., Interventions: The 28 patients underwent 33 operations, either a colposacropexy (23 procedures) or a Zacharin procedure (10 procedures). Of the 28 women 25 were seen in the gynaecological clinic within the last year., Main Outcome Measures: Pre- and post-operative data and any interim prolapse surgery was recorded. Success of the procedure in terms of cure, urinary complications, infection and sexual function., Results: The mean follow-up time was 17.1 months for the colposacropexy and 33 months for the Zacharin. The cure rate for colposacropexy was 91% and that for the Zacharin procedure was 70%. The two commonest complications were development of a voiding difficulty and infection. Three women developed voiding difficulty following the Zacharin and one following colposacropexy. Two women following colposacropexy required removal of the Mersilene mesh due to a persistent discharging sinus., Conclusion: The colposacropexy had a better success rate and, as it is a simpler operation to perform, has become the operation of choice in this unit. It is, however, associated with a risk of infection which can necessitate removal of the supporting mesh.

A questionnaire was circulated to 1147 members (consultant status) and fellows of the Royal College of Obstetricians and Gynaecologists to survey the current management of the vaginal vault following abdominal hysterectomy. Of the 56% who responded, the majority (87%) routinely close the vault. An interrupted mattress suture is used by 60%, a continuous suture by 43% and the Lembert suture by 2%. Chromic catgut is favoured by 60%, a synthetic polymer by 33% and plain catgut by 6%. We then organized a prospective, randomized trial involving 114 women who underwent total abdominal hysterectomy for benign indications. No. 1 polygalactide (Vicryl) was used in 58 women, and No. 1 chromic catgut in 56. Overall, 37 (32%) had vault granulations 6 weeks post-operatively. Chromic catgut had been used in 25 (68%) and polygalactide in the remaining 12 (32%) (P = 0.01). Only 2 (5%) of these women denied any symptoms, while the rest complained of vaginal discharge, bleeding or both. Neither the patients' age, weight or parity, nor the status of the surgeon influenced the occurrence of granulations. We conclude that the widespread use of chromic catgut revealed by our survey is unacceptable: polygalactide, a synthetic polymer, is associated with fewer vaginal vault granulations than chromic catgut.

The author suggests that each gynecological service determine the incidencd of febrile morbidity before adopting routine use of prophylactic antibiotics or vaginal cuff suction drainage.

This paper examines the role of vasoconstrictors, specifically epinephrine, as an etiologic factor in the impairment of the host's defense mechanism. One hundred patients were injected circumferentially around the cervix with a dilute solution of epinephrine before vaginal hysterectomy; these patients were compared to a control group of 100 patients injected in the same manner with a normal saline solution. This randomized prospective study shows that vasoconstrictors significantly predisposed the vaginal cuff surgical site to infection compared to the matched control group. This study shows also that the use of a vasoconstrictor did not significantly reduce blood loss. Based on these data, it is recommended that a locally injected vasoconstrictor not be used during vaginal hysterectomy.