Closing a cuff refers to the surgical step post-hysterectomy where the top of the vagina, known as the vaginal cuff, is sutured or stitched to promote healing.
This procedure follows the removal of the uterus and is critical in ensuring the patient’s recovery and preventing complications.
The cuff closure is delicate as it requires a balance between securing the tissue to avoid dehiscence (separation of the surgical incision) and minimizing damage to nearby tissues.
Techniques for closing the cuff can vary greatly, influenced by the surgeon’s training and preference, patient’s individual characteristics, and the specific surgical case.
As an intricate procedure, cuff closure demands significant technical skill and a comprehensive understanding of the associated risks, including infection and haematoma.
Over recent years there has been a dramatic increase in the rate of laparoscopic procedures being performed in Canada. Across the country, there is a large variation in the way in which the vaginal vault is closed during total laparoscopic hysterectomy. In this video, we aim to highlight this diversity in techniques. Using the CanSAGE Listserv, we invited minimally invasive gynaecologists from across the country to share their methods for laparoscopic closure of the vaginal cuff and their accompanying rationale.
Complexity and Risk Factors
Closure of the vaginal cuff is a biomechanically complex task. In addition to requiring technical skill, the cuff is prone to dehiscence, due to the risk of infection and haematoma, tissue damage by electrocautery, return to sexual activity, advanced age and hypoestrogenism. The literature cites the risk of dehiscence at between 0.5% and 4%, with no significant difference between patients in whom the closure was performed vaginally or laparoscopically, with interrupted, continuous or barbed sutures.
The surgical approach to cuff closure therefore depends on a number of other factors. The age of the patient and their menopausal status, their BMI, the presence of medical comorbidities affecting wound healing, the expertise of the surgeon and surgical assist, the cost of sutures and equipment and the time allocated for completion of the case.
Classification of Vault Closure Techniques in Canada
The various techniques for vault closure shared by Canadian surgeons are classified into four techniques, intra-corporeal knots, extra-corporeal knots, knotless sutures and other innovative variations. These surgeons across Canada use intra-corporeal knots to close the vaginal cuff. Intra-corporeal knots can be tied after placement of figure-of-eight or mattress sutures or after a continuous suture.
For this technique, a suture is driven through the vaginal cuff and a second identical bite is taken a short distance away. A figure-of-eight suture can be placed with instruments either cross-table or with two ipsilateral ports. Advantages of the figure-of-eight suture include low material costs, and the fact that this technique has been performed for the longest length of time, so its efficacy has been repeatedly proven in the literature.
Illustrating the Procedure of Needle Removal through a Five-Millimetre Port
A surgeon’s knot is thrown to secure the suture, followed by two to three additional knots. This video also demonstrates a technique for removal of the needle through a five-millimetre port, by supinating both instruments to straighten the needle and grasping the suture tail to bring the needle vertically through the trocar.
Understanding the Horizontal Mattress Suture Technique
The horizontal mattress is an alternative to the figure-of-eight suture. The technique is similar, except that the direction of the second stitch is reversed, so that the knot is tied on the same side as the tail, in this case, on the anterior cuff. An advantage of this suture over the figure-of-eight is that a horizontal mattress stitch results in a knot which is tied away from the suture line rather than directly on top of it, resulting in excellent eversion of the vaginal cuff.
Preventing Persistent Bleeding with Figure-of-Eight Knot Technique
For this technique, the needle is driven through the left uterosacral ligament and another bite is taken inside the vagina to ensure that the corner of the cuff is secured. The needle is driven through the cuff again and the figure-of-eight knot is tied. Securing the corners of the vaginal cuff in this way prevents persistent bleeding at the angle, which can be difficult to control once the cuff is completely closed.
Incorporation of Uterosacral Ligaments into Vault Closure
Incorporating the uterosacral ligaments into the closure provides support to the vaginal apex. The same suture is then used to close the left side of the vault in a continuous running fashion. An identical stitch is placed on the right-hand side, and the two ends of the suture are ultimately tied to each other in the middle. These surgeons close the vault with extra-corporeal knots. We will demonstrate the knot pusher with a simple knot as well as the Roeder slip knot.
Both of these knots can be used to secure figure-of-eight horizontal mattress or continuous sutures. In this video, the needle is drawn though the vaginal mucosa and then pulled out of the trocar through which it was inserted. A surgeon’s knot is tied and a knot pusher is used to bring the knot into the abdomen. The procedure is repeated until the desired number of knots have been placed. Use of extra-corporeal knot tying is efficient and allows for laparoscopic suturing without the need for intra-corporeal knot tying, which can often be a frustrating and time-consuming step.
Efficiency of Extra-Corporeal Knot Tying
Another technique for extra-corporeal knot tying is the Roeder slip knot. The needle is draw through the vaginal cuff and then brought out of the abdominal cavity through the same trocar. This slip knot is used to place sutures in an interrupted fashion, which may confer a more secure closure than a continuous suture. Using the Roeder slip knot to close the vaginal cuff is also a good opportunity for residents and junior trainees to practice this useful knot tying skill.
Introduction to the Knotless Barbed Suture Technique
Once thrown, the knot is passed into the abdomen with either a knot pusher or simply by placing tension on. The knotless barned suture is by far the most ubiquitously used technique to close the vault in Canada. It can be placed in a continuous fashion or in a wide range of variations. In this video, the suture is brought into the abdominal cavity and is drawn through the vaginal cuff. Placement of the suture requires at least three lateral ports, two instruments for suturing and an additional port for the assistant to hold the suture under tension.
Advantages and Procedure of the Knotless Barbed Suture
A self-anchoring barge suture eliminates the need for a knot, resulting in a suture line without weak points. The absence of knots reduces the quantity of foreign body, decreasing tissue reaction. In addition, tension in the wound is distributed more uniformly along the suture line. The cuff is closed in a continuous fashion, and each throw is singed down in order to ensure that the barbs securely embed into the tissue. The suture is cut flush with the tissue to prevent adhesions or bowel injury.
Innovative Variations of Vault Closure Techniques in Canada
There are a number of other variations used by surgeons across Canada to close the vaginal vault laparoscopically. In this example, the ipsilateral corner is secured with a figure-of-eight stitch, and the cuff is then closed in a continuous fashion with a barbed suture. This technique ensures that the mucosa at the ipsilateral angle is incorporated into the closure. Securing the corner can often be a challenge when using a barbed suture, or when the closure is being performed by a more junior train