Vaginal Cuff Closure in Hysterectomy
For vaginal cuff closure during hysterectomy, use a continuous running suture technique with slowly absorbable monofilament suture material, as this approach reduces operative time while maintaining safety and minimizing complications.
Recommended Suture Technique
Continuous vs. Interrupted Suturing
- Continuous running suture is preferred for vaginal cuff closure as it significantly reduces operative time without increasing complication rates 1, 2, 3
- The continuous technique distributes tension more evenly across the suture line, similar to principles established in other surgical closures 4
- Studies demonstrate no difference in vaginal cuff dehiscence, bleeding, or infection rates between continuous and interrupted techniques, making the faster continuous method the logical choice 2, 3
Specific Technical Approach
- Use a running interlocking technique that keeps the vagina closed at all times during closure to avoid blood loss and spillage of vaginal contents into the peritoneal cavity 1
- The suture should be secured at the angles and run continuously across the cuff 3
- Consider using two separate running sutures if needed for hemostasis and secure closure 1
Optimal Suture Material
Absorbable Monofilament Suture
- Slowly absorbable monofilament suture (such as poliglecaprone or polyglyconate) is the material of choice for vaginal cuff closure 4, 1, 3
- Monofilament sutures cause less bacterial seeding and may be less likely to cause infection compared to multifilament materials 4
- Slowly absorbable sutures reduce the risk of wound complications compared to rapidly absorbable materials 4
Suture Size
- 2-0 absorbable monofilament suture is the standard caliber used for vaginal cuff closure 3
Alternative: Barbed Suture
- Bidirectional or unidirectional barbed sutures (such as Quill SRS™) are safe alternatives that further reduce operative time 2, 3
- Barbed sutures eliminate the need for knot-tying while maintaining comparable safety profiles with no increase in dehiscence, bleeding, or infection 2, 3
- Both welded-loop unidirectional barbed suture and traditional monofilament with clips/knots show equivalent outcomes 3
Abdominal Wall Closure Principles
Mass Closure Technique
- Use mass closure (single-layer technique) for the fascial layer as it is faster than layered closure with no difference in incisional hernia or wound complication rates 4
- Mass closure includes all layers of the abdominal wall except skin in a single bite 4
Continuous Suturing for Fascia
- Continuous suturing is recommended for midline fascial closure as it reduces operative time without increasing complications 4
Suture Length-to-Wound Length Ratio
- Maintain a suture-to-wound length ratio of at least 4:1 (Jenkins Rule) to reduce the risk of incisional hernia and wound complications 4
- Document this ratio at every wound closure 4
Small Bite Technique
- Use small bites (5-8mm from fascial edge, 5mm apart) rather than large bites to prevent incisional hernia, though evidence stems primarily from elective surgery 4
Fascial Suture Material
- Slowly absorbable monofilament suture is recommended for fascial closure to reduce incisional hernia rates 4
- Consider antimicrobial-coated sutures when available, particularly in clean-contaminated or contaminated fields 4
Common Pitfalls to Avoid
- Do not close the peritoneum separately during abdominal wall closure, as this adds time without benefit 4
- Avoid rapidly absorbable sutures for both vaginal cuff and fascial closure due to higher complication rates 4
- Do not use multifilament sutures, as they increase bacterial seeding risk 4
- Ensure adequate visualization during vaginal cuff closure to avoid inadvertent suture placement through adjacent structures 5
- Avoid locking continuous sutures, as this creates excessive tension leading to tissue edema and necrosis 4