Risk-reducing Bilateral Salpingo-oophorectomy: Assessing the Incidence of Occult Ovarian Cancer and Surgeon Adherence to Recommended Practices.

STUDY OBJECTIVE: This study aimed to determine the incidence of ovarian cancer diagnosed at the time of risk-reducing bilateral salpingo-oophorectomy in a large cohort of patients with a BRCA mutation. In addition, we aimed to determine the adherence to the recommended practices for performing a risk-reducing bilateral salpingo-oophorectomy as described by the American College of Obstetricians and Gynecologists and the Society of Gynecologic Oncology. We sought to determine if adherence differed by the type of training (i.e., gynecologic oncologists vs benign gynecologists). DESIGN: Descriptive, retrospective analysis. SETTING: Academic medical center. PATIENTS: Two hundred sixty-nine patients with a known BRCA mutation. INTERVENTIONS: Prophylactic risk-reducing bilateral salpingo-oophorectomy performed either by a gynecologic oncologist or a benign gynecologist between July 2007 and September 2018. MEASUREMENTS AND MAIN RESULTS: Among 269 patients who underwent risk-reducing bilateral salpingo-oophorectomies, 220 procedures were performed by gynecologic oncologists, and 49 were performed by benign gynecologists. Washings were not performed in 5% of the procedures performed by gynecologic oncologists and 37% of the procedures performed by benign gynecologists (p <.001). Complete serial sectioning of the adnexa was not performed in 12% of the procedures performed by oncologists, and 13% of the procedures performed by benign gynecologists (p = .714). There were 8 cases (2.9%) of tubal or ovarian cancer diagnosed within this cohort. Of these cases, only 3 (1.1%) were diagnosed at the time of surgery and met the criteria for conversion to a staging procedure. CONCLUSION: Because the incidence of ovarian cancer diagnosis at the time of risk-reducing bilateral salpingo-oophorectomy is low and is often not diagnosed at the time of surgery owing to the presence of only microscopic disease, it may not be necessary for gynecologic oncologists to exclusively perform these procedures. However, this study also revealed that when this procedure is performed by benign gynecologic surgeons, some of the recommended practices are not routinely followed. If general gynecologic surgeons are to routinely perform risk-reducing bilateral salpingo-oophorectomies, it is important to promote better adherence to these practices.

Intravenous acetaminophen vs saline in perioperative analgesia with laparoscopic hysterectomy.

BACKGROUND: Opioids are effective for the treatment of postoperative pain but can cause nausea and are associated with dependency with long-term use. Nonopioid medications such as acetaminophen offer the promise of decreasing these nondesirable effects while still providing patient comfort. OBJECTIVE: The purpose of this study was to compare intravenous acetaminophen with placebo and to evaluate postoperative pain control and opioid usage after laparoscopic hysterectomy. STUDY DESIGN: We conducted a prospective double-blind randomized study with 183 patients who were assigned randomly (1:1) to receive acetaminophen or placebo (Canadian Task Force Design Classification I). Patients received either 1000 mg of acetaminophen (n=91) or a placebo of saline solution (n=92) at the time of induction of anesthesia and a repeat dose 6 hours later. Both groups self-reported pain and nausea levels preoperatively and at 2, 4, 6, 12, and 24 hours after extubation with the use of a visual analog scale with a score of 0 for no pain to 10 for highest level of pain. Patients self-reported pain, nausea, and postoperative oral opiates that were taken after discharge. All opiates were converted to milligram equivalents of oral morphine for standardization. RESULTS: There were no significant differences in generalized abdominal pain at any time point postoperatively that included 2 hours (placebo 3.6±2.5 vs acetaminophen 4.4±2.5; P=.07) and up to 24 hours (placebo 3.3±2.4 vs acetaminophen 3.6±2.5; P=.28). Similar results were observed for nausea scores. There were no differences in opioid consumption at any time point including intraoperatively (placebo 4.4±3.9 vs acetaminophen 3.3±4.0; P=.06), post anesthesia care unit (placebo 10.5±10.3 vs acetaminophen 9.7±10.3; P=.59), and up to 24 hours after surgery (placebo 1.4±2.0 vs acetaminophen 1.6±2.1; P=.61). There were no differences in demographics or surgical data between groups. CONCLUSION: There was no difference between acetaminophen and placebo groups in postoperative pain, satisfaction scores, or opioid requirements. Given the relatively high cost ($23.20 per dose in our study), lack of benefit, and available oral alternatives, our results do not support routine use during hysterectomy.

The role of appendectomy at the time of laparoscopic surgery for benign gynecologic conditions.

PURPOSE OF REVIEW: The risk-benefit ratio of concurrent appendectomy at the time of gynecologic surgery has long been debated and remains controversial. However, emerging data on the appendix's role in chronic pain syndromes point to a previously unrecognized link between gynecologic disorders and appendicular pathology. In this article, we review the indications for appendectomy at the time of laparoscopic gynecologic surgery for the treatment of endometriosis and chronic pelvic pain. RECENT FINDINGS: The incidence of appendiceal endometriosis is highly variable depending on the patient population selected. Although rare in patients undergoing appendectomy for acute appendicitis, women with endometriosis may experience rates as high as 9.3-39.0%, especially when suffering from deep infiltrative endometriosis. Appendectomy may also significantly reduce pain in women with unexplained chronic pelvic pain. SUMMARY: Despite lack of prospective data, retrospective studies suggest that appendectomy during gynecologic procedures for chronic pelvic pain and severe endometriosis may be beneficial and necessary to fully address the treatment of these complex gynecologic conditions. In these clinical scenarios, the benefits of laparoscopic appendectomy at the time of the primary gynecologic procedure may outweigh the risks and cost, and should be discussed with patients preoperatively.

Use of Uterine Characteristics to Improve Fertility-Sparing Diagnosis of Adenomyosis.

Objective: To describe patient demographics, determine accuracy of clinical diagnosis, and evaluate reliability of laparoscopic uterine characteristics in the diagnosis of adenomyosis. Materials and Methods: Enrollment included 117 patients undergoing laparoscopic hysterectomy for benign indications. Intraoperatively, the attending surgeon predicted uterine weight; evaluated the presence of fibroids; and commented on the uterus' shape, color, and consistency while probing it with a blunt instrument. A prediction was also made about whether final pathology would reveal adenomyosis. Standardized video recordings were obtained at the start of the case. Each video was viewed retrospectively twice by three expert surgeons in a blinded fashion. Uterine characteristics were reported again with a prediction of whether or not there would be a pathologic diagnosis of adenomyosis. These data were used to calculate inter-and intrarater reliability of diagnosis. Results: Women with adenomyosis were more likely to complain of midline pain as opposed to lateral or diffuse pain (p = 0.048) with no difference in the timing of the pain (p = 0.404), compared to patients without adenomyosis. Uterine tenderness on examination was not an accurate predictor of adenomyosis (p = 0.566). Preoperative diagnosis of adenomyosis by clinicians was poor, with an accuracy rate of 51.7%. None of the intraoperative uterine characteristics were significant for predicting adenomyosis on final pathology, nor was any combination of the features (p = 0.546). Retrospective video reviews failed to reveal any uterine characteristics that generated consistent inter- or intrarater reliability (Krippendorff's α < 0.7) in making the diagnosis of adenomyosis. Conclusions: Clinical and video diagnosis of adenomyosis have low accuracy with no uterine characteristics consistently or reliably predicting adenomyosis on final pathology. (J GYNECOL SURG 34:183).

Characterization and Preoperative Risk Analysis of Leiomyosarcomas at a High-Volume Tertiary Care Center.

INTRODUCTION: Uterine morcellation in minimally invasive surgery has recently come under scrutiny because of inadvertent dissemination of malignant tissue, including leiomyosarcomas commonly mistaken for fibroids. Identification of preoperative risk factors is crucial to ensure that oncologic care is delivered when suspicion for malignancy is high, while offering minimally invasive hysterectomies to the remaining patients. OBJECTIVES: The aim of this study was to characterize risk factors for uterine leiomyosarcomas by reviewing preoperative, intraoperative, and postoperative data with an emphasis on the presence of concurrent fibroids. METHODS: A retrospective case-control study of women undergoing hysterectomy with pathologic diagnosis of uterine leiomyosarcoma at a tertiary care center between January 2005 and April 2014. RESULTS: Thirty-one women were identified with leiomyosarcoma and matched to 124 controls. Cases with leiomyosarcoma were more likely to have undergone menopause and to present with larger uteri (19- vs 9-week sized), with the most common presenting complaint being a pelvic mass (35.5% vs 8.9%). Controls were ten times more likely to have undergone a tubal ligation (30.6% vs 3.2%). Endometrial sampling detected malignancy preoperatively in only 50% of cases. Leiomyosarcomas were more commonly present when pelvic masses were identified in addition to fibroids on preoperative imaging. Most leiomyosarcoma cases (77.4%) were performed by oncologists via an abdominal approach (83.9%), with only 2 of 31 leiomyosarcomas being morcellated. Comparative analysis of preoperative imaging and postoperative pathology showed that in patients with leiomyosarcoma, fibroids were misdiagnosed 58.1% of the time, and leiomyosarcomas arose directly from fibroids in only 6.5% of cases. CONCLUSIONS: Leiomyosarcoma risk factors include older age/postmenopausal status, enlarged uteri of greater than 10 weeks, and lack of previous tubal ligation. Preoperative testing failed to definitively identify leiomyosarcomas, although the presence of synchronous pelvic masses in fibroid uteri should raise clinical suspicion. Given the difficulty of preoperative identification, future efforts should focus on the development of safer minimally invasive techniques for uterine morcellation.

Anatomic vascular considerations in uterine artery ligation at its origin during laparoscopic hysterectomies.

Pelvic pathology such as fibroids, endometriosis, adhesions from previous pelvic surgeries, or ovarian remnants can distort anatomy and pose technical challenges during laparoscopic hysterectomies. Retroperitoneal dissection to ligate the uterine artery at its vascular origin can circumvent these obstacles, resulting in a safer procedure. However, detailed anatomic knowledge of the course of the uterine artery and understanding of vascular variations are essential for optimal dissection. We frequently encounter a C-shaped uterine artery variation during retroperitoneal dissection. We describe the key steps in identification and isolation of this variant, approaching the uterine artery origin either from the pararectal space or by utilizing the medial umbilical ligament coursing through the paravesical space. We also review other known uterine artery configurations. These techniques allow for safe completion of complex laparoscopic hysterectomies performed for various gynecologic diseases.

Clinical utility of postoperative hemoglobin level testing following total laparoscopic hysterectomy.

OBJECTIVE: To determine the clinical utility of hemoglobin level testing in guiding postoperative care following total laparoscopic hysterectomies performed for benign indications. STUDY DESIGN: Retrospective cohort study. RESULTS: A total of 629 women underwent total laparoscopic hysterectomies during the 24 month study period. Only 16 (2.5%) developed symptoms and/or signs suggestive of hemodynamic compromise. When compared to asymptomatic patients, symptomatic patients had a larger decrease in postoperative hemoglobin level (2.66 vs 1.80g/dL, P = .007) and were more likely to undergo blood transfusion, pelvic imaging or reoperation (P < .001). Women with a smaller body mass index and/or higher intraoperative intravenous fluid volume were more likely to have a larger decrease in postoperative hemoglobin level (P < .05). Past surgical history, duration and complexity of the hysterectomy, estimated surgical blood loss, uterine weight, and perioperative use of intravenous ketorolac were not associated with a greater decrease in postoperative hemoglobin (P > .05). Using the University of Pittsburgh Medical Center's annual laparoscopic hysterectomy rate and insurance companies' reimbursement for blood hemoglobin testing, we estimated the national annual cost for hemoglobin testing following total laparoscopic hysterectomy to be $2,804,662. CONCLUSION: Hemoglobin level testing has little clinical benefit following elective total laparoscopic hysterectomy and should be reserved for patients who develop signs or symptoms suggestive of acute anemia. Heath care cost savings can be substantial if this test is no longer routinely requested following total laparoscopic hysterectomies.

Small bowel obstruction resulting from laparoscopic vaginal cuff closure with a barbed suture.

Surgical trends favor the minimally invasive approach for gynecologic procedures. Technology, equipment, and surgical materials have evolved to simplify technically challenging skills and decrease operative times to permit successful completion of procedures via the laparoscopic approach. However, with the introduction of new advances, surgeons must also be aware of potential complications that may arise. A barbed suture is an attractive suture option that allows for easier and faster laparoscopic suturing by eliminating repeated knots and the need to maintain tension on the suture line. Here we present the case of a small bowel obstruction caused by barbed suture used for vaginal cuff closure at the time of total laparoscopic hysterectomy. Implementation of a new technology or surgical material in laparoscopy to improve care must be optimized to prevent untoward events in our patients.

Mechanical bowel preparation for gynecologic laparoscopy: a prospective randomized trial of oral sodium phosphate solution vs single sodium phosphate enema.

STUDY OBJECTIVE: To compare the effect of mechanical bowel preparation using oral sodium phosphate (NaP) solution vs single NaP enema on the quality of the surgical field in patients undergoing advanced gynecologic laparoscopic procedures. DESIGN: Single-blind randomized controlled trial (Canadian Task Force classification I). SETTING: Academic teaching hospital. PATIENTS: Women undergoing gynecologic laparoscopic surgery. INTERVENTIONS: Administration of either oral NaP solution or single NaP enema for preoperative bowel preparation. MEASUREMENTS AND MAIN RESULTS: One hundred fifty-six women were enrolled, and 145 were randomized to receive either oral NaP solution (n = 72) or NaP enema (n = 73). Sixty-eight women in the oral solution group and 65 in the enema group completed the study. Assessment of the quality of the surgical field and bowel characteristics was performed using a surgeon questionnaire using Likert and visual analog scales. No significant differences were observed between the 2 groups in evaluation of the surgical field, bowel handling, degree of bowel preparation, or surgical difficulty. Surgical field quality was graded as excellent or good in 85% of women in the oral solution group and 91% of women in the enema group (p = .43). When surgeons were asked to guess the type of preparation used, they were correct only 52% of the time (κ = 0.04). Assessment of patient quality of life in the preoperative period was performed using a self-administered questionnaire using a visual analog scale. Severity of abdominal bloating and swelling, weakness, thirst, dizziness, nausea, fecal incontinence, and overall discomfort were significantly greater in the oral solution group. Women in the oral solution group also rated the preparation as significantly more difficult to administer, and were significantly less willing to try the same preparation in the future. CONCLUSION: Quality of the surgical field in patients undergoing advanced gynecologic laparoscopic procedures is similar after mechanical bowel preparation using either oral NaP solution and NaP enema. Adverse effects are more severe with oral NaP solution compared with NaP enema administration.

Two-Layer Compared With One-Layer Vaginal Cuff Closure at the Time of Total Laparoscopic Hysterectomy to Reduce Complications.

OBJECTIVE: To explore whether two-layer laparoscopic vaginal cuff closure at the time of laparoscopic hysterectomy is associated with a lower rate of postoperative complications compared with a standard one-layer cuff closure. METHODS: A retrospective cohort study of total laparoscopic hysterectomies performed by fellowship-trained minimally invasive gynecologic surgeons between 2011 and 2017 was performed. Surgeons sutured the vaginal cuff laparoscopically, either in a two- or one-layer closure. The primary outcome was a composite of total postoperative complications, including all medical and surgical complications within 30 days and vaginal cuff complications within 180 days. Factors known to influence laparoscopic vaginal cuff complications including age, postmenopausal status, body mass index, tobacco use, and immunosuppressant medications were examined and controlled for, while surgeon skill, colpotomy technique, and suture material remained standardized. We conducted statistical analyses including χ2, Fisher exact test, logistic regression, and post hoc power calculations. RESULTS: Of the 2,973 women who underwent total laparoscopic hysterectomies, 40.8% (n=1,213) of vaginal cuffs were closed with a two-layer closure and 59.2% (n=1,760) with a one-layer technique. Two-layer vaginal cuff closure was associated with decreased numbers of total postoperative complications (3.5% vs 5.7%; P<.01). The primary difference stemmed from lower vaginal cuff complications within 180 days (0.9% vs 2.6%; P<.01); no differences in 30-day medical and surgical postoperative complications were observed between the two groups (2.6% vs 3.1%; P=.77). No patients in the two-layer vaginal cuff closure cohort experienced a vaginal cuff dehiscence or mucosal separation compared with 1.0% in the one-layer group (P<.01). Compared with a one-layer closure, a two-layer closure was protective from postoperative complications (adjusted odds ratio 0.38, 95% CI 0.19-0.74). CONCLUSION: Although postoperative complications with laparoscopic hysterectomies are rare, two-layer laparoscopic vaginal cuff closure is associated with lower total postoperative complications compared with a one-layer closure. The difference was primary driven by cuff complications.

Pediatric and adolescent gynecologic laparoscopy.

Minimally invasive techniques to treat children and adolescents requiring surgery have increasingly become standard of care. Similarly, gynecologists frequently use laparoscopy to treat pelvic pathology. We present the necessary equipment and surgical techniques required to perform gynecologic procedures on the pediatric and adolescent population. We will give particular focus to the treatment of adnexal masses, chronic pelvic pain, endometriosis, and ovarian torsion. We will also discuss the role of the incidental appendectomy in children and adolescents.

Racial and Socioeconomic Disparities in Hysterectomy Route for Benign Conditions.

BACKGROUND: The aim of this paper was to explore disparities associated with the route of hysterectomy in the University of Pittsburgh Medical Center (UPMC) health system and to evaluate whether the hysterectomy clinical pathway implementation impacted disparities in the utilization of minimally invasive hysterectomy (MIH). METHODS: We performed a retrospective medical record review of all the patients who have undergone hysterectomy for benign indications at UPMC-affiliated hospitals between fiscal years (FY) 2012 and 2014. RESULTS: A total number of 6373 hysterectomy patient cases were included in this study: 88.7% (5653) were European American (EA), 11.02% (702) were African American (AA), and the remaining 0.28% (18) were of other ethnicities. We found that non-EA, women aged 45-60, traditional Medicaid, and traditional Medicare enrollees were more likely to have a total abdominal hysterectomy (TAH). Residence in higher median income zip code (> $61,000) was associated with 60% lower odds of undergoing TAH. Both FY 2013 and 2014 were associated with significantly lower odds of TAH. Logistic regression results from the model for non-EA patients for FY 2012 and FY 2014 demonstrated that FY and zip code income group were not significant predictors of surgery type in this subgroup. Pathway implementation did not reduce racial disparity in MIH utilization. CONCLUSION: This study demonstrated that there is a significant disparity in MIH utilization, where non-EA and Medicaid/Medicare recipients had higher odds of undergoing TAH. Further research is needed to investigate how care standardization may alleviate healthcare disparities.

Implementation of Hysterectomy Pathway: Impact on Complications.

OBJECTIVE: Hysterectomy is one of the most common surgical procedures in the United States. For women who need hysterectomy, it is important to ensure that minimally invasive hysterectomy procedures are used appropriately to reduce surgical complications and improve value of care. Although we previously demonstrated a reduction in total abdominal hysterectomy rates after the implementation of hysterectomy pathway treatment algorithm in 2012, this study focuses on exploring the effect of pathways implementation on surgical outcomes. METHODS: All retrospective medical records for hysterectomy surgeries performed for benign indications at University of Pittsburgh Medical Center hospitals between the fiscal years (FY) 2012 and 2014 were identified. We analyzed the health care outcomes by route of surgery and year using Χ2 test for categorical data, and non-parametric approaches for non-normal continuous variables. RESULTS: A total of 6,569 hysterectomies for benign indications were performed between FY 2012 and 2014. In FY 2012, 1,154 patients (59.15%) had a length of stay of 1 day or less, whereas in FY 2014 this number increased to 1,791 (74.53%; p < .0001). Within 3 years of implementing the pathway, surgical site infections had a reduction of 47%, with a considerable trend toward significance (p = .067). CONCLUSIONS: Implementation of hysterectomy pathway has been associated with reduction of surgical complications in benign hysterectomy settings. Implementation of clinical pathways offers an opportunity for improving patient outcomes that should be investigated in various health care settings and across procedures.

Changes in Hysterectomy Trends After the Implementation of a Clinical Pathway.

OBJECTIVE: To investigate the effect of hysterectomy pathway implementation on the proportion of total abdominal hysterectomy (TAH) procedures performed between fiscal years 2012 and 2014. METHODS: We conducted a retrospective medical record review. All hysterectomy surgeries performed for benign indications at University of Pittsburgh Medical Center hospitals from fiscal year 2012 to fiscal year 2014 were identified through various systems including Medipac and EpicCare. We analyzed the cases by surgical approach (TAH compared with minimally invasive hysterectomy), age, and indication of surgery. Changes over time were analyzed using Cochran-Armitage test for linear trends. RESULTS: A total number of 6,544 patients were included in this study. The mean age of the participants was 48.6 years (standard deviation 11.69). In fiscal year 2012, of 1,934 hysterectomies performed as a result of noncancerous conditions, 538 were TAH procedures (27.8%). However, this number declined in fiscal year 2013 to 22% (485 TAH procedures of 2,186 hysterectomies) and further declined in fiscal year 2014 to 17% (413 TAH surgeries of 2,424 hysterectomies). Overall, there was a significant reduction in the proportion of TAH procedures, from 27.8% in fiscal year 2012 to 17% in fiscal year 2014 (P for trend <.001). After adjusting for surgery indication, the decreasing trend of TAH procedures still persisted (P for trend <.001). CONCLUSION: Implementation of a hysterectomy pathway has been associated with a decrease in the proportion of TAH hysterectomy procedures.

Focused assessment of surgical performance: difficulty with faculty compliance.

OBJECTIVE: This study evaluated faculty compliance in the use of the global surgical rating scale of the Objective Structured Assessment of Technical Skills to rate resident surgical performance after every endoscopic procedure. STUDY DESIGN: For this prospective cohort study, 4 faculty members in the Minimally Invasive Gynecology Surgery Program were asked to rate resident surgical performance using the Objective Structured Assessment of Technical Skills instrument after every case. Faculty compliance was analyzed with respect to the influence of the resident or surgical case characteristics. Faculty and residents completed surveys about the value of the case-by-case ratings. RESULTS: Faculty members used the Objective Structured Assessment of Technical Skills instrument 36% of the time (range, 26%-60%). Faculty member compliance did not vary according to resident or surgical case characteristics. Faculty members did not think the forms had much impact on whether they gave feedback. Residents thought the opportunity to read their ratings was helpful. CONCLUSION: Faculty member compliance with case-by-case surgical performance evaluation of the residents was low.

Laparoscopy in the pediatric and adolescent population.

The use of laparoscopy by gynecologists in treating pediatric and adolescent patients is a relatively new phenomenon. This article discusses the specialized instrumentation necessary for operating on these patients and preoperative considerations and generalized techniques unique to this population. Although laparoscopy has a myriad of uses, the main focus is on the diagnosis and treatment of pelvic pain, adnexal masses, and pelvic inflammatory disease. Incidental appendectomy in these patients is also discussed.

Laparoscopic management of hysteroscopic essure sterilization complications: report of 3 cases.

Hysteroscopic Essure sterilizations offer women and physicians another option for contraception. Overall, the procedure is simple to perform and highly efficacious, and as a result, has gained popularity among practicing gynecologists. Unfortunately, complications occur with any type of surgery. We report 3 cases of hysteroscopic Essure sterilization complications where the Essure microinsert was noted to be misplaced or where patients had persistent postprocedure pain in the setting of appropriately placed microinserts. In all 3 cases, the microinserts were successfully removed laparoscopically.

Incidence and patient characteristics of vaginal cuff dehiscence after different modes of hysterectomies.

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.