This document discusses issues related to vaginal vault closure after hysterectomy. It describes different techniques for closing the vaginal vault during abdominal, vaginal, and laparoscopic hysterectomy, including the use of different suture materials and patterns. Potential complications after hysterectomy are also reviewed, such as vaginal vault dehiscence, vault prolapse, and vault hematoma. The document compares techniques for minimizing these risks and supporting the vaginal vault.

1. Issues around vaginal vault closure
Magdy Moustafa MB Bch MSc MD FRCOG FRCS PgD MSc,a,
* Mohamed Elnasharty MB Bch MSc MD MRCOG
b,c
a
Consultant Obstetrician and Gynaecologist, Frimley Park Hospital, Frimley, Camberley, Surrey GU16 7UJ, UK
b
Lecturer in Obstetrics and Gynaecology, Cairo University, Giza 12613, Egypt
c
Clinical Fellow in Obstetrics and Gynaecology, Great Western Hospital, Marlborough Road, Swindon, Wiltshire SN3 6BB, UK
*Correspondence: Magdy Moustafa. Email: magdy_moustafa@live.co.uk
Accepted on 24 September 2018. Published online 26 June 2019.
Key content
Vaginal cuff dehiscence (VCD), vault prolapse, vaginal cuff
granulation and infected vault haematoma are adverse events
following hysterectomy.
There are several approaches to closing the vaginal cuff, each using
different techniques and sutures.
Dehiscence of the vaginal cuff is more common with laparoscopic
hysterectomy. Techniques that minimise excessive use of
diathermy may reduce the risk of vault dehiscence.
The incidence of post-hysterectomy vault prolapse is estimated to
be between 1.8% and 11.6%. McCall culdoplasty seems to be
effective in supporting the vaginal vault.
Different techniques are used to minimise the development of
vault haematoma and granulation tissue.
Learning objectives
To understand the different techniques used for vault closure
during hysterectomy.
To understand the different surgical approaches used to reduce the
risk of vault dehiscence, vault prolapse and haematoma
after hysterectomy.
To understand the post-operative care procedure that should be
followed after hysterectomy to minimise the risk of vaginal
vault complications.
Ethical issues
Patients should be aware of the risk of vaginal vault dehiscence,
vault prolapse, haematoma and granulation tissue formation
after hysterectomy.
Trainees should be well trained using simulators, be supervised
when performing laparoscopic vaginal vault closure and be made
aware that vaginal closure is another safe treatment option.
Keywords: vaginal vault / hysterectomy / closure / sutures / route
of surgery and techniques
Please cite this paper as: Moustafa M, Elnasharty M. Issues around vaginal vault closure. The Obstetrician Gynaecologist 2019;21:203–8.
https://doi.org/10.1111/tog.12573
Introduction
Hysterectomy is one of the most commonly performed surgical
procedures in gynaecological practice. Various techniques
have been described for closing the vaginal vault to minimise
vaginal vault complications such as dehiscence, prolapse,
granulation tissue formation and infected vault haematoma.
There are several approaches to closing the vaginal cuff using
different techniques and different suture materials. This
review discusses these different approaches and reviews the
advantages and disadvantages of each technique.
Vaginal vault closure techniques
Abdominal hysterectomy
Currently, two surgical techniques have been described for
vaginal vault closure after total abdominal hysterectomy. The
first method is to leave the vaginal vault open, while suturing
the circumference of the vagina with a continuous locking
suture. However, the second method, complete closure of the
vaginal vault, is preferred because it is associated with better
healing and a lower risk of granulation tissue formation.1
Complete vaginal closure is initiated with a midline figure-of-
eight stitch, which can help in traction and haemostasis.
Then, both vaginal angles are transfixed with the suture
ligature, which attaches both uterosacral and cardinal
ligaments.2
While this technique is associated with reduced
blood loss and prevents any contamination of the peritoneal
cavity by the vaginal contents, it does cause the vaginal length
to be shortened.2
Vaginal hysterectomy
Closure of the vaginal cuff can be achieved with either a
vertical or horizontal technique, using interrupted, running
or running locking sutures. A running locking stitch may be
associated with better haemostasis. Although it is generally
the surgeon’s choice as to which technique is used, vertical
closure has been found to preserve the vaginal length better
than horizontal closure.3
One randomised controlled study
compared the closed cuff technique with an open vault
technique in which only a continuous, interlocking
ª 2019 Royal College of Obstetricians and Gynaecologists. 203
DOI: 10.1111/tog.12573
The Obstetrician Gynaecologist
http://onlinetog.org
2019;21:203–8
Review

2. polyglycolic acid suture was used that incorporated the
uterosacral ligaments into the vault. No significant difference
was found between this technique and the traditional one.4
Laparoscopic hysterectomy
There are several techniques for closing the vaginal vault in
laparoscopic hysterectomy: vaginal or laparoscopic, continuous
or interrupted sutures, single or double layers, or knotted or
unknotted stitches. Laparoscopic knotting can use intracorporeal,
extracorporeal (Figure 1) or barbed sutures (Figure 2).5
In a prospective study, Jeung et al. (2010) found no
difference between the interrupted figure-of-eight technique
and the knotted double layer continuous technique.6
Shen
et al. (2002) compared three techniques for vaginal cuff
closure: single layer, double layers and open vaginal cuff
closure. They found no statistically significant difference in
terms of intraoperative or postoperative vaginal cuff
complications, apart from a lower incidence of granulation
tissue formation and vaginal discharge with the double layer
closure technique.7
Blikkendaal et al. (2012) found no statistically significant
difference between laparoscopic, single-layer, unknotted
running sutures and laparoscopic or vaginal, knotted,
interrupted sutures. They also found no difference in the
incidence of vaginal cuff dehiscence (VCD) with the use of
running polyglycolic acid sutures with clips.5
Laparoscopic closure of the vaginal cuff allows adequate
visualisation and more effective vaginal vault support by
incorporating the uterosacral ligament, and reduces the risk
of infection with greater vaginal length. However, there is an
increased risk of VCD compared with the vaginal
interrupted technique.8
Influence of suture material
Vaginal cuff closure is a complicated procedure because of
the risk of bacterial contamination and postoperative
granulation tissue formation. The ideal suture material
should prevent bacterial growth, produce minimal tissue
reaction and be absorbable but at the same time maintain
strength for the duration required for wound healing (about
2–4 weeks). The most common types of sutures used are
chromic catgut, multifilament polyglycolic acid sutures,
monofilament sutures and barbed sutures.8
Chromic catgut is associated with increased risk of
granulation tissue formation.9
Duckett and Patil (2012)
found an increased incidence of vaginal discharge, bleeding
and pain with the use of multifilament polyglycolic acid
(Vicryl) compared to polyglecaprone 25 (Monocryl).10
The barbed suture is a new class of knotless suture. Its
surface has barbs that penetrate the tissues and lock them in
place without needing to tie knots,11
so it is technically easier
to use and is thus associated with reduced operative times. It
allows more homogenous distribution of the tension
throughout the suture. Various studies have found that
barbed sutures give better results than other types of suture.
It has also been found that the bacterial adherence of barbed
sutures is similar to the standard monofilament suture but
lower than other types of suture material.12
In one report,
which described the use of barbed sutures in an operation to
remove a small bowel obstruction, the ileum was found to be
attached to the tail of the barbed suture 30 days later, causing
volvulus. It was therefore recommended that the tails of
barbed sutures should be kept short enough to avoid
such complications.13
Vaginal vault complications
Vaginal cuff dehiscence
VCD is the separation of the previously closed vaginal cuff
and is a rare but serious adverse event that can occur after
hysterectomy. It can lead to evisceration (i.e. prolapse) of the
abdominal contents, especially of the terminal ileum, which
can occur a few weeks or even years after hysterectomy.14,15
The incidence of VCD was found to be higher after
laparoscopic hysterectomy compared with abdominal or
vaginal routes (4.9%, 0.29% and 0.12%, respectively).16
VCD
is considered a surgical emergency. Red flag symptoms that
require immediate evaluation include vaginal bleeding,
vaginal discharge, pain and pressure.
Most researchers have hypothesised that the high incidence
of VCD after hysterectomy is either caused by the application
of electrosurgical thermal energy or by the suture techniques.
Laparoscopic colpotomies cause more tissue necrosis and
devascularisation.16
Three different forms of energy are used
for colpotomy: ultrasonic, monopolar and bipolar. In a
comparative study of the thermal damage caused by different
energy sources in the histological assessment of tissues in
swine, Gruber et al. (2011) concluded that ultrasonic energy
causes the least and bipolar energy causes the greatest
amount of tissue damage.17
The incidence of VCD is higher in laparoscopic
hysterectomy because advanced surgical and technical
suturing and knotting skills are required. Suture tension is
less reliable when using laparoscopic instruments compared
with open hysterectomies in which the surgeon uses their
hands. The magnifying effect of the scope can also lead to
insufficient amounts of tissue being sutured and excessive
electrocauterisation as a result of the magnification of small
vessels, which reduces the blood supply and subsequently
impedes the healing process.18
The type of suture material used also affects the incidence
of VCD. The use of early absorbable sutures is associated with
a higher incidence of VCD than when delayed absorbable
sutures are used (2.5% and 0.7%, respectively). This can be
justified by the fact that early absorbable sutures like those
made from polyglycolic acid can effectively support the
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Issues around vaginal vault closure

3. wound for 3 weeks, while delayed absorbable sutures such as
those made from polydiaxone (PDS) are supportive for
6 weeks.19
Siedhoff et al. (2011) found a lower incidence of
VCD, granulation tissue formation, postoperative bleeding
and cellulitis when bidirectional barbed sutures were used.20
With barbed sutures, the average time to develop VCD was
approximately 73 days, but it was 29 days when polyglycolic
acid sutures were used. This difference can be attributed to
the fact that the relative tensile strength of barbed sutures
remains as high as 80% after 4 weeks, while polyglycolic acid
sutures have only 25% of their tensile strength remaining
after the same period of time.21
However, Stefano et al.
(2015) found no difference in the incidence of VCD between
polyglycolic acid sutures and bidirectional barbed sutures.22
Other studies have shown that certain surgical techniques
may reduce the risk of VCD; for example, incising the vaginal
cuff using a cutting mode set to monopolar current is
associated with less thermal spread, and using sutures rather
than electrocoagulation for haemostasis avoids excessive
coagulation. Closing the full thickness of the cuff with two
layers of PDS sutures placed at least 1 cm from the edge, and
the use of bidirectional barbed sutures, are also associated
with reduced VCD risk.14,20
Other factors that may contribute to the occurrence of
VCD include postoperative vault infection or haematoma,
post-menopausal state, use of radiotherapy, chronic
steroid use, chronic increase in intra-abdominal pressure,
obesity, diabetes, immunosuppression and early return to
sexual intercourse.15
Finally, VCD is a surgical emergency that requires
immediate intervention. Initial measures include adequate
hydration and empirical antibiotics. The patient should be
Figure 2. Closure of the vaginal vault using knotless barbed sutures.
Figure 1. Closure of the vaginal vault using extracorporeal sutures.
ª 2019 Royal College of Obstetricians and Gynaecologists. 205
Moustafa and Elnasharty

4. kept in Trendelenburg’s position and the exposed bowel
should be kept moist during transfer to the operating
theatre.23
The American College of Obstetricians and
Gynecologists recommends copious lavage of the exposed
bowel, sufficient debridement of the separate edge before re-
suture, full-thickness interrupted sutures and approximation
of the VCD edge.24
Vaginal vault prolapse
Vaginal vault prolapse (VVP) is defined as descent of
the vaginal vault below a point that is 2 cm less than the
total vaginal length above the plane of the hymen.25
The
incidence of VVP is about 36 per 10 000.26
In attempts to reduce the risk of VVP, different techniques
have been described for prophylactic vaginal vault suspension
such as sacrospinous fixation, sacrotuberous ligament
fixation, McCall culdoplasty, Moschcowitz culdoplasty,
iliococcygeal fixation, Halban culdoplasty, endopelvic fascia
vault fixation, uterosacral ligament suspension, posterior
pelvic shelf colpopexy or simple peritoneal closure.27
However, the most commonly used procedures are sacrospinous
ligament fixation and uterosacral ligament suspension.
Prophylactic sacrospinous fixation is indicated after
vaginal hysterectomy in cases of uterine prolapse at stage 2
or greater.28
However, use of this technique requires adequate
vaginal length and vault width to be able to reach the
sacrospinous ligament.29
The incidence of dyspareunia and
cystocele has been found to increase after sacrospinous
fixation, most probably because of changes to the vaginal
axis.27
Sacrospinous fixation is also associated with vascular
and nerve injuries (e.g. injuries to the sciatic, pudendal and
perirectal vessels).30
Several techniques have been described for using the
uterosacral ligament to support the vaginal vault. In McCall
culdoplasty, the uterosacral ligaments are brought to the
midline by a series of stitches, incorporating the peritoneal
pouch of Douglas and the posterior vaginal cuff to
obliterate the pouch of Douglas and support the
vaginal vault.31
The use of permanent sutures is not recommended during
vaginal hysterectomy because the knot remaining in the
vaginal cavity can cause partner irritation during intercourse.
Moreover, the midline deviation caused by the McCall
culdoplasty technique can result in pain or ureteral injury.32
A modification of the technique has been described in which
purse-string sutures are used to close the pouch of Douglas,
with intraperitoneal hitching of the uterosacral ligaments.
Since this does not involve the cardinal ligaments, it keeps
the ureter away from the stitch.30
Other modifications using different stitches and different
fixation points have also been described.
In Moschcowitz culdoplasty, purse-string sutures are used
to close the pelvic peritoneum, incorporating both the
anterior and posterior peritoneum and the uterosacral
ligaments to close the pouch of Douglas.33
The Halban culdoplasty, which is used to prevent
enterocele formation, involves placement of vertical purse-
string sutures between the uterosacral ligaments to shorten
them. However, it has no role in the prevention or treatment
of VVP.34
Uterosacral ligament suspension can be done abdominally,
vaginally or laparoscopically. The incidence of ureteric injury
associated with uterosacral ligament suspension can be up to
11%, especially when performed vaginally. An extraperitoneal
approach for uterosacral ligament fixation was associated
with lower incidence of ureteric injury.27
No technique has yet been found to be superior over
another for the prevention of VVP. Two cohort studies
showed that McCall culdoplasty is more effective than
Moschcowitz culdoplasty or simple peritoneal closure for
maintaining vault support for up to 3 years after surgery.32,35
.
Some studies have also showed that McCall culdoplasty gives
better anatomical and functional results, with improved
overall patient sexual satisfaction.30
In terms of prolapse
recurrence and patient satisfaction, other studies found no
difference between McCall culdoplasty and ligament
suspension procedures.36
Maintaining the cervix may improve sexual and urinary
functions after hysterectomy. In 2012, a systematic review
found no difference in urinary, bowel or sexual functions
with subtotal hysterectomy. Another review, conducted in
2015, concluded that subtotal hysterectomy did not protect
against urinary incontinence or pelvic organ prolapse.37,38
The Royal College of Obstetricians and Gynaecologists
does not recommend subtotal hysterectomy for the
prevention of post-hysterectomy vault prolapse (PHVP).39
Robinson et al. (2017) described the role of sacro-
colpopexy in the treatment of PHVP, which has a success
rate of 78–100%. It carries the risk of cystotomy, ureteric
injuries, enterotomy and injury of the presacral veins.
Depending on the type of mesh used, there is also the
risk of mesh erosions. A higher risk has been associated
with polyethylene terephthalate (Mersilene) compared with
polypropylene (Prolene).40
The intrafascial technique for total abdominal hysterectomy
has the advantage of supporting the vaginal vault. It preserves
the complex anatomic relationships between the endopelvic
fascia and the vagina by maintaining attachment of the
uterosacral ligament and incorporating it into the vaginal
cuff closure. It also maintains the length and axis of the vagina.
However, intrafascial hysterectomy is only indicated for the
treatment of benign disease.41
Vaginal vault haematoma
Vaginal vault haematoma is more common after vaginal
hysterectomy and has an incidence of between 25% and 59%.
206 ª 2019 Royal College of Obstetricians and Gynaecologists.
Issues around vaginal vault closure

5. Haematoma may occur as a result of postoperative bleeding
during vaginal hysterectomy. In most cases, haematoma is
asymptomatic, but it may occasionally result in prolonged
hospital admission, pyrexia, anaemia, secondary haemorrhage,
blood transfusion, pelvic discomfort or secondary surgery for
haematoma evacuation.42
Interventions to reduce the risk of vault haematoma
include adequate haemostasis, use of antibiotics and proper
surgical techniques. The traditional hysterectomy technique
is to close the peritoneum and the vaginal vault separately;
however, this creates a potential space haematoma
formation. The aims of closing the vaginal vault are to
extra-peritonealise the vascular pedicles, maintain support
of the vault and ensure adequate haemostasis. Wood et al.
(1997) proposed that suturing the edges of the peritoneum
to the vault of the vagina up to the uterosacral ligaments may
reduce the risk of haematoma formation.43
Miskry and Magos (2001) described a mass closure
technique to reduce the risk of haematoma formation.44
This
technique involves mass closure of the full thickness of the
anterior vaginal epithelium, the anterior peritoneum, medial
aspect of the right round ligament and uterosacral pedicles,
then the posterior peritoneum and posterior vaginal
epithelium. An additional stitch is then taken laterally
through the vaginal epithelium to emerge near to the original
point of entry, before being tied.The same stepsare repeated on
the left side. Two other figure-of-eight stitches are taken
medially to the angle sutures. The medial bite into the posterior
peritoneum is placed high to decrease the risk of enterocele.
This technique is easier, faster, has no intraoperative
complications and is effective in preventing VVP.44
Morris et al. (2001) described another technique in which
the peritoneum remains attached to the posterior vaginal
skin.42
In this technique, the cervix is incised in a ‘V’ shaped
incision and suturing starts vertically from the posterior
vaginal wall. The incidence of vault haematoma in this study
was 1.7%.42
Recently, studies have shown that use of a bipolar vessel
sealing system is associated with a lower risk of vault
haematoma.45
However, no proven benefit was identified for
routine vault drainage.46
Vaginal vault granulation
Vaginal vault granulation is a common complication
following abdominal hysterectomy. In most cases, it is
benign and tends to regress spontaneously over a few
months. However, it may be symptomatic, causing copious
vaginal discharge, bleeding and sometimes infection. Surgical
technique and the type of suture material used are the most
common contributing factors.1
The closed cuff technique, in which healing occurs by
primary intention, has been associated with reduced risk of
granulation tissue formation compared with the open cuff
technique, in which healing occurs by secondary intention.
Several studies concluded that the perioperative use of
antibiotics and the choice of suture material can help to
reduce the risk of such complications.1
Management of vaginal vault granulation usually involves
2–3 additional outpatient clinic visits for cauterisation, silver
nitrate application or cryotherapy. Admission to the hospital
for diathermy under anaesthesia may be required.1
Post-hysterectomy prolapse of the fallopian tube is an
uncommon complication that is often confused with vault
granulation tissue. Diagnosis should be considered if the
lesion at the vaginal vault does not respond to conservative
management. In such rare conditions, a biopsy of the area
can be performed to confirm tubal epithelium. Treatment is
mainly surgical, as the surrounding vaginal epithelium is
incised and widely undermined and the tube is removed.47
Postoperative care
Currently, there are no documented, evidence-based measures
that can help to reduce the risk of vault complications.
However, the most commonly recommended measures are to
avoid lifting heavy objects to reduce the risk of vault prolapse
and to avoid sexual intercourse for the first 3 months after
laparoscopic hysterectomy.
Conclusion
Closure of the vaginal vault is associated with possible
complications. Patients should be well informed before
undergoing such a procedure and advised of the
postoperative care that will be required. Although patient
characteristics and early sexual coitus are known to predispose
to complications, choice of surgical technique remains the
most important contributing factor.
Disclosure of interests
There are no conflicts of interest.
Contribution to authorship
MM instigated and edited the article. ME researched and
wrote the article. Both authors read and approved the final
version of the manuscript.
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208 ª 2019 Royal College of Obstetricians and Gynaecologists.
Issues around vaginal vault closure