Outcomes of Different Techniques of Vaginal Vault Closure for Laparoscopic and Robotic Benign Hysterectomies: a Systematic Review

Abstract

Objective: To evaluate outcomes of different techniques for vaginal cuff closure after total hysterectomies for benign conditions, focusing on vaginal cuff dehiscence (VCD) incidence. Data Sources: English-language studies on Medline (PubMed), Scopus, and Web of Science were searched (2015-2025) using the query ("vaginal cuff dehiscence" OR "vaginal vault dehiscence") AND (robotic OR laparoscopy OR laparoscopic hysterectomy). Study Selection: Out of 192 studies identified, 30 met the inclusion criteria, mostly comprising randomized controlled trials (RCT), retrospective and prospective cohort studies. Data Collection: Two authors independently extracted data on study characteristics, sample size, surgical techniques, suture materials, VCD rate, onset, and triggers. Data Synthesis: Cumulative VCD incidence ranged from 0% to 4%, with a median of 0.86%, and a total of 170 cases identified among the 30435 patients. The highest reported rate was 4.8%. Time to dehiscence varied from immediate to 240 days post-surgery. Sexual intercourse was the most common trigger. Studies comparing barbed and non-barbed sutures showed mixed results, and non-absorbable sutures had lower VCD rates than absorbable ones. Double-layer closure was linked to fewer VCD cases, while running vs. single-knot sutures showed no difference. Laparoscopic closure was associated with lower risk of dehiscence than transvaginal. Among hysterectomy techniques, robot-assisted laparoscopic hysterectomy had a higher VCD rate. No cases were reported with vNOTES. Conclusion: VCD rates vary greatly among studies and no consistent data regarding superiority of any closure technique, suture material and closure approach was found. Laparoscopic approaches may pose a slightly higher risk of VCD. Limited number of RCT and heterogeneity of studies limit evidence strength and encourage further investigation.