Optimizing Vaginal Cuff Closure: A Systematic Review and Meta-Analysis of Barbed Versus Conventional Sutures in Total Laparoscopic and Robot-Assisted Hysterectomies

A potential major complication of total endoscopic hysterectomy is vaginal cuff dehiscence (VCD), which is defined as partial or complete separation of the vaginal cuff edges after hysterectomy. Delayed diagnosis and treatment of VCD can lead to severe adverse outcomes such as bowel perforation, peritonitis, and sepsis; VCD incidence is higher for laparoscopic hysterectomy compared with abdominal or vaginal hysterectomy, and previous literature has estimated the risk of VCD at 0.64% to 4.93% for laparoscopic, 0.12% for abdominal, and 0.29% for vaginal methods. Vaginal cuff closure (VCC) can be performed with various methods, and preferences surrounding the performance of VCC vary based on provider and institution; VCC has been shown to decrease rates of VCD in laparoscopic hysterectomy. Vaginal cuff suture type can influence the duration of surgery and strength of sutures, which can both affect the risk of VCD. This study was designed to assess evidence surrounding barbed sutures compared with conventional sutures for VCC. This was a systematic review and meta-analysis, with databases searched including PubMed-MEDLINE and Embase between 2004 and 2024. The inclusion criteria for studies were peer-reviewed comparative studies focusing on the comparison of barbed to conventional sutures for VCC in patients undergoing total laparoscopic or robot-assisted hysterectomy. The exclusion criteria were abstract-only articles, editorials, commentaries, review articles without original data, single-arm studies, case studies, and case reports. The primary outcome of this study was VCD, with secondary outcomes of operative time, suture time, blood loss, total postoperative complications, surgical site infection, and development of granulation tissue. Publication bias was assessed with funnel plots and the Risk Of Bias in Nonrandomized Studies of Interventions for observational studies and the Risk of Bias 2 tool for randomized controlled trials. The final analysis included 24 studies, with 6 randomized controlled trials, 4 prospective cohort studies, 13 retrospective cohort studies, and 1 case-control study. VCD was investigated as a primary outcome in all the included studies. Among 1891 patients in 19 studies who had barbed sutures, VCD was observed in 13; out of 1746 patients across the same studies who had conventional sutures, 23 were diagnosed with VCD. This difference was not significant. No significant differences were detected in VCD incidence between laparoscopic and robotic approaches. For secondary outcomes, using barbed sutures resulted in a decreased operative time in both laparoscopic (8.58-min reduction) and robot-assisted hysterectomies (37.82-min reduction), although the results for laparoscopic surgery showed significant heterogeneity. Similarly, barbed sutures were found to significantly reduce suture time compared with conventional sutures for laparoscopic hysterectomy (a reduction of 4.90 min) but not for robot-assisted hysterectomies. Barbed sutures significantly reduced blood loss in laparoscopic surgeries by 5.42 mL, but not in robot-assisted surgeries. Total postoperative complications did not show any significant differences in either type of surgery. In addition, no significant differences were found in surgical site infection or the development of granulation tissue for laparoscopic surgery. There was a significant difference for robot-assisted surgery, with barbed sutures reducing the development of granulation tissue (4.88% vs. 17.9%). These results indicate that there was no difference in VCD when comparing barbed sutures to conventional sutures for either laparoscopic or robotic hysterectomy. This is in conflict with previous literature showing a reduction in VCD with barbed sutures, though previous studies have not separated surgical techniques as this study did. Future research should focus on reducing the risk of bias for future analyses as well as reducing heterogeneity and increasing generalizability through prospective research.