|Year : | Volume
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Laparoscopic management of vaginal evisceration of the small bowel
Vivek Kumar Bhagat1, Aditya Baksi1, Kalika Dubey2, Meenakshi Gothwal2, Ashok Kumar Puranik1
1 Department of General Surgery, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
2 Department of Obstetrics and Gynaecology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
|Date of Submission||03-Oct-2021|
|Date of Decision||06-Dec-2021|
|Date of Acceptance||01-Apr-2022|
|Date of Web Publication||06-Jul-2022|
Department of General Surgery, All India Institute of Medical Sciences, Jodhpur, Rajasthan
Source of Support: None, Conflict of Interest: None
Vaginal vault dehiscence leading to bowel evisceration is a rare but potentially lethal surgical emergency. Various aetiologies have been reported in the literature, but the condition is most commonly seen after hysterectomy in post-menopausal women. Prompt reduction of the bowel is necessary to prevent ischaemic complications. Although most cases in the past have been managed by exploratory laparotomy, the condition may be managed laparoscopically if the prolapsed bowel is viable, giving the benefit of minimally invasive surgery to the patient. A hybrid approach of laparoscopic bowel reduction and per vaginal repair of the vault is technically simple and can be performed even by non-expert surgeons in an emergency setting.
Keywords: Emergency surgery, minimally invasive surgery, vaginal cuff dehiscence, vaginal evisceration, vaginal vault dehiscence, vaginal vault rupture
| ¤ Introduction|| |
Vaginal vault dehiscence (VVD) leading to bowel evisceration is an unusual clinical presentation. Various aetiologies have been reported in the literature, including transvaginal ultrasound probe and vigorous intercourse. However, the condition is more commonly seen in post-menopausal women with a history of hysterectomy. Most of the cases reported in the literature have been managed by exploratory laparotomy. We report a case of successful management of this condition using a hybrid laparoscopic and vaginal approach.
| ¤ Case Report|| |
A 52-year-old post-menopausal woman presented to the emergency with small bowel evisceration per vagina soon after receiving vaginal brachytherapy. She had undergone Wertheim's hysterectomy for Stage II A cancer cervix 4 months ago. The histopathology report revealed a moderately differentiated squamous cell carcinoma with 0.7 cm thickness of the uninvolved cervical wall and a vaginal cuff of 1 cm. Following surgery, she received external beam radiotherapy and was planned for vaginal brachytherapy. After the first brachytherapy, she went to the washroom and noticed a loop of bowel coming out of her vagina as she passed urine. She also developed a pain abdomen and was immediately brought to the emergency.
On examination, her pulse was 82/min and her blood pressure was 120/72 mmHg. Lower midline scar of the previous laparotomy was noted; her abdomen was soft on palpation. About 80 cm of small bowel was found lying outside the vagina [Figure 1]. The bowel loops were slightly congested but showed peristalsis. Gentle per vaginal examination revealed a 4–5 cm defect at the vault. Rectal examination was unremarkable.
Saline-soaked gauze pads were placed over the bowel loops. Intravenous fluids, broad-spectrum antibiotics and analgesics were administered, and the patient was shifted to the operating room. Under general anaesthesia, nasogastric intubation and urinary catheterisation were done, and the patient was placed in a lithotomy position. An attempt was made to reduce the bowel into the peritoneal cavity without success. Pneumoperitoneum was created and an 11 mm supraumbilical port was placed for the telescope. Two 5 mm working ports were placed on either side, 5 cm lateral to the umbilicus. Using atraumatic graspers, the eviscerated bowel was reduced into the peritoneal cavity with guidance from the gynaecology team on the perineal side. The bowel regained its pinkish colour within minutes. The entire length of the small bowel was examined to rule out any signs of injury or ischaemia. The margins of the defect at the vaginal vault appeared healthy. The defect was closed per vagina with interrupted 1-0 polydioxanone sutures [Figure 2]. After a final laparoscopic view of the closed vaginal vault, the ports were closed.
Post-operative recovery was uneventful. Clear liquids were allowed orally on the same day and semi-solid diet on the 1st post-operative day. The patient was discharged on oral antibiotics on the 2nd post-operative day. At 2 months after surgery, she is doing well. Further, brachytherapy has not been advised by the radiotherapist.
| ¤ Discussion|| |
A review of the literature by Thomopoulos and Zufferey in 2016 found 116 published cases of VVD with bowel evisceration, of which only 2% were treated totally laparoscopically and 10% by a combined approach (laparoscopic and vaginal). We resorted to the hybrid approach, as we felt that it was technically easier, and that a total laparoscopic approach would not give any added benefit to the patient.
The clinical presentation is pathognomonic. It is imperative to reduce the bowel as soon as possible, without wasting time on unnecessary investigations, to prevent ischemia and further complications. The initial attempt of bowel reduction should be done in the operating room, under sedation or general anaesthesia. In case the attempt of reduction is unsuccessful, the managing team can proceed with laparoscopy immediately.
The incidence of VVD has been found to be higher after laparoscopic or robotic hysterectomy. With an increasing number of these procedures being performed globally, surgeons should be aware of this complication and its management. Involvement of both surgery and gynaecology teams, as in this case, can expedite decisions and improve the overall outcome of the patient.
| ¤ Conclusion|| |
VVD leading to bowel evisceration is a rare but potentially lethal surgical emergency. Prompt reduction of the bowel is necessary to prevent ischaemic complications. Laparoscopic bowel reduction and per vaginal repair of the VVD is a technically easy management strategy that can be performed even by non-expert surgeons in an emergency, providing the benefit of minimally invasive surgery to the patient.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| ¤ References|| |
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[Figure 1], [Figure 2]