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Transvaginal Evisceration After Abdominal Hysterectomy

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Transvaginal Evisceration After Abdominal Hysterectomy TRANSVAGINAL EVISCERATION AFTER ABDOMINAL HYSTERECTOMY. CASE REPORT Palabras clave: Prolapso visceral; Histerectomía; Colostomía. Keywords: Visceral Prolapse; Hysterectomy; Colostomy. James Neira Professor, Department of General Surgery - Universidad de Guayaquil - Guayaquil - Ecuador. Irlanda Moyota Lúver Macías J. David Yépez Graduate resident of General Surgery - Hospital Luis Vernaza - Guayaquil - Ecuador. TRANSVAGINAL EVISCERATION AFTER ABDOMINAL HYSTERECTOMY ABSTRACT hysterectomy (47%), followed by vaginal hys- e. terectomy (29.4%) and laparoscopic proce- 2.45 Evisceration is a condition in which abdom- dure (23.6%). Meanwhile, a study conducted inal viscera protrude through an unnatural hole, in 2012 indicates a higher incidence of vaginal with an incidence between 0.03 and 4.1%. cuff dehiscence after undergoing laparoscopic This condition often occurs after an abdomi- hysterectomy (1.14%) than after undergoing nal hysterectomy (47%), vaginal hysterectomy abdominal (0.10%) and vaginal (0.14%) hys- (29.4%) or laparoscopic approach (23.6%). It terectomy (3). has the highest incidence in hysterectomized When analyzing the different laparoscopic postmenopausal women, while the time inter- approaches to hysterectomy, it is possible to val between surgery and complication onset observe that the incidence of evisceration is may vary from a few days to a few years. More- higher in total laparoscopic hysterectomy than over, in most cases, the eviscerated organ is in vaginal hysterectomy by laparoscopy; on the small intestine, which represents a surgical the other hand, for laparoscopic hysterecto- emergency. Transvaginal evisceration is a rare my, intracorporeal suturing of the vaginal cuff entity and is scarcely documented; the case of yields better results than vaginal suture (4). a 81-year-old patient with a history of abdomi- The predisposing factors for this condition nal hysterectomy, who attended the medical include pregnancy, pelvic surgery, multiparity, service after eight hours of evolution of a clin- neuropathy, obesity, menopause and smoking, ical picture characterized by pelvic pain and in addition to factors associated with the race ejection of the large intestine (sigmoid colon) of the patient (5); the time elapsed between through the vaginal canal is presented here. surgery and complication onset may vary from The patient underwent an exploratory laparot- 1 day to 25 years (6). The study required for omy, Hartmann colostomy, rectopexy to the diagnosis is clinical and is evaluated accord- promontory and restitution of traffic in a subse- ing to the symptoms presented, which consist quent procedure; after presenting a satisfactory of fullness sensation or perception of a foreign evolution, she was discharged. body in the vagina, and presence of a soft bulky mass, which often presents along with INTRODUCTION urinal symptoms. Physical examination is key; if total prolapse Intestinal transvaginal evisceration after hyster- is not evident, the patient is requested to push ectomy is an unusual situation and little known once to observe the protrusion of the organ by health professionals, as evidenced in the few (6,7,8). Vaginal evisceration is a surgical emer- cases published to date, hence the uniqueness gency that can be handled by vaginal or ab- and importance of the case reported here. dominal way, or both depending on the case. With an incidence between 0.03 and 4.1% (1), evisceration is a condition in which abdom- CLINICAL CASE inal viscera protrude through an unnatural hole, leaving them exposed to external agents. In 81-year-old patient with a medical history of 2009, Partsinevelos et al. (2) published a re- hypertension and diabetes mellitus. Surgi- view of 51 cases which found that the highest cal history includes abdominal hysterectomy percentage of cases occurred after abdominal plus colporrhaphy performed twice; the first CASE REPORTS one was done due to genital prolapse two the following signs: blood pressure 150/80 e. years before admission, and the second, four mmHg; pulse 95/min; respiratory rate 22/ 2.46 months before admission. Obstetric history min; temperature 36 ºC, and saturation 98%. includes four vaginal deliveries. The patient presented with dry oral muco- The patient attended medical consultation sa, soft, pitting, painful superficial and deep with a clinical picture of eight hours of evolu- palpation in the lower abdomen, mild pain, de- tion characterized by severe pain in the lower creased bowel sounds, and no signs of peri- abdomen which radiated to the genital re- toneal irritation. The mass protruding from the gion, and by ejection of the sigmoid intestine vagina, and corresponding to a segment of the through the vagina after performing Valsal- large intestine (sigmoid) with discoloration, va maneuver. Physical examination showed can be observed in Figure 1. Figure 1. Sigmoid ejection through the vaginal orifice with color changes (arrow). Source: Own elaboration based on the data obtained in the study. The following results were obtained in the The patient underwent an exploratory laparo- laboratory tests: blood count- leukocytes: tomy and manual reduction of hernia. The most 16,310/mm3; neutrophils: 88.2%; hemoglo- important findings were the presence of a sig- bin: 12.5 g/dL; hematocrit: 38.4%; pH: 7.2 moid hernia ejected through vaginal orifice with PCO2:27.5 mmHg; HCO3:16.6 mEq/L; Na: color changes (Figure 2 and 3). A resection of 132 mEq/L; K: 3.9 mEq/L; Cl: 98 mEq/L; approximately 20 cm in the devitalized sigmoid PCR: 8.99 mg/L; 3.0 mmol/L lactate. On the colon segment, Hartmann colostomy formation, other hand, hydro-aerial levels were found in with primary raffia in vaginal cuff without mesh abdominal radiography. Diagnosis on admis- placement, and rectopexy of the endopelvic sion: intestinal transvaginal evisceration. fascia anterior to rectum were performed. TRANSVAGINAL EVISCERATION AFTER ABDOMINAL HYSTERECTOMY e. 2.47 Figure 2. Sigmoid colon segment reduced, with color changes (arrow). Source: Own elaboration based on the data obtained in the study. Figure 3. Resected segment of sigmoid colon. Source: Own elaboration based on the data obtained in the study. CASE REPORTS The patient was discharged 10 days after or lump through introitus, mass protruding e. surgery, in good general condition. Six mon- through the vagina, back pain, urinary incon- 2.48 ths after surgery, successful return of intesti- tinence, and vaginal bleeding. nal transit was performed. Surgery aims to reduce the intestine, the eventual resection of devitalized intestinal DISCUSSION loops, and vaginal defect repair using stit- ches with non-absorbable material or by pla- Evisceration is a rarely reported complication; cing a non-absorbable polypropylene mesh the terminal ileum is the organ that is primar- (8). The approach may be vaginal, abdomi- ily involved. Notwithstanding, there are cases nal, or combined, depending on the condi- that report omentum, fallopian tubes, appen- tions of the patient and bowel viability at the dix and ovarian cyst ejection (3.4). This case time of treatment (8,9). reports evisceration of the sigmoid colon. According to the literature, the combined The main factor associated with intestinal approach is considered as the most appro- evisceration through vaginal cuff is vaginal, priate, especially when intestinal ischemia is abdominal or laparoscopic hysterectomy, as it suspected; it is also recommended for the causes a shortening of the round and broad proper evaluation and effective repair of the ligaments, leaving them without support, besi- tissues involved, while repairing the pelvic des of cutting and leaving, with or without su- floor during surgery (11). While other authors pport, the uterosacral and cardinal ligaments. defend repair in a subsequent procedure The loss of these supports relaxes the pelvic (6), infection is reduced with the use of this diaphragm and the perineal membrane (2,3,4). approach, although surgical and anesthetic Other associated factors include hypo-es- risk increase; however, treatment depends on trogenic state, which produces atrophy of the the patient’s hemodynamic status and pollu- vaginal cuff; poor surgical technique; postsur- tion in the moment. gical infection or hematoma; intercourse befo- Nevertheless, other authors prefer primary re complete healing; Valsalva maneuvers; age; repair (8-10,12). An effective technique for smoking; chronic treatment with corticoste- pelvic floor repair is McCall modified culdo- roids; radiotherapy, and obesity. The time elap- plasty to prevent recurrence of enterocele; sed between surgery and the onset of compli- obliteration of recto-uterine pouch may also cation varies as reported in the literature, and be useful (Moschowitz procedure) (8,10,12). may be from 1 day to 25 years after surgery (6); In many cases, simple closure of the vaginal in this case, 20 years passed. cuff is sufficient, but a non-resorbable polyte- The vaginal cuff prolapse is classified into trafluoroethylene or polypropylene mesh could three degrees (3): be placed to reinforce the suture. In the case reported here, resection of the • Grade I: does not reach the introitus devitalized sigmoid segment was performed, fo- • Grade II: reaches introitus llowed by Hartman colostomy and sacra recto- • Grade III: goes beyond introitus. pexy in order to resolve the emergency, as well as associated comorbid factors. The restitution The clinical picture is characterized by of intestinal transit was carried out in a subse- vaginal or pelvic
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