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Management of Transvaginal Bowel Revista Colombiana de Obstetricia y Ginecología Vol. 70 No. 2 • Abril-Junio 2019 • (129-135) C ASE REPORT DOI: https://doi.org/10.18597/rcog.3141 MANAGEMENT OF TRANSVAGINAL BOWEL EVISCERATION SECONDARY TO VAGINAL CUFF DEHISCENCE FOLLOWING HYSTERECTOMY: CASE REPORT AND REVIEW OF THE LITERATURE Manejo de evisceración intestinal transvaginal secundaria a dehiscencia de la cúpula vaginal posterior a histerectomía: reporte de caso y revisión de la literatura Santiago Rueda-Espinel, MD*1; Facundo Cobos-Mantilla, MD2 Received: February 04/18 - Accepted: June 28/19 ABSTRACT “vaginal cuff dehiscence,” “transvaginal bowel Objectives: To report a case of transvaginal evisceration,” “dehiscence following hysterectomy,” bowel evisceration following total abdominal “hysterectomy complications,” and applying a hysterectomy, and to conduct a review of the snowball search strategy based on the studies literature on its diagnosis and treatment. identified, both in English and Spanish. Materials and methods: A 48-year-old female Results: Fourteen studies were included. The patient who presented to a high complexity diagnosis of transvaginal evisceration is primarily institution with transvaginal bowel evisceration clinical with the observed bulging of the abdominal lasting 10 hours. Laparotomy was performed in order content through the vagina. It may also be associ- to reduce the evisceration and repair the vaginal ated with signs of peritonitis or bowel obstruction. cuff defect. A search was conducted in Medline via Initial management must be an attempt at vaginal PubMed, Embase, Elsevier, Medigraphic, Wolters packing and prophylactic antibiotics. Several surgi- Kluwer Health and UpToDate using the terms cal techniques have been described for vaginal cuff correction and reinforcement of the dehiscence closure. Conclusions: Transvaginal evisceration is consid- ered a surgical emergency. Further studies assessing * Correspondence: Santiago Rueda Espinel, calle 37 #15-25, oficina 403. the safety and effectiveness of the various manage- santiago.r [email protected] 1 Surgeon, Universidad Industrial de Santander, Bucaramanga (Colombia). ment interventions are required. 2 Obstetrics and Gynecology Specialist. Professor, Universidad Industrial de Santander-Hospital Universitario de Santander, Bucaramanga Key words: Surgical wound dehiscence; visceral (Colombia). prolapse; hysterectomy. Rev Colomb Obstet Ginecol ISSN 2463-0225 (On line) 2019;70:129-135 130 Revista Colombiana de Obstetricia y Ginecología Vol. 70 No. 2 • 2019 RESUMEN introitus (2). It constitutes one of the surgical Objetivos: reportar un caso de evisceración intes- emergencies in gynecology due to the risk of bowel tinal transvaginal posterior a histerectomía abdo- perforation, necrosis and secondary sepsis (3). minal total y realizar una revisión de la literatura The reported incidence of vaginal cuff dehis- sobre su diagnóstico y tratamiento. cence ranges between 0.03 and 4.1% in women Materiales y métodos: se presenta el caso de una taken to hysterectomy (1, 4, 5). This variability paciente de 48 años que consulta a una institución could be due to under-reporting or to technologies de alta complejidad por evisceración intestinal that increase risk (6). transvaginal de 10 horas de evolución, se realiza Transvaginal evisceration due to vaginal cuff laparotomía para reducción de la evisceración y dehiscence was reported for the first time in 1864 reparación del defecto de cúpula vaginal. Se hace by Hyernaux (7). Its incidence ranges between 0.32 una búsqueda en Medline vía PubMed, Embase, (8) and 1.2%. This higher frequency has been as- Elsevier, Medigraphic, Wolters Kluwer Health sociated with robotic hysterectomy (9). y UpToDate con los términos: “dehiscencia de Several factors associated with the risk of vaginal cúpula vaginal”, “evisceración intestinal transva- cuff dehiscence have been identified, mainly those ginal”, “dehiscencia posterior a histerectomía”, related to advanced age, increased abdominal pres- “complicaciones histerectomía”, y en bola de nieve sure and impaired healing secondary to malignant a partir de los estudios identificados, en idiomas conditions, radiotherapy, chronic steroid use, inglés y español. malnutrition, anemia and immunosuppression (6, Resultados: se incluyeron 14 estudios. El diag- 10). Obese patients have more complications and nóstico de la evisceración transvaginal es eminen- they also have other comorbidities such as arte- temente clínico al observar salida de contenido rial hypertension and diabetes, further increasing abdominal por vagina, se puede asociar a signos the risk (11). Other factors found to be associated de peritonitis u obstrucción intestinal. Su manejo with vaginal cuff compromise are multiparity, inicial debe intentar el empaquetamiento vaginal menopause, smoking, constipation, chronic cough, y la profilaxis antibiótica Se han descrito varias hypothyroidism and surgical site infection or he- técnicas quirúrgicas para corregir el defecto de la matoma (1-3). cúpula vaginal y reforzar el cierre de la dehiscencia Vaginal cuff dehiscence may occur spontane- de la cúpula. ously with no triggering factor. However, in pre- Conclusiones: la evisceración transvaginal se con- menopausal women, the most frequent trigger is sidera una urgencia quirúrgica. Se requieren más resumption of intercourse before the cuff is fully estudios que evalúen la seguridad y la efectividad de healed (1-3). In postmenopausal women, the trig- las diferentes intervenciones para el manejo. gering event is increased intra-abdominal pressure Palabras clave (MesSH): dehiscencia de la herida (3, 10), associated with pelvic prolapse or previous operatoria; prolapso visceral; histerectomía. vaginal surgery (8). Post-hysterectomy dehiscence has been fund to be associated with a poor surgi- INTRODUCTION cal technique, cuff hematoma or infection (12). Vaginal cuff dehiscence is defined as cuff separation In terms of risk factors for evisceration, the most or rupture of of the vaginal or peritoneal incision important of all is cuff dehiscence (12). following a hysterectomy procedure (1). It may or Transvaginal evisceration is considered a surgical may not be accompanied by evisceration, where emergency requiring management by a gynecologist the intraperitoneal content is expelled through as soon as possible after making a prompt diagnosis. the defect until it protrudes through the vaginal The objective of this article is to report the case MANAGEMENT OF TRANSVAGINAL BOWEL EVISCERATION SECONDARY TO VAGINAL CUFF DEHISCENCE FOLLOWING HYSTERECTOMY: CASE REPORT AND REVIEW OF THE LITERATURE 131 of a patient presenting with acute abdomen due to spontaneously or manually (Figure 1). No para- small bowel evisceration secondary to vaginal vault clinical tests were performed on admission and dehiscence following total abdominal hysterectomy, immediate surgical management was indicated due and to review the literature on diagnosis and treat- to suspected bowel obstruction secondary to trans- ment of this condition. vaginal evisceration through a vaginal cuff defect. The patient was intervened by the general sur- CASE PRESENTATION geon and the gynecologist through an initial median A clinical case is presented of a 48-year-old patient infraumbilical laparotomy approach. Evisceration who came to the emergency service at Hospital of a portion of terminal ileum through a vaginal Universitario de Santander (Santander University cuff defect approximately 3 cm in diameter was Hospital) located in the city of Bucaramanga, identified (Figure 2). The loops were reduced into a high-complexity public referral center in the abdominal compartment and were not resected northeastern Colombia that serves population given that they had not sustained irreversible isch- under state-subsidized healthcare coverage provided emia; the cuff defect was corrected using a 10-0 by the General Social Security system. The patient vycril crossed running suture and a Moschowitz complained of a painful mass protruding through technique in the cul-de-sac. Antibiotic therapy the vagina and concomitant generalized abdominal with first generation cephalosporins was initiated. pain, predominantly of hypogastric location, and Oral intake of clear fluids was initiated on the sec- multiple episodes of gastric content vomiting. ond postoperative day. Later, outpatient follow-up The patient reported a surgical history of total showed adequate correction of the defect. abdominal hysterectomy and cystopexy 11 months Ethical considerations. A written informed consent before due to a benign condition, followed by ante- was obtained from the patient authorizing publica- rior and posterior vaginal repair 5 months later. Re- tion of this clinical case. The necessary precautions garding gynecological history, the patient reported were taken to ensure information confidentiality menarche at 15 years of age with regular cycles and and patient anonymity. the date of the last menstruation 2 years before the event; 2 pregnancies, 2 eutocic deliveries of babies MATERIALS AND METHODS weighing 3000 and 2700 grams; last delivery 15 To answer the question “Which is the treatment years before; never used contraception and had not for patients presenting with transvaginal eviscera- had intercourse during the past 6 years; had never tion secondary to vaginal cuff dehiscence follow- been screened for cervical cancer. ing hysterectomy?” a search of the literature was On physical examination at the time of admis- conducted in the Medline via
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