Small Bowel Evisceration Following Vaginal Hysterectomy is a General Surgical Emergency–A Case Report and Review of the Literature

doi:10.4236/ss.2011.22017

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Surgical Science, 2011, 2, 77-79

doi:10.4236/ss.2011.22017 Published Online April 2011 (http://www.SciRP.org/journal/ss)

Small Bowel Evisceration Following Vaginal Hyster ectomy

is a General Surgical Emergency–A Case Report and

Review of the Literature

Mandana Sigaroudinia, David Bowden, Deb Maitra, Graham Cawdell

Departments of General Surgery & Gynaecol ogy St Hel e ns & Knowsley NHS Trust Liverpool,

Merseyside, United Kingdom

E-mail: [email protected]

Received December 15, 2010; revised January 25, 2011; accepted March 11, 201 1

Abstract

Small bowel evisceration through the vagina is a rare condition, which tends to affect post-menopausal

women who have undergone vaginal hysterectomy. It is a surgical emergency with a favourable outcome if

diagnosed and treated in a timely fashion. Delay in diagnosis can precipitate infarction of small bowel loops

with associated morbidity and mortality. Treatment involves laparotomy, reduction of the incarcerated loops,

plus/minus small bowel resection) and repair of the vaginal rupture. The purpose of this paper is to report a

case of small bowel evisceration through the vagina, to review the literature pertaining to this topic and to

raise awareness of this condition in the general surgical community.

Keywords: Small Bowel Evisceration, Vaginal Rupture, Hysterectomy

1. Case Report

A 67 year old lady underwent a vaginal hysterectomy in

November 2008 and made an uneventful post operative

recovery, being discharged on the 3rd day. She was re-

viewed once in the outpatient department and subse-

quently fol l ow e d up by her GP.

7 months later she presented to her GP complaining of

a ‘dragging’ sensation in her vagina. She also described

feeling a ‘bubble’ protruding through the vagina. She

was not examined but was referred to the gynaecological

outpatients department, at which time a vaginal prolapse

was diagnosed. As a result she was given physiotherapy

exercises as a means of treatment.

Over the following weeks she experienced increasing

amounts of pain, which had become more stabbing in

nature and was said to radiate to the peri-umbilical re-

gion. This pain was worse on walking, sitting down and

on carrying out her exercises. She became reliant on

regular analgesics.

She had no history of bleeding PV or PR and no

change in her bowel habit. She had been passing some

yellow jelly-like discharge and as such was using pads

on her underwear.

6 weeks after being reviewed in the outpatient de-

partment she was trying to pass urine when she felt faint

and had a severe stabbing pain in the pelvic region. She

noticed that she was bleeding and called an ambulance.

On examination in A&E she was found to have 2

loops of small bowel protruding through the vagina.

These were oedematous but viable. She underwent a

laparotomy as a joint procedure between the gynaecolo-

gists and the general surgeons. At laparotomy approxi-

mately 1.5 feet of proximal ileum was protruding

through a large defect in the posterior vaginal wall and

vault. This was resulting from a wound dehiscence re-

lated to previous vaginal hysterectomy. The small bowel

was reduced and the hernial sac was excised. The vaginal

wall was repaired with vicryl and she was given 3 days

of intravenous antibiotics. She made a good recovery and

was discharged on the 4th post-operative day.

2. Discussion & Literature Review

The first reports of vaginal evisceration appear in the

literature from C1950 as a complication of vaginal hys-

terectomy [1]. Over the ensuing years it is a condition

which has been scantily reported in gynaecological jour-

nals most frequently in association with post menopausal

women who have had a history of gynaecological surgery

78 M. SIGAROUDINIA ET AL.

Figure 1. Small bowel loops eviscerating from the vagina.

or enterocoele [2]. It also tends to be associated with

increased intra-abdominal pressure and conditions, which

lead to weakened pelvic tissues [3]. The most common

surgical precursor is the vaginal hysterectomy, which has

been reported to account for over 60% of cases. Ab-

dominal and laparoscopic hysterectomy may also con-

tribute in approximately 30% and 5% of cases respec-

tively [4]. Whilst vaginal evisceration is most common in

the post-menopausal woman, it has been reported in the

premenopausal lady who has had an abdominal hyster-

ectomy, as a complication following coitus and posterior

vaginal fornix rupture [5]. Other presentations, which are

even more unusual, include following intra-peritoneal

chemotherapy for ovarian cancer [6], evisceration sec-

ondary to water sports [7] or the use of vaginal brachy-

therapy [8].

Presenting features are vaginal bleeding or oozing,

pelvic pain and a feeling of pressure in the abdomen

and/or pelvis. The majority of cases find small bowel

loops to be the eviscerating organ although greater

omentum has also been described [9]. If the problem is

not recognised early enough small bowel may incarcerate,

requiring small bowel resection with its associated mor-

bidity and mortality.

Surgery is the mainstay of treat ment using a combined

abdominal and vaginal approach, between the general

surgeons and gynecologists [10]. More recently a pure

vaginal approach has been described [11], as well as a

combined vaginal and laparoscopic approach [12]. The

small bowel is reduced and inspected for viability, the

hernial sac is excised and the vaginal defect is repaired,

usually with an absorbable suture such as Polyglactin or

Polydiaxone. A small bowel resection may be performed

in cases of bowel infarction. The patient is treated with

broad-spectrum antibiotics.

Whilst in the majority of cases a primary repair of the

vaginal defect is sufficient, some authors have reported

using a mesh to reinforce the defect [13, 14]. Further-

more, techniques such as graciloplasty to reconstruct the

rectovaginal septum and allogenic dermal grafting have

also been descr i b ed [15, 16].

The majority of cases report a favourable outcome if

this condition is iden tified early and surgical interv ention

is prompt, highlighting the necessity for increased

awareness about this condition in both the general surgi-

cal and gynaecological communities.

2.1. Figure 1

3. References

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