|Ahead of print publication
Vaginal cuff dehiscence with small-bowel evisceration following total laparoscopic hysterectomy – An unusual case
Vaidehi D Thakur, Manoj M Paprikar, SM Singh
Department of Obstetrics and Gynaecology, INHS Kalyani, Visakhapatnam, Andhra Pradesh, India
|Date of Submission||16-Feb-2020|
|Date of Decision||23-Feb-2020|
|Date of Acceptance||07-Jun-2020|
|Date of Web Publication||02-Sep-2020|
Vaidehi D Thakur,
Department of Obstetrics and Gynaecology, INHS Kalyani, Gandhigram, Visakhapatnam - 530 005, Andhra Pradesh
Source of Support: None, Conflict of Interest: None
Small bowel evisceration from dehiscent vaginal cuff is unusual subsequent to laparoscopic hysterectomy. This complication is seldom cited in studies and reviews. We present an uncommon case of evisceration of small bowel from vaginal cuff dehiscence (VCD). The event occurred approximately 2 hours subsequent to the first act of coitus performed 3 months after the laparoscopic hysterectomy. Patient was brought to the emergency department for primary treatment. Urgent surgical intervention was planned. Small intestine was reposed after saline wash. Repairing of the vault was done with continuous suture by polyglactin-910 braided synthetic absorbable suture no.1. Patient was sent to home after 5 days of surgery. The strength of vaginal vault in laparoscopic hysterectomy depends on technique of vaginal cuff closure and types of suture materials used during surgery. Postoperative counseling of patients for recommencing physical activity and sexual intercourse is also of utmost significance.
Keywords: Evisceration, postcoital, small bowel, technique of vault closure, vaginal cuff dehiscence
| Introduction|| |
In premenopausal women, small bowel evisceration through vaginal cuff dehiscence (VCD) following laparoscopic hysterectomy is an infrequent yet severe life-threatening condition. Review of literature reveals the occurrence of dehiscence post hysterectomy between 5 days to as late as 30 years, with average being 6.1 weeks–1.6 years. Coitus is the important precipitating factor for dehiscence, with the incidence being approximately 8%–48%. VCD is commonly observed in the initial 12 weeks of hysterectomy, especially if intercourse is recommenced prior to adequate healing. Post surgery, the possibility of herniation of intra-abdominal organ is 67%. Herniation of small intestine surges the postsurgery mortality rate by 5.6%.
| Case Report|| |
A 47-year-old P1 L1 woman reported with the symptoms of severe pain in the lower abdomen associated with serous discharge along with herniation of some mass per vaginum. Vital parameters of the patient were within normal limits. Local examination revealed that there was herniation of small bowel of approximately 4–5” from the vagina. The appearance of the herniated tissue appeared normal. There were no ischemic changes or features suggestive of obstruction of the herniated segment [Figure 1].
The patient had coitus 2 h prior to the onset of symptoms. Previous surgical details revealed that the patient had undergone total laparoscopic hysterectomy (TLH) along with bilateral salpingo-oophorectomy 3 months back for abnormal uterine bleeding. Surgical notes also revealed that the vaginal vault was closed endoscopically using poly glycolic barbed suture. Nonetheless, postoperatively, she started physical activity including weight bearing within 2 months of surgery. A diagnosis of “small-bowel evisceration post sexual intercourse from dehiscent vaginal cuff 3 months post TLH with bilateral salpingo-oophorectomy” was made. An immediate medical aid was started by wrapping the eviscerated segment of the small intestine with saline-soaked surgical pads. Intravenous broad-spectrum antibiotics were given. An unsuccessful attempt was made to repose the bowel, following which the patient was shifted immediately to the operation theater. The eviscerated bowel and mesentery were examined. As there were no signs of ischemia, necrosis, or strangulation, vaginal approach to close the vault was planned. The edges of the vaginal cuff were refreshed. After saline wash of the protruded segment of the small intestine, reposition was performed. The vault was closed with polyglactin-910 braided synthetic absorbable suture no. 1 by continuous suture. Complete hemostasis was achieved [Figure 2].
Postoperatively, intravenous broad-spectrum antibiotics were continued for 3 days. The patient went on discharge on the 5th postoperative day. Postoperative counseling for restriction of physical activities and sexual intercourse were given.
| Discussion|| |
Common presentations of VCD include pain lower abdomen (58%–100%), serous or bloody discharge per vaginum (33%–90%), and evisceration of abdominal contents (70%). Small intestine, mainly the distal ileum, is the most common content to herniate. Herniation of other organs such as Fallopian tube More Detailss, omentum, or appendices epiploicae is additionally mentioned in the literature. The risk factors of VCD can be due to surgical or nonsurgical reason. Surgical risk factors comprise of hysterectomy techniques, colpotomy approach, and technique of closure of vault. The technique of hysterectomy is of utmost importance. Literature cites VCD incidence of 1.1%–4.9% post-TLH and 3% post-robotic hysterectomy versus 0.29% postvaginal hysterectomy and 0.12% post-tota abdominal hysterectomy., Colpotomy technique is also critical. Electrocautery used in laparoscopic hysterectomy for colpotomy increases the chance of VCD. Vaginal vault closure includes (a) route of closure, (b) suture material, and (c) suture technique. The route of closure is an important step. Literature cites the occurrence of cuff dehiscence as 0.86% by laparoscopic route versus 0.24% with vaginal route for vault closure. The suture material has a vital role to play.Polyglycolic barbed sutures are substitute for knot tying. Barbed sutures have the advantage of self-holding the tissues at almost every 0.1 cm and hence, tension in the wound is spread evenly, giving it better approximation when compared to traditional continuous sutures. It is theorized as “knotless continuous interrupted” closure. Benefits of barbed sutures are that they are knotless, provide uniform dispersion of strength across the suture line, and reduce the operative duration over conventional sutures. Various studies compared barbed sutures versus polyglactin 910 for closing the vault in laparoscopic hysterectomies. However, there was no statistical variations in the incidence of VCD with barbed suture against polyglactin 910. More detailed studies on barbed sutures of superior and vast magnitude are desirable for elucidating the benefits and sequels. Techniques of closure also play a vital role. Addition of reinforcing sutures may provide benefit in postoperative outcomes. However, the ideal technique remains elusive.
Nonsurgical risk factors include weight-bearing exercise, restarting coitus before proper wound healing, chronic constipation and cough, intraoperative and postoperative infection, hematoma formation, adjuvant chemotherapy or radiotherapy, and trauma to the vagina. Resuming coitus prior to adequate healing of the wound increases the chances of dehiscence in those undergoing hysterectomy. No studies precisely describe about when to resume intercourse after hysterectomy. However, on an average, it is recommended to avoid sexual intercourse for 2–3 months postoperatively.
In our patient, the presentation was typical. She presented with small bowel herniation from VCD three months after laparoscopic surgery. She developed this subsequent to the first act of coitus post surgery. Vault closure was done with polyglycolic-barbed sutures endoscopically. Use of electrocautery for colpotomy caused slow wound healing. Resumption of weight-bearing exercises at 8 weeks and the vaginal coitus before proper wound healing acted as triggering factors for evisceration of the small bowel through VCD. VCD with evisceration requires urgent surgical intervention. The choice of the route (abdominal, vaginal, or laparoscopic) depends on the vitality of the protruded segment and the surgical skill of the surgeon. In case of viable and nonstrangulated herniated segment, vaginal route is recommended. The life-threatening complications of herniation of bowel from dehiscent vaginal cuff include bowel ischemia, necrosis, peritonitis, and sepsis.,
| Conclusion|| |
Post hysterectomy, VCD with small-bowel evisceration following sexual intercourse is a life-threatening condition. In the era of minimally invasive surgeries, correct surgical techniques and suture materials delivering better strength to the vault need to be practiced. Because dehiscence of vault after sexual intercourse is preventable, appropriate postoperative advice should be offered to patients to prevent this complication.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]