Vaginal Small-Bowel Evisceration Complicated by Meckel's Diverticulitis

Introduction

Small-bowel evisceration through dehiscence of the vaginal cuff is a rare postoperative complication following hysterectomy. Most commonly involving the terminal ileum, other sites of prolapse including the colon, fallopian tube, and appendix have been reported.^1–4 Vaginal small-bowel evisceration most commonly occurs in postmenopausal women because of the increased atrophic changes that occur at the vaginal apex.^5,6 Further predisposing factors that contribute to weakness of the vaginal apex include vaginal cuff cellulitis or hematoma formation, premature resumption of coitus, exposure to chemotherapy or radiation, poorly controlled diabetes, chronic renal failure, history of immunosuppresion, poor surgical technique, and malnutrition.^7,8 Considered a surgical emergency, vaginal small-bowel evisceration requires immediate assessment of the prolapsed bowel for viability, followed by repair of the vaginal cuff. We report a unique case of vaginal small-bowel evisceration of a portion of the terminal ileum with an associated Meckel's diverticulitis.

Case

A 62-year-old Latin-American female presented to the outpatient gynecology clinic 4 years after undergoing a total vaginal hysterectomy with complaints of abdominal pain and bloody vaginal discharge. Her prior medical history was complicated only by type 2 diabetes mellitus that was well controlled. She denied recent sexual intercourse and reported no strenuous activity or exercise. Her vital signs were unremarkable, except for a low grade temperature of 100.9°F. Physical examination demonstrated an exquisitely tender lower abdomen and a polypoid, cystic mass at the vaginal cuff. Immediate surgical intervention was arranged, and upon further inspection of the vaginal cuff in the operating room, a small loop of hyperemic and edematous small bowel was discovered. An exploratory laparotomy was then performed, revealing a 15 cm segment of nonviable appearing ileum that contained a communicating 5 cm abscess adherent to the anterior vaginal cuff. The nonviable bowel segment, along with the abscess cavity, was resected and a side-to-side ileal reanastomosis was performed. The vaginal cuff was then approximated in an interrupted figure-of-eight manner. After copious pelvic irrigation, the abdomen was closed. The patient's postoperative course was uncomplicated, and she was discharged home on postoperative day 3. Final pathology revealed a necrotic segment of terminal ileum containing a perforated Meckel's divertculum. Follow-up pelvic examination, conducted at 6 weeks and 3 months postoperatively, revealed an intact vaginal cuff that was healing well.

Discussion

We believe that in this case, Meckel's diverticulitis incited a localized inflammatory response, resulting in the breakdown of the vaginal apex and a delayed presentation of vaginal small-bowel evisceration. To our knowledge, the simultaneous presentation of Meckel's diverticulitis and a vaginal small-bowel evisceration is unique and has not previously been reported.

The Meckel's diverticulum, named after Johann Friedrich Meckel, who described its embryological origin in 1808, is a vestigial remnant of an incompletely obliterated omphalomesenteric duct that occurs during the fifth week of gestation.^9,10 It is the most common congenital anomaly of the gastrointestinal tract, and is located on the antimesenteric border of the terminal ileum, usually within about 60–100 mm of the ileocecal valve. Occurring in approximately 1% of the general population, the overwhelming majority of Meckel's diverticula are asymptomatic. ¹¹ Affected pediatric patients usually present with an intestinal obstruction related to an underlying intessuption or volvulus, while symptomatic adult patients present with painless lower gastrointestinal bleeding, intestinal obstruction, or localized peritonitis. ¹⁰ While the majority of Meckel's diverticula are histologically normal, gastric, duodenal, pancreatic, and carcinoid ectopic tissue have been reported.^12–14 Depending upon the degree and extent of any associated compromised bowel, the surgical management of a symptomatic Meckel's diverticulum may range from simple diverticulectomy to the segmental resection of the involved bowel segment followed by diversion or reanastomosis. Debate exists around whether asymptomatic Meckel's diverticula, discovered incidentally, require resection. In a population-based, epidemiologic study, Cullen et al. suggest the removal of all Meckel's diverticula discovered at the time of surgery, ¹⁵ while in a case series of 1,476 patients, Park et al. recommend the removal of Meckel's diverticula in patients who are male, aged less than 50 years, where ectopic tissue is present, or where the diverticular length is greater than 2 cm, since these are risk factors for the development of symptoms in the future. ¹⁰

The combination of weakened vaginal mucosa coupled with the increased prevalence of chronic medical conditions that impair wound healing, such as diabetes mellitus or chronic renal failure, predispose postmenopausal women to develop vaginal small-bowel evisceration following hysterectomy. Postmenopausal estrogen deficiency may lead to atrophy of the urogenital mucosa, thereby further contributing to the risk of vaginal cuff dehiscence. In a randomized controlled trial of 65 postmenopausal women undergoing vaginal reconstructive surgery, Karp et al. found that early administration of vaginal estrogen resulted in improved tissue quality postoperatively compared to placebo. ¹⁶ Vaginal small-bowel evisceration may occur spontaneously, but also may result from increases in intra-abdominal pressure seen, for example, during the Valsalva maneuver. ¹⁷ Less commonly, vaginal small-bowel evisceration may occur in premenopausal women with a prior history of sexual or obstetrical trauma.^18,19 In a recent review of 95 cases by Ramirez et al., 63% of vaginal evisceration occurred following a vaginal hysterectomy, 32% following an abdominal hysterectomy, and 5% after a laparoscopic hysterectomy. ⁶ It should be noted, however, that the laparoscopic hysterectomy group only contained three patients. Indeed, an increased incidence of vaginal cuff dehiscence has been reported following robotic laparoscopic hysterectomy because of the increased thermal spread that occurs with the use of monopolar cautery during the creation of the colpotomy. ²⁰ Also, Nezhat et al. described patients undergoing laparoscopic hysterectomy as being at a higher risk for vaginal cuff dehiscence because of shorter recovery times and, correspondingly, a higher rate of premature resumption of coitus. ²¹

Once recognized, vaginal small-bowel evisceration is considered a surgical emergency. Immediate inspection of the bowel segment for viability is paramount in order to prevent complications associated with incarcerated or strangulated bowel. Certainly, the presence of abdominal guarding, rigidity, distention, or rebound tenderness, especially when associated with fevers, tachycardia, hypotension, or diminished urinary output, would indicate the presence of an underlying peritonitis with impending hemodynamic collapse and should hasten evaluation in the operating room.

While a variety of surgical approaches to vaginal small-bowel evisceration have been described, including open abdominal, laparoscopic, or vaginal, the surgeon must be able to assess the viability of the prolapsed bowel along with any adjacent portions of bowel, resect any necrotic segments of bowel, reanastomose or proximally divert the remaining bowel, and adequately close the vaginal cuff. The vaginal approach, while less invasive, may not afford the necessary visualization required for complex bowel surgery and, therefore, should be reserved for patients without an acute abdomen or nonviable appearing prolapsed bowel. In addition, the inspection of the remainder of the small bowel and its mesentery is significantly hindered without an open abdominal or laparoscopic approach. The role of laparoscopic surgery continues to expand as surgeons gained more familiarity with laparoscopic techniques. Laparoscopic surgery for vaginal small-bowel evisceration, however, may be technically challenging given the degree of inflamed bowel and increased vascularity. Also, the duration of the surgery may be less with an open abdominal compared to the laparoscopic approach.

Following the assessment and management of the small bowel, attention should be turned to inspection of the vaginal cuff. Any necrotic edges of the vaginal cuff should be debrided until viable tissue is obtained. Closure of the vaginal cuff should be full thickness and incorporate the vaginal epithelium, vaginal musculature, and the pubocervical fascial ring. Techniques of vaginal cuff reinforcement following vaginal evisceration, including mesh reinforcement, adductor magnus, and omental flap coverage, may also be utilized. ²²

Conclusions

In conclusion, vaginal small-bowel evisceration is a rare complication following hysterectomy. Although this patient was postmenopausal and a type 2 diabetic, she denied any recent episodes of increased abdominal pressure or sexual activity. We propose in this case that episodes of localized Meckel's diverticulitis occurred, creating inflammatory changes at the vaginal apex and eventual erosion of the Meckel's diverticulum, along with its associated small-bowel segment through the vaginal cuff.