Vaginal Evisceration Repaired by Sacrocolpopexy: A Case Report and Mini-Review of the Literature

Introduction

In different reported cases of vaginal evisceration, there are wide variations. These variations include menopausal status; having undergone hysterectomy or not; if so, route of hysterectomy, its indicatins, interval between the surgery and the occurrence of evisceration; predisposing factors; and treatment methods. This case presentation and mini-review focuses on and combines these different items, so that all gynecologists can be well-informed about the condition.

Case

An 83-year-old woman was admitted to an emergency department, 1 day after a history of falling down at home. The fall was followed by sudden enlargement of an old standing vaginal-vault prolapse. As this woman was enroute to the hospital, vaginal evisceration occurred. On examination, she was observed to be vitally stable, with a blood pressure of 130/90 mm Hg, a pulse of 89 beats per minute, and a temperature of 37.2°C. An abdominal examination elicited pain but no rigidity or rebound tenderness. A pelvic examination by the emergency-room resident revealed the presence of an edematous, congested long loop of small bowel that was seen prolapsing through the patient's perforated vaginal vault. The same findings were confirmed by a gynecology specialist and consultant.

The patient was immediately transferred to an intensive-care unit (ICU) to be prepared for surgery. Four hours later, soiling of the bowel loops with stool was noticed. The possibility of having anal incontinence was raised because of the patient's advanced age. On careful reexamination and washing of the soiled loops, a perforation was visualized. The exact time and cause of perforation were not clear. The possibility of perforation at time of evisceration and becoming evident with bowel motions was suggested. At the same time, the chance of the small bowel being traumatized during repeated examinations of the congested loop could not be ignored.

According to this patient's obstetrical history, she was gravida 3, para 3, with normal vaginal deliveries. According to her gynecologic history, she had underwent a vaginal hysterectomy for a uterine prolapse 20 years prior to her current presentation. That operation had been followed, a few months later, by a vaginal-vault prolapse, but the patient had refused to undergo further surgery. This patient had noticed a gradual enlargement of the protruding vaginal mass over the last 20 years (mostly in the form of an enterocele). According to her medical history, this patient had an ischemic heart disease (from an old myocardial infarction) and was maintained on antiischemic therapy and an oral anticoagulant (warfarin, 5 mg/day).

She received a broad-spectrum antibiotic and her prolapsed bowel was wrapped with warm, sterile saline-soaked gauze. Initial laboratory investigations revealed a prolonged international normalized ratio (INR) of 2.5. Reversal of this patient's anticoagulant state was accomplished with administration of vitamin K, and surgery was performed once her INR reached 1.2. The time lapsed since evisceration until surgery was from 8–10 hours.

In the operative theater, combined epidural and general anesthesia with endotracheal intubation was adminstered, to provide the patient with adequate postoperative analgesia. Reduction of the eviscerated loops through the vagina was not possible because of the edema, distension, and congestion of the prolapsed loops. Her bowel edema was impressive, compared to the lapsed time since evisceration had occurred, and this edema was explained by the patient's congestive heart failure resulting from her myocardial infarction, which, in turn, caused organ congestion that was exaggerated in the prolapsed bowel loops. Laparotomy was performed through a midline incision, followed by a combined abdominovaginal reduction of the loops after careful washing with a povidone iodine antiseptic solution. The edge of the perforated vaginal vault was identified, being ∼8 cm. The adherent bowel loops on the posterior vaginal wall (because of the patient's long-lasting enterocele) were carefully dissected. Closure of the opened vaginal vault was done in two layers, using an absorbable suture (polyglactin, Vicryl 1,^® Ethicon, Johnson & Johnson). The first layer was continuous locked sutures followed by continuous nonlocked sutures. Then the closed vault was suspended via sacrocolpopexy using a polypropylene mesh that was 4×10 cm. The small-bowel perforation was found 10 cm away from the ileocecal junction. After resection of 50 cm of the prolapsed loops, including the perforated site, end-to-end anastmosis was performed. Finally, the patient was put in the lithotomy position to assess any need for any vaginal repair, and a posterior colporrhaphy was done. Colpocleisis could have been a good choice owing to the patient's age and medical condition, but the presence of the perforated damaged loop made intestinal resection and reanastmosis through the vagina technically difficult, and this necessitated better exposure via laparotomy. In addition, the long-lasting neglected vaginal-vault prolapse in a patient of such an advanced age, with atrophic thinned-out vaginal epithelium and the adherent enterocele, made colpocleisis not the best choice, and sacrocolpopexy was thus justified.

Results

This patient was returned to the ICU after full recovery. Analgesia through the epidural catheter was maintained for the next 48 hours. TPN (total parentral nutrition) was given for 8 days then a gradual oral diet was started. The patient's abdomen was lax, with no tenderness, and with well-heard peristalsis. She was was vitally stable throughout the whole postoperative period, and was discharged from the hospital on the eleventh day postsurgery. This patient was followed up for 1 year with no complications or recurrence of the vault prolapse.

Discussion: A Mini-Review

Although transvaginal small-bowel evisceration is a rare gynecologic emergency, reports of cases are increasing worldwide. From 1907, when Mc Gregor described the first reported case ¹ to 1995 in a case report by Rollinson et al., there were only 47 case reports appearing in the literature. ² By 2010, the number of these reports almost doubled to reach 85 cases. ³ This can be explained simply by the increasing rates of hysterectomy using different techniques, in addition to easier reporting via online submission of manuscripts. This increased reporting supports Partsinevelos et al.'s ⁴ emphasizing that vaginal evisceration is a rare condition that gynecologists should be familiar with.

By reviewing the different reported cases of vaginal evisceration, it becomes clear that there are wide variations among them. The variations include menopausal status, hysterectomy or no hysterectomy, route of hysterectomy, its cause, interval between the surgery and evisceration, predisposing factors, and treatment approaches. This review focuses on and combines these different items to familiarize gynecologists with this condition.

It is more common for vaginal evisceration to occur through a vaginal-vault defect (i.e., in women who have undergone hysterectomy). However, vaginal evisceration is also reported to occur in premenopausal women (with intact uteri), through the posterior fornix as a result of vaginal trauma by rape, coitus, forceps delivery, or foreign-body insertion. ⁵

In postmenopausal women who have undergone hysterectomy, vaginal evisceration may occur spontaneously and the risk of occurrence is helped by factors of aging, vaginal atrophy, and the presence of an enterocele. Vaginal evisceration is usually precipitated by traumas, including falling or coitus, or increased intraabdominal pressure (e.g., straining during defecation).

Past hysterectomy is the most common finding in most reported cases. But cases have differed with respect to route of hysterectomy and its indication; 50%–75% of the reported cases had underwent vaginal hysterectomy previously and 25% had underwent an abdominal hysterectomy. ³ Two cases were reported by Nezhat et al. ⁶ and by Thomson et al. ⁷ to occur after total laparoscopic hysterectomy. The evisceration followed hysterectomy for benign conditions (e.g., uterine prolapse or fibroid tumor) or occurred after radical hysterectomy for squamous-cell carcinoma of the cervix. ⁸ In addition, a massive evisceration was reported as a complication following sacrospinous vaginal-vault fixation. ⁹

The interval between vaginal evisceration and the previous surgery varied in different reports. It occurred after 8 days after radical hysterectomy, mostly because of vault infection ⁸ ; or after few months ¹ ; after years, for example, 5 years ¹⁰ ; up to 20 years, as in the current case; or even after 30 years. ³

There is no doubt that vaginal evisceration is a gynecologic emergency, necessitating immediate surgical management, but the surgical lines of treatment varied in the different case reports. In most reports, vaginal reduction of the prolapsed loops was unsuccessful because of the marked edema of the loops, but two case reports described possible bowel replacement and vaginal-wall defect repair transvaginally.^11,12

Moreover, transvaginal bowel resection and reanastmosis was also reported. ¹² Both reports concluded that surgical repair can be performed totally transvaginally, thereby avoiding the morbidity associated with laparotomy. But, these researchers emphasized that factors, such as the medical condition of the patient and the viability of the herniated viscus, should dictate the optimal approach in each case.^11,12 However, a combined abdominovaginal approach was described in most reports,^2,10,13 allowing thorough examination of the bowel and the mysentry for trauma and facilitating the repair. The vaginal-vault defect can be closed by nonabsorbable interrupted sutures, ⁴ or by absorbable sutures (Polygleprone 2), ³ or repaired in double layers: the first layer would be continuous locked and the second layer would continuous nonlocked, using absorbable (polyglactin, Vicryl 1,^® Ethicon, Johnson & Johnson) sutures.

Closure of the vaginal vault is not sufficient; a report described attaching the vaginal vault to the shortened uterosacral ligaments, obliteration of the cul de sac using a Moschowitz procedure, and repair of the defect in the levator plate. ² In another study by Brehm et al., a graciloplasty was performed to reconstruct the rectovaginal septum. ¹⁴ In the current case, a sacrocolpopexy with a prolene mesh, measuring 4×10 cm, was performed, followed by a posterior colporrhaphy. In addition to vaginal, abdominal, or combined abdominovaginal approaches, a laparoscopic repair of vaginal evisceration has been recently reported. ¹⁵

Conclusions

Reported cases of vaginal evisceration vary in the literature, with no standardized method of repair. Sacrocolpopexy, using a polypropelene mesh, might be an ideal approach.