Recurrent wound infection due to abdomino-vaginal fistula after abdominal hysterectomy.

Abstract

A 48 year old moderately obese woman presented with a one year history of a recurrent abdominal wound infection which was unresponsive to repeated medical and surgical treatments. Three months before the onset of infection she underwent abdominal hysterectomy with bilateral salpingo-oophorectomy at another hospital due to ultrasonographic diagnosis of uterine mass combined with recurrent menorrhagia and pelvic relaxation symptoms. There was no history of pelvic inflammatory disease and no adhesions were found at surgery. The operation note stated that the vaginal vault was fixed to the shortened round ligament to prevent vault prolapse and that the operation had been successful. Histology confirmed benign uterine leiomyoma. The early post-operative weeks were uneventful, but erythema and pus appeared below the abdominal wound three months later. Abdominal wall debridement was performed and after two weeks of intravenous antibiotics, the wound was closed with non-absorbable sutures. She was discharged on oral antibiotics. Over the next four months, the abdominal wound failed to heal and infection persisted. Further wound debridement was performed and oral antibiotics prescribed at the outpatient clinic. However, the wound infection continued. After 12 months of persistent wound infection, she was referred to our hospital. The only abnormalities were a purulent discharge from the abdominal wound and from the vagina. On examination, the depth of the vaginal canal extended toward the abdominal wall and instillation of methylene-blue revealed a fistula. A computerised tomographic (CT) scan confirmed the abnormality (Fig. la). A laparotomy was performed, and the structures were sepa-