Small bowel evisceration: a late complication following vaginal hysterectomy

Abstract

We present a case of small bowel evisceration occurring as a late complication following vaginal hysterectomy and subsequent vault prolapse.Case history: A 92-year-old female presented with sudden onset severe abdominal pain, followed by the sensation of vaginal fullness and the discovery of a large prolapse per vagina, with no history of trauma or sexual intercourse.Past medical history consisted of vaginal hysterectomy 20 years previously with a subsequent sacrospinous vault fixation.On examination, a vaginal vault prolapse was found with 3 feet of oedematous small bowel prolapsed through it. Peristalsis remained visible.An emergency laparotomy was undertaken as a joint procedure between the gynaecology and general surgery teams. The small bowel was gently manipulated back through a 3 cm defect in the vault. Once in the abdomen, it was found to be viable and no resection was required. The vault defect was closed with 1/0 Vicryl and the vault was then fixed to the left lateral side wall of the peritoneum. Routine closure of the abdomen was performed after saline washout.Recovery was complicated by a postoperative ileus requiring nasogastric tube insertion for two days. She recovered well following this and will be followed up in the gynaecology outpatient clinic.Discussion: Small bowel evisceration is a rare complication following hysterectomy. With relatively few cases reported in the literature, incidence is difficult to determine. The most commonly reported risk factors are postmenopausal atrophy, previous vaginal surgery and enterocele. Cases have been reported following both abdominal and vaginal surgical approaches, and are commonly precipitated by sexual intercourse, introduction of a foreign body into the vagina or increased intra-abdominal pressure (Gandhi and Jha 2011).Vaginal evisceration is a gynaecological emergency. Prompt recognition is vital in order to prevent compromise of intra-abdominal contents (Codd et al. 2010). Management requires a multidisciplinary approach and early transfer to theatre for urgent surgical repair; various different approaches have been described, however, if there is any question about organ viability exploration via a midline laparotomy is indicated (Gandhi and Jha 2011).Educational message/learning point: We have presented this case in order to raise awareness of small bowel evisceration as a late complication following hysterectomy. Clinicians in both general surgery and gynaecology should be aware of its potentially non-specific presenting symptoms, as eviscerated organs may not be particularly evident on admission. This is a life threatening condition that requires immediate recognition and management via a multidisciplinary approach.