Treatment of Vaginal Cuff Evisceration

Abstract

Vaginal cuff dehiscence is defined as partial or full separation of the vaginal cuff (vaginal incision), whereas evisceration refers to prolapse of intraperitoneal contents (usually ileum) through the cuff defect. Evisceration, a rare but potentially morbid complication of total hysterectomy, is a surgical emergency due to the potential for bowel injury and peritonitis. Minimally invasive hysterectomy techniques (robotic or laparoscopic- assisted) are associated with significantly higher rates of cuff dehiscence and evisceration than abdominal or vaginal hysterectomies. The frequency of vaginal cuff dehiscence and evisceration has increased in recent years largely due to the increased use of such minimally invasive procedures. Historically, urgent laparotomy was recommended for management of vaginal cuff evisceration, and it was believed that there was no role for transvaginal repair. Recently, successful outcomes have been reported in several case and retrospective studies using a less invasive vaginal or combined vaginal and laparoscopic approach. The aims of this article were to review an algorithm for transvaginal repair of vaginal cuff evisceration and to describe experience with this technique at a single institution. All women selected for transvaginal closure were medically stable and had no evidence of peritonitis or bowel injury. After administration of broad-spectrum antibiotics, the prolapsed bowel was copiously irrigated with warm saline solution and gently replaced into the abdomen through the vaginal cuff. After the cuff was sharply debrided of necrotic tissue, a full-thickness cuff closure was performed using a delayed absorbable monofilament suture. Between 2009 and 2014, 4 cases of vaginal cuff evisceration were successfully managed with a transvaginal approach. There were no intraoperative or postoperative complications. All 4 patients were discharged home on postoperative day 2 and did not require repeat surgery. These findings show that vaginal cuff dehiscence and evisceration can be managed by transvaginal bowel reduction and cuff closure in medically stable patients who have no evidence of peritonitis or bowel injury.