BACKGROUND: Vaginal evisceration is an extremely rare gynecological event, which represents a surgical emergency. METHODS: We present an interesting and unusual case of strangulated intra-abdominal segment of small intestine associated with spontaneous evisceration of an incarcerated but viable loop of the distal ileum through vaginal vault six months following vaginal hysterectomy. RESULTS: The predisposition factors, mode of presentation, pre-operative management and surgical approach are discussed. A MEDLINE search (English language; 1900, July 2005; search terms: "Vaginal", "evisceration" and "Maydl's hernia") revealed no other cases. CONCLUSIONS: Our case suggests that a combined abdominal and vaginal approach should be performed when the viability of the bowel or mesenteric involvement cannot be adequately assessed. We recommend that postural or manual reduction via a vaginal approach should not be attempted as it may result in a gangrenous intraabdominal loop of bowel being missed; a lethal outcome if unrecognized.