Vaginal Vault Dehiscence Research Articles

Investigation of risk factors for vaginal dehiscence and development of small bowel evisceration after robot-assisted radical cystectomy for female bladder cancer and an improved vaginal reconstruction technique to prevent its onset.

Transvaginal organ prolapse, such as small bowel evisceration, is a rare complication after radical cystectomy (RC) in female patients with invasive bladder cancer, However, it often requires emergency surgical repair. Here, we describe our experience with such a case and a review of similar previously reported cases, along with evaluation of the risk factors. We also propose a vaginal reconstruction technique to prevent this complication during robot-assisted laparoscopic radical cystectomy (RARC). A total of 178 patients who underwent laparoscopic radical cystectomy (LRC) or RARC were enrolled, 34 of whom (19%) were female. One of the 34 female patients had transvaginal small bowel evisceration after RARC. We evaluated our case and six such previously reported cases, to determine vaginal reconstruction techniques during RARC to prevent this complication postoperatively. Median age of these cases was 73 (51-80) years, and all patients were postmenopausal. The median time to small bowel evisceration was 14 (6-120) weeks postoperatively. In addition, we changed the methods of the vaginal reconstruction technique during RARC from the conventional side-to-side closure technique to the improved caudal-to-cephalad closure technique. Since implementing this change, we have not experienced any cases of vaginal vault dehiscence or organ prolapse. Transvaginal small bowel evisceration after RC can easily become severe. Therefore, all possible preventive measures should be taken during RARC. We believe that our vaginal reconstruction techniques might reduce the risk of developing this complication.

Vaginal vault dehiscence with small bowel evisceration, bowel necrosis, and intra-abdominal haemorrhage: a case report

Abstract Vaginal vault dehiscence with evisceration is a rare but a potentially life-threatening complication of total hysterectomy that requires prompt recognition, diagnosis, and management. The overall incidence of vaginal vault dehiscence is 0.53%. The mortality rate increases to 5.6% when bowel evisceration is present. We report a case of vaginal vault dehiscence with small bowel evisceration complicated by bowel necrosis and intra-abdominal haemorrhage in a 48-year-old woman following her first sexual intercourse 4 months after her total abdominal hysterectomy.

Management of Vaginal Vault Dehiscence after Laparoscopic Hysterectomy

<h3>Study Objective</h3> To review the epidemiology, diagnosis and management of vaginal vault dehiscence, and to illustrate a 5-step surgical approach to laparoscopic vault repair. <h3>Design</h3> Surgical footage was obtained from an emergency case after appropriate consent from the patient. <h3>Setting</h3> A tertiary care centre. <h3>Patients or Participants</h3> A 34-year-old female who presented 8 weeks after a total laparoscopic hysterectomy with a complete vault dehiscence. <h3>Interventions</h3> Vaginal vault dehiscence complicates 0.64% to 1.35% of laparoscopic hysterectomies, and can be categorized as complete cuff dehiscence, partial cuff dehiscence or partial thickness. Protective factors include the use of barbed sutures as compared to non-barbed sutures and laparoscopic closure as compared as compared to vaginal closure. Smoking and low BMI have been associated with an increased risk of dehiscence. <h3>Measurements and Main Results</h3> The surgical approach to a laparoscopic repair of cuff dehiscence can be standardized in 5 reproducible steps: abdominal survey, bladder and/or rectal dissection, vault debridement, vault closure and cystoscopy. <h3>Conclusion</h3> Vaginal vault dehiscence being uncommon, residents may graduate without being exposed to a case. This video represents an educational tool that covers the clinical and surgical approaches to the reproducible management of vaginal vault dehiscence.

Delayed vaginal vault dehiscence with irreducible omental prolapsed after laparoscopic hysterectomy

Delayed vaginal vault dehiscence with irreducible omental prolapsed after laparoscopic hysterectomy

Robotic surgery in gynaecology: Scientific Impact Paper No. 71 (July 2022).

The use of robotic-assisted keyhole surgery in gynaecology has expanded in recent years owing to technical advances. These include 3D viewing leading to improved depth perception, limitation of tremor, potential for greater precision and discrimination of tissues, a shorter learning curve and improved comfort for surgeons compared with conventional keyhole and open abdominal surgery. Robotic-assisted keyhole surgery, compared with conventional keyhole surgery, improves surgical performance without increasing operating time, minimises blood loss and intra- or postoperative complications, while reducing the need to revert to abdominal surgery. Moreover, surgeons using a robot experience fewer skeletomuscular problems of their own in the short and long term than those operating without a robot as an additional tool. This Scientific Impact Paper looks at the use of a robot in different fields of gynaecological surgery. A robot could be considered safe and a more effective surgical tool than conventional keyhole surgery for women who have to undergo complex gynaecology surgery or have associated medical issues such as body-mass index (BMI) at 30 kg/m2 or above or lung problems. The introduction of the use of robots in keyhole surgery has resulted in a decrease in the number of traditional open surgeries and the risk of conversion to open surgery after traditional keyhole surgery; both of which should be considered when examining the cost-benefit of using a robot. Limitations of robotic-assisted surgery remain the associated higher costs. In womb cancer surgery there is good evidence that introducing robotics into the service improves outcomes for women and may reduce costs.

Management of Vaginal Vault Dehiscence After Laparoscopic Hysterectomy

Vaginal vault dehiscence is a rare but serious complication of laparoscopic hysterectomy. Here we review the epidemiology, diagnosis, and management of vaginal vault dehiscence, and illustrate a 5-step surgical approach to laparoscopic vault repair. At a tertiary care centre, surgical footage was obtained from a 34-year-old female presenting 8 weeks after total laparoscopic hysterectomy with complete vault dehiscence following intercourse. Vaginal vault dehiscence complicates 0.64%–1.35% of laparoscopic hysterectomies, and can be categorized as complete cuff dehiscence, partial cuff dehiscence, or partial thickness cuff dehiscence.

A novel approach to minimally invasive hysterectomy without the use of a uterine manipulator: Kamran\u2019s TLH

BackgroundHysterectomy remains one of the most common major gynaecological procedures, with total laparoscopic hysterectomy (TLH) now established as the technique of choice over conventional open approaches. This approach depends on the use of a uterine manipulator to facilitate uterine retraction and colpotomy. This study describes a novel approach in performing total laparoscopic hysterectomy without the use of uterine manipulator or vaginal tubes and reports the intra- and postoperative outcome of this technique.MethodsA single-centre retrospective analysis of patients who underwent TLH without uterine manipulator or vaginal tube “Kamran’s TLH” for benign conditions was performed from January 2017 to October 2019. Data collected included patients’ demographics, intraoperative finding and postoperative course.ResultsA total of eighty-six hysterectomies were performed utilizing the Kamran’s TLH (KTLH) approach. Mean age was 52.2 (± 11) years old and BMI was 28.2 (± 7). TLH with bilateral salpingo-oophorectomy was performed in 63 (73.3%) patients and TLH with preservation of ovaries in 23 (26.7%) patients. Mean operative time was 64.7 (± 27.9) min and estimated bloods loss was 46.2 (± 54.6) ml. No intraoperative complications were recorded and there was no conversion to open surgery. Only one patient required readmission and surgery for vaginal vault dehiscence during their postoperative course.ConclusionUterine manipulator is a key component in performing laparoscopic hysterectomy. However, our approach demonstrated that TLH can be safely performed without the use of any uterine or vaginal manipulation.

Total laparoscopic hysterectomy without uterine manipulator. A retrospective study of 1023 cases

ObjectiveThe aim of this study was to evaluate the feasibility and safety of a total laparoscopic hysterectomy (TLH) without the use of a uterine manipulator in women with benign indications for hysterectomy. Study designBetween January 2011 and January 2020, 1023 patients underwent a TLH without the use of any type of uterine manipulator. The indications for hysterectomy were all benign conditions. The patients’ details were obtained from the hospital medical records and the indications for hysterectomy, the surgical data and the intra and postoperative complications were evaluated. All operations were performed by the same surgical team. ResultsThe median age was 48.2 years, while the BMI ranged from between 26.2 kg/m2 and 47.8 kg/m2. A small percentage of the women were menopausal (278, 27 %) and, following a detailed consultation with 563 (55 %) of the patients, we performed a TLH with adnexectomy. The mean operative time was 78 min (43–168 min), while the estimated blood loss was 59 mL (20–260 ml) and the mean uterine weight was 255 g (40–1510 g). There was no case of conversion to laparotomy. A blood transfusion was required for 14 patients (1.4 %), while there was one case of ureteral injury and three cases where the bladder was opened and fixed laparoscopically. The average hospital stay was 1.1 days, with only 38 patients staying for two or more days. In the long term, we had five cases (0.5 %) of vaginal vault dehiscence and one case of vaginal vault hematoma. ConclusionA TLH without the use of a uterine manipulator is a feasible and safe procedure. While it is perhaps a more demanding procedure for young doctors, when performed by well-trained and experienced laparoscopic surgeons, the procedure entails a short operative time and a low complications rate. As such, it should be the first step in the training of young doctors for performing laparoscopic radical hysterectomies.

Issues around vaginal vault closure

Key content Vaginal cuff dehiscence (VCD), vault prolapse, vaginal cuff granulation and infected vault haematoma are adverse events following hysterectomy. There are several approaches to closing the vaginal cuff, each using different techniques and sutures. Dehiscence of the vaginal cuff is more common with laparoscopic hysterectomy. Techniques that minimise excessive use of diathermy may reduce the risk of vault dehiscence. The incidence of post‐hysterectomy vault prolapse is estimated to be between 1.8% and 11.6%. McCall culdoplasty seems to be effective in supporting the vaginal vault. Different techniques are used to minimise the development of vault haematoma and granulation tissue. Learning objectives To understand the different techniques used for vault closure during hysterectomy. To understand the different surgical approaches used to reduce the risk of vault dehiscence, vault prolapse and haematoma after hysterectomy. To understand the post‐operative care procedure that should be followed after hysterectomy to minimise the risk of vaginal vault complications. Ethical issues Patients should be aware of the risk of vaginal vault dehiscence, vault prolapse, haematoma and granulation tissue formation after hysterectomy. Trainees should be well trained using simulators, be supervised when performing laparoscopic vaginal vault closure and be made aware that vaginal closure is another safe treatment option.

Vaginal Length After Laparoscopic Versus Vaginal Closure

INTRODUCTION: Despite the increasing numbers of total laparoscopic hysterectomies (TLH) being performed each year, randomized comparisons between laparoscopic versus vaginal cuff closure are lacking. The purpose of this study is to determine the change in vaginal length after TLH with laparoscopic cuff closure (LC) versus vaginal cuff closure (VC). METHODS: Randomized study of women undergoing TLH. Vaginal length was measured pre-operatively and then 6–12 weeks and 6–12 months postoperatively. The primary outcome was change in vaginal length. Secondary outcomes were vaginal vault dehiscence and cuff closure operative time. Analysis was per-protocol using Mann-Whitney U test and Wilcoxon signed rank test. RESULTS: 68 patients were randomized, 34 patients were excluded due to inadequate follow-up, malignancy or alternative closure. No significant differences in age, BMI or parity were found. The median preoperative vaginal lengths were similar: LC 9.0 cm vs VC 9.25 cm; P=.23. The difference in median vaginal lengths at 6–12 weeks were: LC 9.0 cm versus VC 8.9 cm (P=.68). The median vaginal lengths at 6–12 months were both 9.5 cm (P=.94). When compared to the preoperative lengths, there were no significant differences at the 6–12 evaluation. The cuff closure time was significantly longer in the LC group (20 min versus 8 minutes, P<.05). There were no cases of vaginal cuff dehiscence. CONCLUSION: After total laparoscopic hysterectomy, the vaginal length at 12 months did not differ based on method of vaginal closure. Laparoscopic cuff closure times are longer than vaginal cuff closures and neither method had cases of vaginal cuff dehiscence.

Vaginal Morcellation Inside Protective Pouch: A Safe Strategy for Uterine Extration in Cases of Bulky Endometrial Cancers: Operative and Oncological Safety of the Method

To evaluate the operative and oncologic outcomes of an innovative technique for organ morcellation in patients scheduled for laparoscopic treatment of uterine malignancies. Endoscopy is currently considered the standard of care for the operative treatment of endometrial cancer; however, the use of minimal invasive surgery (MIS) is restricted in patients with a bulky uterus or narrow vagina. Conventional unprotected intraperitoneal uterine fragmentation is indeed contraindicated in these cases. Consequently, oncologically safe methods to render these patients eligible for MIS are urgently needed. Prospective study of women with histologically proven endometrial cancer in which uterus removal was a realistic concern owing to both organ size and proportionality. The patients underwent laparoscopic staging, including retroperitoneal lymphadenectomy, total hysterectomy, and bilateral salpingo-oophorectomy, followed by vaginal morcellation of the uterus inside a protective pouch (LapSac). In our series of 30 cases, we achieved successful completion in all patients, without conversion to laparotomy. No surgery-related casualty or intraoperative morbidity was observed. The mean organ size was 246 g (range, 148-420 g), and the average additional operative time related to vaginal morcellation was 16 minutes (range, 9-28 minutes). Proper histopathological staging according to 2009 FIGO staging guidelines could be performed in all specimens. Two patients (6%) presented with significant postoperative complications, 1 each with vesicovaginal fistula and vaginal vault dehiscence. Fourteen patients (46%) needed adjuvant therapy. After a median follow-up of 20 months (range, 6-38 months), the 12-month and 24-month overall survival was 100% and 73.4% (95% confidence interval, 51%-96%), respectively. Four patients with positive lymph nodes died of distant metastasis. No case of pelvic or local relapse was observed. Vaginal morcellation following oncologic principles is a feasible method that permits rapid uterine extraction and potentially avoids unnecessary laparotomies. This series suggests that the technique may be oncologically safe and also can be used in cases of uterine pathology of uncertain malignancy.

Perioperative outcomes of three-port robotically assisted hysterectomy: a continuous series of 53 cases.

This study evaluated the feasibility and safety of 3-port robotically assisted laparoscopic hysterectomy (RALH), using a consecutive series of women who underwent 3-port RALH in a university hospital. From November 2010 until June 2013 we operated on 53 women, whose mean age was 48.4±7.7years (range 35-68years), and mean body mass index was 27.1±5.1kg/m(2) (range 19.5-42.9kg/m(2)). The indications for hysterectomy were myoma in 31 (58.5%), adenomyosis in 10 (18.9%), cervical dysplasia in 4 (7.5%), neoplasia in 4 (7.5%), and recurrent polyps or postmenopausal bleeding in the remaining 4 women (7.5%). We performed total RALH in 50 cases (94.3%) and subtotal in the others. The median duration of total intervention was 169min (interquartile range 147.5-206.5min). The mean weight of the uterus was 209.8±166.6g (range 36-790g) and mean estimated blood loss was 72.3±75.9ml (range 0-300ml). There were no perioperative complications, in particular no blood transfusions nor conversions to laparotomy. The median hospital stay was 4days (interquartile range 3-4days). One patient was reoperated 1month later for vaginal vault hematoma and another was readmitted 3weeks post-operatively due to vaginal vault dehiscence after premature intercourse, but did not require reoperation. Three-port RALH is feasible and safe for simple hysterectomy. We believe this experience using minimum ports to be useful to prepare for robotically assisted single-port hysterectomy.

Laparoscopic Extrafascial Hysterectomy (Completion Surgery) After Primary Chemoradiation in Patients With Locally Advanced Cervical Cancer: Technical Aspects and Operative Outcomes

This study aimed to evaluate the feasibility and safety of laparoscopic extrafascial hysterectomy and bilateral salpingo-oophorectomy after primary chemoradiation (CRT) in patients with locally advanced cervical cancer (LACC) without evidence of nodal metastasis. Currently, the standard of care for patients with advanced cervical cancer is concurrent CRT. There is an unequivocal correlation between presence of residual disease and risk of local relapse. Nevertheless, the importance of hysterectomy in adjuvant setting remains controversial. Prospective study with patients affected by bulky LACC (International Federation of Gynecology and Obstetrics stage IB2 up to IIB) treated initially with radical CRT who underwent laparoscopic surgery 12 weeks after therapy conclusion. Inclusion criteria were absence of signs for extrapelvic or nodal involvement on initial imaging staging, as well as complete clinical and radiologic response. From January 2011 to March 2013, 33 patients were endoscopically operated. The mean age was 44 years (range, 21-77 years). Histologic finding revealed squamous cell carcinoma in 19 (60%) cases and adenocarcinoma in 14 (40%) cases. International Federation of Gynecology and Obstetrics stages distribution were as follow: 1B2, n = 3 (9%); IIA, n = 4 (11%); and IIB, n = 26 (80%). The mean pretherapeutic tumor size was 5.2 cm (range, 4-10.2 cm). Estimated blood loss was 80 mL (range, 40-150 mL), and mean operative time was approximately 104 minutes (range, 75-130 minutes). No casualty or conversion to laparotomy occurred. Hospital stay was in average 1.7 days (range, 1-4 days). Significant complication occurred in 12% of the cases; 2 vaginal vault dehiscence, 1 pelvic infection, and 1 ureterovaginal fistula. Nine (27%) patients had pathologic residual disease, and in 78% of these cases, histologic finding was adenocarcinoma (P = -0.048). All patients had free margins. After median follow-up of 16 months, all women have no signs of local recurrence. Laparoscopic extrafascial hysterectomy (completion surgery) after primary CRT in patients with apparent node-negative LACC is a feasible and safe strategy to improve tumor local control mainly in cases of adenocarcinoma.

Dehiscencia de cúpula vaginal tras histerectomía laparoscópica: a propósito de un caso

Vaginal vault dehiscence after total hysterectomy with small bowel prolapse through the vagina is a rare complication, especially in premenopausal women. Appropriate management includes early diagnosis and surgical treatment. The combination of an abdominal and vaginal approach may facilitate repair.We present the case of a premenopausal woman with prolapse of the small bowel through vaginal cuff dehiscence 7 months after total laparoscopic hysterectomy.

Histerectomia Totalmente Laparoscópica: Análise Retrospetiva de 262 Casos

Hysterectomy is one of the most common gynecological procedures and may be performed either by vaginal approach, laparotomy or laparoscopy. Although total laparoscopic hysterectomy has multiple advantages, conflicting major complication rates have been previously reported. To describe our experience performing TLH and to evaluate complication rates. A retrospective observational study of all total laparoscopic hysterectomy performed in our department, by the same surgical team, between April 2009 and March 2013 (n = 262), was conducted. Medical records were reviewed for patient characteristics, operating time, uterine weight, post-operative hemoglobin variation, length of hospital stay, and intra and postoperative complications. Patient average age was 48.9 ± 9.0 years and 49.2% had previous abdominopelvic surgery. The average body mass index was 26.5 ± 4.5 kg/m(2) and 42% of women were either overweight or obese. The mean operating time during the total study period was 77.7 ± 27.5 minutes, but it decreased significantly as the surgical team's training increased. Average uterine weight was 241.0 ± 168.4 g and average hospital stay was 1.49 ± 0.9 days. The mean postoperative hemoglobin variation was -1.5 ± 0.8 g/dL. The major and minor complication rates were 1.5% (n = 4) and 11.5% (n = 30), respectively. One procedure was converted to laparotomy and two women had a vaginal vault dehiscence. No important urinary tract or bowel injuries occurred. This study demonstrates that, in experienced hands, total laparoscopic hysterectomy is safe and with low complications rates.

Vaginal Vault Dehiscence After Robotic Hysterectomy for Gynecologic Cancers: Search for Risk Factors and Literature Review

Vaginal vault dehiscence following robotic-assisted hysterectomy for gynecologic cancer may be attributed to surgical techniques and postoperative therapeutic interventions. We searched for risk factors in patients with gynecologic cancers and complemented this with a literature review. Evaluation of prospectively gathered information on all consecutive robotic surgeries for gynecologic cancers was performed in a tertiary academic cancer center between December 2007 and March 2012. The literature was reviewed for articles relevant to "gynecologic oncology" and "robotics" with "vaginal cuff dehiscence" in the English and French languages. Respective authors were contacted to complete relevant information. Seven dehiscences were identified of 441 cases with established gynecologic cancers. The closures in these 7 were performed using interrupted 1-Vicryl (Ethicon Inc) (3/167; 1.8%), combination of interrupted 1-Vicryl and 1-Biosyn (Covidien Inc) (3/156, 1.9%), and V-Loc (Covidien Inc) (1/118, 0.8%) sutures. Associated risk factors included adjuvant chemotherapy and/or brachytherapy, early resumption of sexual activity, and low body mass index (mean, 23 ± 3.23 kg/m²). Dehiscences occurred regardless of suturing by staff or trainees. Review of operative videos did not reveal a detectable etiologic factor, such as excessive cautery damage to the vaginal cuff or shallow tissue sutured. All 7 colporrhexis repairs were performed through a vaginal approach without the need of laparoscopy or laparotomy. Postoperative chemotherapy, brachytherapy, and early resumption of sexual activities are risk factors for vaginal vault dehiscence. Surgical technique, particularly the use of delayed absorbable sutures, deserves further evaluation.

Vaginal Vault Dehiscence and Increased Use of Vaginal Vault Brachytherapy

Literature reports describe the potential for increased incidence of vaginal vault dehiscence after minimally invasive surgery, and incidental reports of vaginal vault dehiscence with vaginal vault brachytherapy. This review explores the risk of increased vaginal complications in a setting of greater use of both minimally invasive surgical techniques and adjuvant vaginal vault brachytherapy in early endometrial cancer. The impact of associated patient-related and tumor-related risk factors on clinical decision making is evaluated in selecting therapy that provides optimal tumor control while minimizing treatment adverse effects.

Vaginal vault dehiscence after laparoscopic hysterectomy over a nine‐year period at Sydney West Advanced Pelvic Surgery Unit – our experiences and current understanding of vaginal vault dehiscence

A retrospective analysis of all women undergoing hysterectomy at Sydney West Advanced Pelvic Surgery Unit (SWAPS) was performed in the nine-year period from 2001 to 2009. To evaluate the incidence, timing and presenting symptoms of vaginal vault dehiscence after hysterectomy, especially via the laparoscopic approach to gain further understanding of patient risk factors and surgical factors that may predispose to this complication. Women who presented with vaginal vault dehiscence were identified and possible pre-operative, intra-operative and post-operative risk factors were assessed. A comprehensive literature search was performed to assess the current understanding and incidence of vault dehiscence after laparoscopic hysterectomy. A total of 1224 hysterectomies were performed between 2001 and 2009. 989 (80.80%) were performed laparoscopically of which five women (0.42%) presented with vault dehiscence post-operatively. All had undergone total laparoscopic hysterectomy resulting in a vault dehiscence rate of 1.59% after total laparoscopic hysterectomy specifically. Baseline characteristics included a mean age of 42.8 years (37-51 years), mean BMI of 26.8 kg/m(2) (23.8-32.3 kg/m(2)) and a mean parity of two deliveries (1-3 deliveries). The main presenting symptom of vaginal vault dehiscence was vaginal bleeding. Women with confirmed vaginal vault dehiscence readmitted to hospital at a mean of 18 days (11-28 days) post-operatively. Vaginal vault dehiscence is a rare complication after hysterectomy, but more common after a laparoscopic approach. A delayed presentation with vaginal bleeding was the main presenting symptom in this study - a literature review has shown common presenting symptoms to include abdominal pain, vaginal evisceration and vaginal bleeding. Techniques specific to total laparoscopic hysterectomy seem especially important in the increased risk of vaginal vault dehiscence seen after laparoscopic hysterectomy.

An unusual case of small bowel evisceration

British Journal of Hospital MedicineVol. 72, No. 2 Case ReportAn unusual case of small bowel eviscerationKaji Sritharan, Shabnam Parkar, Jonathan Lewin, Sufian SultanKaji SritharanSearch for more papers by this author, Shabnam ParkarSearch for more papers by this author, Jonathan LewinSearch for more papers by this author, Sufian SultanSearch for more papers by this authorKaji Sritharan; Shabnam Parkar; Jonathan Lewin; Sufian SultanPublished Online:16 Aug 2013https://doi.org/10.12968/hmed.2011.72.2.114AboutSectionsView articleView Full TextPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareShare onFacebookTwitterLinked InEmail View article References Agdi M, Al-Ghafri W, Antolin R et al. (2009) Vaginal vault dehiscence after hysterectomy. J Minim Invasive Gynecol 16(3): 313–17 Crossref, Medline, Google ScholarHur HC, Guido RS, Mansuria SM, Hacker MR, Sanfilippo JS, Lee TT (2007) Incidence and patient characteristics of vaginal cuff dehiscence after different modes of hysterectomies. J Minim Invasive Gynecol 14(3): 311–17 Crossref, Medline, Google ScholarKowalski LD, Seski JC, Timmins PF, Kanbour AI, Kunschner AJ, Kanbour-Shakir A (1996) Vaginal evisceration: presentation and management in post-menopausal women. J Am Coll Surg 183(3): 225–9 Medline, Google ScholarRamirez PT, Klemer DP (2002) Vaginal evisceration after hysterectomy: a literature review. Obstet Gynecol Surv 57(7): 462–7 Crossref, Medline, Google Scholar FiguresReferencesRelatedDetails 1 February 2011Volume 72Issue 2ISSN (print): 1750-8460ISSN (online): 1759-7390 Metrics History Published online 16 August 2013 Published in print 1 February 2011 Information© MA Healthcare LimitedPDF download

Vaginal vault dehiscence with evisceration after total laparoscopic hysterectomy

Vault dehiscence and evisceration of peritoneal contents is a rare complication following total hysterectomy. A 43-yearold lady presented with history of something soft coming out per vaginum. She underwent total laparoscopic hysterectomy 2 months back for 16-week fibroid uterus. The surgery was uneventful, vaginal vault was sutured laparoscopically with no 1 polyglactin, interrupted figure of eight sutures. She was discharged after 48 h with uneventful recovery and subsequently presented with mass protruding per vaginum. Speculum examination showed loops of small bowel protruding in the vagina (Fig. 1). She was hospitalized and scheduled for reduction of the prolapsed bowel with vault repair. On examination under anaesthesia, there was complete dehiscence of the vaginal vault with loops of small bowel protruding through the defect. To maintain the pneumoperitoneum vagina was blocked using a simple vaginal tampon soaked in betadine solution (Fig. 2) [1]. On Laparoscopic evaluation the entire vault was deficient. There were no bowel, bladder or omental adhesions to the vault. The prolapsed ileal loops were seen just at the vault, with healthy pink colour and regular peristalsis. On giving Trendelenburg’s position the reposition was smooth. After confirming that the vault was free of any adhesions, the vault was closed vaginally using interrupted no 1 Polydioxone II sutures (Fig. 3). Patient was discharged on the third post-operative day and is asymptomatic at 6-month follow-up. Vaginal vault dehiscence with evisceration posthysterectomy can occur up to few weeks to even few years after hysterectomy. The commonest organ to eviscerate is small bowel, particularly terminal ileum. Several factors which may contribute to weakness of vaginal apex are poor surgical techniques, post-operative wound haematoma and cuff infection, post-menopausal status, any activity resulting in increased intra-abdominal pressure, early resumption of sexual activity, chronic steroid administration, history of previous radiotherapy in cases of radical hysterectomy [2] and systemic illness like diabetes mellitus and immunecompromised status [3].