Small bowel evisceration after abdominal hysterectomy with open vaginal cuff technique: A case report.

Key Clinical Message: Vaginal cuff dehiscence post-hysterectomy is rare yet significant. Early recognition and prompt surgical intervention are crucial to prevent complications like bowel infarction. Consider second-look laparotomy in cases of uncertain bowel viability. Abstract: Vaginal cuff dehiscence (VCD) is a rare but potentially life-threatening complication following a hysterectomy characterized by the separation of the vaginal vault. This condition, which may result in vaginal evisceration (VE), presents a significant risk of pelvic contents, particularly the small bowel, protruding into the vagina. Early diagnosis and prompt surgical intervention are paramount to prevent severe complications, including bowel infarction, obstruction, and peritonitis. Although VCD and VE are rare, they require urgent surgical management to avoid adverse outcomes. We reported a case of small bowel evisceration in a woman with a history of total abdominal hysterectomy 6 months ago. VCD and VE are very rare but life-threatening complications of hysterectomy. Discussing the symptoms with patients who have multiple risk factors is crucial to avoid severe sequels following hysterectomy. Based on our experience, performing a second-look laparotomy is a reliable approach to ensure the viability of the intestinal loop. However, it will likely increase the risk of infection.

An Unforeseen Complication: Intestinal Prolapse After Total Abdominal Hysterectomy.

After total abdominal hysterectomy (TAH), intestinal prolapse is uncommon. We report an instance of a 48-year-old woman who had TAH and then intestinal prolapse. Two weeks after the operation, symptoms started to show up, and the vaginal vault developed a bulging bulge. The problem was satisfactorily treated with an urgent laparotomy. The significance of being vigilant for unusual complications following TAH is shown by this example.

Recurrent vaginal evisceration of abdominal contents with subsequent resection of necrotic omentum in a 35-year-old woman.

Vaginal evisceration is a rare surgical emergency in which intra-abdominal contents protrude through a dehisced vaginal cuff, which can lead to bowel ischemia and abdominal sepsis. This condition occurs due to vaginal cuff weakness secondary to prior surgeries or trauma. Recurrence after repair is rare and few cases have been documented. Here we present a young woman with multiple prior gynecologic surgeries who presented with eviscerated small bowel and omentum from her vagina five months following surgical treatment of a previous vaginal evisceration. Via a transabdominal surgical approach, general surgery and gynecology teams reduced the intra-abdominal contents, resected a pedicle of necrotic omentum, suture repaired the vaginal cuff, and placed a dehydrated placental allograft. This extremely rare case of recurrent vaginal evisceration demonstrates the importance of taking appropriate preventative surgical measures, maintaining a healthy level of suspicion for recurrence, knowing potential complications, and educating patients to prevent recurrent vaginal evisceration.

Rate of Vaginal Cuff Dehiscence When Using Vicryl (Poliglactyn 910) Compared to PDS (Polydioxanone) for Vaginal Cuff Closure in Laparoscopic Hysterectomy.

Objective: To compare the vaginal cuff dehiscence (VCD) rates using Vicryl (Poliglactyn 910) and Polydioxanone (PDS) in patients who underwent laparoscopic hysterectomy. Materials and methods: A retrospective, monocentric study was conducted, including all patients undergoing laparoscopic hysterectomy at the Department of Obstetrics and Gynaecology, Azienda di Rilievo Nazionale e di Alta Specializzazione (ARNAS) Garibaldi Nesima, Catania, between January 2014 and December 2021. Patients underwent hysterectomy for benign gynecologic pathologies (endometriosis, leiomyomas, or benign pelvic pathologies) or malignant gynecologic pathologies (endometrium cancer, complex endometrial hyperplasia, ovarian cancer, cervix cancer, or uterine carcinosarcoma). The Z-score calculation was performed to find eventual statistically significant differences between the two populations regarding VCD rates. Results: Laparoscopic vaginal cuff closure was performed, with Vicryl sutures in 202 patients and PDS sutures in 184 women. Demographic and baseline characteristics were not significantly different in the two groups. VCD occurred in three patients in the Vicryl group and did not occur in the PDS group. The three cases of VCD were precipitated by intercourses that occurred within 90 days of surgery. However, there was not a significant statistical difference between the two groups regarding VCD (p = 0.09). Conclusions: Vicryl and PDS sutures seem to be similar for vaginal cuff closure in laparoscopic hysterectomy. The VCD rate was low, and the observed differences between the Vicryl and PDS groups did not reach statistical significance. Further research through prospective studies is essential.

"It just wasn't right down there": Surgical treatment of small bowel evisceration after hysterectomy with indocyanine green angiography, a case report.

This is a case of a 70-year-old female with small bowel evisceration through vaginal cuff dehiscence 14 months after hysterectomy. She presented with a loop of ileum herniated through the vagina. The bowel was irreducible and she was taken to the operating room for exploratory laparotomy, reduction of herniated bowel contents, and repair of vaginal cuff. During surgery, the eviscerated bowel had questionable viability and indocyanine green angiography was used to assess perfusion. After the repair of the vaginal cuff, indocyanine green angiography was performed and the bowel was saved from resection. In the discussion, light is shed upon the rarity of vaginal cuff dehiscence and the few cases of small bowel evisceration after a dehiscence. Possible causes of the evisceration, updates to technique, and recommendations for management are also discussed. The ultimate recommendation is for use of indocyanine green angiography in assessment of intestinal viability during surgical exploration for small bowel evisceration.

Vaginal Cuff Dehiscence in Transgender Patients After Minimally Invasive Hysterectomy.

STUDY OBJECTIVE: To compare rates of vaginal cuff dehiscence (VCD) in transgender patients with cisgender patients after minimally invasive hysterectomy (MIH). DESIGN: We performed a single-surgeon, retrospective cohort analysis comparing the rates of VCD in patients undergoing MIH for gender affirmation with other indications (benign, malignant, prophylactic) with our study surgeon between January, 2015, and December, 2021. SETTING: Major, urban, academic tertiary care hospital in the United States. PATIENTS: 166 patients met inclusion criteria with 49 of those patients undergoing MIH (29.5%) for gender affirmation. Of the remaining 117 patients, 92 (78.6%) underwent MIH for cancer, 15 (12.8%) for prophylaxis, and 10 (8.5%) for benign indications. INTERVENTIONS: Not applicable. MEASUREMENTS: We assessed included patients for baseline demographics, presence of risk factors for VCD, details of index hysterectomy, and details of cuff dehiscence events. MAIN RESULTS: Transgender patients tended to be younger at the time of surgery, but demographics were otherwise similar between both groups. Most transgender patients (n = 36, 73.5%) had both ovaries removed at the time of hysterectomy, 100% were on testosterone therapy pre- and postoperatively, and none used supplementary estrogen. Three of the 49 transgender patients (6.1%) experienced postoperative dehiscence of the vaginal cuff compared with 2 of the 117 cisgender patients (1.7%). This failed to reach statistical significance; however, our descriptive analysis showed that all cases of dehiscence in the cisgender group had identifiable precipitating factors (i.e., trauma). By comparison, all cases of dehiscence in the transgender group were spontaneous with few identifiable risk factors. CONCLUSION: Transgender patients undergoing MIH may be at increased risk of VCD, although the rarity of this surgical complication precluded determination of statistical significance in our data set. We propose testosterone exposure as a possible risk factor for VCD, although we cannot exclude other factors, such as young age, as drivers of VCD in this population. Future studies of biospecimens are needed to evaluate for cellular differences in these patients.

Hysterectomy Trends and Risk of Vaginal Cuff Dehiscence: An Update by Mode of Surgery.

STUDY OBJECTIVE: To analyze hysterectomy trends and vaginal cuff dehiscence (VCD) rates by mode of surgery at a tertiary care medical center and to describe characteristics of VCD cases. DESIGN: Observational retrospective cohort study. SETTING: Large academic hospital and affiliated community hospital. PATIENTS: 4722 patients who underwent hysterectomy at Columbia University Irving Medical Center between January 2010 and August 2021. INTERVENTIONS: Current Procedural Terminology and International Classification of Diseases codes identified hysterectomies and VCD cases. Hysterectomy trends and VCD rates were calculated by mode of surgery. Relative risks of VCD for each mode were compared with total abdominal hysterectomy (TAH). Clinical characteristics of VCDs were reviewed. MEASUREMENTS AND MAIN RESULTS: There were 4059 total hysterectomies. Laparoscopic hysterectomies, including total laparoscopic hysterectomies (TLHs), laparoscopic-assisted vaginal hysterectomies, and robot-assisted TLHs (RA-TLHs), increased from 41.9% in 2010 to 65.9% in 2021 (p <.001). RA-TLH increased from 5.7% in 2010 to 40.2% in 2021. Supracervical hysterectomies followed similar trends and were excluded from VCD analysis. There were 15 VCDs (overall rate 0.37%). VCD was highest after RA-TLH (0.66%), followed by TLH (0.32%) and TAH (0.27%), with no VCDs after laparoscopic-assisted vaginal hysterectomy or total vaginal hysterectomy. Compared with TAH, the relative risk for VCD after RA-TLH was 2.44 (95% confidence interval 0.66-9.00) and after TLH was 1.18 (95% confidence interval 0.24-5.83), which were not statistically significant. The mean time to dehiscence was 39 days (range 8-145 days). The most common trigger event was coitus (41%). CONCLUSION: VCD rates were low (<1%) for all modes of hysterectomy, and rates after robotic and laparoscopic hysterectomy were much lower than previously reported. Although VCD rates trended higher after robotic and laparoscopic hysterectomy compared with abdominal hysterectomy, the difference was not significant. It is difficult to determine whether this finding represents true lack of difference vs a lack of power to detect a significant difference given the rarity of VCD.

Vaginal Cuff Dehiscence After Total Laparoscopic Hysterectomy: Prospective Comparison Of Two Types Of Suturing Techniques.

BACKGROUND: To compare the frequency of vaginal cuff dehiscence after total laparoscopic hysterectomy between two different suturing techniques. Place and duration of study: The study was conducted at three centers; postgraduate tertiary care hospital, university affiliated hospital and private multidisciplinary hospital. The studied duration was from January 2019 to June 2020. METHODS: All patients with indication of total laparoscopic hysterectomy during the study period were included. These were randomly divided in to two groups A and B. Group A was performed upon the conventional interrupted figure of 8 vault suturing and group B with continuous, running, double layered suturing. Keeping the demographics almost same the frequency of a known but rare complication of vaginal cuff dehiscence (VCD) was determined. RESULTS: A total of 195 patients were enrolled. Of these 87 were in group A and 108 in group B. The results were unequivocal as only one patient had the said complication. CONCLUSIONS: The morbid complication has no relation with the technique of vault suturing.

Laparoscopic management of vaginal evisceration of the small bowel.

Vaginal vault dehiscence leading to bowel evisceration is a rare but potentially lethal surgical emergency. Various aetiologies have been reported in the literature, but the condition is most commonly seen after hysterectomy in post-menopausal women. Prompt reduction of the bowel is necessary to prevent ischaemic complications. Although most cases in the past have been managed by exploratory laparotomy, the condition may be managed laparoscopically if the prolapsed bowel is viable, giving the benefit of minimally invasive surgery to the patient. A hybrid approach of laparoscopic bowel reduction and per vaginal repair of the vault is technically simple and can be performed even by non-expert surgeons in an emergency setting.

Omentum Mimicking as a Vaginal Prolapse in a Delayed Vaginal Cuff Dehiscence.

A rare consequence of hysterectomy is vaginal vault dehiscence, which commonly occurs five to seven weeks after the procedure. Its frequency ranges from 0% to 7.5%. The incidence of delayed dehiscence is rare. The small bowel is the organ that prolapses most frequently, but other organs and multi-organ prolapses have also been documented. Due to potential catastrophes such as intestinal ischemia, blockage, and perforation, transvaginal protrusion of abdominal viscera is an emergency. A laparoscopic approach facilitates a thorough evaluation of the abdominal contents and provides assistance in challenging circumstances where the contents are not reducible.

Vaginal Evisceration After Abdominal Hysterectomy: A Case Report.

Vaginal cuff dehiscence (VCD) is an extremely rare complication after a hysterectomy, with possible life-threatening consequences. Multiple cases of pelvic organ evisceration through the vaginal cuff have been reported, most frequently precipitated by sexual intercourse. Surgeons should be suspicious of clinical signs of VCD postoperatively, as any intervention should be prompt. Patients at high-risk patients of developing vaginal cuff dehiscence should be advised to refrain from straining exercises for longer periods of time. Herein, we present the case of a 46-year-old with this complication.

Experience in the Management of Vaginal Cuff Dehiscence and Evisceration: A Retrospective 37-Year Single-Center Study.

Purpose: Vaginal cuff dehiscence (and evisceration) (VCD(E)) is an extremely rare and late-onset complication of total hysterectomy (TH). Limited evidence is available to guide clinicians in managing VCD(E). This study aimed to summarize the clinical characteristics of patients with VCD(E) treated in our center and share our experience in managing VCD(E). Patients and methods: From 1983 to 2020, a total of 14 cases of VCD(E), including 10 cases in our hospital and 4 cases in other hospitals, were included. Medical records were reviewed to summarize the clinical features and management of VCD(E). Results: The incidence of VCD(E) in our hospital was 10/46,993 (0.02%), and all 10 patients underwent laparoscopic hysterectomy. The median TH-to-VCD(E) interval was 3.13 months (8 days-27.43 months), and 11/14 (78.57%) patients experienced VCD(E) after coitus. The 3 major symptoms included abdominal pain in 11 patients, irregular vaginal bleeding in 8, and sensation of bulging or prolapsed organs in 4. Except for 2, most patients presented to our hospital within 72 h since the onset of the discomfort. All 14 cases were diagnosed through speculum examination: 3 had simple VCD, and 11 had VCDE. The protruding bowels of 4 patients were immediately manually repositioned in the emergency department without anesthesia. Regarding the surgical approach, 11 patients underwent simple transvaginal, 2 patients underwent laparoscopic-vaginal combined (transvaginal cuff closures), and 1 patient underwent laparoscopic. All but 1 patient did not undergo resection of the eviscerated organs. The median follow-up period was 39.33 (7.9-159.33) months. No patients showed any evidence of recurrence to date. Conclusions: Laparoscopic hysterectomy is a risk factor for VCD(E), and early initiation of sexual intercourse is the most common trigger of VCD(E). Clinicians should educate patients to postpone sexual intercourse for at least 3-6 months after TH. Immediate medical attention and patient-specific surgical management are crucial to avoid serious complications.

Case of vaginal cuff dehiscence and small bowel evisceration after laparoscopic radical cystectomy.

INTRODUCTION: Vaginal cuff dehiscence and small bowel evisceration after laparoscopic radical cystectomy, although rare, can be a critical complication. However, little has been reported about it by urologists. CASE PRESENTATION: A 79-year-old woman underwent laparoscopic radical cystectomy for invasive bladder carcinoma. Thirteen months postoperatively, she experienced vaginal cuff dehiscence and small bowel evisceration, and underwent emergency surgery. Intraoperatively, we detached the vaginal apex from the surrounding tissue to lengthen it and performed vaginal uterosacral ligament suspension, with no subsequent recurrence. CONCLUSION: Urologists should pay attention to vaginal cuff dehiscence and small bowel evisceration after laparoscopic radical cystectomy in female patients. In this case, the short vaginal length without vaginal uterosacral ligament suspension might have led to vaginal dehiscence.

Small Bowel in Vagina: A Case for Pelvic Exams.

Vaginal cuff dehiscence with small bowel evisceration is a serious but uncommon postoperative complication of total laparoscopic hysterectomies. The severity of surgical site dehiscence can range from small, partial to full-thickness wound dehiscence, manifesting with acute abdominal pain, vaginal bleeding, or discharge, and is often precipitated by sexual intercourse. While imaging, including a pelvic ultrasound and computed tomography (CT), may help in undifferentiated acute abdominal pain, vaginal cuff dehiscence remains a clinical diagnosis found on physical exam. Because vaginal cuff dehiscence is a clinical diagnosis, sparse data exist regarding radiographic sensitivities and specificities in the identification of vaginal cuff dehiscence. Despite the increasing literature suggesting that pelvic exams are invasive with often limited utility, the authors argue that pelvic exams remain essential in identifying complications of hysterectomies. The authors present a case of a 40-year-old woman with acute abdominal pain found to have loops of small bowel in the vaginal vault, discovered only on physical exam after negative CT and ultrasound imaging.

Vaginal cuff dehiscence: report of two cases.

Vaginal cuff dehiscence is a rare but potentially life-threatening post-hysterectomy complication. Here we report two cases of vaginal cuff dehiscence with distinct imaging features and describe the CT findings of vaginal cuff dehiscence. Both patients underwent repair surgery, and the diagnoses were confirmed. Radiologic features of vaginal cuff dehiscence are uncommonly described in the literature. Vaginal cuff mural discontinuity and omental fat tissue or bowel herniation into the vaginal canal are the most common appearances of vaginal cuff dehiscence. Pelvic hematoma, bowel obstruction, and pneumoperitoneum can accompany. These two cases highlight the CT appearances, potential presentations, and management of vaginal cuff dehiscence in the emergency setting.

Incidence of and risk factors for vaginal cuff dehiscence following total laparoscopic hysterectomy: a monocentric hospital analysis.

PURPOSE: Vaginal cuff dehiscence (VCD) is one of the major surgical complications following hysterectomy with data on incidence rates varying largely and studies assessing risk factors being sparse with contradictive results. The aim of this study was to assess the incidence rate of and risk factors for VCD in a homogenous cohort of women treated for benign uterine pathologies via total laparoscopic hysterectomy (TLH) with standardized follow-up. METHODS: All patients undergoing TLH at the Department of Gynecology and Obstetrics, Saarland University Hospital between November 2010 and February 2019 were retrospectively identified from a prospectively maintained service database. RESULTS: VCD occurred in 18 (2.9%) of 617 patients included. In univariate and multivariate analyses, a lower level of surgeon laparoscopic expertise (odds ratio 3.19, 95% confidence interval (CI) 1.0-9.38; p = 0.03) and lower weight of removed uterus (odds ratio 0.99, 95% CI 0.98-0.99; p = 0.02) were associated positively with the risk of VCD. CONCLUSION: In this homogenous cohort undergoing TLH, laparoscopic expertise and uterine weight influenced the risk of postoperative VCD. These findings might help to further reduce the rate of this complication.

Split-thickness skin graft as a treatment for voluminous vaginal fluid discharge after surgery due to vesico-intestino-vaginal fistulation: A case report and review of the literature.

•Repeated pelvic surgery in irradiated tissue increases the risk for vaginal rupture.•We present a rare case with heavy secretion from the ruptured vagina.•Split skin grafting was used as an unusual treatment for this complication.

Trends and Risk Factors for Vaginal Cuff Dehiscence after Laparoscopic Hysterectomy.

STUDY OBJECTIVE: The primary objective was to assess the effect of the route of closure of the vaginal cuff on the incidence of vaginal cuff dehiscence (VCD) in laparoscopic hysterectomy (LH). The secondary objective was to assess patient- and surgical-risk factors associated with VCD, rate of perioperative complications by route of closure, and impact of surgeon volume on complications. DESIGN: Retrospective chart review with case-control component. SETTING: Tertiary care center (main hospital and regional hospitals). PATIENTS: A total of 1278 women underwent LH or robot-assisted hysterectomy in 2016, and met the inclusion criteria. Independently, 26 cases of VCD were identified from 2009 through 2016. INTERVENTIONS: A retrospective comparison of patients with vaginal cuff closure and laparoscopic cuff closure (LCC) undergoing LH or robot-assisted hysterectomy in 2016. Patients with VCD from 2009 through 2016 (n = 26) were matched by route of cuff closure to the next 7 patients who underwent hysterectomies (n = 182), who became controls. MEASUREMENTS AND MAIN RESULTS: In 2016, there were 9 cases of VCD (0.70%). There was no significant difference in VCD between LCC (8/989; 0.81%) and vaginal cuff closure (1/289; 0.35%; p = .41). Seven VCD cases were performed by high-volume surgeons (>30 hysterectomies per year) who were more likely to perform LCC and use barbed suture. There were no significant differences in the rates of perioperative complications or surgeon volume between routes of cuff closure. The case-control patients differed in smoking status (p = .010) and history of prior laparotomy (p = .017). Logistic regression showed that increasing age (odds ratio 0.95; 95% confidence interval, 0.91-0.99) and increasing body mass index (odds ratio 0.98; 95% confidence interval, 0.83-0.97) were protective for VCD. CONCLUSION: VCD is a rare but serious complication of LH. Despite previous studies, we did not find a significant difference in VCD or intra- and perioperative complications by route of cuff closure or surgeon volume. Given the lack of evidence favoring one route of cuff closure, we recommend that, to optimize patient outcomes, surgeons employ the closure technique that they are best accustomed to.

Vaginal cuff dehiscence following transvaginal oocyte retrieval: a case report.

BACKGROUND: Vaginal cuff dehiscence (VCD) is a rare but potentially serious complication following hysterectomy with an estimated incidence of 0.14-1.4%. There is a wide range of risk factors thought to contribute to VCD, but due to its rare occurrence, much still remains to be learned about the true impact of risk factors leading to dehiscence. We present here the second known report of VCD to occur in a patient undergoing transvaginal oocyte retrieval during her fertility treatment. This case highlights what may become a more common clinical scenario as more premenopausal women are diagnosed with reproductive tract cancers and access assisted reproductive therapies to preserve fertility. CASE PRESENTATION: Our patient is a 35-year-old G1 P0 A1 who had undergone ovary-sparing total laparoscopic hysterectomy (TLH) following diagnosis of endometrial adenocarcinoma. She underwent two in-vitro fertilization (IVF) cycles after TLH to bank frozen blastocysts, the first vaginal oocyte retrieval (VOR) taking place 12 weeks following hysterectomy. She experienced VCD during her second VOR that occurred 17 weeks after TLH, the second case of VCD to be reported in the literature during fertility preservation treatment following hysterectomy. The patient underwent an emergent and uncomplicated repair of the defect vaginally the same day. CONCLUSIONS: Currently there are no guidelines in place for women who have undergone hysterectomy with regard to when they can begin fertility treatment in the post-operative period. Based on now two case reports, it is worth considering extension of the typical 6-week timeline of avoidance of vaginal procedures to allow for full cuff healing. Infertility providers should also be mindful of limiting transvaginal ultrasounds where possible to reduce force along the cuff.

Laparoscopic assessment and transvaginal reparation of post-coital vaginal cuff dehiscence with bowel evisceration: a case report.

Vaginal cuff dehiscence (VCD) is a rare postoperative complication of total hysterectomy. Presenting symptom is acute pelvic or abdominal pain accompanied by nausea and vomiting. Immediate recognition and surgical repair are crucial for successful management. A 40-year-old para 1+0 presented with complaints of pelvic pain associated with sexual activity, three months after a total laparoscopic hysterectomy. Speculum examination revealed the presence of bowel into the vagina. Diagnostic laparoscopic assessment combined with VCD repair through the transvaginal route. The occurrence of VCD after laparoscopic hysterectomy has been linked to overuse of electrocautery, prolonged inflammatory response and suturing methods. Laparoscopic, abdominal and vaginal approaches are the routes for repairing VCD. However, it depends on the clinical presentation and surgeon expertise. Careful history, and physical examination are vital factors in guiding clinicians to diagnose and treat VCD. Nevertheless, an ideal modality remains variable to each case.