Discussion:
Transvaginal evisceration is a rare complication that was reported the first time in 1907 by Mc Gregor [1]. The incidence was estimated from 0.034% to 0.28% [4, 6], but it may be probably higher.
The average intervals reported between evisceration and surgery are 20 months after vaginal hysterectomy, 6 months after abdominal hysterectomy and 4 months after laparoscopic hysterectomy [5].
Many factors risk have been noted, there is a strong correlation between age and tansvaginal evisceration, in the premenopausal period, sexual trauma is the principal cause of evisceration, and in postmenopausal period, devascularisation and foreshortening of the vaginal tissue facilitate the spontaneous rupture [5].
There are also haematoma, premature resumption of sexual activity after surgery, pelvic floor defects, prior radiation therapy, chronic steroid administration, malnutrition that contributes to the reliability of the vaginal apex [5- 8].
Total laparoscopic hysterectomy may be related with an increased risk of vaginal cuff dehiscence compared with other techniques of total hysterectomy, however, prospective randomized trials are needed to support this hypothesis. [4]
For minimal invasive surgeries, transvaginal cuff repair was associated with a lower incidence (0.18%) %) than for both laparoscopic (0.64%) and robotic procedures (1.64%) [9]. This is probably due to high technical demand for laparoscopic and robotic suturing and knotting, magnifying effect of the scope causing insufficient amount of tissue during suturing, magnification of small vessels, and excessive thermocoagulation that impedes blood supply and healing [4]. Furthermore, the tension of the suture and the knot is more reliable when directly maintained by hands [9]. Whether running suture or interrupt suture for transvaginal cuff closure has a lower incidence of vaginal cuff dehiscence justifies further research.
Several surgical methods such of bilateral vaginal uterosacral ligament suspension, vertical suturing, conserving the length of the vaginal apex, and cutting with minimal coagulation have been reported to prevent vaginal dehiscence. [10, 11]
In the present case, the predictive factors of evisceration were post menopausal period, history of pelvic surgery and increased intra-abdominal pressure caused by carrying of heavy loads.
Vaginal cuff dehiscence can cause evisceration of the bowel, adnexa, and omentum, which can be strangulated. Transvaginal evisceration requires a prompt diagnosis and emergency surgery to prevent a serious complications such of bowel ischemia, bowel necrosis, ileus, bacteremia, peritonitis and sepsis .Therefore, early diagnosis is critical. [12]
The diagnosis of vaginal cuff dehiscence in mainly based on the clinical history and pelvic examination. However, because of its low incidence the diagnosis may be ambiguous and delayed patient management. [13]
Transvaginal evisceration is a gynecological emergency and immediate recognition and surgical repair are crucial, the medical management initially begins with resuscitation: early antibiotic therapy and fluid therapy [14- 16].
The surgical approach depends on the viability of the eviscerated intestine, it can be managed by a vaginal approach and/or laparoscopic approach [18], in case of unsuccessful reduction or any suspicion regarding the viability of the bowel, a laparotomy is obligatory to explorate the abdominal cavity and to achieve the resection of the ischemic bowel [14, 15].
In this case, the eviscerated bowel was viable, pink, with peristalsis, and the patient was stable, the vaginal approach was appropriated, and the bowel was reduced back into abdominal cavity through the vagina, and repair attempted vaginally. [16]
Successful repair of the vaginal cuff defect necessitate well-vascularized and healthy tissue. The vaginal cuff edges should be sharply debrided until bleeding edges are achieved. The surgeon should be attentive to any adherent loops of bowel or omentum that require sharp dissection to permit a full-thickness cuff closure. For suture selection, we recommend using delayed absorbable monofilament suture such as 0-Polydioxanone instead of braided suture owing to the theoretically lower risk of infection. [14] Early absorbable sutures was realted with increased risk of vaginal cuff dehiscence (2.5%) compared with the delayed absorbable sutures (0.7%). [17] Full-thickness interrupted sutures are placed to re-approximate but not strangulate the cuff edges. If there is any doubt for a vaginal cuff abscess or hematoma, a vaginal drain can be sutured in place and removed in 24–48 hours. [14]