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]