Heidi J. Purcell and Laurie S. Swaim
History of preset illness
A 79-year-old gravida 5, para 5 white woman with multiple medical comorbidities presented to the emergency department with a sudden onset of severe vaginal and lower abdominal pressure after defecation one hour prior. She rated her pain at 10 out of 10 on the pain scale. Prior to this acute event, she was feeling well and in her usual state of health.
Review of her medical history revealed hypertension, hyperlipidemia, stable angina, and a remote history of a tran- sient ischemic attack. Her surgical history is remarkable for a vaginal hysterectomy, anterior colporrhaphy, and transobtura- tor sling uretheral suspension four months prior for a grade III cystocele, uterine prolapse, and stress urinary incontinence.
Her surgery was uncomplicated, and her pathology was benign.
She reports that she has had no medical/surgical restrictions since her postoperative examination two months ago. She denied a history of smoking or alcohol use. The patient’s prior obstetrical history was significant forfive uncomplicated spon- taneous vaginal deliveries.
Physical examination
General appearance: Woman who appears her stated age and is in significant distress
Vital signs:
Temperature: 37.0°C Pulse: 62 beats/min
Blood pressure: 151/69 mmHg Respiratory rate: 24 breaths/min
Oxygen saturation: 96% saturation on room air BMI: 22 kg/m2
HEENT:Unremarkable Neck:Supple
Cardiovascular:Regular rhythm, without murmurs, rubs, or gallops
Lungs:Clear to auscultation bilaterally
Abdomen:Soft, without distension, severe tenderness to palpation in lower right and left quadrants, bowel sounds were not appreciated
Extremities:Warm, well perfused, nontender, without edema
Neurologic:Nonfocal. The patient was appropriately oriented
Genitourinary:Multiple loops of dark purple, edematous, andfirm bowel protruding from vaginal introitus. The
remainder of gynecologic examination could not be accomplished secondary to protrusion of bowel and the patient’s severe pain (Fig. 25.1)
Laboratory studies:
WBCs: 10 000/μL (normal 4000–11 000/μL) Neutrophils: 82% (normal 40–74%)
Blood chemistries and coagulation studies: All within normal limits
How would you manage this patient?
The patient has vaginal cuff dehiscence with bowel eviscer- ation. The patient’s presentation was consistent with a bowel evisceration following a vaginal cuff dehiscence. After the
Acute Care and Emergency Gynecology, ed. David Chelmow, Christine R. Isaacs and Ashley Carroll. Published by Cambridge University Press.
© Cambridge University Press 2015.
Fig. 25.1 Multiple loops of dark purple, edematous, andfirm bowel protruding from vaginal introitus.
diagnosis had been established, general surgery was immedi- ately consulted. Broad spectrum antibiotics were adminis- tered prophylactically. The patient was rapidly transported to the operating room where a triple lumen central line was placed. A midline vertical abdominal incision was performed to assess the anatomy from above and attempt to reduce the bowel back into the abdomen. As this could not be performed without risking bowel perforation due to the intraluminal distension and extensive necrosis of the eviscerated segment, a small bowel resection was performed via a vaginal approach. This was followed by an intra-abdominal bowel reanastomosis once the remaining bowel segments could be reduced through the vaginal cuff. The vaginal cuff was then repaired transvaginally with interrupted stitches of delayed absorbable suture. The patient tolerated the procedure well and was taken to the ICU for further recovery. She was ultimately discharged home on postoperative day 8 as she was tolerating a general diet and ambulating without diffi- culty. The patient was seen six weeks postoperatively and was noted to have made a full recovery with excellent healing of the vaginal cuffobserved.
Vaginal cuff dehiscence
Vaginal cuffdehiscence (separation of the vaginal incision) is a rare yet potentially dangerous complication of a hysterec- tomy, especially when followed by bowel evisceration. Previ- ous studies have estimated the incidence of cuff dehiscence to be 0.03–0.39%. A recent cohort study of 12 472 patients undergoing hysterectomy estimated the 10-year cumulative incidence of dehiscence after all modes of hysterectomy to be 0.24%. The incidence, however, is variable based on the route of hysterectomy. Cuffdehiscence is highest after total laparo- scopic hysterectomy, with an incidence of 0.75%, followed by laparoscopic-assisted vaginal hysterectomy (0.46%), total abdominal hysterectomy (0.38%), and lowest with total vaginal hysterectomy (0.08–0.11%) [1].
Several factors have been identified which predispose a patient to cuff dehiscence after hysterectomy. These include increased parity, postoperative surgical site infection, postme- nopausal status, vaginal trauma from intercourse or foreign body, presence of prolapse and pelvicfloor disorders, history of vaginal surgery, previous radiation therapy, and tobacco use [2,3,4,5]. In this patient, her prior surgery, age, postmenopau- sal status, and medical comorbidities likely predisposed her to the event.
Prevention of dehiscence begins preoperatively by adminis- tering appropriate antibiotic prophylaxis and screening for vaginal infections in patients who are symptomatic prior to surgery. Good surgical technique is also important and should include minimizing the use of electrocautery along the colpot- omy, and placing sutures at least 1 cm from the vaginal cuff edge while including full thickness of the vaginal epithelium and underlying supporting tissues. The studies regarding suture type and use of a running versus interrupted closure are inconclusive with some studies showing benefit to the use of a bidirectional barbed suture and others showing no differ- ence [6]. Although not evidence based, most pelvic surgeons recommend pelvic rest and avoidance of heavy lifting for at least six to eight weeks postoperatively.
Diagnosis of vaginal cuff dehiscence primarily relies on physical examination with particular attention to key histor- ical details. Dehiscence typically occurs within the first few months after surgery with a median time for occurrence of 1.5–3.5 months, but the time interval has been shown to range from 6 to 20 months [7,8,9]. After prompt diagnosis of the vaginal cuff dehiscence (and bowel evisceration in this case), the initiation of broad spectrum antibiotics with immediate surgical repair is paramount to preserve any viable bowel and to minimize patient morbidity. Vaginal cuff dehiscence without bowel evisceration may be repaired vaginally without an abdominal survey. In the case of more minor eviscerations, bowel replacement via the vaginal route followed by vaginal cuff closure may be considered if the eviscerated bowel segment has remained viable and non- edemetous. Because the patient in this case had eviscerated bowel that was necrotic, edematous, and essentially incarcer- ated outside of the vaginal introitus, a laparotomy was neces- sary to facilitate the surgical management and to inspect for any visceral injury.
Key teaching points
Vaginal cuffdehiscence most commonly present within the first few months after vaginal surgery.
The incidence of vaginal cuffdehiscence varies by route of hysterectomy, and is highest following total laparoscopic hysterectomy.
Diagnosis is always clinical and relies on a thorough pelvic examination.
Treatment consists of prompt broad spectrum antibiotic administration and surgical intervention.
References
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Case 25: Acute vaginal and abdominal pain after defecation in a 79-year-old woman
5. Hur HC, Guido RS, Mansuria SM, et al.
Incidence and patient characteristics of vaginal cuffdehiscence after different modes of hysterectomies.J Minim Invasive Gynecol2007;14(3):311–17.
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