Vaginal evisceration

Vaginal evisceration is typically obvious upon presentation, as intestine (typically ileum) can be seen protruding from the introitus. Other symptoms include a sense of pressure in the pelvis and vaginal bleeding.

Complications of surgery can include injury to the bladder, rectum, or ureter, especially in cases where there has been tissue necrosis. Surgeons typically perform intraoperative cystoscopy with dye to assess potential bladder or ureter injuries.

Vaginal evisceration is a serious complication of dehiscence (where a surgical wound reopens after the procedure), which can be due to trauma. 63% of reported cases of vaginal evisceration follow a vaginal hysterectomy (where the uterus removal surgery is performed entirely through the vaginal canal). Most instances of vaginal evisceration following a laparoscopic hysterectomy result from sexual intercourse among women approaching menopause, and from the combination of heightened pressure within the abdomen and weakened vaginal muscles among those who have experienced menopause.{{Cite journal|title = Vaginal evisceration after hysterectomy: a literature review|journal = Obstetrical & Gynecological Survey|date = Jul 2002|issn = 0029-7828|pmid = 12172223|pages = 462–467|volume = 57|issue = 7|doi = 10.1097/00006254-200207000-00023|first1 = Pedro T.|last1 = Ramirez|first2 = David P.|last2 = Klemer|s2cid = 23957831}} Other risk factors include regular Valsalva maneuver, advanced age, obesity, smoking, immunosuppressive therapy, vaginoplasty, anemia, poor surgical technique, malnutrition, and postoperative/perioperative infection.{{cite web|title=Hysterectomy|date=13 March 2015|access-date=4 May 2015|work=DynaMed|publisher=EBSCO|url=http://search.ebscohost.com/login.aspx?direct=true&db=dme&AN=116102&site=dynamed-live&scope=site}} {{Subscription or libraries|s}} One case has been reported as of 2015 where placement of a pessary caused an evisceration.{{Cite journal|title = Vaginal evisceration during pessary fitting and treatment with immediate colpocleisis|journal = Obstetrics and Gynecology|date = Aug 2010|issn = 1873-233X|pmid = 20664431|pages = 496–498|volume = 116 Suppl 2|doi = 10.1097/AOG.0b013e3181da371d|first1 = Rachel|last1 = Rubin|first2 = Keisha A.|last2 = Jones|first3 = Ozgur H.|last3 = Harmanli|issue = 2|s2cid = 43190771}}

Dehiscence is more common in laparoscopic hysterectomy than in open hysterectomy.{{Cite journal|title = Incidence of vaginal cuff dehiscence after open or laparoscopic hysterectomy: a case report|journal = The Journal of Reproductive Medicine|date = Mar–Apr 2010|issn = 0024-7758|pmid = 20506682|pages = 171–174|volume = 55|issue = 3–4|first1 = Michel E.|last1 = Rivlin|first2 = G. Rodney|last2 = Meeks|first3 = Warren L.|last3 = May}}

File:Total laparoscopical hysterectomy.jpg

When performing a vaginal hysterectomy, surgeons should aim to avoid damaging surrounding tissue or drying the vaginal cuff. Surgeons should take extra care to align the tissues, and include sufficient undamaged tissue. Instead of single-layer figure-of-eight sutures, two-layer sutures can aid in preventing vaginal evisceration.

Emergently, vaginal eviscerations are treated by keeping the exposed intestines moist and wrapped, while waiting for definitive surgical treatment. Vaginal evisceration is usually treated by removing damaged tissue along the edges of the vaginal cuff, re-suturing the opening, and giving the patient broad-spectrum antibiotic prophylaxis.{{cite book|last1=Hoffman|first1=B.L.|last2=Schorge|first2=J.O.|last3=Schaffer|first3=J.I.|last4=Halvorson|first4=L.M.|last5=Bradshaw|first5=K.D.|last6=Cunningham|first6=F.|last7=Calver|first7=L.E.|display-authors=1|editor1-last=Hoffman|editor1-first=B.L.|editor2-last=Schorge|editor2-first=J.O.|editor3-last=Schaffer|editor3-first=J.I.|editor4-last=Halvorson|editor4-first=L.M.|editor5-last=Bradshaw|editor5-first=K.D.|editor6-last=Cunningham|editor6-first=F.|editor7-last=Calver|editor7-first=L.E.|display-editors=1|title=Chapter 42. Minimally Invasive Surgery|date=2012|publisher=McGraw-Hill|location=New York, NY|work=Williams Gynecology|edition=2}}

Surgery can be conducted via a laparotomy, though research from the 2010s shows that a transvaginal or laparoscopic approach can also be used safely and successfully if an infection has not developed. If left untreated, it can cause peritonitis or injury to the exposed bowel, including strangulation or mesenteric tears. Cellulitis, abscesses, hematomas, and other complications can appear at the same time as an evisceration. Abscesses and hematomas can be resolved after surgery with a surgical drain.

Post-surgical treatment includes continuation of antibiotics and, in some postmenopausal people, vaginal estrogen to speed recovery. After surgery, people with vaginal evisceration are advised to avoid intercourse until the surgical site is fully healed.

Though it is a rare complication, as the popularity of laparoscopic hysterectomy has risen, the rate of vaginal evisceration has also risen. Vaginal cuff dehiscence occurs in 0.24–0.39% of cases; of these, vaginal evisceration occurs in 35%–67%. When all surgical procedures are considered, the rate of vaginal evisceration is 0.032–1.2%.{{Cite journal|title = Vaginal cuff dehiscence: Risk factors and management|last = Cronin|first = Beth|date = 27 August 2011|journal = Am J Obstet Gynecol|doi = 10.1016/j.ajog.2011.08.026|pmid = 21974989|pages =284–8|pmc=3319233|volume=206|issue = 4}}

The first report of vaginal evisceration in the medical literature was published in 1864 by Belgian obstetrician Léon Hyernaux; it occurred secondary to traumatic rupture of the vagina during an unsuccessful attempt at forceps delivery. The patient, a 42-year-old woman, survived and made a complete recovery.{{cite journal |doi = 10.1016/j.ijgo.2006.05.012 |last1 = Peltecu |first1 = GC |last2 = Vasilescu |first2 = C |title = Vaginal evisceration |volume = 95 |issue = 1 |date = October 2006 |journal=International Journal of Gynecology & Obstetrics |pages=60–61|pmid = 16828098 |s2cid = 27200087 }}{{cite journal |author = M. Hyernaux |title = Rupture traumatique du vagin; issue des intestines à l'extérieur; application du grand forceps au détroit supérieur; guerison |journal = Bull Mem Acad Med Belg, 2 |date = 1864 |url=https://books.google.com/books?id=k5NNAAAAcAAJ}}

{{reflist}}

• [https://emedicine.medscape.com/article/268258-overview#a5|Enterocele Massive Vaginal Eversion: Background, Problem, Epidemiology]

Category:Injuries of abdomen, lower back, lumbar spine and pelvis

Category:Medical emergencies

Category:Gynecological surgery

Category:Vagina