Small bowel trans-vaginal evisceration following vault biopsy: general surgeons beware!

Abstract

A case-report of vaginal evisceration following vault biopsy is described. This case highlights the importance of good surgical technique when performing a vaginal biopsy in order to avoid this rare, but life-threatening, complication. General surgeons may well be faced with this acute presentation and prompt management is vital in order to preserve the involved small bowel.

Trans-vaginal evisceration of the small intestine is rare with fewer than 100 cases reported in the literature.¹ It was first reported by Hyernaux in 1864.² It may occur as a result of trauma or due to a sudden change in intra-abdominal pressure such as coughing or straining. Some 68% of cases occur in post-menopausal women with 73% of these having had previous pelvic or vaginal surgery.³ It can be associated with sexual intercourse or vaginal instrumentation in premenopausal women.⁴ We present a case of small bowel evisceration occurring as an early complication following vaginal vault biopsy.

Case history

A 68-year-old woman attended accident and emergency 3 days after vaginal vault biopsy with a short history of lower abdominal pain and a feeling of vaginal fullness. She had first begun to feel unwell whilst straining to open her bowels that morning and this was shortly followed by the sensation of a vaginal mass. On examination, she appeared to be in some discomfort and displayed tachycardia. She was normotensive and afebrile. Her abdomen was soft, but tender suprapubically with localised guarding. Examination of the perineum revealed dusky loops of small bowel prolapsing through the vagina (Fig. 1).

Figure 1.

Small bowel protruding through vagina.

Her past medical history included a hysterectomy performed 3 years previously for an enterocoele. She was under the care of the gynaecologists because of a recurrent enterocoele and a lesion of the vaginal vault. She had undergone a vaginal vault biopsy 3 days prior to this presentation, under general anaesthetic, as a day-case procedure. A 1-cm area of tissue, thought to be a granuloma, had been excised with scissors. The defect was closed per vagina with interrupted sutures. Histology showed this lesion to be a benign area of chronic inflammation and granulation tissue.

Management

During this emergency admission, she was resuscitated appropriately, given broad-spectrum antibiotics and transferred to theatre for an urgent laparotomy. At laparotomy, she was found to have 30 cm of ileum prolapsing through a 3-cm defect in the vault of the vagina. The bowel was reduced and held in warm packs. The defect in the vaginal vault was clean with no evidence of infection or haematoma and it was closed with interrupted 1/0 vicryl. Following 10 minutes of warming, the colour of the small bowel had improved. No resection was performed and the abdomen was closed. The patient had an uneventful postoperative recovery and was discharged 3 days later.

Discussion

Small bowel evisceration following a vaginal vault biopsy is extremely rare. There are no reports currently in the literature. It has previously been reported following coitus, vaginal trauma and vaginal instrumentation, usually in premenopausal women. In postmenopausal women evisceration is often associated with chronic pelvic prolapse, prolapse repair and other forms of pelvic surgery.⁵

Vaginal evisceration usually presents suddenly and can be very distressing for the patient. Symptoms include abdominal pain, pelvic pain, vaginal bleeding, a vaginal mass and fluid discharge from the vagina.⁵ Intra-abdominal viscera may be seen protruding from the vagina. This is a potentially life-threatening condition that should be managed as an emergency. Management includes resuscitation with fluids, antibiotics, analgesia and preserving the bowel in moist saline soaked swabs.⁵ The patient should be transferred to theatre for immediate surgical repair. Small defects in stable patients have been repaired via a vaginal or a laparoscopic approach. However, if there is any question about organ viability, exploration should be via a midline laparotomy.⁵

We have reported this case in order to raise awareness of vaginal evisceration as a rare complication following vaginal vault biopsy. It demonstrates the importance of good surgical technique and safe wound closure when performing this procedure. General surgeons may well be faced with this acute presentation and prompt management is vital in order to preserve the involved small bowel.