Surgical Science, 2011, 2, 77-79
doi:10.4236/ss.2011.22017 Published Online April 2011 (
Copyright © 2011 SciRes. SS
Small Bowel Evisceration Following Vaginal Hyster ectomy
is a General Surgical Emergency–A Case Report and
Review of the Literature
Mandana Sigaroudinia, David Bowden, Deb Maitra, Graham Cawdell
Departments of General Surgery & Gynaecol ogy St Hel e ns & Knowsley NHS Trust Liverpool,
Merseyside, United Kingdom
Received December 15, 2010; revised January 25, 2011; accepted March 11, 201 1
Small bowel evisceration through the vagina is a rare condition, which tends to affect post-menopausal
women who have undergone vaginal hysterectomy. It is a surgical emergency with a favourable outcome if
diagnosed and treated in a timely fashion. Delay in diagnosis can precipitate infarction of small bowel loops
with associated morbidity and mortality. Treatment involves laparotomy, reduction of the incarcerated loops,
plus/minus small bowel resection) and repair of the vaginal rupture. The purpose of this paper is to report a
case of small bowel evisceration through the vagina, to review the literature pertaining to this topic and to
raise awareness of this condition in the general surgical community.
Keywords: Small Bowel Evisceration, Vaginal Rupture, Hysterectomy
1. Case Report
A 67 year old lady underwent a vaginal hysterectomy in
November 2008 and made an uneventful post operative
recovery, being discharged on the 3rd day. She was re-
viewed once in the outpatient department and subse-
quently fol l ow e d up by her GP.
7 months later she presented to her GP complaining of
a ‘dragging’ sensation in her vagina. She also described
feeling a ‘bubble’ protruding through the vagina. She
was not examined but was referred to the gynaecological
outpatients department, at which time a vaginal prolapse
was diagnosed. As a result she was given physiotherapy
exercises as a means of treatment.
Over the following weeks she experienced increasing
amounts of pain, which had become more stabbing in
nature and was said to radiate to the peri-umbilical re-
gion. This pain was worse on walking, sitting down and
on carrying out her exercises. She became reliant on
regular analgesics.
She had no history of bleeding PV or PR and no
change in her bowel habit. She had been passing some
yellow jelly-like discharge and as such was using pads
on her underwear.
6 weeks after being reviewed in the outpatient de-
partment she was trying to pass urine when she felt faint
and had a severe stabbing pain in the pelvic region. She
noticed that she was bleeding and called an ambulance.
On examination in A&E she was found to have 2
loops of small bowel protruding through the vagina.
These were oedematous but viable. She underwent a
laparotomy as a joint procedure between the gynaecolo-
gists and the general surgeons. At laparotomy approxi-
mately 1.5 feet of proximal ileum was protruding
through a large defect in the posterior vaginal wall and
vault. This was resulting from a wound dehiscence re-
lated to previous vaginal hysterectomy. The small bowel
was reduced and the hernial sac was excised. The vaginal
wall was repaired with vicryl and she was given 3 days
of intravenous antibiotics. She made a good recovery and
was discharged on the 4th post-operative day.
2. Discussion & Literature Review
The first reports of vaginal evisceration appear in the
literature from C1950 as a complication of vaginal hys-
terectomy [1]. Over the ensuing years it is a condition
which has been scantily reported in gynaecological jour-
nals most frequently in association with post menopausal
women who have had a history of gynaecological surgery
Figure 1. Small bowel loops eviscerating from the vagina.
or enterocoele [2]. It also tends to be associated with
increased intra-abdominal pressure and conditions, which
lead to weakened pelvic tissues [3]. The most common
surgical precursor is the vaginal hysterectomy, which has
been reported to account for over 60% of cases. Ab-
dominal and laparoscopic hysterectomy may also con-
tribute in approximately 30% and 5% of cases respec-
tively [4]. Whilst vaginal evisceration is most common in
the post-menopausal woman, it has been reported in the
premenopausal lady who has had an abdominal hyster-
ectomy, as a complication following coitus and posterior
vaginal fornix rupture [5]. Other presentations, which are
even more unusual, include following intra-peritoneal
chemotherapy for ovarian cancer [6], evisceration sec-
ondary to water sports [7] or the use of vaginal brachy-
therapy [8].
Presenting features are vaginal bleeding or oozing,
pelvic pain and a feeling of pressure in the abdomen
and/or pelvis. The majority of cases find small bowel
loops to be the eviscerating organ although greater
omentum has also been described [9]. If the problem is
not recognised early enough small bowel may incarcerate,
requiring small bowel resection with its associated mor-
bidity and mortality.
Surgery is the mainstay of treat ment using a combined
abdominal and vaginal approach, between the general
surgeons and gynecologists [10]. More recently a pure
vaginal approach has been described [11], as well as a
combined vaginal and laparoscopic approach [12]. The
small bowel is reduced and inspected for viability, the
hernial sac is excised and the vaginal defect is repaired,
usually with an absorbable suture such as Polyglactin or
Polydiaxone. A small bowel resection may be performed
in cases of bowel infarction. The patient is treated with
broad-spectrum antibiotics.
Whilst in the majority of cases a primary repair of the
vaginal defect is sufficient, some authors have reported
using a mesh to reinforce the defect [13, 14]. Further-
more, techniques such as graciloplasty to reconstruct the
rectovaginal septum and allogenic dermal grafting have
also been descr i b ed [15, 16].
The majority of cases report a favourable outcome if
this condition is iden tified early and surgical interv ention
is prompt, highlighting the necessity for increased
awareness about this condition in both the general surgi-
cal and gynaecological communities.
2.1. Figure 1
3. References
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Copyright © 2011 SciRes. SS
Copyright © 2011 SciRes. SS
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