Hernia (2013) 17:279–283 DOI 10.1007/s10029-011-0848-3
CASE REPORT
Transvaginal strangulated small intestinal hernia after abdominal sacrocolpopexy: case report and literature review Y. Halwani • V. Nicolau-Toulouse • J. Oakes J. Leipsic • R. Geoffrion • S. M. Wiseman
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Received: 3 March 2011 / Accepted: 18 June 2011 / Published online: 15 July 2011 Ó Springer-Verlag 2011
Abstract Purpose To report a case of transvaginal small intestinal hernia following abdominal sacrocolpopexy and review this clinical presentation in the current literature. Methods A review of our case and a literature review of vaginal evisceration were carried out. Results The patient underwent sacrocolpopexy and a Burch procedure. Six months later, a recurrent enterocele through a 1 cm defect in the vaginal vault was diagnosed. Several weeks later she presented with an incarcerated and strangulated loop of small intestine extending beyond the introitus. This required an urgent exploratory laparotomy, ileocecal resection, and vaginal vault closure. Postoperatively, she experienced gradual prolapse recurrence and is currently successfully managed with a pessary. Risk factors that include vaginal atrophy, chronic constipation, and previous pelvic surgery may have contributed to the evisceration, mesh erosion, and may have caused the breakdown in the vaginal vault mucosa ultimately responsible Y. Halwani S. M. Wiseman (&) Department of Surgery, St Paul’s Hospital and University of British Columbia, C 303-1081 Burrard Street, Vancouver, BC V6Z 3W8, Canada e-mail:
[email protected] V. Nicolau-Toulouse J. Oakes R. Geoffrion Departments of Obstetrics and Gynecology, St Paul’s Hospital and University of British Columbia, Vancouver, BC, Canada J. Leipsic Department of Radiology, St Paul’s Hospital and University of British Columbia, Vancouver, BC, Canada R. Geoffrion Division of Urogynecology, Departments of Obstetrics and Gynecology, St Paul’s Hospital and University of British Columbia, Vancouver, BC, Canada
for the evisceration. In addition, placement of the sacrocolpopexy mesh without tension, and utilization of an interposition graft to reinforce the weakened vaginal vault tissue, are aspects of the surgical procedure that may influence outcomes. At the time of evisceration repair, the best approach to resuspend the vaginal vault, and prevent recurrent prolapse or evisceration, is currently unknown. Conclusion Vaginal evisceration is a potential complication of abdominal sacrocolpopexy. Early recognition and treatment of this complication is critical, and prolapse recurrence may occur even after surgical repair. Keywords Vaginal evisceration Sacrocolpopexy Vaginal hernia
Introduction Sacrocolpopexy is the gold standard abdominal operation for treatment of vaginal vault prolapse. Following this procedure reported complications have included: mesh erosion, prolapse recurrence, and bowel obstruction [1]. Literature review suggests that these complications have not been previously reported to occur concurrently with vaginal evisceration (VE) and bowel incarceration. VE of the small intestine is a rare life-threatening surgical emergency. Several case reports have identified multiple risk factors for this complication, including previous pelvic surgery, postmenopausal status, and the presence of an enterocele [2]. Hysterectomy is the surgical procedure that most commonly may lead to VE [3]. A retrospective review of 3,593 cases reported the rate of post-hysterectomy vaginal evisceration to be 0.28% [4]. If left untreated, VE may lead to intestinal obstruction that progresses to strangulation, perforation, and possibly
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even to septic shock and death. The primary aim of this report is to highlight the predisposing risk factors and the clinical presentation of VE, an uncommon surgical complication, as well as to review relevant details of the surgical technique of sacrocolpopexy.
Materials and methods A retrospective chart review of the case was carried out. A Pubmed search was carried out using a combination of the terms: ‘‘vaginal evisceration’’, ‘‘small bowel’’, ‘‘pelvic prolapse repair’’, ‘‘small bowel obstruction’’ and ‘‘ischemic bowel’’. Thirty-five studies with abstracts available in English were selected. Another Pubmed search using the term ‘‘abdominal sacrocolpopexy’’ was also carried out.
Case report The patient in our case is a 62-year-old gravida 2 para 2 postmenopausal caucasian woman. Her past medical and surgical history are notable for constipation, breast cancer treated with a bilateral mastectomy 10 years prior to presentation, and osteoporosis treated with Alendronate and calcium supplements. She had previously undergone two spontaneous vaginal deliveries, and one required an episiotomy. She had also undergone a total abdominal hysterectomy for menorrhagia 15 years prior to presentation. She has never used hormone replacement therapy and is a nonsmoker with a BMI of 18.7. She noticed the gradual onset of vaginal bulging symptoms and was diagnosed with a marked cystocele and moderate vault prolapse. She declined a pessary and instead chose surgical treatment. She underwent an abdominal sacrocolpopexy and Burch colposuspension carried out by a general gynecologist. The details of the sacrocolpopexy surgical technique have been previously well described [5]. A single posterior prolene mesh was utilized and was secured to the sacral promontory with 2.0 PDS sutures. It was then ‘‘placed with tension from the posterior vaginal vault rounding around the vagina onto the anterior vagina’’ and secured with 0 prolene sutures. A 5 mm inadvertent vaginotomy was repaired with 2.0 vicryl and the retroperitoneal space was closed using a running 3.0 chromic suture. Several months after her operation the patient noted some increased vaginal pressure symptoms. She consulted her gynecologist who diagnosed her with a recurrent enterocele, through a 1 cm defect at the vaginal vault with a very thin film of vaginal mucosa surrounding the prolapse that descended through the introitus. An outpatient referral to a urogynecologist was initiated. Three
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weeks later, during a vacation, the patient’s prolapse worsened. She noted prolapse that extended beyond the introitus when she stood, and was associated with foul smelling bloody discharge. She subsequently developed nausea and vomiting, abdominal distension, anorexia, and obstipation. She denied any urinary symptoms. She presented to the emergency department with these symptoms. Her vital signs were stable and she was afebrile. Her abdomen was distended and she was diffusely tender. At pelvic examination, there was a 30 cm length of small intestine prolapsing through the vagina, and extending well beyond the introitus (Fig. 1). The intestine was immediately covered with moist guaze, broad spectrum antibiotics were started (Cefazolin and Metronidazole), and a nasogastric tube was placed. An emergent CT scan revealed a high-grade mechanical small bowel obstruction with herniation of small intestine through a defect in the vaginal vault (Fig. 2). The patient was taken urgently to the operating room for repair. At the time of laparotomy there was a 2.5 cm defect in the vaginal apex through which the ileum was herniated. The eviscerated small intestine was incarcerated and could not be reduced manually. The intestine was transected intraabdominally, which allowed for it to be removed transvaginally. The ischemic incarcerated ileum and adjacent cecum were resected and a side-to-side stapled anastomosis of ileum to the ascending colon was carried out. The defect in the vaginal vault was located just to the left of the mesh insertion. The prolene mesh was found to be intraperitoneal, rather than retroperitoneal, and suspended the right side of the vault under tension. The left sided defect in the vaginal vault was closed with 2.0 vicryl sutures. Due to the thinness of the vaginal tissue, and concerns regarding possible infection, due to concurrent bowel surgery, no further mesh reattachment or new mesh placement was undertaken. Overall, our patient had an uneventful postoperative course. On postoperative day 9, the patient was seen in follow up and she was recovering well. A speculum examination revealed vaginal atrophy and an intact suture line at the vaginal vault. There was no evidence of prolapse. Given her previous history of breast cancer, she refused vaginal estrogen therapy. Despite counselling regarding the safety of low dose vaginal estrogen, she chose a non-hormonal vaginal moisturizer. Over the ensuing weeks the patient’s vaginal pressure symptoms gradually returned and she was subsequently diagnosed with stage 2 recurrent anterior and stage 1 left-sided apical prolapse (recurrent enterocele). She was given the option of further surgery or a pessary, and she selected the latter. A number 2 ring with membrane pessary was successfully fitted. She subsequently returned for several follow-up visits and was self-managing her pessary well.
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Fig. 1 Computed tomography (CT) scan of case. a Coronal image, b Transverse Axial image showing vaginal evisceration (VE) of the small intestine
Fig. 2 Clinical presentation of VE of small intestine
Discussion This report describes a rare complication of abdominal sacrocolpopexy. Seven months postoperatively, recurrent prolapse, VE, and finally transvaginal incarceration and strangulation of the small intestine occurred. Six weeks after urgent surgical management, prolapse recurred and is now being managed with a pessary. To our knowledge, this is the first reported case of a VE that developed post-sacrocolpopexy. Two cases of VE that developed following sacrospinous fixation have been reported in the literature. In the first case, the VE was recognized early enough to preserve the intestine. Vault closure through an abdominal approach and enterocele repair were also carried out [6]. In the second case, a partial thickness vaginal mucosal defect was diagnosed 5 months after sacrospinous fixation. Rupture did not seem imminent
and the patient was placed on the urgent waiting list for an abdominal sacrocolpopexy. In the meantime, she developed VE and strangulation of the ileum that was managed with intestinal resection, vault closure, and colpocleisis [7]. Risk factors for VE following pelvic surgery are listed in Table 1. Our patient had several of these risk factors including: postmenopausal state, multiparity, constipation, vaginal atrophy and the presence of an enterocele. Case reports have shown that the time of onset of the VE is variable and may range from weeks to years after surgery [7–13]. The trigger event for VE is usually trauma or early coitus in premenopausal patients, while it happens spontaneously or with increased intra-abdominal pressure in postmenopausal patients [3]. Early recognition and management are important to avoid increased morbidity [14]. Earlier presentations that do not involve intestinal compromise may be managed less invasively by a vaginal or laparoscopic approach with good patient outcomes [10, 15, 16]. Abdominal sacrocolpopexy is the gold standard abdominal repair for vaginal vault prolapse. It is associated with increased durability when compared with sacrospinous fixation [17]. Success rates of abdominal sacrocolpopexies range from 78 to 100% [1]. Nygaard et al. [1] reviewed abdominal sacrocolpopexy and found that the median reoperation rates for pelvic organ prolapse were 4.4%, the median rate of reported small bowel obstruction was 1.1%, and the rate of mesh erosion was 3.4%. Little is known about the effect of surgical technical variations on patient outcomes. Our patient underwent a tensioned sacrocolpopexy repair, similar to the patients in the two reported cases of VE that followed sacrospinous repair [6, 7]. However, compared to sacrospinous suspension, sacrocolpopexy requires mesh utilization and thus introduces the additional risk of mesh erosion [18]. In the
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282 Table 1 Risk factors associated with vaginal evisceration (VE) [2, 13, 20–23] Risk factors associated with vaginal evisceration Postmenopausal patient Vaginal atrophy Presence of an enterocele Multiparity Pelvic surgery Hysterectomy (abdominal, vaginal, laparoscopic, radical) Sacrospinous fixation Colpocleisis Trauma: Early coitus post operatively Obstetrical instrumentation Water-slide injury Straining (Valsalva maneuver) Smoking Intraperitoneal chemotherapy Radiation therapy for cervical cancer Self-induced by manually reducing a cystocele Medical conditions: Cushing’s
setting of a tensioned repair with mesh placement on weakened vaginal tissue, along with a concomitant Burch repair that pulls the vaginal axis forward and the occurrence of an intraoperative inadvertent vaginotomy, vaginal vault tears with subsequent dehiscence may be more common. This combination of elements, in addition to our patient’s risk factors for VE, likely contributed to this outcome. Elements of the surgical technique that may have prevented this outcome include careful attention to a tension free attachment of the vagina to the sacral promontory. In addition, repair of inadvertent vaginotomy in several layers, or using a reinforcing omental flap or allogenic absorbable graft, may have prevented the erosion and tearing responsible for evisceration at the vaginal vault. Retroperitonealization of the mesh could have been achieved with a longer lasting absorbable suture such as vicryl. Finally, at postoperative follow-up, when the narrow defect at the left vaginal vault was diagnosed, an urgent intraoperative consultation with review of the sacrocolpopexy could have been obtained to possibly avoid incarceration of the bowel, septic complications and subsequent need for bowel resection. Still unanswered remains the question of what is the best surgical approach to take at the time of VE repair in order to close the vaginal vault and prevent VE recurrence. With the mesh remaining in place there is a risk of recurrent erosion. Several cases in the literature have been reported that successfully utilize non-synthetic grafts for vaginal surgery when vault closure is challenging after VE. One
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group described a rectovaginal septum that was reconstructed with a graciloplasty [19]. In two other cases, an omental flap was incorporated into the vaginal closure in order to provide a blood supply to a previously irradiated vault [16]. Finally, an allogenic dermal graft was utilized to close the vaginal defect of a patient who had undergone a colpocleisis [13]. An interposition graft, either omental or a biological mesh product, may have been utilized to reinforce the vaginal vault in our case, either at the time of vaginotomy with sacrocolpopexy, or at the time of small intestinal resection. However, it is not clear whether this approach would have changed the outcome of prolapse recurrence for our patient. In conclusion, VE following abdominal sacrocolpopexy is an uncommon complication associated with high patient morbidity and presents several treatment challenges. Our case suggests that care should be taken at the initial operation to ensure a tensionless mesh placement, and minimize the risk of VE. In a critically ill patient with compromised bowel, such as ours, a second operation for definitive management and resuspension of the vaginal vault may be required. Since vaginal resuspension may not be feasible at the time of intestinal resection, the optimal approach to closing the torn vaginal vault, and thus minimizing the risk of recurrence, is currently controversial. Further study documenting outcomes and complications is needed to better determine how to best manage this potentially devastating complication.
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