UKZN Lecturer and Specialist General Surgeon in the Department of General Surgery, Dr Aslam Noorbhai, recently co-authored a case report on transvaginal small bowel evisceration.
The report, co-authored with UKZN’s Department of General Surgery Emeritus Professor Thandinkosi Madiba, was published in The South African Journal of Surgery (SAJS).
According to Noorbhai, this was the first report of transvaginal small bowel evisceration in Africa and concerned a rare entity of transvaginal small bowel herniation following a transvaginal hysterectomy.
‘Transvaginal small bowel evisceration is a rare, but life-threatening condition, which tends to occur in postmenopausal women,’ explained Noorbhai.
A 71-year-old woman underwent a transvaginal hysterectomy for utero-vaginal prolapse. Despite the operation, she experienced discomfort from anterior vaginal prolapse and had incomplete bladder emptying.
He said further surgery was not considered because of multiple comorbidities, most importantly congestive cardiac myopathy, dyslipidaemia and chronic obstructive pulmonary disease.
Nine months later, she presented with a 24-hour history of a painful mass protruding from her vagina. She was haemodynamically stable, with diffuse abdominal tenderness and distension with guarding. The protruding mass was a segment of ischaemic small bowel, which eviscerated via a tight vaginal vault defect.
In view of her co-morbidities, an extra-abdominal resection of the protruding small bowel was attempted. However, the healthy small bowel could not be delivered through the small defect in the vaginal vault, and she was then submitted to laparotomy. The bowel was reduced intra-abdominally via a bimanual manoeuvre.
A stapled functional end-to-end anastomosis was then performed about 10cm from the ileocaecal junction. The vaginal vault defect was closed, and a vaginopexy to the sacrospinous ligament was performed using polydioxanone.
Noorbhai said the patient made an uneventful recovery and was discharged five days later. She was seen at six months for follow-up and was well.
Following this presentation, another patient presented in early 2016 with the same condition. The same guidelines were applied by Noorbhai and the patient recovered remarkably well.
He said an awareness of the condition and knowledge of the methods used to address both the ischaemic bowel and ruptured vaginal vault could result in minimal operative time and improved patient outcomes.
‘This case report illustrates that in patients with a previous vaginal hysterectomy who present with the previously described symptoms, a transvaginal evisceration should be high on the differential diagnosis.
‘When it does occur, it is a surgical emergency which warrants prompt intervention. Early diagnosis and management is important as this condition is associated with high morbidity and mortality,’ Noorbhai added.