Case Report

A 50-year-old woman was diagnosed with International Federation of Gynecology and Obstetrics stage IB1 squamous cell carcinoma of the cervix and underwent a total laparoscopic radical hysterectomy with pelvic lymphadenectomy. The vaginal wall was incised circumferentially with a needle coagulator, and bleeding was controlled with bipolar and monopolar coagulation. The vaginal mucosa was closed with an interrupted extracorporeal suture made of absorbable glyconate monofilament (Monosyn 0; B-Brown, Tuttllingen, Germany). The pelvic peritoneum was closed around the cuff; the retroperitoneum was opened bilaterally. After surgery, drains were placed in the parametria. No intra- or postoperative complications occurred. The patient had an uneventful recovery and was discharged on postoperative day 8. The final pathologic report was invasive squamous cell carcinoma with evidence of an 8 to 15 mm stromal invasion. The surgical margin was free of disease, and there was no lymphovascular invasion. Three courses of adjuvant chemotherapy (paclitaxel and carboplatin) were administered after surgery. Two months after the last cycle of chemotherapy (ie, 7 months after the operation), a mass protruded through the vagina while the patient was straining to defecate. Portions of the small bowel and omentum were observed in the introitus. The loops of prolapsed small bowel were wrapped with moist saline pads, and an emergency laparoscopic repair was performed. After the entire pelvic cavity was inspected, 3-4 cm defects in the vaginal cuff and edematous omentum were noted, and a partial omentectomy was performed. The vagina had been closed through the vagina with interrupted Monosyn 0, then an interrupted peritoneal suture was performed laparoscopically with Monosyn 0 after the ragged tissues were removed to diminish the risk of further evisceration. Postoperatively, a drain was placed in the pelvic cavity. She had an uneventful postoperative course and was discharged on day 4 after repair of the vaginal cuff. After 10 months of follow-up, there was no evidence of weakness that involved the vaginal cuff.

Comment

Previously, 4 cases of vaginal evisceration developed after radical hysterectomy after laparotomies. A radical hysterectomy is believed to pose a higher risk for evisceration than a traditional hysterectomy for the following reasons: (1) a remaining short vagina after radical hysterectomy, (2) adjuvant radiotherapy after surgery, (3) the possible involvement of tissues in the tumor, and (4) reduced tissue vascularity because of the radical nature of the surgery. Moreover, laparoscopic surgery is a risk factor for increased vaginal cuff dehiscence and ultimately for increased vaginal evisceration and because of the thermal energy that is used in laparoscopic surgery and other unique techniques. Thus, to prevent vaginal evisceration after a laparoscopic radical hysterectomy, it may be prudent to minimize the use of thermal energy while cutting the vaginal cuff. Furthermore, for each of the previous vault dehiscences that developed after total laparoscopic hysterectomy, the stumps were closed with multifilament polyglactin sutures; most of procedures used delayed absorbable polydioxane suture for repair. Therefore, for stump sutures after laparoscopic surgery, delayed absorbable monofilament sutures may be beneficial at the time of total laparoscopic radical hysterectomy.

Vaginal evisceration is an emergency situation, and immediate surgical intervention is required. In most cases, abdominal, vaginal, or combined vaginal-abdominal approaches have been used for repair. According to the recent literature, the combined vaginal-abdominal approach offers the potential benefits of inspection of the entire abdominal cavity and meticulous lavage of the peritoneal cavity, compared with the vaginal approach. The laparoscopic-vaginal approach appears to have similar advantages to the vaginal-abdominal approach and minimizes the inherent morbidity that is associated with laparotomy; however, only a few cases have been reported. Gynecologic oncologists who use skilled laparoscopic techniques will be fully capable of correcting vaginal evisceration through the laparoscopic-vaginal approach without the need for a laparotomy.