Vaginal cuff dehiscence with small bowel prolapse 10 years after vaginal hysterectomy

PURPOSE:(1) To describe a case of cuff dehiscence with bowel evisceration ten years after vaginal hysterectomy.(2) To critically review the literature of incidence and risk factors for cuff dehiscence.(3) To propose recommendations for management and prevention. METHODS:A 74-year-old female, twenty years post-menopausal, presented for vaginal pain and pain across her lower abdomen after feeling something protruding from her vagina.She has a past surgical history of vaginal hysterectomy ten years ago and has since dealt with prolapse requiring use of a pessary.She was fitted with a ring pessary May 2020.She was using a size 4 which was then removed for six months due to ulcerations.In August 2021, she was refitted with a size 3.It subsequently fell out and a donut pessary was placed a week later.Due to ongoing discomfort it was replaced with a ring in December 2021.She has been on 1 mg of oral estrogen daily for several years.She has a past medical history significant for rheumatoid arthritis treated with 4 mg methylprednisolone daily as well as type 2 diabetes mellitus.She has a remote smoking history and quit over 35 years ago.On exam, she had elevated blood pressure.She was found to have small bowel protruding from her vagina.Additionally, prior surgical incisions from a hip surgery and oophorectomy in 2019 were noted and partially open.Her small bowel was wrapped in sterile gauze soaked in saline and she was transferred to the operating room for exploratory laparotomy.Approximately 40 cm of distal ileum was reduced back into the peritoneal cavity.No injuries to the bowel were noted and the vaginal cuff appeared relatively avascular.After the edges were trimmed, the cuff was closed with running suture.Additional interrupted sutures were used to prevent recurrent dehiscence.She remained stable after surgery and was discharged on postoperative day three.She had a follow up appointment one month later and the vaginal cuff appeared surprisingly well healed. RESULTS:Vaginal cuff dehiscence is a rare but potentially detrimental complication of gynecological surgery.The risk factors for its occurrence are not completely clear due to the low incidence and number of studies.Proposed risk factors include increased age, increased number of vaginal surgeries, post-operative cuff infection or hematoma, increased intra-abdominal pressure (for example, patients with chronic cough), the mode of hysterectomy, and poor wound healing.Numerous factors can lead to poor wound healing in patients, including poor nutrition, malignancy, or chronic steroid use, as was the case for this patient as evidenced by the cuff dehiscence many years after surgery and poor wound healing of more recent incisions.