Transvaginal strangulated small intestinal hernia after abdominal sacrocolpopexy: case report and literature review

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 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.