Delayed Vaginal Evisceration after radical cystectomy and hysterectomy

The incidence Vaginal evisceration is a rare surgical emergency where abdominal contents herniate through a vaginal wall defect. The estimated incidence is 0.032–1.2% after hysterectomy, trachelectomy or uppervaginectomy. We present a 78-year-old lady who developed vaginal evisceration 2 years after radical cystectomy and hysterectomy forbladder cancer.The key principle of early management involves an attempt to gently reduce the bowel into the peritoneal cavity, and packing the vagina with moistened gauze. If the bowel is unable to be reduced, it should be covered with moist gauze before definitive surgery. Given the rarity of this condition, there is no consensus on the optimal operative approach for vaginal cuff dehiscence and each case should be treated on its own merits. Surgical treatment can be transabdominal, transvaginal or both based largely on the expertise available and the clinical situation of the patient. Transvaginal approach is generally believed to be the least morbid, with primary closure of the vaginal vault if the tissue is healthy. Transabdominal assessment can be via laparoscopy or laparotomy, with repair of the vaginal vault essential to prevent recurrence. The use of mesh or omental flap to re-enforce the vaginal vault can be utilized based on the clinical situation. As our patient did not present with overt signs of bowel ischaemia, we opted for a transvaginal repair with the aim to proceed to laparotomy if unsuccessful. It is likely that a combination of the various risk factors led to her vaginal cuff breakdown. Despite the previous pelvic radiation, she had very good quality tissue, hence primary closure was performed.This case highlights a rare surgical emergency that requires prompt recognition and damage control with bowel reduction and packing. Definitive repair can then be performed once appropriate expertise is

available.