Introduction

Vaginal evisceration following hysterectomy is a rare occurrence with only a few cases being documented worldwide (1). Vaginal evisceration is a potentially life threatening complication of a very common gynecological operation which should be recognized and treated without delay. A thorough clinical examination and high index of suspicion will clinch the diagnosis. We report a case of spontaneous vault rupture, long after hysterectomy without any known etiological risk factors (2).

Case Report

A 38 year old P₄L₄A₂ with a history of vaginal hysterectomy two years back came in emergency with complaints of something coming down per vaginum and excruciating pain in lower abdomen since 1 day. There was no history of chronic cough, constipation, coitus, heavy manual work or trauma.

On examination, the patient was apprehensive but her vitals were stable. General physical examination and systemic examination were normal. On per abdomen examination there was vague tenderness in lower abdomen and hernial orifices were normal. Speculum examination revealed that there was an irregular bifid mass of 5cm x 3cm size, (fleshy, thick red, no indurations and did not bleed on touch), coming through a narrow opening of around 1 cm in vaginal vault. Vaginal examination showed same mass/growth was palpable with slight bleeding on gloved finger. No abnormality was detected on per rectal examination. Routine laboratory investigations were normal except total leukocyte count which was 15,290/mm3. Ultrasonography (USG) of pelvis was done to rule out any pelvic pathology and this was normal. Since the patient was stable, she was taken up for examination under anesthesia/ exploration in the O.T. the next morning.

The patient was posted for examination under anesthesia and exploration in operation room. Intraoperatively we observed a tongue shaped fleshy mass simulating omentum lying in the vagina protruding through a hole of 1.5 cm. diameter in the vaginal vault. The mass was gently pulled down till a normal looking omentum came out, which was identified. This was transfixed and excised between clamps and returned back into the peritoneal cavity. Edges of the opening were freshened and repaired with polyglactic acid (vicryl) suture. Histopathology examination of the excised mass confirmed that it was omentum. The post operative period remained uneventful and the patient was discharged after two days.

Figure 1

Fig 1: Showing omental prolapse through vaginal vault

Figure 2

Fig II. Demonstrating rent in vaginal vault.

Discussion

Vaginal evisceration after hysterectomy is mentioned in the literature as early as 1864(3). Since then few cases have been mentioned. Rupture of vaginal vault during convalescent period following sexual trauma is known. Also there have been cases reported in the older patients with increased intra abdominal pressure as the precipitating event. Steroids and other medications causing vaginal wall atrophy may also be implicated. Small bowel is the commonest organ to get prolapsed, presenting sometimes as an emergency (4). However, spontaneous and delayed vault rupture in a young patient with a successful transvaginal repair has not been reported (5).

This case is reported because of its rarity and to emphasize the need for an adequate closure of the vault following vaginal hysterectomy. In the follow up period, patient needs to be examined to check integrity of the vaginal vault.