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Vagina and Urethra

Anterior Repair and Kelly Plication
Site Specific Posterior Repair
Sacrospinous Ligament Suspension of the Vagina
Vaginal Repair of Enterocele
Vaginal Evisceration
Excision of Transverse Vaginal Septum
Correction of Double-Barreled Vagina
Incision and Drainage of Pelvic Abscess via the Vaginal Route
Sacral Colpoplexy
Le Fort Operation
Vesicovaginal Fistula Repair
Transposition of Island Skin Flap for Repair of Vesicovaginal Fistula
McIndoe Vaginoplasty for Neovagina
Rectovaginal Fistula Repair
Reconstruction of the Urethra
Marsupialization of a Suburethral Diverticulum by the Spence Operation
Suburethral Diverticulum via the Double-Breasted Closure Technique           
Urethrovaginal Fistula Repair via the Double-Breasted Closure Technique
Goebell-Stoeckel Fascia Lata Sling Operation for Urinary Incontinence
Transection of Goebell-Stoeckel Fascia Strap
Rectovaginal Fistula Repair via Musset-Poitout-Noble Perineotomy

Sigmoid Neovagina

Watkins Interposition Operation

Vaginal Evisceration

Although vaginal evisceration of the intestine is rare and usually follows hysterectomy within the immediate postoperative period, some cases have been reported years after surgery. The problem can arise after abdominal as well as vaginal hysterectomy and also as a sequela of the rupture of large enteroceles, with or without previous hysterectomy.

A contemporary source of vaginal evisceration has been suction curettage for termination of pregnancy. During this procedure, if the uterine wall is perforated, the small intestine can be sucked into the eye of the vacuum curet and pulled through the perforation in the uterus and out into the vagina.

The etiology of vaginal evisceration, except for that associated with suction for termination of pregnancy, is not associated with any specific pattern of events.

Physiologic Changes. The anatomy of the small bowel and the length of its mesentery make vaginal evisceration difficult. If a laceration occurs in the mesentery of the small bowel, evisceration is more likely. All patients with vaginal evisceration must undergo an exploratory laparotomy with extensive inspection of the small bowel and its mesentery. Because of the unique blood supply to the small bowel, an undiagnosed laceration in its mesentery may result in necrosis. This may explain why the overall mortality from vaginal evisceration is as high as approximately 10%.

Points of Caution. No attempt should be made to simply replace the bowel through the vaginal cuff and close it. All patients should be treated with an abdominoperineal approach. The entire length of the small bowel should be carefully inspected for areas of devascularization.

A classic repair for obliteration of the cul-de-sac through use of the vaginal cuff, the uterosacral ligaments, and the anterior rectal wall should be made to reduce the chance of recurrence.


A sagittal view of the evisceration is shown. In this particular case, the evisceration has occurred through an open vaginal cuff after a hysterectomy. B identifies the bladder; and R, the rectum. The insert to Figure 1 shows the perineal view with the anatomical location of the cecum and other loops of small bowel.


An exploratory laparotomy has been performed, and the loops of the eviscerated small bowel are carefully withdrawn into the peritoneal cavity.


The entire small bowel is carefully inspected from the ileocecal junction to the ligament of Treitz.

In a are areas of devascularization and laceration in the mesentery that cause acute loss of blood to the small bowel. In b, a potential enterotomy with laceration of the serosa and muscularis is causing the intestinal mucosa to balloon through a crack in the bowel serosa. Contusions and necrosis are depicted in c.

It is wise for the surgeon to resect all areas of contusion, necrosis, and enterotomy and to carefully inspect the vasculature in the small bowel mesentery. Linen-shod clamps are placed in an oblique fashion away from the defect to ensure that the antimesenteric border of the small bowel used in the anastomosis will have an excellent blood supply.

The anastomosis is performed according to the Gambee or stapler technique as indicated in the section Small Bowel. The insert shows the mesentery plicated with interrupted absorbable suture.

The opening in the vagina through which the evisceration occurred is shown. After the small bowel has been adequately inspected and cared for, the defect in the pelvis must be repaired. The important structures shown here are the cardinal ligaments, uetrosacral ligaments, anterior rectum, and vagina. The cardinal ligaments should be reapproximated to the angles of the vagina. The vaginal defect itself should be closed with 0 synthetic absorbable suture.

The cul-de-sac should be obliterated by several 0 synthetic absorbable sutures placed in the posterior vaginal wall through the uetrosacral ligaments, the anterior wall of the rectum, the uetrosacral ligament on the opposite side, and back to the posterior vaginal wall. After all of these sutures have been placed, they should be progressively tied from the deepest to the most superficial.

The pelvic peritoneum should be reconstructed. If there has been any contamination from intestinal contents, a suction drain should be placed in the pelvis.













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