Laparoscopic repair of vaginal rupture and evisceration in a young girl

Laparoscopic repair of vaginal rupture with evisceration in a young girl
Vishwanath Golash

Abstract

Background

Vaginal evisceration is an extremely rare condition which sometime presents in postmenopausal women and after pelvic surgery. It is rarer in premenopausal women. This is a true surgical emergency can be repaired by an abdominal, vaginal, combined vaginal and abdominal, combined laparoscopic and vaginal route or by laparoscopy alone as in our case.

Method

This 14 year old girl presented with vaginal rupture and evisceration following a fall on a sharp object. Laparoscopically the herniated omentum was reduced and vaginal rupture sutured.

Conclusion

Vaginal rupture and evisceration can be managed by laparoscopy alone. We believe this to be the first case of vaginal evisceration in a young unmarried girl managed laparoscopically to be reported.

Keywords: Vaginal rupture, evisceration, laparoscopy

Introduction

A 14 year old girl presented to the emergency department with more than a 24 hour history of severe lower abdominal pain, vaginal bleeding and a painful protruding mass from the vagina following impalement. Apparently she was well before and accidentally fell on a sharp object. The mass was extremely tender to touch and gave rise to severe abdominal pain. On examination she was of normal build with well developed secondary sex characters. (She had achieved her menarche one year previous). The temperature was 38°C, pulse rate of 120 per minute and blood pressure of 120/70 mm Hg. Local examination revealed foul smelling serosanguinous discharge from the vagina with an omental like structure protruding out of vagina giving her severe abdominal pain on minimal manipulation. The mass was almost filling her vagina. Further examination was not possible due to pain and tenderness. There were no other associated injuries elsewhere. Abdominal examination showed signs of peritonitis but the remaining examination was normal. It was apparent that she had suffered a vaginal rupture and the abdominal contents were herniating through. She was given parenteral antibiotics and prepared for examination under general anesthesia. Further examination of vagina under general anaesthesia confirmed the evisceration. An O° laparoscope was introduced through an umbilical port. The greater omentum could be seen herniating through the tear in the anterior vaginal wall, plugging it and possibly preventing other viscera from herniation.

Figure 1: Herniation of omentum through the anterior vaginal wall rupture

Video of procedure modem broadband

Two further ports were inserted. There was minimal free blood in the peritoneal cavity, no foreign materials and no other visceral injury. The greater omentum was slowly pulled out of the tear. An endoloop was placed over the remaining herniated part of omentum which was excised and sent for biopsy.

Figure 2: Herniated omental plug

The vaginal tear was closed with single layer running '0' vicryl suture laparoscopically. The peritoneal cavity was thoroughly irrigated with warm saline. Postoperatively she made an uneventful recovery and was discharged home on 5th post operative day. She was seen subsequently in outpatient 3 and 6 months after her surgery with no complications. Histology simply confirmed normal omentum.

Figure 3: Anterior vaginal wall tear

Figure 4: Endosuturing the anterior vaginal wall tear

Discussion

Impalement injuries in children are relatively uncommon and having the vaginal rupture with evisceration is even rarer 1. The most common presentation is vaginal bleeding and a through examination is mandatory 2. Other associated injuries may include ruptured rectum, urethra, or hollow viscus 3,4. To develop guidelines for management, various types of genital injuries are described based on the object: straddle injuries, nonpenetrating injuries, penetrating injuries and torque injuries. The most dangerous injuries are penetrating injuries 5,6 requiring surgical intervention in two third of the patients. Vaginal evisceration has been reported in postmenopausal women, premenopausal women, after pelvic surgery, after abdominal or vaginal hysterectomy and after coitus. These injuries are conventionally managed surgically by an abdominal approach, vaginal approach or by combined route 7,8,9,10.

Minimal invasive surgery has added a new therapeutic option in managing these cases. It has the added advantages of assessment of the viability of bowel, identification of other visceral injuries and the possibility of suture of the vaginal rupture laparoscopically 11. Laparoscopic surgery, alone or in combination with a vaginal approach, is an effective solution to the management of vaginal tear.

Conclusion

Laparoscopic evaluation and repair in vaginal evisceration is feasible and has all of the advantages common to minimal invasive surgery.

References

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