Multidisciplinary Surgical Management of Vaginal Evisceration: A Case Report.

Abstract: Vaginal dehiscence with evisceration is a surgical emergency where all cases are surgically managed. However, identifying the optimal approach in a patient with a history of prior chemoradiation and multiple native-tissue pelvic reconstructive surgical procedures may be challenging. We present here a multidisciplinary case of a 74-year-old patient where flap and graft material placement were utilized as part of her management. She presented as a transfer from an outside hospital for vaginal evisceration of small bowel contents. She was hemodynamically stable, and physical examination revealed 14 cm of edematous, nonreducible, hyperemic bowel protruding beyond her introitus. General surgery and plastic surgery services were consulted for multidisciplinary management. She underwent urgent exploratory laparotomy with an oblique rectus abdominus flap (performed by plastic surgery), small bowel resection and right hemicolectomy (by general surgery), and closure of the distal posterior vaginal wall dehiscence site with placement of a saline-reconstituted decellularized fish skin xenograft within the vaginal defect (by urogynecology). Her postoperative course was uncomplicated, and she was discharged home on postoperative day (POD) 11. She was recovered and asymptomatic at her 4-week postoperative follow-up visit, where she declined scheduling further follow-up appointments. In conclusion, vaginal incision dehiscence with evisceration is best approached early on in a multidisciplinary manner. Select patients, such as those with an extensive pelvic surgical history, multiple vulnerable vaginal incision lines, and history of recurrent prolapse may benefit from consideration of flap placement and application of graft material for wound healing and surgical site integrity at the time of repair.