Transvaginal small bowel evisceration is a rare surgical condition first described by Hypernaux et al. in 1864. Nearly 100 cases have been reported so far, all of which occurred after total hysterectomy, and more than 70% of them are postmenopausal women. Transvaginal small bowel evisceration is mainly related to a history of vaginal surgery, enterocele, and other factors, which may be related to decreased vaginal wall vascularity and atrophy of the vaginal wall in post-menopausal women [3, 4]. In premenopausal women, it is associated with sexual intercourse and vaginal trauma.
Cervical LEEP, a widely used outpatient electrosurgical treatment, emerged in the 1990s, using a 30 ~ 40 W high-frequency electric knife for the treatment of cervical lesions. Complications of LEEP include bleeding, infection, cervical adhesion, cervical insufficiency during pregnancy, and rare cervical or uterine perforation [5]. The perforation from the anterior cervical wall to the uterine bladder peritoneal reflection is extremely rare, which can lead to bowel evisceration.
The cervical LEEP instrument used in this case was an electrified wire loop. We speculated that the excision was deep in the process of resection of the anterior lip of the cervix, and the patient’s uterus was backward flexion, thus leading to the perforation from the anterior cervical wall to the peritoneum of the uterovesical peritoneal reflection. Apart from the deep resection site, there was also heat damage and subsequent local inflammation, which contributed to the peritoneal perforation. Due to the burning wound and other factors affecting surgical field exposure during cervical LEEP, it is difficult to be detected in time, which laid a hidden danger for the subsequent small bowel prolapse.
Patients with transvaginal evisceration of the intra-abdominal organs often presented with pelvic or vaginal pain, vaginal mass, or visible lumps between the legs, and more often occur in the vaginal cuff dehiscence. The distal ileum is the most common protruding viscera, although other organs such as epiploon, and fallopian tubes have also been described. Small bowel prolapse may be complicated by the insufficient blood supply to the bowel, and then intestinal ischemia and necrosis [6]. In this case, the anterior cervical wall has a smaller wound area and more dense surrounding tissue, and the probability of intestinal necrosis and intestinal obstruction symptoms will also increase.
Transvaginal small bowel evisceration is a surgical emergency, and there is a certain risk of death, about 6 to 8%. Once the transvaginal small bowel evisceration is found, the prolapsed bowel should be reduced urgently. If the small bowel is not damaged and the vaginal elasticity is good, it can be reduced trans-vaginally, but laparotomy was more recommended [4]. In this case, the scope of the opening in the anterior cervical wall was small, and the elasticity of the tissues around the electrical cauterization was poor, accompanied by pus mosses and the adhesion of the intestinal tube, so laparotomy was adopted. The incidence of small bowel damage is up to 15 ~ 20%, which is related to the occurrence time and degree of prolapse. Bowel resection needs to be performed on about 20% of patients [7]. The intestinal blood supply and activity should be carefully investigated, and the gynecologists and surgeons should work together.
