Images for surgeons
In conclusion, vaginal evisceration is a rare condition that presents with protruding mass, vaginal bleeding and pelvic pain. It is most commonly associated with previous vaginal surgery but may occur spontaneously, and represents a surgical emergency.
References 1. Nasr AO, Tormey S, Aziz MA, Lane B. Vaginal herniation: case report and review of the literature. Am. J. Obstet. Gynecol. 2005; 193: 95–7. 2. Woo KC, Linden JA, Lowenstein RA, Varghese JC, Burch MA. Subtle vaginal evisceration resulting in small bowel evisceration: a case report. J. Emerg. Med. 2012; 43: e125–8. 3. Virtanen HS, Ekholm E, Kiilholma PJA. Evisceration after enterocele repair: a rare complication of vaginal surgery. Int. Urogynecol. J. Pelvic Floor Dysfunct. 1996; 7: 344–7. 4. Yaakovian MD, Hamad GG, Guido RS. Laparoscopic management of vaginal evisceration: case report and review of the literature. J. Minim. Invasive Gynecol. 2008; 15: 119–21. 5. Croak AJ, Gebhart JB, Klingele CJ, Schroeder G, Lee RA, Podratz KC. Characteristics of patients with vaginal rupture and evisceration. Obstet. Gynecol. 2004; 103: 572–6.
691
6. Guttman A, Afilalo M. Vaginal evisceration. Am. J. Emerg. Med. 1990; 8: 127–8. 7. Ramirez PT, Klemer DP. Vaginal evisceration after hysterectomy: a literature review. Obstet. Gynecol. Surv. 2002; 57: 462–7. 8. Kowalski LD, Seski JC, Timmins PF, Kanbour AI, Kunschner AJ, Kanbour-Shakir A. Vaginal evisceration: presentation and management in postmenopausal women. J. Am. Coll. Surg. 1996; 183: 225–9. 9. Yaakovian MD, Hamad GG, Guido RS. Laparoscopic management of vaginal evisceration: case report and review of the literature. J. Minim. Invasive Gynecol. 2008; 15: 119–21.
Asiri Arachchi, MBBS Fanny Lie, MBBS Adee Davidson, MBBS Cham Saranasuriya, MBBS, FRACS Abinav Vasudevan, MBBS Department of General Surgery, Maroondah Hospital, Melbourne, Victoria, Australia doi: 10.1111/ans.12512
Transrectal negative pressure sponge treatment of full-thickness rectal perforation A 45-year-old female presented to our institution with fevers and severe lower abdominal pain. She underwent colonic irrigation by an alternative healthcare practitioner 36 h prior and experienced severe pain during and after the procedure. The patient was febrile (38.9°C) on admission, and computed tomography scanning demonstrated extra peritoneal free gas in the presacral space consistent with a rectal injury (Fig. 1). Examination under anaesthetic and flexible endoscopy showed an area of mucosal abnormality posteriorly within the lower third of the rectum, consistent with trauma, but no defect in the wall of the rectum was demonstrable. The patient rapidly improved on intravenous antibiotics and was discharged on oral antibiotics. At review 2 weeks later, she complained of feeling generally unwell, with low grade temperatures and rectal discharge. Repeat exam under anaesthetic revealed a full-thickness defect in the rectum 5 cm from the anal verge which drained frank pus (Fig. 2).An endoscope was introduced through the defect into the presacral space and a thorough saline lavage performed. The situation was discussed with the patient who was adamant she wanted to exhaust all therapeutic options, including ‘off-label’ therapies that may result in a therapeutic response, and declined defunctioning surgery unless her clinical condition worsened. A decision was made to attempt to manage the defect in the rectum with a negative pressure dressing given the option of forming a laparoscopic diverting loop colostomy was not available. In Europe, a proprietary product, the Endo-sponge (B. Braun Melsungen AG, Melsungen, Germany), is available for this purpose, but not in Australia. Instead, a conventional VAC sponge (KCI Inc., San Antonio, TX, USA) was utilized. The sponge was cut to size and sutured around VAC suction tubing (KCI Inc.). This was introduced through the rectal wall defect into the presacral space and placed on continuous suction at 125 mmHg of continuous negative pressure. The patient was permitted to eat and drink. Bowel actions occurred with the sponge in situ. However, the patient normally experienced only one bowel action per week. It is conceivable © 2014 Royal Australasian College of Surgeons
Fig. 1. Extraperitoneal rectal injury with gas in presacral space.
that this more limited exposure to the injury site by faecal material may have reduced the overall degree of sepsis the patient experienced. The patient tolerated the sponge and remained clinically well with no further constitutional symptoms. Four days later, the sponge was exchanged, and the presacral cavity was now granulating (Fig. 3) and closing down in size. Intravenous antibiotics were discontinued and oral antibiotics commenced. The sponge was exchanged on day 9, and at this time, the defect had closed down further in size and continued to demonstrate evidence of
692
Fig. 2. Endoscopic view of rectal injury.
Images for surgeons
Fig. 4. Endoscopic view after 23 days of therapy showing almost complete healing.
We have described an approach to managing full-thickness extraperitoneal rectal perforation that avoided the need for defunctioning surgery. This may be appropriate to discuss with some patients, particularly those who are otherwise medically well and are adamant they will not accept defunctioning surgery. We would strongly advocate that patients who do not improve using this technique are managed with defunctioning surgery. We believe consideration to such a technique should also be reserved for extraperitoneal rectal injuries and avoided in settings where there is an intraperitoneal injury or intraperitoneal sepsis.
References
Fig. 3. Endoscopic view of rectal injury post-negative pressure dressing therapy with evidence of granulation.
healing and an absence of any signs of infection. Antibiotic therapy was discontinued. Further changes of the sponge were undertaken on four occasions over a 2-week period. On each occasion, reduction in cavity size was noted such that on the last occasion, it was no longer practical to insert a sponge. The patient went home and remained well. A follow-up examination under anaesthetic with endoscopy demonstrated almost complete healing (Fig. 4) and complete resolution of any symptoms. Management of clinical problems in Australia using transrectal negative pressure dressings is very limited, and we do not believe that the use of such a device to successfully manage a rectal injury has been described previously in this country. A proprietary product does not exist in Australia, although we have demonstrated a conventional VAC sponge can be easily adapted for transrectal use. There is a report of a patient being managed in this manner in Europe after a colonoscopic perforation.1 The remaining literature on this subject is limited.2–5 The focus of this literature is on the use of transrectal negative pressure dressings in managing anastomotic leaks following creation of colorectal, ileorectal or ileoanal anastomoses in patients who either have had surgery for colorectal cancer or inflammatory bowel disease. This literature describes a group of patients who have largely been defunctioned. In this setting, the reported success using this technique is 66–95%,2,6,7 the largest reported study being a series of 29 patients.6
1. Richterich JP, Heig A, Muff B, Luchsinger S, Gutzwiller JP. EndoSPONGE a new endoscopic treatment option in colonoscopy. Gastrointest. Endosc. 2008; 68: 1019–22. 2. van Koperen PJ, van Berge Henegouwen MI, Rosman C et al. The Dutch multicenter experience of the Endo-Sponge treatment for anastomotic leakage after colorectal surgery. Surg. Endosc. 2009; 23: 1379–83. 3. Arezzo A, Miegge A, Garbarini A, Morino M. Endoluminal vacuum therapy for anastomotic leaks after rectal surgery. Tech. Coloproctol. 2010; 14: 279–81. 4. Riss S, Stift A, Kienbacher C et al. Recurrent abscess after primary successful endo-sponge treatment of anastomotic leakage following rectal surgery. World J. Gastroenterol. 2010; 16: 4570–4. 5. van Koperen PJ, van Berge Henegouwen MI, Slors JFM, Bemelman WA. Endo-sponge treatment of anastomotic leakage after ileo-anal pouch anastomosis: report of two cases. Colorectal Dis. 2009; 10: 943–4. 6. Weidenhagen R, Gruetzner KU, Wiecken T, Spelsberg F, Jauch KW. Endoscopic vacuum-assisted closure of anastomotic leakage following anterior resection of the rectum: a new method. Surg. Endosc. 2008; 22: 1818–25. 7. Riss S, Stift A, Meier M, Haiden E, Grunberger T, Bergmann M. Endosponge assisted treatment of anastomotic leakage following colorectal surgery. Colorectal Dis. 2009; 12: e104–8.
Kenneth Buxey,* MBBS (Hons) Pravin Ranchod,† MBChB, FRACS *General Surgery, The Alfred Hospital and †Department of Colorectal Surgery, Cabrini Medical Centre, Melbourne, Victoria, Australia doi: 10.1111/ans.12523 © 2014 Royal Australasian College of Surgeons
In conclusion, vaginal evisceration is a rare condition that presents with protruding mass, vaginal bleeding and pelvic pain. It is most commonly associated with previous vaginal surgery but may occur spontaneously, and represents a surgical emergency.
References 1. Nasr AO, Tormey S, Aziz MA, Lane B. Vaginal herniation: case report and review of the literature. Am. J. Obstet. Gynecol. 2005; 193: 95–7. 2. Woo KC, Linden JA, Lowenstein RA, Varghese JC, Burch MA. Subtle vaginal evisceration resulting in small bowel evisceration: a case report. J. Emerg. Med. 2012; 43: e125–8. 3. Virtanen HS, Ekholm E, Kiilholma PJA. Evisceration after enterocele repair: a rare complication of vaginal surgery. Int. Urogynecol. J. Pelvic Floor Dysfunct. 1996; 7: 344–7. 4. Yaakovian MD, Hamad GG, Guido RS. Laparoscopic management of vaginal evisceration: case report and review of the literature. J. Minim. Invasive Gynecol. 2008; 15: 119–21. 5. Croak AJ, Gebhart JB, Klingele CJ, Schroeder G, Lee RA, Podratz KC. Characteristics of patients with vaginal rupture and evisceration. Obstet. Gynecol. 2004; 103: 572–6.
691
6. Guttman A, Afilalo M. Vaginal evisceration. Am. J. Emerg. Med. 1990; 8: 127–8. 7. Ramirez PT, Klemer DP. Vaginal evisceration after hysterectomy: a literature review. Obstet. Gynecol. Surv. 2002; 57: 462–7. 8. Kowalski LD, Seski JC, Timmins PF, Kanbour AI, Kunschner AJ, Kanbour-Shakir A. Vaginal evisceration: presentation and management in postmenopausal women. J. Am. Coll. Surg. 1996; 183: 225–9. 9. Yaakovian MD, Hamad GG, Guido RS. Laparoscopic management of vaginal evisceration: case report and review of the literature. J. Minim. Invasive Gynecol. 2008; 15: 119–21.
Asiri Arachchi, MBBS Fanny Lie, MBBS Adee Davidson, MBBS Cham Saranasuriya, MBBS, FRACS Abinav Vasudevan, MBBS Department of General Surgery, Maroondah Hospital, Melbourne, Victoria, Australia doi: 10.1111/ans.12512
Transrectal negative pressure sponge treatment of full-thickness rectal perforation A 45-year-old female presented to our institution with fevers and severe lower abdominal pain. She underwent colonic irrigation by an alternative healthcare practitioner 36 h prior and experienced severe pain during and after the procedure. The patient was febrile (38.9°C) on admission, and computed tomography scanning demonstrated extra peritoneal free gas in the presacral space consistent with a rectal injury (Fig. 1). Examination under anaesthetic and flexible endoscopy showed an area of mucosal abnormality posteriorly within the lower third of the rectum, consistent with trauma, but no defect in the wall of the rectum was demonstrable. The patient rapidly improved on intravenous antibiotics and was discharged on oral antibiotics. At review 2 weeks later, she complained of feeling generally unwell, with low grade temperatures and rectal discharge. Repeat exam under anaesthetic revealed a full-thickness defect in the rectum 5 cm from the anal verge which drained frank pus (Fig. 2).An endoscope was introduced through the defect into the presacral space and a thorough saline lavage performed. The situation was discussed with the patient who was adamant she wanted to exhaust all therapeutic options, including ‘off-label’ therapies that may result in a therapeutic response, and declined defunctioning surgery unless her clinical condition worsened. A decision was made to attempt to manage the defect in the rectum with a negative pressure dressing given the option of forming a laparoscopic diverting loop colostomy was not available. In Europe, a proprietary product, the Endo-sponge (B. Braun Melsungen AG, Melsungen, Germany), is available for this purpose, but not in Australia. Instead, a conventional VAC sponge (KCI Inc., San Antonio, TX, USA) was utilized. The sponge was cut to size and sutured around VAC suction tubing (KCI Inc.). This was introduced through the rectal wall defect into the presacral space and placed on continuous suction at 125 mmHg of continuous negative pressure. The patient was permitted to eat and drink. Bowel actions occurred with the sponge in situ. However, the patient normally experienced only one bowel action per week. It is conceivable © 2014 Royal Australasian College of Surgeons
Fig. 1. Extraperitoneal rectal injury with gas in presacral space.
that this more limited exposure to the injury site by faecal material may have reduced the overall degree of sepsis the patient experienced. The patient tolerated the sponge and remained clinically well with no further constitutional symptoms. Four days later, the sponge was exchanged, and the presacral cavity was now granulating (Fig. 3) and closing down in size. Intravenous antibiotics were discontinued and oral antibiotics commenced. The sponge was exchanged on day 9, and at this time, the defect had closed down further in size and continued to demonstrate evidence of
692
Fig. 2. Endoscopic view of rectal injury.
Images for surgeons
Fig. 4. Endoscopic view after 23 days of therapy showing almost complete healing.
We have described an approach to managing full-thickness extraperitoneal rectal perforation that avoided the need for defunctioning surgery. This may be appropriate to discuss with some patients, particularly those who are otherwise medically well and are adamant they will not accept defunctioning surgery. We would strongly advocate that patients who do not improve using this technique are managed with defunctioning surgery. We believe consideration to such a technique should also be reserved for extraperitoneal rectal injuries and avoided in settings where there is an intraperitoneal injury or intraperitoneal sepsis.
References
Fig. 3. Endoscopic view of rectal injury post-negative pressure dressing therapy with evidence of granulation.
healing and an absence of any signs of infection. Antibiotic therapy was discontinued. Further changes of the sponge were undertaken on four occasions over a 2-week period. On each occasion, reduction in cavity size was noted such that on the last occasion, it was no longer practical to insert a sponge. The patient went home and remained well. A follow-up examination under anaesthetic with endoscopy demonstrated almost complete healing (Fig. 4) and complete resolution of any symptoms. Management of clinical problems in Australia using transrectal negative pressure dressings is very limited, and we do not believe that the use of such a device to successfully manage a rectal injury has been described previously in this country. A proprietary product does not exist in Australia, although we have demonstrated a conventional VAC sponge can be easily adapted for transrectal use. There is a report of a patient being managed in this manner in Europe after a colonoscopic perforation.1 The remaining literature on this subject is limited.2–5 The focus of this literature is on the use of transrectal negative pressure dressings in managing anastomotic leaks following creation of colorectal, ileorectal or ileoanal anastomoses in patients who either have had surgery for colorectal cancer or inflammatory bowel disease. This literature describes a group of patients who have largely been defunctioned. In this setting, the reported success using this technique is 66–95%,2,6,7 the largest reported study being a series of 29 patients.6
1. Richterich JP, Heig A, Muff B, Luchsinger S, Gutzwiller JP. EndoSPONGE a new endoscopic treatment option in colonoscopy. Gastrointest. Endosc. 2008; 68: 1019–22. 2. van Koperen PJ, van Berge Henegouwen MI, Rosman C et al. The Dutch multicenter experience of the Endo-Sponge treatment for anastomotic leakage after colorectal surgery. Surg. Endosc. 2009; 23: 1379–83. 3. Arezzo A, Miegge A, Garbarini A, Morino M. Endoluminal vacuum therapy for anastomotic leaks after rectal surgery. Tech. Coloproctol. 2010; 14: 279–81. 4. Riss S, Stift A, Kienbacher C et al. Recurrent abscess after primary successful endo-sponge treatment of anastomotic leakage following rectal surgery. World J. Gastroenterol. 2010; 16: 4570–4. 5. van Koperen PJ, van Berge Henegouwen MI, Slors JFM, Bemelman WA. Endo-sponge treatment of anastomotic leakage after ileo-anal pouch anastomosis: report of two cases. Colorectal Dis. 2009; 10: 943–4. 6. Weidenhagen R, Gruetzner KU, Wiecken T, Spelsberg F, Jauch KW. Endoscopic vacuum-assisted closure of anastomotic leakage following anterior resection of the rectum: a new method. Surg. Endosc. 2008; 22: 1818–25. 7. Riss S, Stift A, Meier M, Haiden E, Grunberger T, Bergmann M. Endosponge assisted treatment of anastomotic leakage following colorectal surgery. Colorectal Dis. 2009; 12: e104–8.
Kenneth Buxey,* MBBS (Hons) Pravin Ranchod,† MBChB, FRACS *General Surgery, The Alfred Hospital and †Department of Colorectal Surgery, Cabrini Medical Centre, Melbourne, Victoria, Australia doi: 10.1111/ans.12523 © 2014 Royal Australasian College of Surgeons
