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      Prolapsed Epiploica of the Sigmoid Colon After Total Laparoscopic Hysterectomy

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          Abstract

          A laparoscopic approach is recommended for the complication of prolapsed sigmoid colon epiploica after total laparoscopic hysterectomy.

          Abstract

          Prolapsed epiploica of the sigmoid colon through the vaginal cuff is a rare finding that has never been reported after total laparoscopic hysterectomy. We encountered a case of prolapsed epiploica of the sigmoid colon in a 40-year-old female, 4 months status after total laparoscopic hysterectomy. Diagnostic laparoscopy demonstrated prolapsed epiploica of the sigmoid colon through a dehisced vaginal cuff.

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          Most cited references 8

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          Incidence and patient characteristics of vaginal cuff dehiscence after different modes of hysterectomies.

          The purposes of this study were to estimate and compare the incidence of vaginal cuff dehiscence after different modes of hysterectomies (abdominal, vaginal, laparoscopic-assisted vaginal and laparoscopic) and to review the characteristics of hysterectomies complicated by vaginal dehiscences. Observational case series (Canadian Task Force classification II-3). Large, urban, university teaching hospital. All patients undergoing a total hysterectomy or vaginal dehiscence repair at Magee-Womens Hospital (MWH) from January 2000 through March 2006 were analyzed. Vaginal repair of vaginal cuff separation with reduction of eviscerating organ when appropriate. From January 2000 through March 2006, 7286 hysterectomies (7039 total and 247 supracervical) were performed at MWH by abdominal, vaginal, laparoscopic-assisted vaginal, or laparoscopic approach. Ten of these hysterectomies were complicated by vaginal cuff dehiscences and were repaired during this time period. The resulting overall cumulative incidence of vaginal cuff dehiscence after total hysterectomy at MWH was 0.14%. The annual cumulative incidence of vaginal dehiscences after total hysterectomy was 0%, 0%, 0%, 0%, 0.09%, 0.70%, and 0.31% from January 2000 to March 2006, respectively. There was a notable increase in the cumulative incidence of dehiscence in 2005 and thereafter. From January 2005 through March 2006, the cumulative incidence of vaginal dehiscence by mode of hysterectomy was 4.93% among total laparoscopic hysterectomies (TLH), 0.29% among total vaginal hysterectomies (TVH), and 0.12% among total abdominal hysterectomies (TAH). The relative risks of a vaginal cuff dehiscence complication after TLH compared with TVH and TAH were 21.0 and 53.2, respectively. Both were statistically significant, with 95% CIs of 2.6 to 166.9 and 6.7 to 423.4, respectively. Among the 10 dehiscences repaired, 8 (80%) were complications of TLHs, 1 (10%) was associated with TAH, and 1 (10%) followed a TVH. The median age at time of dehiscence was 39 years, and the median time between initial hysterectomy to vaginal dehiscence was 11 weeks. Six of the 10 patients presented with both cuff dehiscence and bowel evisceration. Six patients reported first postoperative intercourse as the trigger event. Half the patients with dehiscence report smoking cigarettes. All patients with dehiscence received preoperative prophylactic antibiotics at the time of hysterectomy. Until October 2006, there have been no reported recurrent dehiscences at MWH. Total laparoscopic hysterectomies may be associated with an increased risk of vaginal cuff dehiscence compared with other modes of total hysterectomy. We postulate that the use of thermal energy in addition to other factors unique to laparoscopic surgery may be responsible; however, prospective randomized trials are needed to support this hypothesis. When performing laparoscopic hysterectomies, a supracervical approach should be considered unless a clear indication for a TLH is present.
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            Incidence and characteristics of patients with vaginal cuff dehiscence after robotic procedures.

            To estimate the incidence and characteristics of patients with vaginal cuff dehiscence after robotic cuff closure. We reviewed medical records from March 2004 to December 2008 of all patients with vaginal cuff dehiscence after a robotic simple and radical hysterectomy, trachelectomy, and upper vaginectomy using the robotic da Vinci Surgical System. Twenty-one of 510 patients were identified with vaginal cuff dehiscence (incidence 4.1%, 95% confidence interval 2.3-5.8%). In nine patients, the robotic procedure was performed for a gynecologic malignancy. Coitus was the triggering event in 10 patients. Patients most commonly presented with vaginal bleeding and sudden gush of watery vaginal discharge. Bowel evisceration was associated in six patients. Median time to presentation was 43 days or 6.1 weeks. Nineteen cases were repaired through a vaginal approach and one combined vaginal and laparoscopic. Three of 21 patients experienced a repeat dehiscence and required a second repair. Vaginal cuff dehiscence should be considered in patients with vaginal bleeding and sudden watery discharge after robotic cuff closure. The incidence is similar as previously reported for laparoscopic procedures. Contributing factors remain unknown but thermal effect and vaginal closure technique probably play major roles. III.
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              Vaginal vault dehiscence after hysterectomy.

              The purpose of our study was to evaluate factors predisposing vault dehiscence after hysterectomy and its manifestation. Case series and review of the literature (Canadian Task Force classification II-3). Multicenter study. Retrospective analysis of 16 unpublished cases of vaginal vault dehiscence after total laparoscopic hysterectomy from physicians who participated in the exchange on the topic of vaginal vault dehiscence at the American Association of Gynecologic Laparoscopists Endo Exchange List (group A) and review of 38 reported cases in the literature (group B). The participating physicians were asked to complete a detailed questionnaire related to vault dehiscence. In addition, we performed literature search using the keywords "vault dehiscence," "vaginal vault dehiscence," "vault prolapse," and "hysterectomy," and conducted the search in MEDLINE, EMBASE, and Cochrane Database of Systematic Reviews. We estimated risk factors and characteristic features for vaginal vault dehiscence. The incidence of vault dehiscence was higher after laparoscopic hysterectomy (1.14%) than after abdominal hysterectomy (0.10%, p <.0001, OR 11.5) and after vaginal hysterectomy (0.14%, p <.001, OR 8.3). The time interval between hysterectomy and occurrence of vault dehiscence in the laparoscopic group (8.4 +/- 1.2 weeks) was significantly shorter than in the abdominal hysterectomy (112.7 +/- 75.1 weeks, p = .01) and in vaginal hysterectomy (136.5 +/- 32.2 weeks, p <.0001) groups, respectively. It appears that sexual intercourse was the main triggering event for vault dehiscence (58.8%). Vaginal bleeding (50%) and vaginal evisceration (48.1%) were the main symptoms. Our data suggest that vaginal vault dehiscence is rare but may occur more often after laparoscopic hysterectomy than after other hysterectomy approaches. Whether it is related to the technique of laparoscopic suturing is unclear. Other risk factors such as early resumption of regular activities and sexual intercourse may play a role.
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                Author and article information

                Contributors
                Department of Gynecology-Obstetrics, University at Buffalo, The State University of New York Buffalo, New York, USA.
                Department of Gynecology-Obstetrics, University at Buffalo, The State University of New York Buffalo, New York, USA.
                Department of Obstetrics and Gynecology, Sisters of Charity Hospital, Buffalo, New York, USA.
                Journal
                JSLS
                JSLS
                jsls
                jsls
                JSLS
                JSLS : Journal of the Society of Laparoendoscopic Surgeons
                Society of Laparoendoscopic Surgeons (Miami, FL )
                1086-8089
                1938-3797
                Apr-Jun 2011
                : 15
                : 2
                : 252-253
                Affiliations
                Department of Gynecology-Obstetrics, University at Buffalo, The State University of New York Buffalo, New York, USA.
                Department of Gynecology-Obstetrics, University at Buffalo, The State University of New York Buffalo, New York, USA.
                Department of Obstetrics and Gynecology, Sisters of Charity Hospital, Buffalo, New York, USA.
                Author notes
                Address correspondence to: Ali Ghomi, MD, Department of Obstetrics and Gynecology, Sisters of Charity Hospital, 2157 Main Street, 1st Floor, Buffalo, New York 14214, USA. Fax: (716) 862-1873, E-mail: aghomi@ 123456yahoo.com
                Article
                10-03-040
                10.4293/108680811X13071180406718
                3148883
                21902987
                © 2011 by JSLS, Journal of the Society of Laparoendoscopic Surgeons.

                This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial No Derivatives License ( http://creativecommons.org/licenses/by-nc-nd/3.0/), which permits for noncommercial use, distribution, and reproduction in any medium, provided the original work is properly cited and is not altered in any way.

                Product
                Categories
                Case Reports

                Surgery

                sigmoid colon, prolapse, total laparoscopic hysterectomy

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