Prolapsed Epiploica of the Sigmoid Colon After Total Laparoscopic Hysterectomy.

2011·0.13 MB·English

by  Askari, Reza

C R
ASE EPORT
Prolapsed Epiploica of the Sigmoid Colon After Total
Laparoscopic Hysterectomy
Reza Askari, MD, Samadh F. Ravangard, DO, Ali Ghomi, MD
ABSTRACT INTRODUCTION
Prolapsed epiploica of the sigmoid colon through the Vaginalcuffdehiscenceandeviscerationofabdominalcontents
vaginalcuffisararefindingthathasneverbeenreported afterhysterectomyisararecomplicationthatwasfirstdescribed
after total laparoscopic hysterectomy. We encountered a intheearly1900s.1 Theincidencerangesfrom0.03%to0.3%
case of prolapsed epiploica of the sigmoid colon in a afterabdominalorvaginalhysterectomy.Thisnumberhasre-
40-year-old female, 4 months status after total laparo- centlybeenreportedtobeapproaching5%aftertotallaparo-
scopic hysterectomy. Diagnostic laparoscopy demon- scopic or robotic-assisted hysterectomy.2–4 Herein, we report
strated prolapsed epiploica of the sigmoid colon through the first known case of prolapsed epiploica of the sigmoid
a dehisced vaginal cuff. colonaftertotallaparoscopichysterectomy.
Key Words: Total laparoscopic hysterectomy, Sigmoid
colon, Prolapse. CASE REPORT
A 40-year-old woman, gravida 4, para 3, underwent total
laparoscopichysterectomyforasymptomaticfibroiduterus.
The procedure was performed in the usual fashion as de-
scribed by Sokol et al.5 Colpotomy was performed utilizing
the Harmonic scalpel (Ethicon Endo-Surgery, Cincinnati,
OH)andtheKOHColpotimizer(CooperSurgical,Trumbull,
CT).Electrocautorywasnotusedduringthecolpotomy.The
vaginal cuff was closed with interrupted figure-of-eight
stitchesofdelayedabsorbablesuturesonCT-1needles.The
knots were secured extracorporeally. The procedure was
uncomplicated with an uneventful postoperative course.
Thepatientwasdischargedaftera23-hourobservation.
Four months postoperatively, the patient presented as an
outpatient complaining of diffuse abdominal discomfort,
postcoital bleeding, and vaginal discharge. On physical ex-
amination,theabdomenwasbenign.Speculumexamination
revealed a 3cm(cid:1)3cm soft tissue mass, firm and globular,
protrudingfromthevaginalapexconsistentwithprolapsed
viscera.Uponobtainingfurtherhistory,thepatientreported
resuming sexual activity 2 weeks postoperatively. She was
scheduled to undergo a diagnostic laparoscopy the follow-
ing day. Intraoperatively, a moderate amount of dense ad-
DepartmentofGynecology-Obstetrics,UniversityatBuffalo,TheStateUniversityof hesionsofthesmallandlargeboweltothevaginalcuffwas
NewYorkBuffalo,NewYork,USA(DrsAskari,Ravangard). noted.Sharpenterolysiswascarriedoutlaparoscopicallyto
DepartmentofObstetricsandGynecology,SistersofCharityHospital,Buffalo,New obtain visualization of the vaginal cuff. A soft tissue mass,
York,USA(DrGhomi).
deemedtobeprolapsedepiploicaofthesigmoidcolon,was
Addresscorrespondenceto:AliGhomi,MD,DepartmentofObstetricsandGyne- subsequentlyreducedfromthevaginalcuff(Figure1).The
cology,SistersofCharityHospital,2157MainStreet,1stFloor,Buffalo,NewYork
cuffappearedcompletelydehisced.Nosignsofcuffcellulitis
14214,USA.Fax:[phone],E-mail:[email protected]
or pelvic infection were noted. Inspection of the bowel
DOI:10.4293/108680811X13071180406718
revealed no evidence of ischemia or serosal injury. The
©2011byJSLS,JournaloftheSocietyofLaparoendoscopicSurgeons.Publishedby
theSocietyofLaparoendoscopicSurgeons,Inc. Harmonic scalpel (Ethicon Endo-Surgery, Cincinnati, OH)
252 JSLS(2011)15:252–253
ergymodalityusedduringcolpotomyintheroboticapproach.
Inthiscase,webelieveearlyresumptionofintercoursewasa
significantcontributingfactortothecuffdehiscencealongwith
ultrasonic-inducedtissuedamageoftheHarmonicscalpel(Ethi-
conEndo-Surgery,Cincinnati,OH).
CONCLUSION
Prolapseoftheepiploicaofthesigmoidcolonisarareand
potentialcomplicationoftotallaparoscopichysterectomy.A
laparoscopicapproachmaybesuccessfullyusedintheman-
agementofsuchacomplication.Asencounteredinthiscase,
visceral prolapse through the vaginal cuff does not always
present acutely after laparoscopic hysterectomy. Gyneco-
logic surgeons performing laparoscopic hysterectomy
Figure 1. Epiploica originating from the sigmoid colon pro-
shouldbeintimatelyfamiliarwithdifferentclinicalscenarios
lapsedthroughvaginalcuff.
in which such complications can present. In addition, in-
depth knowledge of possible causes of cuff dehiscence in
was used to transect the fatty appendage from the sigmoid
laparoscopic hysterectomy is a prerequisite to prevention
colon.Thevaginalcuffwasreapproximatedlaparoscopically
and accurate diagnosis of such complications. This is espe-
with interrupted figure-of-eight stitches by using 2-0 poly-
cially important as laparoscopic hysterectomy continues to
dioxanone suture (Ethicon, Somerville, NJ). The patient’s
sidelineconventionalhysterectomyviatheabdominalroute.
recovery was uncomplicated, and she was discharged on
postoperative day 2. The final pathology revealed “fat pad”
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