Pneumomediastinum from vaginal cuff dehiscence four months after laparoscopic-assisted vaginal hysterectomy: A case report

Introduction Vaginal cuff dehiscence (VCD) is a rare post-operative complication after hysterectomy in which the approximated edges of the vaginal cuff separate. Associated presentations range from simple separation with minimal bothersome symptoms to pain, infection, and surgical emergencies such as bowel evisceration. In this report we describe a rare and delayed presentation of VCD. Case A 34-year-old woman underwent laparoscopy-assisted vaginal hysterectomy (LAVH) for persistent cervical dysplasia. Four months after surgery, she presented to the emergency department with diffuse vaginal bleeding and chest and abdominal pain. Prior to symptom onset she had attempted sexual intercourse for the first time since her surgery.On pelvic exam, she had a one centimeter VCD. Chest, abdomen, and pelvis computerized tomography (CT) imaging showed pneumoperitoneum and pneumomediastinum. She was taken to the operating room for diagnostic laparoscopy, sigmoidoscopy, and endoscopy, which were unremarkable, as well as VCD repair. Discussion We discuss how the patient's pneumomediastinum arose secondary to air introduced into the vagina during intercourse, which then traversed the following anatomic route: abdominal cavity, diaphragmatic hiatus, retroperitoneum, and mediastinum. Conclusion We report an unusual and delayed presentation of VCD after LAVH resulting in pneumoperitoneum and pneumomediastinum. The patient was managed surgically with exploration and VCD repair and had complete resolution of symptoms. Surgeons should understand that the risk of VCD exists as long as 8-12 weeks after surgery and VCD's varying presentations due to anatomic connection between abdominal cavity and mediastinum.