Incisional hernia of the vaginal apex following vaginal hysterectomy in a premenopausal, sexually inactive woman.

A woman experienced a small-bowel herniation through a rupture in the vaginal fascia at the apex of a well-supported vagina, leaving the small bowel covered only by a transparent mucosal membrane. This condition developed after a vaginal hysterectomy, with prophylactic plication of the uterosacral ligaments to obliterate the cul-de-sac, had been performed for uterine prolapse, which in turn developed subsequent to a high retropubic urethral suspension. This woman was premenopausal and sexually inactive, and had no other risk factors for failure of the vaginal apical scar. At the time of surgical repair, it appeared that the vaginal incision had failed because the apex was placed on tension between the anterior vaginal wall's attachment to the iliopectineal line and the opposing posterior traction of the uterosacral plication on the posterior vagina. This phenomenon seemed to be a consequence of the original alteration of the vaginal axis by the urethral suspension combined with subsequent enterocele prophylaxis.