AFJOG

African Journal of Obstetrics and Gynaecology | Volume 3 | Issue 2 | 2025 | 19 CASE REPORT African Journal of Obstetrics and Gynaecology | Volume 3 | Issue 3 | 2025 | Individualised Management of Bowel Injury in Benign Gynaecologic Surgery: Conservative Versus Surgical Approaches in a Resource-Limited Setting INTRODUCTION The vaginal route for gynaecological procedures—such as vaginal hysterectomy, pelvic organ prolapse repair, or vaginal vault vesicovaginal fistula repair—is generally associated with lower morbidity and mortality compared to abdominal or laparoscopic approaches 1 . Despite this advantage, rectosigmoid injury remains a serious, albeit uncommon, complication of vaginal surgery. Reported incidences range from 0.07% to 1.5%, depending on procedure type, surgical complexity, and study methodology 2 . The close anatomical proximity of the uterus, ovaries, cecum, sigmoid colon, and rectum predisposes the rectosigmoid to potential mechanical trauma (e.g., from surgical instruments, clamps, or sutures) or thermal injury during pelvic surgery, irrespective of surgical route 3 .Among gynaecological procedures, hysterectomy—performed for either benign or malignant indications—remains the leading cause of iatrogenic rectosigmoid injuries. 2,4 . These injuries can result in devastating consequences, including widespread intra- or extraperitoneal infection, deep pelvic abscesses, fistula formation, the need for additional corrective surgeries with or without colostomy, severe sepsis, and even death. 2,4 Delayed recognition of rectosigmoid injury is particularly harmful, with mortality rates reported between 3.3% and 7.2%, compared to 0% to 1.7% when injuries are detected and repaired intraoperatively 5,6 . Multiple factors increase the risk of rectosigmoid injury during gynaecological surgery. These include prior pelvic surgery leading to adhesions and fibrosis, locally advanced pelvic tumours, limited surgeon experience, and patient- related factors such as obesity, which complicate exposure and dissection 7,8 . Given the rarity and potential severity of rectosigmoid injuries, prompt diagnosis and timely intervention are essential to prevent life-threatening sequelae. However, management decisions must be individualized, taking into account the extent of injury, time to recognition, patient comorbidities, and available surgical expertise. The following two cases illustrate contrasting management strategies from a tertiary referral facility in a resource- limited setting. The first case describes a delayed-recognition extraperitoneal rectal injury successfully managed conservatively without diversion, while the second highlights a complex sigmoid injury with multi-organ fistula formation requiring advanced laparoscopic surgery and temporary colostomy. Together, these cases underscore the role of multidisciplinary team (MDT) decision-making and context- sensitive approaches to optimize outcomes for patients with iatrogenic bowel injuries during gynaecologic surgery. CASE 1: SIGMOID INJURY DURING VAGINAL VAULT FISTULAREPAIR A 46-year-old woman, gravida 4 para 4, with a history of type 2 diabetes mellitus (HbA1C 7.6%) and fibromyalgia, both well- controlled on medical therapy, underwent a total laparoscopic hysterectomy in March 2024 for abnormal uterine bleeding secondary to uterine fibroids. Intraoperatively, she sustained an iatrogenic bladder injury. Subsequent evaluation confirmed a supra-trigonal vesicovaginal fistula (VVF) located on the posterior superior bladder wall, measuring approximately 3–4 cm in diameter, classified as GOH 1ci. One month later, she underwent robotic-assisted VVF repair with omental flap interposition. Despite prolonged catheterization, she experienced persistent leakage, and after four weeks was diagnosed with failed repair. A second repair was attempted two months later via the vaginal route, resulting in partial improvement with a reduction in fistula size, but persistent urinary leakage. Three months later, a third attempt was undertaken, using a Latzko technique. At this point, the fistula was <2 cm, with moderate-to-severe fibrosis at its edges. Successful closure was achieved intraoperatively. On postoperative day 4, the patient reported feculent discharge per vagina, though her vital signs remained stable with no evidence of systemic sepsis. Speculum examination revealed Fecal content emerging from the repair site. A contrast-enhanced abdominopelvic CT scan demonstrated a localized collection of feculent material between the bladder, vagina, and bowel, with some drainage through the vaginal vault (Figure 1). There was no evidence of intraperitoneal free fluid or widespread contamination. The patient was taken for emergency laparoscopic exploration, Fredrick B Mbise, 1 Jude Kluge, 1 Nancy Kazadi 2 , Cheslie Saaiman 2 , Khumbo Jere 3 1 Urogynaecology Fellow, Stellenbosch University, Tygerberg Hospital, Cape Town, SA 2 Obstetrics and Gynaecology Senior Registrar, Stellenbosch University, Tygerberg Hospital, Cape Town, SA 3 Urogynaecologist, Head Of Urogynaecology Unit, Stellenbosch University, Tygerberg Hospital, Cape Town, SA CORRESPONDENCE: F Mbise | Email: bahatifreddy8@gmail.com Individualised Management of Bowel Injury in Benign Gynaecologic Surgery: Conservative Versus Surgical Approaches in a Resource-Limited Setting ABSTRACT Bowel injury during vaginal and minimally invasive gynaecologic surgery is a rare but serious complication associated with significant morbidity when diagnosis is delayed. We present two cases illustrating different levels of bowel involvement and tailored management strategies. The first case involved a rectal injury following posterior vaginal wall repair for pelvic organ prolapse. The second case involved a sigmoid injury secondary to iatrogenic vaginal vault fistula formation after laparoscopic hysterectomy for uterine fibroids. Both patients presented with feculent vaginal leakage. Clinical evaluation, including physical examination and computed tomography (CT) imaging, localized the injuries and associated collections. The patient with the distal rectal injury was managed conservatively using wound debridement, broad-spectrum antibiotics, bowel rest, and sitz bathing, resulting in complete healing without diversion. In contrast, the patient with the more proximal sigmoid injury underwent surgical resection with the creation of a diverting stoma. These cases highlight the importance of early recognition and individualized, multidisciplinary decision-making in the management of bowel injuries during gynaecologic surgery, demonstrating that a tailored approach—ranging from conservative management to definitive surgical intervention—can optimize patient outcomes, particularly in resource-limited settings.. Keywords: Rectosigmoid injury, vaginal surgery, gynaecology, Vesico-vaginal fistula, Rectal vaginal fistula