AFJOG

African Journal of Obstetrics and Gynaecology | Volume 3 | Issue 3 | 2025 | 20 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 which revealed extensive pelvic adhesions but no intraperitoneal spread of contamination. A diverting loop colostomy was created at the site of sigmoid bowel injury to allow the repair to heal and prevent further contamination. A urethral catheter was maintained for 21 days postoperatively to ensure continuous bladder drainage. At both six-week and three-month follow-up visits, the patient demonstrated complete resolution of leakage, with a dry, intact repair and no recurrent fistula. She successfully resumed normal daily activities and is currently awaiting planned colostomy reversal. Figure1: Abdo-pelvic CT scan revealing collection of faecal content at the vaginal vault following a defect from the bowel injury. CASE 2: RECTAL INJURY DURING POSTERIOR VAGINAL WALLPROLAPSE SURGERY A 66-year-old para 2 was referred to our tertiary referral facility with a complaint of faecal leakage per vagina two weeks after undergoing vaginal hysterectomy, anterior and posterior colporrhaphy, and sacrospinous ligament fixation for advanced pelvic organ prolapse. On admission, she appeared acutely unwell with clinical signs of sepsis, including tachycardia, hypotension, fever, and leukocytosis. Laboratory investigations revealed anaemia, with a haemoglobin level of 8 g/dL. Vaginal examination demonstrated feculent discharge emerging from the repaired posterior vaginal wall at the mid-vaginal level, approximately 3 cm proximal to the posterior fourchette. A digital rectal examination confirmed a rectovaginal fistula measuring approximately 4 cm, located in the mid-vagina and not involving the anal sphincter complex. The leakage had tracked along the rectovaginal fascia into the left ischiorectal fossa, where a large abscess had formed, extending into the left buttock. The patient was extensively counselled regarding two management options: 1. Conservative management , consisting of debridement, wound care, antibiotics, andmedical stool regulationwith the aim of spontaneous healing. 2. Surgical management , which would involve the same wound care combined with a diverting colostomy to protect the repair. Given the extraperitoneal nature of the injury and her strong preference to avoid a stoma, the multidisciplinary team (MDT) and patient agreed on a conservative approach. An urgent extensive debridement was performed, opening the ischiorectal fossa and tracking the dissection to the left buttock to fully drain the abscess and remove necrotic tissue (Figure 2). The rectal mucosawas assessed intraoperatively and found to be viable and strong, allowing for primary repair with interrupted 2-0 PDS sutures. The wound was thoroughly irrigated using normal saline and povidone-iodine solution. A corrugated drain was inserted, and a gentamicin-soaked sponge dressing was applied to cover the wound bed, providing local antimicrobial protection. Postoperatively, the patient was commenced on intravenous Augmentin, intravenous fluids, and oral loperamide to minimize stool frequency. She was also placed on a light, high-protein diet to promote wound healing and was instructed to undertake regular sitz baths. Dressing changes were performed every 48 hours. Due to her anaemia, she received two units of whole blood to optimize haemoglobin levels and recovery. Over the subsequent days, serial wound debridement’s were carried out to maintain a clean wound environment and to encourage healthy granulation tissue. As the wound improved, care transitioned to advanced modalities, including Prontosan solution irrigation and negative-pressure wound therapy using a vacuum-assisted closure system. This helped to reduce dead space, improve perfusion, and accelerate tissue healing. Throughout this period, the rectal mucosal repair remained intact, with no evidence of recurrent leakage. On postoperative day 8, the patient was given a gentle laxative and successfully passed stool, confirming the integrity of the rectal repair. This milestone demonstrated that bowel continuity had been preserved without compromise. After three weeks of meticulous wound care and monitoring, the defect was ready for secondary surgical closure. The wound was closed in two layers, ensuring tension-free approximation and optimal anatomical restoration (Figure 3). The patient’s postoperative recovery was uneventful, and she regained full continence. At follow-up visits, there were no signs of recurrent fistula, abscess formation, or sepsis. This case demonstrates that, with intensive multidisciplinary care and vigilant monitoring, non-diversional conservative management can successfully treat select extraperitoneal rectal injuries following vaginal surgery. Careful case selection, combined with aggressive infection control and advanced wound management techniques, allowed for complete healing while avoiding themorbidity of a colostomy, thus preserving the patient’s quality of life. Figure2a: Initial presentationoftheperinealwound showingextensivenecrosisandfeculent contamination, withtracking intothe left ischiorectal fossa. Figure2b: Healthygranulationtissueevident afterserial debridement andnegative-pressurewoundtherapy, demonstratingprogressivewoundbedhealingand control ofsepsis. Figure3: Final appearanceoftheperinealwound followingthreeweeksof intensivewoundcareand successful secondaryclosure,withcompleteanatomical restorationandno rectal leakage. DISCUSSION Rectosigmoid injuries during gynaecologic surgery can be challenging to recognize, particularly when small or extraperitoneal. These injuries are classified by timing of recognition as either early (intraoperative) or delayed (postoperative). Early recognition and immediate repair 2a 2b 3