AFJOG

African Journal of Obstetrics and Gynaecology | Volume 3 | Issue 2 | 2025 | 21 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 significantly reduce morbidity and mortality.¹ Intraoperative detection relies on direct visualization of the bowel wall, presence of feculent material, or adjunctive tests such as digital rectal examination, rectal dye instillation, or an air leak test to confirm rectal wall integrity. 8,9 Delayed diagnosis is more complex and carries higher risk. Patients typically present with sepsis, abdominal pain, or fistula formation, as seen in our two cases. Clinical presentation may include feculent vaginal discharge, pneumaturia, or leakage of stool through the vagina or urethra. The average time to presentation is reported between 2–3.5 days, with a range of up to two weeks. 8,10 Diagnosis relies on imaging, including abdominal X-ray to detect free air (e.g., Rigler’s sign or cupola sign), ultrasound to identify free or loculated fluid, and contrast- enhancedCT scan, which remains the gold standard for localizing the injury and assessing for complications such as abscess or peritonitis 11 . Endoscopic tools such as flexible sigmoidoscopy and cystoscopy are especially useful for evaluating suspected fistula tracts 12 . Management decisions depend on the location and size of the injury, extent of contamination, and overall patient condition. Treatment options range from conservative non-surgical care (bowel rest, IV fluids, broad-spectrum antibiotics) to surgical correction via open or laparoscopic approaches. 13 Conservative treatment is appropriate only for hemodynamically stable patients with small, contained extraperitoneal injuries and no signs of generalized peritonitis. 14 Surgical repair involves resection or direct closure of the defect, typically in three layers—mucosal, seromuscular, and surrounding tissue—using absorbable monofilament sutures. 14 Traditionally, intraperitoneal injuries were managed with primary repair, while extraperitoneal defects more often required faecal diversion. A stoma is generally recommended for injuries >2 cm, those identified >24 hours after occurrence, or when contamination is extensive. 15 Laparoscopic techniques are increasingly favoured for appropriate cases due to reduced pain, shorter hospital stays, and lower infection risk. In patients with poor tissue quality, such as post-radiation or severe fibrosis, vascularized tissue flaps (e.g., omental or gracilis muscle flaps) can be interposed to improve healing and reduce recurrence. 3 Prevention remains paramount1. Surgeons should perform thorough preoperative risk assessment, careful dissection, judicious use of energy devices, and meticulous inspection of the surgical field at the beginning and end of each procedure. Intraoperative rectal integrity tests, such as the air leak test, further reduce the risk of missed injury. 12,19,20 Close postoperative monitoring is essential, especially in high-risk patients, to identify early signs of rectosigmoid injury such as unexplained abdominal pain, sepsis, or unusual vaginal or urethral discharge. 8 CONCLUSION Although rectosigmoid injuries are rare during vaginal gynaecologic surgeries, their occurrence poses significant physical and psychological burdens for both patients and surgical teams. Early recognition and accurate diagnosis are critical to minimizing morbidity and mortality. Imaging and endoscopic tools play a central role in confirming the diagnosis and guiding management. Treatment must be individualized: conservative care can be successful in select stable patients with localized injuries,whilesurgicalrepairanddiversionremainthestandardfor larger or more complex injuries. Strengthening multidisciplinary collaboration and adopting meticulous intraoperative and postoperative protocols are essential to improving outcomes and preventing these devastating complications. CONFLICT OF INTEREST : None CONSENT: Consent was obtained from the patient to take and use pictures for this case report AUTHORS CONTRIBUTION: The case was managed by all mentioned authors. This case report was prepared by FBM and reviewed by KJ. REFERENCES £ ° § ¥ ¦ ¦ £ § £ ¯ ¦ £ £ § ® § £ § ¥ _ _ _ _ _ ¢ ¾ ¨¡ ¡ ¦ £ £ ş ·® µ Ş ¿ § À¿ ¿ ® ¢ § § § ¥ ■ Á Á ¥ £ ¡ £ § ¨ £ £ § § § § £ §