Bowel Obstruction After Sacrocolpopexy: A Case Series

Abstract

It is estimated that more than 30 million women in the United States are affected by pelvic floor disorders. Of these, 3 million experience pelvic organ prolapse. A robust surgical option for treatment of vaginal vault prolapse is sacrocolpopexy (SC).A rare but life-threatening possible sequela of SC is bowel obstruction. There are only limited data on its prevention, prevalence, detection, and management.Previous studies reported rates of bowel obstruction after SC ranging from 1.9% to 2.5%. A comprehensive review found that bowel obstruction after SC was managed surgically in 0.6%-8.6% of cases. Few studies have described the diagnosis, therapeutic options, and long-term consequences of bowel obstruction. Although early detection and treatment can prevent patient morbidity and mortality from adverse events of obstruction such as bowel incarceration and ischemia, presenting symptoms can be mistakenly attributed to other diagnoses. Especially in the immediate postoperative period, common symptoms of bowel obstruction are often indistinguishable from those of ileus. Bowel obstruction can occur from 5 days to 14 years after surgery, further challenging its diagnosis.The aim of this study was to identify clinical and surgical factors associated with occurrence of bowel obstruction after SC and to describe its presentation, management strategies (medical vs surgical), and long-term sequelae. The authors obtained data from a retrospective case series of patients who underwent open, laparoscopic, or robotic SC between January 1, 2009 and December 31, 2019 at hospitals within a large health maintenance organization and a single academic medical center in Southern California.Of 3231 patients, 32 (1.0%) who underwent SC experienced a subsequent bowel obstruction. Thirteen (40.6%) of the 32 patients underwent SC using an open abdominal approach, and 19 (59.4%) via laparoscopic or robotic approach. Among the 32 patients experiencing bowel obstruction, medical management was undertaken in 19 (59.4%). Of the 13 patients managed surgically, 8 (61.5%) had severe bowel obstruction requiring bowel resection, and 3 (23.1%) had partial mesh excision. Two (10.5%) of the medically managed, and 2 (15.4%) of the surgically managed cases had recurrent obstruction.Findings in this small case series suggest that the type of hysterectomy may not be a risk factor for bowel obstruction. The timing of occurrence of this complication spans from days to nearly a decade after SC, which emphasizes the need for surveillance in the immediate postoperative period as well as long-term. Conservative management may be effective long-term as shown by similar rates of recurrence between medically and surgically managed patients. The data provide information to guide surgeons in patient selection, informed counseling, surgical planning before SC, and may aid in diagnosis and management of bowel obstruction after SC. The study is limited by its small sample size secondary to the low prevalence of bowel obstruction.