Vaginal evisceration is a rare emergency. This movie demonstrates the key steps of the repair procedure.

A 79 year old woman presented to the emergency department with bowels herniating out of the vagina after a fall. She had a history of prior hysterectomy and was known to have a vaginal enterocele with thin vaginal tissues despite the use of vaginal hormones. After being evaluated, started on intravenous antibiotics, and consented for an exploratory surgery, she was urgently taken to the operating room.

A midline suprapubic abdominal incision was carried out. Due to the large herniation of non-reducible bowels, access to the urethra to drain her bladder in retention was not possible. Therefore, a spinal needle was inserted in the bladder dome to drain her urine, allowing space to work in the pelvis area to reduce the eviscerated bowels. Normal pink bowel loops were identified leading to the point of herniation. The herniated loops of bowel were then slowly and carefully withdrawn superiorly into the abdominal cavity. Once the urethral meatus became visible, a Foley catheter was inserted. A Lonestar retractor was positioned. The vaginal tear site was inspected. The thin vaginal tissue area at the site of the herniation was excised.The vaginal cuff was then closed with running and reinforcing interrupted absorbable sutures. Corner vaginal sutures were left to guide the later fixation of the newly repaired vaginal vault. 
Colo-rectal surgery was consulted regarding the condition of the bowels. Bowel inspection and irrigation with warm saline was performed. All herniated bowel loops were carefully inspected for signs of ulceration or tear. The intestines were viable on inspection. To confirm good vascular supply, intraoperative fluorescence angiography was performed using the SPY Elite system. Two milliliters of ICG dye were injected intravenously followed by 10 milliliters of IV normal saline. Good perfusion of the entirety of the affected small intestines was noted. No area of ischemia was seen. 
The procedure was concluded with a vault fixation using a peritoneocolpopexy using two sets of running V loc sutures, incorporating the repaired vaginal apex and the remnants of the uterosacral ligaments on each side. 
 Recovery was uneventful. Patient was discharged home on post-operative day 3 after resuming bowel function. There has been no vault prolapse recurrence on last evaluation at 18 months postoperatively.

Vaginal evisceration is a rare emergency requiring repair of the vaginal herniation site after reduction of the intestines, bowel inspection with possible fluorescence angiography, and vault fixation.