Mustafa Kucuk

Research article
BMC Women's Health 2002, 2:2       


       Fallopian tube prolapse as a complication of abdominal  hysterectomy is a rare occurrence. A case with fallopian tube prolapse  was managed by a combined vaginal and laparoscopic approach and  description of the operative technique is presented.
       
       


       A 39-year-old woman with vaginal prolapse of the fallopian tube  after total abdominal hysterectomy presented with an incorrect diagnosis  of adenocarcinoma of the vaginal apex. The prolapsed tube and cystic  ovary were removed by vaginal and laparoscopic approach. The  postoperative course went well.
       
       


       Early or late fallopian tube prolapse can occur after total  abdominal hysterectomy and vaginal hysterectomy. Symptoms consist of  persistent blood loss or leukorrhea, dyspareunia and chronic pelvic  pain. Vaginal removal of prolapsed tube with laparoscopic surgery may be  a suitable treatment. The abdominal or vaginal approach used in  surgical correction of prolapsed tubes must be decided in each case  according to the patient's individual characteristics.     

 
       Fallopian tube prolapse (FTP) is an unusual complication of both abdominal       and vaginal hysterectomies. Sporadic cases have been added to the       literature about predisposing factors and techniques of management [1].       The diagnosis of FTP needs postoperative observation and careful       examination of the vaginal vault. A biopsy is necessary to differentiate       between this lesion and the presence of vaginal granulation tissue. The       presence of cellular atypias may result in an unnecessary additional       operation. These changes are probably secondary to the severe underlying       inflammatory reaction. Vaginal infection, postoperative bleeding, a       defective surgical technique, and poor physical condition of the patient       are the most important predisposing factors for intravaginal prolapse of       the fallopian tube [2]. An       excisional biopsy constitutes the definitive diagnostic procedure and       adequate treatment for this posthysterectomic vaginal complication.       

We have       managed a woman with FTP on combining a simple vaginal approach and       laparoscopic total salpingectomy and oophorectomy. The operative technique       described in this case with this condition provides the advantages of       total salpingectomy without laparotomy.

A 39-year-old woman, gravida 9, para 8, has been performed a  total abdominal hysterectomy and left salpingo-oophorectomy in two years  ago for menometrorrhagica. She admitted complaining of vaginal spotting  and pain with sexual intercourse of 3 months' duration. Pelvic  examination revealed a mass at the apex of the cuff, with an erroneous  diagnosis of adenocarcinoma of the vaginal apex. On ultrasonographic  examination, the right ovary was cystic appearance in diameter 38 mm ×  40 mm. Microscopic examination of a biopsy specimen from the mass  revealed the prolapsed fimbrial end of a fallopian tube. Acute and  chronic inflammation were present. After her admission medical and  surgical treatment options were discussed with the patient. The right  fallopian tube and ovary were removed together with granulation tissue,  as described below.

 
       Simultaneous vaginal and standard laparoscopic technique with  additional puncture in the suprapubic region and at McBurney's point  were used because of cystic appearance of the right ovary. These sites  were used for the insertion of the bipolar forceps, and laparoscopic  scissors. Thick and thin pelvic adhesions were incised, freeing the tube  from the pelvic sidewall and minor bowel attachments and mobilizing the  mesosalpinx. We made an elliptical incision around the vaginal mucosa  and by sharp dissection, freed the tube from vagina after laparoscopic  mobilization of the tube and ovary. The tube and ovary were withdrawn  through transvaginally when freed from attachments. The pelvic  peritoneum and vaginal mucosa were closed. Prophylactic antibiotic was  administered.


       FTP may cause symptoms serious enough to warrant treatment. The fallopian       tube is unlike other abdominal viscera in that it is sensitive to touch,       cutting and crushing [3]. Because       dense adhesions may involve the tube, ovary, bladder, and bowel, most       authors have performed partial salpingectomy [1].       However, total salpingectomy is preferred, for the reason that continued       pain by traction on the remaining portion of the prolapsed fallopian tube.       

Factors that       may contribute to FTP include pelvic infection, poor hemostasis,       intraperitoneal vaginal drains or packs, and failure to close the vaginal       cuff [1,3].       These may lead to the development of a defect between the pelvic       peritoneum and the vagina [1,4].       As has been note by others, prolapse of the fallopian tube following       vaginal or abdominal hysterectomy is probably much more common than the       numbers of reports in the literature indicate [3,5].       FTP after vaginal hysterectomy is more common than abdominal hysterectomy [6,7].       However, it was also reported that most cases occurred after abdominal       hysterectomies [5].

In present       case, because the right ovary was bound by dense adhesions to the right       fallopian tube, a right salpingo-oophorectomy was performed.       Postoperatively, she did very well and within a few days after surgery,       she was pain free. The exact incidence of FTP is difficult to estimate,       because cases may go undiagnosed and may resolve before detection. In the       present woman, factors associated with development of FTP include grand       multiparity and low socioeconomic status. The diagnosis of FTP should be       suspected when a red, granular, polypoid mass or lesion is seen at the       vaginal cuff protruding into the vagina after hysterectomy. The       differential diagnosis that must be considered includes proliferative       granulation tissue related to surgery, malignant lesion. The definitive       identification is made by histopathologic examination. In the present       case, the pathological result of right fallopian tube and ovary was       revealed as tube and cystic ovary with inflammation. Wetchler and Hurt       describe their technique for total excision of the prolapsed fallopian       tube via the vaginal approach [8].       Letterie and associate operative technique combines a vaginal approach       with laparoscopic total salpingectomy [9].


       The described method should be applicable in most clinical circumstances       when salpingectomy is indicated, and may be performed on an outpatient       basis. This combined technique allows adhesiolysis and full mobilization       of the adnexa. However, dense bowel, bladder, and adnexal adhesions that       prevent full mobilization of the involved tube often prevent total       excision by a laparoscopic approach. Under these circumstances as partial       salpingectomy or an abdominal approach must be considered. Following       surgery, complete symptom resolution is usually observed and no recurrence       has been reported [10].

 
       The author wish to thank Professor Engin Aydin, MD, Department of  Pathology, Inonu University Hospital, Malatya, and Associate Professor  Cemal Gundogdu, MD, Department of Pathology, Ataturk University  Hospital, for histopathologic evaluation. Written consent was obtained  from the patient or their relative for publication of the patient's  details.

1. 	  	Wetchler SJ, Hurt WG: A technique for surgical correction fallopian tube.Obstet Gynecol 1986, 67:747-749. [

2. 	  	Bilodeau B: Intravaginal prolapse of the fallopian tube following vaginal hysterectomy.Am J Obstet Gynecol 1982, 143:970-971. [

3. 	  	Carmichael DE: Prolapse of the fallopian tube into the vaginal vault.Am J Obstet Gynecol 1976, 125:266-267. [

4. 	  	De Clippel K, Coenen M, Bhal PS, Amso N: Fallopian tube prolapse following abdominal hysterectomy.Aust N Z J Obstet Gynaecol 2001, 41:106-108. [

5. 	  	Ramin SM, Ramin KD, Hemsell DL: Fallopian tube prolapse after hysterectomy.South Med J 1999, 92:963-966. [

6. 	  	Candiani GB, Candiani M: Posthysterectomy fallopian tube herniation. A report of two cases.J Reprod Med 1996, 41:915-920. [

7. 	  	Muntz HG, Falkenberry S, Fuller AF: Fallopian tube prolapse after hysterectomy. A report of two cases.J Reprod Med 1988, 33:467-469. [

8. 	  	Wetchler SJ, Hurt WG: A technique for surgical correction of fallopian tube prolapse.Obstet Gynecol 1986, 67:747-749. [

9. 	  	Letterie GS, Byron J, Salminen ER, Miyazawa K: Laparoscopic management of fallopian tube prolapse.Obstet Gynecol 1988, 72:508-510. [

10. 	  	Piacenza JM, Salsano F: Post-hysterectomy fallopian tube prolapse.Eur J Gynecolo Reprod Biol 2001, 98:253-255. [

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Â© 2002 Kucuk; licensee BioMed Central Ltd. This is an Open Access article: verbatim copying and redistribution of this article are permitted in all media for any purpose, provided this notice is preserved along with the article's original URL. 

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Fallopian tube prolapse as a complication of abdominal hysterectomy is a rare occurrence. A case with fallopian tube prolapse was managed by a combined vaginal and laparoscopic approach and description of the operative technique is presented.

Mustafa Kucuk

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