Rectal Injury Due to the Incorrect Insertion of a Vagi-Pipe Into the Rectum During Total Laparoscopic Hysterectomy: A Case Report

TL;DR

A surgical tool was mistakenly inserted into the rectum instead of the vagina during a gynecologic procedure, causing injury and prompting a safety change.

Contribution

Highlights a preventable complication from vaginal pipe misuse and introduces a practical safety measure to avoid rectal injury.

Findings

A Vagi-Pipe was incorrectly inserted into the rectum during a total laparoscopic hysterectomy, causing rectal injury.

A narrow vaginal orifice contributed to the misidentification of the rectum as the vagina by the assistant surgeon.

Covering the anus with a cloth was implemented to prevent future misinsertions.

Abstract

Total laparoscopic hysterectomy (TLH) is the most common gynecologic surgery. The use of a vaginal pipe to facilitate TLH is a popular method for enabling incision into the vaginal canal. However, this device is associated with serious complications. We report the case of a patient who underwent laparoscopic low anterior resection due to rectal injury caused by the incorrect insertion of a Vagi-Pipe (Hakko Co. Ltd., Nagano, Japan) into the rectum during TLH for endocervical positive margins after conization of cervical intraepithelial neoplasia. In the present case, the narrow vaginal orifice made it difficult for the assistant surgeon to distinguish between the vagina and anus. Based on this experience, a change was made at our institution to cover the anus with a cloth to prevent misidentification. Surgeons performing TLH should be mindful that the use of a vaginal pipe can lead to incorrect insertion into the rectum.

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