Vaginal Cuff Dehiscence as an Unusual Cause of Pneumoperitoneum: A Case Series.

Pneumoperitoneum is most commonly associated with gastrointestinal perforation and often prompts emergent surgical exploration; however, gynecologic sources such as vaginal cuff dehiscence (VCD) can rarely be the cause. We present two unusual cases of pneumoperitoneum secondary to VCD following remote hysterectomy, each with distinct presentations and operative findings. The first case involves a 38-year-old woman with prior Roux-en-Y gastric bypass and hysterectomy who presented with acute-on-chronic abdominal pain and imaging evidence of free intraperitoneal air. Diagnostic laparoscopy and intraoperative endoscopy ruled out gastrointestinal perforation, and subsequent exploration revealed complete VCD with a localized abscess and adherent small bowel requiring resection and open cuff repair reinforced with an omental patch. The second case involves an 83-year-old woman with a history of hysterectomy and planned vaginal prolapse repair who presented with suprapubic pain and vaginal bulging. Imaging revealed a small bowel herniation through the vaginal vault, and diagnostic laparoscopy confirmed complete cuff dehiscence, which was successfully repaired laparoscopically using barbed absorbable sutures. Both patients recovered uneventfully. VCD remains a rare but potentially serious postoperative complication, with a presentation as pneumoperitoneum being exceptionally uncommon. Awareness of this entity is critical to prevent unnecessary bowel resections when bowel viability is preserved and to guide timely, multidisciplinary management tailored to intraoperative findings.