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Letter to ‘Silent uterine rupture occluded by intestinal adhesions following laparoscopic myomectomy: A case report’: Do some remain permanently silent?

Fukutani et al. reported silent uterine rupture: rupture was covered/occluded by the intestine and mesentery, making it asymptomatic. As was cited, we also previously reported a similar case of uterine rupture: the intestine/mesentery covered/occluded the rupture, preventing catastrophe. The case described by Fukutani et al. showed no bleeding, and rupture was revealed at term cesarean section, whereas our case had uterine contractions and hemoperitoneum, prompting preterm cesarean section. If the patient of Fukutani et al. had experienced uterine contractions, rupture may have become larger, causing bleeding/hemoperitoneum, similar to our case. Thus, these two cases may illustrate different phases of the same pathophysiology. Although, to our knowledge, only two patients with such occluded rupture have been reported (the patient described by Fukutani et al. and our patient), we believe that some cases of such uterine rupture may remain unnoticed/unreported. In the case described by Fukutani et al., if the uterus had remained un-exteriorized, ‘posterior’ uterine perforation/rupture may have gone unrecognized. Image analyses did not reveal uterine rupture, suggesting that some occluded rupture may have been overlooked. Further widening this concept, some occluded uterine rupture may spontaneously resolve: mesenteric adhesion may facilitate this. We postulate two reasons. First, a high percentage (86%) of uterine perforation caused by dilatation and evacuation was revealed only by laparoscopy, otherwise it may have remained unrecognized, and all ruptures were considered to have spontaneously resolved; we believe that intestinal/ mesenteric covering may have occurred in some cases as a natural host-defense mechanism. Second, adhesion is intentionally used in surgical practice other than obstetrics, as ‘intentional rupture-masking.’ An ‘omental patch repair’ is often employed to repair perforated gastrointestinal peptic ulcers. It is sometimes also employed for urinary bladder rupture. Covering perforation/rupture not only prevents symptom manifestation but also facilitates spontaneous closure of the perforation/rupture. Whether this also holds true for uterine rupture remains unclear; however, these findings may support our concept. We were the first to report the concept of ‘masked uterine rupture.’ Masking by the intestine/mesentery may delay not only its diagnosis but also catastrophic occurrence, with the latter providing obstetricians with time to take action. Thus, at present, we cannot determine whether ‘masked rupture’ is a friend or foe. Here, we widen the concept, as ‘spontaneous closure of masked rupture’: intestinal/mesenteric adhesion may facilitate spontaneous closure of the delivery-/ pregnancy-related uterine rupture. This can be a reality, especially when rupture is relatively small and free from infection. Although we have no evidence to confirm this phenomenon at present, future observation/investigation may confirm it.