Conservative surgeries for genital prolapse

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  • 1. Conservative Surgeries For Genital Prolapse

2. Operative Treatments of ProlapseThe type of surgery offered to the patient withprolapse depends on the A) Age of the patientB) Her desire to retain the uterus either for reproductive or menstrual reasonsC) Her menstrual historyD) Her general conditionE) Degree of uterine prolapse 3. List of conservative surgeriesConservative procedures are which preserves the menstural and childbearing functions.1) Colporrhaphy ( anterior/ posterior)2) Fothergills repair(Manchester operation)3) Shirodkars procedure4) Abdominal sling operation a)Abdominocervicopexy b)Shirodkars abdominal sling operation c)Khannas abdominal sling operation 4. Anterior colporrhaphyPrinciple -An anterior repair is a vaginal surgery tocorrect a cystocele, when the "upper" wall ofthe vagina that is in contact with the bladder issagging down, or coming outside of the vaginalopening.Indications a)cystoceleb)Cystourethrocele 5. Steps a)Traction is given to the cervix to expose the anterior vaginal wall.b) An inverted T- shaped incision is made , starting with a transverse incision in the bladder sulcus and through its mid point ,vertical incision extended up to the urethral opening.c) The vaginal walls are reflected to either side to expose the bladder and vesicovaginal fascia.d) The overlying vesicovaginal fascia is tightened and the excess vaginal wall excised to correct the laxity, and vaginal wall sutured. 6. Complications - Risks of colporrhaphy include potential complications associated with-1.Anesthesia,2.Infection,3.Bleeding,4.Injury to other pelvic structures,5.Dyspareunia (painful intercourse),6.Recurrent prolapse,7. Failure to correct the defect. 7. Posterior colporrhaphyPrinciple A posterior repair is a vaginal surgery to correct a rectocele, when the "lower" wall of the vagina that is in contact with the rectum is bulging into the vagina, or coming outside of the opening of the vagina.Indications a) Rectocele b) Repair of deficient perineum 8. Steps a) This is done by making a triangular or diamond-shapedincision, and removing some of the extra skin of the wallof the vaginab) After this skin is removed, the strong tissues underneathare brought together with strong stitches.c) The lax vagina over the rectocele is excised , and therectovaginal facia repaired after reducing the rectocele.d) The approximation of the medial fibers of the levator anihelps to restore the caliber of the haitus urogenitalis, restore the perineal body and provide an adequateprenium. 9. Complications-One possible risk of this surgery is that thevaginal opening may become narrow with scartissue, and there may be some discomfortwith sexual activity. The rest of thecomplications are same as that of AnteriorColporrhaphy. 10. Shirodkars procedurePrinciple Cervical cerclage , also known as a cervical stitch, is used for the treatment of cervical incompetence ,a condition where the cervix has become slightly open and there is a risk of miscarriage because it may not remain closed throughout pregnancy and may even cause prolapse.Indications a)To avoid miscarriage and preterm deliveryb)Prolapse of uterusc) Prolapse of vaginad)Maintainence of fertility 11. Steps a) Anterior colporrhaphy is performed as usualb) Attachment of mackenrodt ligament to the cervix on eachside is exposedc) The vaginal incision is then extended posteriorly round thecervixd) The pouch of douglus is opened , uterosacral ligamentsidentified and devide close to the cervixe) The stumps of these ligaments are crossed and stichedtogether in front of cervixf) A high closure of the peritonium of the pouch of douglus iscarried out. 12. Complications-1. Cervical Dystocia with failure to dilate requiring Cesarean Section2. Displacement of the cervix3. Injury to the cervix or bladder4. Cervical rupture (may occur if the stitch is not removed before onset of labor)5. Infection of the cervix6. Infection of the amniotic sac (chorioamnionitis) 13. Fothergills repairPrinciple A vaginal operation for prolapsed uterus consistingof cervical amputation and parametrial fixation ofthe cervical ligaments of the uterus. Also calledManchester Operation.Indications a)Cervical elongationb)2nd and 3rd degree Prolapsec)Preservation of menstrual and childbearingcapabilities. 14. Steps a)The surgeon combines an anterior colporraphy with amputaion ofcervixb) Then sutures the cut ends of the meckenrodt ligament in front ofthe cervixc) Covers the raw area of the amputed cervix with vaginal mucosad) Follows it up with a colpoperineorrhaphy (suture of the rupturedvagina and perineum)Complications-1) Incompetent cervical os.2)Habitual abortion or preterm deliveries3) Excessive fibrosis may lead to cervical stenosis and distocia duringlabour4) Heamatometra5) Recurrence of prolapse may occur following vaginal deliveries insome cases 15. Abdominal sling operationsPrinciple- the objective of this operation is to buttress the weakened supports (mackenrodt and uterosacral ligaments) of the uterus by providing asubstitute in the form of nylon or dacron tapes , used a slings to supportthe uterusIndications-1) 3rd or 4th degree uterine prolapse2) Women who are desirous of retaining their childbearing and menstrualfunctions3) EnteroceleOperation in common practice include 1)Abdomino cervicopexy2)Shirodkars abdominal sling operation3) Khannas abdominal sling operation 16. Steps -1)Opening of the abdominal wall through a low transverse supra pubic incision deepened down up to the rectus sheath2)Two musculofascial slings are elevated from the midline outwards and laterally up to the lateral border of the rectus abdominus muscle on either side3) The peritoneum is opened in the mid line , and the uterus brought up into view4)The uterovesical fold is incised ,and the bladder mobilised from the front of the uterine isthmus5)Presently the surgeons uses a 12 long mersilene/nylon tape to provide a new artificial suppport for the uterus6) The tape is fixed at its mid point to the uterine isthmus anteriorly, and its lateral ends brought out retropritoneally between the two leaves of the broad ligament7) The ends of the tape are now fixed to the aponeurosis of the external oblique muscle of the abdominal wall 17. Complications-1) Intraoperative bladder or urethra injury2) Infections associated with screw or staple points3) Rejection of sling material from a donor or erosion of synthetic sling material4) Infection,5) Bleeding,6) Injury to other pelvic structures,7) Dyspareunia (painful intercourse 18. Thank you!!!