VAULT PROLAPSE

DR.V.D.PATKARDR.V.D.PATKAR

EMERITUS PROF. ,EMERITUS PROF. ,

LTMGH & LTMMC,LTMGH & LTMMC,

SIONSION

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INTRODUCTIONINTRODUCTION It is It is most distressingmost distressing to find to find

a patient coming back with complaints a patient coming back with complaints

of SCOPV after a hysterectomy of SCOPV after a hysterectomy

The first reaction of the doctor is to The first reaction of the doctor is to

disbelievedisbelieve the symptom and give it a the symptom and give it a

short shrift short shrift

Tackling of Tackling of vault prolapsevault prolapse (VP (VP) is relatively ) is relatively

rare and uncommon rare and uncommon

Knowing the aftermaths of hysterectomy it takesKnowing the aftermaths of hysterectomy it takes

time for a Gynecologist to time for a Gynecologist to mentally get tunedmentally get tuned to the to the

fact that patient requires fact that patient requires repeat surgeryrepeat surgery VDP

The dilemma faced is whether to go abdominally The dilemma faced is whether to go abdominally

or vaginally (or vaginally (million dollar question.)million dollar question.)

Pelvic floor disorders continue to become evenPelvic floor disorders continue to become even

more prevalent as women lead longer lives.more prevalent as women lead longer lives.

Lifetime Lifetime riskrisk of surgery for pelvic organ prolapse is of surgery for pelvic organ prolapse is 11%.11%.

Re-operation Re-operation rate for failure is rate for failure is 29%.29%.

Thorough understanding of the pelvic Thorough understanding of the pelvic anatomy and anatomy and

relationship of vaginarelationship of vagina is imperative. is imperative.

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evolutionevolution From quadriped to biped with loss of tail------From quadriped to biped with loss of tail------

Loss of muscle in iliococcygeus, pyriformis and coccygeus.Loss of muscle in iliococcygeus, pyriformis and coccygeus.

Change in type of muscles of levator aniChange in type of muscles of levator ani

Change in configuration of endopelvic fascia.Change in configuration of endopelvic fascia.

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Relevant AnatomyRelevant Anatomy

Pelvis is divided into Pelvis is divided into false and false and

true pelvis.true pelvis.

In upright position angle betweenIn upright position angle between

inlet and outlet is inlet and outlet is 15-20 degrees.15-20 degrees.

Bony landmarks of importance —Bony landmarks of importance —

- - Ischial spines and tuberosity Ischial spines and tuberosity

- Sacral promontary- Sacral promontary

- S1-S2- S1-S2VDP

Pelvic Ligaments –Pelvic Ligaments –

condensation of visceral connective condensation of visceral connective

tissue that assume special tissue that assume special

supportive role.supportive role.

- Sacrospinous lig.- Sacrospinous lig.

- Sacrococcygeus lig. - Sacrococcygeus lig.

- Arcus Tendinous Fascia Pelvis- Arcus Tendinous Fascia Pelvis

- Arcus Tendinous Levator Ani- Arcus Tendinous Levator Ani

- Cardinal / Utero-sacral ligament- Cardinal / Utero-sacral ligament

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Levator Ani Muscle –Levator Ani Muscle –forms pelvic floorforms pelvic floor

- predominantly - predominantly type 1 muscle fibrestype 1 muscle fibres

- are in a state of constant Contraction.- are in a state of constant Contraction.

- - flap-valve effectflap-valve effect- by normal - by normal

tone of ms and adequate tone of ms and adequate

depth of vagina. depth of vagina.

During periods of increased abdominal During periods of increased abdominal

pressure,upper vagina is compressed pressure,upper vagina is compressed

against levator plate.against levator plate.

“The Posterior Pelvic Floor is the Achilles heel of the Pelvic diaphragm because of its vulnerability during Child Birth & Aging . ….Max Bloom

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Urogenital diaphragmUrogenital diaphragm

- Is a dense fibromuscular - Is a dense fibromuscular

tissue that spans the opening tissue that spans the opening

of the anterior pelvic outletof the anterior pelvic outlet

- it consists of –- it consists of –

Perineal bodyPerineal body and and

2 strap muscles – 2 strap muscles –

compressor urethrae,compressor urethrae,

sphincter urethraesphincter urethrae

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PELVIC CONNECTIVE TISSUE

Visceral fascia – collagen,elastin,adipose tissue, smooth ms

Helps in expansion of organsReduced smooth ms predisposes to

Laxity and prolapse

Parietal fascia – organized arrangement Of collagen, proteoglycans

increase in type 3 collagen predisposes To laxity and prolapse VDP

Fascia – Fascia –

- - Pubovescico-cervical Pubovescico-cervical

- Paravaginal fascia- Paravaginal fascia

- Rectovaginal fascia- Rectovaginal fascia

- Recto-vaginal septum- Recto-vaginal septum

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De Lancey vaginal supportsDe Lancey vaginal supports..

LevelLevel SupportSupport DefectDefect

11

ProximalProximal

(upper)(upper)

Paracolpium ligsParacolpium ligs

USL & Cardinal.USL & Cardinal.

.UV prolapse.UV prolapse

.vault prolapse.vault prolapse

.enterocole.enterocole

22

MidvaginalMidvaginal

Lat attachment Lat attachment to pelvic side to pelvic side wall to ATFP, wall to ATFP, ATLAATLA

Anterior & Anterior & post wall post wall defects & SUI.defects & SUI.

33

DistalDistal

vaginalvaginal

Pubocx fascia & Pubocx fascia & RVS fusion to RVS fusion to UGD , PBUGD , PB

Lax perineum, Lax perineum, low low rectocoele, rectocoele, anal anal incontinence.incontinence.

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““Pelvic Organ Prolapse is often a reflection Pelvic Organ Prolapse is often a reflection of our Obstetrical Incompetence”of our Obstetrical Incompetence”

……Lean Van Dongen ……Lean Van DongenETIOLOGY:ETIOLOGY:

Increasing parityIncreasing parity - 1.2 times risk with each vaginal delivery. - 1.2 times risk with each vaginal delivery.

- 8.4 times with 2 vaginal deliveries (Oxford Family Planning – - 8.4 times with 2 vaginal deliveries (Oxford Family Planning –

Mant 1997)Mant 1997)

- 11.4 times with 4 vaginal deliveries (Turkish study – Erata 2002)- 11.4 times with 4 vaginal deliveries (Turkish study – Erata 2002)

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In vaginal delivery pelvic floor exposed to compressive and In vaginal delivery pelvic floor exposed to compressive and

expulsive forces. expulsive forces. 238 – 403 mmHg.238 – 403 mmHg.

Prolonged 2Prolonged 2ndnd stage- stage- O2 deprivationO2 deprivation causes causes necrotic changes. necrotic changes. Ms , Ms ,

paravaginal tissue severely atrophied or dysfunctional.paravaginal tissue severely atrophied or dysfunctional.

Pudendal neuropathyPudendal neuropathy following delivery following delivery.

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MacrosomiaMacrosomia

Epidural analgesiaEpidural analgesia

Instrumental deliveries & Instrumental deliveries &

Oxytocin, PG augmentation Oxytocin, PG augmentation

Age- risk increases 8% at 40yrs,11% at 50yrs. Due to hypoestrogenism, Age- risk increases 8% at 40yrs,11% at 50yrs. Due to hypoestrogenism,

degenerative and organic diseases related to aging. degenerative and organic diseases related to aging.

Genetic predisposition- weak fascia,collagen (type 3) or muscle(type 1).Genetic predisposition- weak fascia,collagen (type 3) or muscle(type 1). VDP

“Good mid-wifery is the essence of preventive gynaecology” (Novak)

• Chronic increased intra abdominal pressureChronic increased intra abdominal pressure- obesity, constipation, - obesity, constipation,

COPD,Hypothyroidsism, lifting heavy weight.COPD,Hypothyroidsism, lifting heavy weight.

• Following hysterectomy ,Following hysterectomy , secondary hypotrophy of the cardinal- secondary hypotrophy of the cardinal-

uterosacral ligament complex .(iatrogenic) uterosacral ligament complex .(iatrogenic)

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Separation of pubocervical fascia from Separation of pubocervical fascia from

rectovaginal fasciarectovaginal fascia causes apical enterocoele, commonly seen in post- causes apical enterocoele, commonly seen in post-

hysterectomy patients, hence, essential to get them together with the hysterectomy patients, hence, essential to get them together with the

vaginal muscularis and the uterosacral ligs.vaginal muscularis and the uterosacral ligs.

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PRESENTING SYMPTOMS

Apical VPApical VP

More anterior vaginal wall prolapseMore anterior vaginal wall prolapse

Enterocele with posterior vaginal wall Enterocele with posterior vaginal wall

prolapse prolapse

All of above with lax perineumAll of above with lax perineum

All of above with laxity of introitus All of above with laxity of introitus

(puborectalis or bulbocavernous)(puborectalis or bulbocavernous)

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Site Specific Prolapse Site Specific Prolapse RepairRepair

CYSTO/RECTOCOELECYSTO/RECTOCOELE

- - DislocationDislocation - - OverdistentionOverdistention CAUSECAUSE

Damage to lateralDamage to lateral Destruction of fibr Destruction of fibrconnective tissue connective tissue omuscular elasticity support omuscular elasticity support

with increase total with increase total length & width of length & width of

vag wall & fornices vag wall & fornicesCORRECTIONCORRECTION

Restoration of vaginal Restoration of vaginal Reduction of widthReduction of widthdepth, axis and depth, axis and support.support.

Inverted ‘T’ Repair Parachute RepairInverted ‘T’ Repair Parachute Repair VDP

ENTEROCOELE WITH VPENTEROCOELE WITH VP TypeType LocationLocation TreatmentTreatmentCongenitCongenitalal

Btwn post vag Btwn post vag wall & ant wall & ant rectal wallrectal wall

Excision of sac with high Excision of sac with high ligation & ligation & approximation approximation of USLof USL

PulsionPulsion Eversion of Eversion of vaultvault

CuldoplastyCuldoplasty if ligs strong if ligs strong

If poor support then do If poor support then do sacrospinous fixationsacrospinous fixation

TractionTraction Cysto & recto Cysto & recto pulling vault pulling vault into eversioninto eversion

In addition In addition anterior and anterior and posterior colporrhaphyposterior colporrhaphy..

IatrogenicIatrogenic Change in Change in axis of vagaxis of vag

Obliterate sacObliterate sac & restore & restore axis.axis.

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Classification of VaultClassification of Vault Prolapse Prolapse

11stst degree degree – vaginal apex is visible – vaginal apex is visible

when perineum is depressed.when perineum is depressed.

22ndnd degree degree – apex extends just – apex extends just

through the introitus.through the introitus.

33rdrd degree degree – upper 2/3rds of the – upper 2/3rds of the

vagina is outside the introitus.vagina is outside the introitus.

44thth degree degree – entire vagina is outside the introitus – entire vagina is outside the introitus

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EvaluationEvaluation Pre-operative assessment of sites of damage.Pre-operative assessment of sites of damage.

Determine pre-operatively whether lower urinary tract Determine pre-operatively whether lower urinary tract

dysfunction and defecatory dysfunction dysfunction and defecatory dysfunction co-exist.co-exist.

Configuration of – abdominal wall, sacral promontary, ischial Configuration of – abdominal wall, sacral promontary, ischial

spine, depth of pelvis and previous surgery with resultant spine, depth of pelvis and previous surgery with resultant

adhesions.adhesions.

Dynamic analysis by Dynamic analysis by MRI.MRI. Technical error- patient is evaluated Technical error- patient is evaluated

in recumbent rather than standing position.in recumbent rather than standing position.

Dynamic pelvic floor fluoroscopyDynamic pelvic floor fluoroscopy . Also accurately . Also accurately

identifies enterocoele.– Done abroad.identifies enterocoele.– Done abroad.

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Prediction with reasonable Prediction with reasonable accuracy in VH – who will develop accuracy in VH – who will develop

Vault Prolapse - Vault Prolapse - BonneyBonney Pt. in lithotomy posn. Pt. in lithotomy posn. Reposit procidentia in pelvisReposit procidentia in pelvis Ask pt. to bear down or cough.Ask pt. to bear down or cough. Observe what protrudes out first.Observe what protrudes out first. If cervix, uterus or vault appear first- level 1 If cervix, uterus or vault appear first- level 1

damage ( card / USL)- Primary Pexy with surgerydamage ( card / USL)- Primary Pexy with surgery If cystocele , rectocele appear first- level 2/3 If cystocele , rectocele appear first- level 2/3

damage ( pelvic diaphragm)- VH with AP repair damage ( pelvic diaphragm)- VH with AP repair adequate adequate

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Choice and Route of SurgeryChoice and Route of Surgery No general consensus on best procedureNo general consensus on best procedure

Choice of surgery depends on-Choice of surgery depends on-

- Comfort & skill of surgeon- Comfort & skill of surgeon

- Primary or recurrent prolapse- Primary or recurrent prolapse

- Patient factor : age, health status , - Patient factor : age, health status ,

state of tissues, sexual activity.state of tissues, sexual activity.

Transvaginal route safer- VP aft. Vag hyst Transvaginal route safer- VP aft. Vag hyst

Transabdominal route for – VP after abdo.Transabdominal route for – VP after abdo.

hyst., lap hyst., harmonic vessel sealhyst., lap hyst., harmonic vessel seal

- Failure of previous vaginal approach- Failure of previous vaginal approach

- Foreshortened vagina.- Foreshortened vagina.

“Surgery is Anatomy Practically Applied” …Campbell

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DIFFICULTIES DURING DIFFICULTIES DURING SURGERYSURGERY

VAGINAL APPROACHVAGINAL APPROACH

Post menopausal Post menopausal atrophic atrophic vagina vagina

Skimpy Pubovesical fascia and absence of support to bladder base (as uterus absent)-Skimpy Pubovesical fascia and absence of support to bladder base (as uterus absent)-difficult to difficult to

take buttressing suturestake buttressing sutures during A repair. during A repair.

Incomplete receding of bladder bulgeIncomplete receding of bladder bulge even after repair (Surgeon does not have satisfaction of doing even after repair (Surgeon does not have satisfaction of doing

a complete repair).a complete repair).

““ABILITY AND NECESSITY DWELL NEAR ABILITY AND NECESSITY DWELL NEAR

EACH OTHER “ ….EACH OTHER “ ….PythagorasPythagoras

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VAGINAL APPROACHVAGINAL APPROACH

DIFFICULTIES…..DIFFICULTIES…..

‘‘Hypoestrogenic vagina , Hypoestrogenic vagina , attenuated uterosacralattenuated uterosacral

ligamentsligaments--enterocele sac separation difficult enterocele sac separation difficult

Occasional Occasional impaction of intestine impaction of intestine with adhesion in with adhesion in

POD , - difficult and dangerous to approach sac - difficult POD , - difficult and dangerous to approach sac - difficult

in in enterocoele repair - often incomplete enterocoele repair - often incomplete

Thinned out Dennonvillers fasciaThinned out Dennonvillers fascia makes buttressing makes buttressing

sutures of rectocele repair untenable.sutures of rectocele repair untenable.

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VAGINAL APPROACH DIFFICULTIES…VAGINAL APPROACH DIFFICULTIES…

Sacrospinopexy Sacrospinopexy

- Obesity, Obesity, ATROPHIC vagina, para vagina looseATROPHIC vagina, para vagina loose

areolar tissue and coccygeal sacrospinal complex–areolar tissue and coccygeal sacrospinal complex–

increase chances of failure.increase chances of failure.

- osteoporosis (old age) osteoporosis (old age) of ischial spines- of ischial spines-

periosteitis.periosteitis.

- malpositioning of malpositioning of pudendal pudendal /gluteal vessels and/gluteal vessels and

nerves.nerves.

- - Anatomy relatively unexploredAnatomy relatively unexplored VDP

ABDOMINAL APPROACH DIFFICULTIESABDOMINAL APPROACH DIFFICULTIES

Old ageOld age High risk for anesthesia & surgeryHigh risk for anesthesia & surgery

ObesityObesity, pendulous abdomen, pendulous abdomen

Loss of Loss of abdominal muscle tone abdominal muscle tone

Venous stasis & vascular impedenceVenous stasis & vascular impedence – –

increased Oozing in Retroperitoneal spaceincreased Oozing in Retroperitoneal space

Osteoporosis –Osteoporosis – periosteitis periosteitis at site of sacropexyat site of sacropexy

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ABDOMINAL APPROACH DIFFICULTIES…

Bladder and rectum adherent to Bladder and rectum adherent to

vagina and overhang the vault–vagina and overhang the vault– difficulty difficulty

in locating the vaginal vault and dissectingin locating the vaginal vault and dissecting

the anterior and posterior vaginal walls. the anterior and posterior vaginal walls.

Ureters –medial Ureters –medial ,close to apex with fibrosis of adjacent fascia-,close to apex with fibrosis of adjacent fascia-

chances of ureteric damage when passing sling needle.chances of ureteric damage when passing sling needle.

Uterosacral ligaments attenuated & shortened.Uterosacral ligaments attenuated & shortened.

Posterior peritoneum puckeredPosterior peritoneum puckered , needle difficult to pass. , needle difficult to pass.

Round ligament shortened and bladder overhangingRound ligament shortened and bladder overhanging– –

pexy difficultpexy difficult VDP

PREVENTIONPREVENTION Preoperative Bonneys AssessmentPreoperative Bonneys Assessment

Paracolpium (endo.Fascia +vag. MusParacolpium (endo.Fascia +vag. Mus

supports vaultsupports vault following hysterectomy following hysterectomy

provided it is provided it is effectively attachedeffectively attached to the vault. to the vault. Thorough Thorough reassessment of sites of damagereassessment of sites of damage

prior to hysterectomy achieves a more perfect prior to hysterectomy achieves a more perfect RECONSTRUCTIONRECONSTRUCTION..

Keep Keep Adequate vaginal lengthAdequate vaginal length..

“The operative treatment of prolapse has been the mirror of

our knowledge of pelvic anatomy”….George Noble

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Adequate Repair of cystocoele/rectocoele and Adequate Repair of cystocoele/rectocoele and

vault hook up.vault hook up.

Anterior vagina sits and derives support from Anterior vagina sits and derives support from

an adequate posterior wall. an adequate posterior wall. Anterior Anterior

colporrhaphy should be followed by repair of colporrhaphy should be followed by repair of

demonstrable damage to posterior walldemonstrable damage to posterior wall. Failure . Failure

to do so- reoperation in later years.to do so- reoperation in later years.

Take care during Take care during non descent hysterectomynon descent hysterectomy

When When vessel seal/ harmonic vessel seal/ harmonic opted for do not opted for do not

forget forget buttressing vaultbuttressing vault..

In In Lap. hystLap. hyst, , suture uterosacralssuture uterosacrals to vaginal to vaginal

vault.vault. VDP

PREVENTION

SURGERIES FOR SURGERIES FOR

VAULT PROLAPSEVAULT PROLAPSE

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VAGINALVAGINAL

McCall’s culdoplastyMcCall’s culdoplasty

Sacrospinous ligament fixationSacrospinous ligament fixation

High Uterosacral ligament suspe-High Uterosacral ligament suspe-

- nsion with fascial reconstruction- nsion with fascial reconstruction

Iliococcygeus fascia suspensionIliococcygeus fascia suspension

MeshplastyMeshplasty

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ABDOMINALABDOMINAL

Abdominal sacral colpopexyAbdominal sacral colpopexy

High uterosacral ligament suspensionHigh uterosacral ligament suspension

Laproscopic approachLaproscopic approach

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OBLITERATIVEOBLITERATIVE

LeFort’s Partial ColpocleisisLeFort’s Partial Colpocleisis

Introital tighteningIntroital tightening

ColpectomyColpectomy

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P1000701.jpg

McCall CuldoplastyMcCall Culdoplasty A wedge of posterior vaginal wall A wedge of posterior vaginal wall

and peritoneum removedand peritoneum removed

Enterocole sac freed Enterocole sac freed and excisedand excised

Two internal sutures Two internal sutures (permanent) placed(permanent) placed

approximating both USL and posterior approximating both USL and posterior

peritoneum.peritoneum.

One external suture One external suture thru USL , post peritoneum thru USL , post peritoneum

& brought out thru post vaginal wall.& brought out thru post vaginal wall.

This obliterates cul-de-sac, supports vaginal apex This obliterates cul-de-sac, supports vaginal apex

& lengthens posterior vaginal wall.& lengthens posterior vaginal wall.

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P1000701.jpgP1000701.jpg

High USL fixation with fascial High USL fixation with fascial reconstruction (Richardsonreconstruction (Richardson))

Identifying defect in endopelvic fasciaIdentifying defect in endopelvic fascia Reducing enterocoele sacReducing enterocoele sac Closing fascial defectClosing fascial defect Resuspension of vagina to original level 1 supportResuspension of vagina to original level 1 support Non absorbable sutures put through USL at level of ischial spine Non absorbable sutures put through USL at level of ischial spine

and tied across in midline to form a ridge to which vagina is to be and tied across in midline to form a ridge to which vagina is to be anchoredanchored

Absorbable sutures are used to suspend ant. And post. Vaginal Absorbable sutures are used to suspend ant. And post. Vaginal walls to the USL ridge. walls to the USL ridge.

These are tied to suspend vagina in the hollow of sacrumThese are tied to suspend vagina in the hollow of sacrum Perform cystoureteroscopy to evaluate ureteral integrity.Perform cystoureteroscopy to evaluate ureteral integrity.

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Sacrospinous ligament Sacrospinous ligament fixationfixation

Principles to follow while dissecting to reach Principles to follow while dissecting to reach

sacrospinous lig- work sacrospinous lig- work lateral to rectal lateral to rectal wallwall

- go posterior to uterosacral ligs- go posterior to uterosacral ligs

- start dissecting cranial to levator belly,- start dissecting cranial to levator belly,

pierce pararectal ligament. Locate SSL.pierce pararectal ligament. Locate SSL.

Taking Taking sutures thru SSLsutures thru SSL

Suspending the vault with Suspending the vault with pulley stitch pulley stitch or placing or placing

sutures thru full thickness of vagina.sutures thru full thickness of vagina.

Other Pexy : vagina to pelvic fasc: Shull,Other Pexy : vagina to pelvic fasc: Shull,

Vagina to sacrotuberous : AmreichVagina to sacrotuberous : Amreich

Vagina to arcus tendinous : WhiteVagina to arcus tendinous : White

Vagina to sacrospinous lig: RichterVagina to sacrospinous lig: Richter VDP

Iliococcygeus fascia Iliococcygeus fascia suspension (Inmon)suspension (Inmon)

Repair any anterior compartment defect Repair any anterior compartment defect

Iliococcygeus ms Iliococcygeus ms identified lateral to identified lateral to

rectum & rectum & anterior to ischial spineanterior to ischial spine

Sutures placed Sutures placed anterior to ischial spine anterior to ischial spine

Passed thru vaginal apexPassed thru vaginal apex

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MeshplastyMeshplasty MRI and CT delineation of defects in the MRI and CT delineation of defects in the

fascial planes causing anterior or posterior fascial planes causing anterior or posterior

defects – precise positions of defects which defects – precise positions of defects which

are difficult to correct,are difficult to correct,

Hence, proponents feel meshes are idealHence, proponents feel meshes are ideal

ApogeeApogee: for posterior defect: for posterior defect

PerigeePerigee : for anterior defect : for anterior defect

PROLIFTPROLIFT and likes: for vault prolapse and likes: for vault prolapse

Is beset with its own problems and Is beset with its own problems and

complicationscomplicationsVDP

Apex of vault held with Allis and pushed up.Apex of vault held with Allis and pushed up.

IncisionIncision-Infraumbilical midline incision taken -Infraumbilical midline incision taken

Preparation of vaginal vaultPreparation of vaginal vault – –

- Peritoneum over vault incised- Peritoneum over vault incised

- Plane developed between - Plane developed between

posterior wall & rectum posterior wall & rectum

- Bladder base dissected off the - Bladder base dissected off the

superior aspect of anterior vaginasuperior aspect of anterior vagina

Preparation of sacrumPreparation of sacrum – –

- sigmoid pushed to left- sigmoid pushed to left - peritoneum over promontary & 1- peritoneum over promontary & 1stst 3 3

sacral vertebrae incised & continued to vaginal incision.sacral vertebrae incised & continued to vaginal incision.

Abdominal Sacral ColpopexyAbdominal Sacral Colpopexy

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Placement of mersilene tape / mesh –Placement of mersilene tape / mesh –

- length 3X15cms.- length 3X15cms.

- - tape/ mesh sutured tape/ mesh sutured to vaginal tissues using full to vaginal tissues using full

thickness thickness interrupted non-absorbable suturesinterrupted non-absorbable sutures..

- continue anteriorly taking care- continue anteriorly taking care

of any cystocoeleof any cystocoele

- tape/ mesh turned back - tape/ mesh turned back towards towards

apex & then towards the sacrumapex & then towards the sacrum

- - secured to sacrumsecured to sacrum

Reperitonealisation done.Reperitonealisation done.

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High USL fixation with High USL fixation with fascial reconstructionfascial reconstruction

Reducing enterocoele sac by Reducing enterocoele sac by

multiple sutures through USLmultiple sutures through USL

Closing fascial defectClosing fascial defect

Resuspension of vagina to Resuspension of vagina to

original level 1 supportoriginal level 1 support VDP

Laparoscopic approachLaparoscopic approach Rise in adoption of laparoscopic approach.Rise in adoption of laparoscopic approach.

AdvantagesAdvantages- Improved haemostasis - Improved haemostasis

improved visualization of anatomy improved visualization of anatomy

Reduced hospital stay, post-operative painReduced hospital stay, post-operative pain

Reduced overall costReduced overall cost

DisadvantagesDisadvantages- technical difficulty in retroperitoneal dissection- technical difficulty in retroperitoneal dissection

steep learning curvesteep learning curve

Increased operative room time increasing cost.Increased operative room time increasing cost.

Risk of injury to vital structures.Risk of injury to vital structures.VDP

LeFort Colpocleisis / ColpectomyLeFort Colpocleisis / Colpectomy Small Kelly’s RepairSmall Kelly’s Repair—SUI—SUI

Marking out rectangular / triangular flaps on Marking out rectangular / triangular flaps on

Anterior and posterior vaginal wallsAnterior and posterior vaginal walls

Repeated Repeated sucessive stitches to invert sucessive stitches to invert

the tissuesthe tissues

Suturing of uppermost horizontal part Suturing of uppermost horizontal part

of rectangular flaps to each other with of rectangular flaps to each other with

delayed absorbable sutures.delayed absorbable sutures.

Small P repairSmall P repair, if necessary, if necessary

To supplement , do To supplement , do introital tightening introital tightening ifif

extreme laxityextreme laxityVDP

COMPARATIVE STUDY of 56 CASES (23-A, 33-V)AP REPAIR AP REPAIR enterocele enterocele

correction and correction and USL pli in USL pli in

SACROSPINOSACROSPINO

PEXY with/ out AP PEXY with/ out AP RepairRepair

ABDOMINAL ABDOMINAL SACROCOLPOSACROCOLPO

PEXY with/out AP PEXY with/out AP RepairRepair

Kelly’s + Kelly’s + COLPO COLPO

CLEISIS CLEISIS with introital with introital

tighteningtightening

INDICATIONINDICATION Ant. & post. Ant. & post. Defect , apex Defect , apex

pulled uppulled up

Following VH , Following VH , good vag lengthgood vag length

Following abdo/ lap. Following abdo/ lap. Hyst.Hyst.

Aged pt. Aged pt. high risk high risk

NUMBER OF PTS NUMBER OF PTS 1717 1212 1515 1212

DIFFICULTY IN DIFFICULTY IN SURGERYSURGERY

00 44 88 00

SUBJECTIVE SUBJECTIVE RESPONSE RESPONSE

FairFair GoodGood GoodGood GoodGood

COMPLICATIONS COMPLICATIONS to look out for to look out for

bleedingbleedingIncompl Incompl

repairrepairHunt for Hunt for atten USLatten USL

Pudendal vs Pudendal vs injuryinjury

Sciatic nerve Sciatic nerve injuryinjury

Bleeding Bleeding Anatomical Anatomical distortion distortion

Adhesions Adhesions Difficult fixation Difficult fixation

(sacral and vaginal)(sacral and vaginal)

Minimal Minimal bleedingbleedingPrevent Prevent

over over correctioncorrection

FAILURE FAILURE SUBJECTIVESUBJECTIVE

12.2%12.2% 9.6%9.6% 8.3%8.3% 9.1%9.1%

VDPFAILURE ABSOLUTE: RECURRENCE OF V.P. ….. 3 (5.35%)

Pointers to successful surgeryPointers to successful surgery AgeAge Proper counsellingProper counselling High risk factors High risk factors Previous surgeries performedPrevious surgeries performed No. of attempts at repairNo. of attempts at repair Symptoms and signsSymptoms and signs Type of vault prolapseType of vault prolapse Defects in supports identifiedDefects in supports identified Skill, knowledge and experience of surgeonSkill, knowledge and experience of surgeon Comfort, confidence with particular surgeryComfort, confidence with particular surgery

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THE BEST DEFENCE IS A GOOD THE BEST DEFENCE IS A GOOD

SURGICAL OFFENSESURGICAL OFFENSE

No stereotyping patients, - INDIVIDUALISATION - the No stereotyping patients, - INDIVIDUALISATION - the

NEED !NEED !

SURGERY SHOULD FIT THE PATIENT , THE PATIENT SURGERY SHOULD FIT THE PATIENT , THE PATIENT

SHOULD NOT FIT THE SURGERY.SHOULD NOT FIT THE SURGERY. - - Michael SmithMichael Smith

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