Conservative Surgeries For Genital Prolapse

Presented by :-

Dr Nikhil BansalJ.N.M.C.,Wardha

Operative Treatments of Prolapse

The type of surgery offered to the patient with prolapse depends on the –

A) Age of the patientB) Her desire to retain the uterus either for

reproductive or menstrual reasonsC) Her menstrual history D) Her general conditionE) Degree of uterine prolapse

List of conservative surgeries

Conservative procedures are which preserves the menstural and childbearing functions.

1) Colporrhaphy ( anterior/ posterior)2) Fothergill’s repair(Manchester operation)3) Shirodkar’s procedure4) Abdominal sling operation a)Abdominocervicopexy

b)Shirodkar’s abdominal sling operationc)Khanna’s abdominal sling operation

Anterior colporrhaphy

Principle -An anterior repair is a vaginal surgery to correct a cystocele, when the "upper" wall of the vagina that is in contact with the bladder is sagging down, or coming outside of the vaginal opening.

Indications – a)cystocele b)Cystourethrocele

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.

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.

Posterior colporrhaphy

Principle – 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

Steps –a) This is done by making a triangular or diamond-shaped

incision, and removing some of the extra skin of the wall of the vagina

b) After this skin is removed, the strong tissues underneath are brought together with strong stitches.

c) The lax vagina over the rectocele is excised , and the rectovaginal facia repaired after reducing the rectocele.

d) The approximation of the medial fibers of the levator ani helps to restore the caliber of the haitus urogenitalis , restore the perineal body and provide an adequate prenium.

Complications-One possible risk of this surgery is that the

vaginal opening may become narrow with scar tissue, and there may be some discomfort with sexual activity. The rest of the complications are same as that of Anterior Colporrhaphy.

Shirodkar’s procedure

Principle – 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

Steps –a) Anterior colporrhaphy is performed as usualb) Attachment of mackenrodt ligament to the cervix on each side is

exposedc) The vaginal incision is then extended posteriorly round the cervix d) The pouch of douglus is opened , uterosacral ligaments

identified and devide close to the cervixe) The stumps of these ligaments are crossed and stiched together

in front of cervixf) A high closure of the peritonium of the pouch of douglus is

carried out.

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)

Fothergill’s repair

Principle – A vaginal operation for prolapsed uterus consisting of

cervical amputation and parametrial fixation of the cervical ligaments of the uterus. Also called Manchester Operation.

Indications –a)Cervical elongationb)2nd and 3rd degree Prolapse c)Preservation of menstrual and childbearing

capabilities.

Steps –a)The surgeon combines an anterior colporraphy with amputaion of

cervixb) Then sutures the cut ends of the meckenrodt ligament in front of

the cervixc) Covers the raw area of the amputed cervix with vaginal mucosa d) Follows it up with a colpoperineorrhaphy (suture of the ruptured

vagina and perineum)

Complications-1) Incompetent cervical os.2)Habitual abortion or preterm deliveries3) Excessive fibrosis may lead to cervical stenosis and distocia during

labour4) Heamatometra5) Recurrence of prolapse may occur following vaginal deliveries in

some cases

Abdominal sling operations

Principle- the objective of this operation is to buttress the weakened supports ( mackenrodt

and uterosacral ligaments) of the uterus by providing a substitute in the form of nylon or dacron tapes , used a slings to support the uterus

Indications- 1) 3rd or 4th degree uterine prolapse2) Women who are desirous of retaining their childbearing and menstrual

functions 3) Enterocele

Operation in common practice include –1)Abdomino cervicopexy2)Shirodkar’s abdominal sling operation3) Khanna’s abdominal sling operation

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 side

3) The peritoneum is opened in the mid line , and the uterus brought up into view

4)The uterovesical fold is incised ,and the bladder mobilised from the front of the uterine isthmus

5)Presently the surgeons uses a 12” long mersilene/nylon tape to provide a new artificial suppport for the uterus

6) 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 ligament

7) The ends of the tape are now fixed to the aponeurosis of the external oblique muscle of the abdominal wall

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

Thank you!!!