Operative Treatments of ProlapseThe 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 historyD) Her general conditionE) Degree of uterine prolapse
List of conservative surgeriesConservative 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 operation c)Khanna’s abdominal sling operation
Anterior colporrhaphyPrinciple -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 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
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 vaginab) 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 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
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 cervixd) 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 repairPrinciple – 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 Prolapsec)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 mucosad) 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 operationsPrinciple- 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 uterusIndications-1) 3rd or 4th degree uterine prolapse2) Women who are desirous of retaining their childbearing and menstrual functions3) EnteroceleOperation 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 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
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