Figo vault prolapse - dr vivekpatkar


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Figo vault prolapse - dr vivekpatkar

  2. 2. INTRODUCTION <ul><li>It is most distressing to find </li></ul><ul><li>a patient coming back with complaints </li></ul><ul><li>of SCOPV after a hysterectomy </li></ul><ul><li>The first reaction of the doctor is to </li></ul><ul><li>disbelieve the symptom and give it a </li></ul><ul><li>short shrift </li></ul><ul><li>Tackling of vault prolapse (VP ) is relatively </li></ul><ul><li>rare and uncommon </li></ul><ul><li>Knowing the aftermaths of hysterectomy it takes </li></ul><ul><li>time for a Gynecologist to mentally get tuned to the </li></ul><ul><li>fact that patient requires repeat surgery </li></ul>VDP
  3. 3. <ul><li>The dilemma faced is whether to go abdominally </li></ul><ul><li>or vaginally ( million dollar question.) </li></ul><ul><li>Pelvic floor disorders continue to become even </li></ul><ul><li> more prevalent as women lead longer lives. </li></ul><ul><li>Lifetime risk of surgery for pelvic organ prolapse is 11%. </li></ul><ul><li>Re-operation rate for failure is 29%. </li></ul><ul><li>Thorough understanding of the pelvic anatomy and </li></ul><ul><li>relationship of vagina is imperative. </li></ul>VDP
  4. 4. evolution <ul><li>From quadriped to biped with loss of tail------ </li></ul><ul><li>Loss of muscle in iliococcygeus, pyriformis and coccygeus. </li></ul><ul><li>Change in type of muscles of levator ani </li></ul><ul><li>Change in configuration of endopelvic fascia. </li></ul>VDP
  5. 5. Relevant Anatomy <ul><li>Pelvis is divided into false and </li></ul><ul><li>true pelvis. </li></ul><ul><li>In upright position angle between </li></ul><ul><li> inlet and outlet is 15-20 degrees. </li></ul><ul><li>Bony landmarks of importance — </li></ul><ul><li>- Ischial spines and tuberosity </li></ul><ul><li>- Sacral promontary </li></ul><ul><li>- S1-S2 </li></ul>VDP
  6. 6. <ul><li>Pelvic Ligaments – </li></ul><ul><li>condensation of visceral connective </li></ul><ul><li>tissue that assume special </li></ul><ul><li>supportive role. </li></ul><ul><li>- Sacrospinous lig. </li></ul><ul><li>- Sacrococcygeus lig. </li></ul><ul><li>- Arcus Tendinous Fascia Pelvis </li></ul><ul><li>- Arcus Tendinous Levator Ani </li></ul><ul><li>- Cardinal / Utero-sacral ligament </li></ul>VDP
  7. 7. <ul><li>Levator Ani Muscle – forms pelvic floor </li></ul><ul><li>- predominantly type 1 muscle fibres </li></ul><ul><li>- are in a state of constant Contraction. </li></ul><ul><li>- flap-valve effect - by normal </li></ul><ul><li>tone of ms and adequate </li></ul><ul><li>depth of vagina. </li></ul><ul><li>During periods of increased abdominal </li></ul><ul><li>pressure,upper vagina is compressed against levator plate. </li></ul>“ The Posterior Pelvic Floor is the Achilles heel of the Pelvic diaphragm because of its vulnerability during Child Birth & Aging . ….Max Bloom VDP
  8. 8. <ul><li>Urogenital diaphragm </li></ul><ul><li>- Is a dense fibromuscular </li></ul><ul><li>tissue that spans the opening </li></ul><ul><li>of the anterior pelvic outlet </li></ul><ul><li>- it consists of – </li></ul><ul><li>Perineal body and </li></ul><ul><li>2 strap muscles – </li></ul><ul><li>compressor urethrae, </li></ul><ul><li>sphincter urethrae </li></ul>VDP
  9. 9. VDP PELVIC CONNECTIVE TISSUE Visceral fascia – collagen,elastin,adipose tissue, smooth ms Helps in expansion of organs Reduced smooth ms predisposes to Laxity and prolapse Parietal fascia – organized arrangement Of collagen, proteoglycans increase in type 3 collagen predisposes To laxity and prolapse
  10. 10. <ul><li>Fascia – </li></ul><ul><li>- Pubovescico-cervical </li></ul><ul><li>- Paravaginal fascia </li></ul><ul><li>- Rectovaginal fascia </li></ul><ul><li>- Recto-vaginal septum </li></ul>VDP
  11. 11. <ul><li>De Lancey vaginal supports . </li></ul>VDP Level Support Defect 1 Proximal (upper) Paracolpium ligs USL & Cardinal. .UV prolapse .vault prolapse .enterocole 2 Midvaginal Lat attachment to pelvic side wall to ATFP, ATLA Anterior & post wall defects & SUI. 3 Distal vaginal Pubocx fascia & RVS fusion to UGD , PB Lax perineum, low rectocoele, anal incontinence.
  12. 12. “ Pelvic Organ Prolapse is often a reflection of our Obstetrical Incompetence” ……Lean Van Dongen <ul><li>ETIOLOGY: </li></ul><ul><li>Increasing parity - 1.2 times risk with each vaginal delivery. </li></ul><ul><li>- 8.4 times with 2 vaginal deliveries (Oxford Family Planning – Mant 1997) </li></ul><ul><li>- 11.4 times with 4 vaginal deliveries (Turkish study – Erata 2002) </li></ul>VDP
  13. 13. <ul><li>In vaginal delivery pelvic floor exposed to compressive and expulsive forces. 238 – 403 mmHg. </li></ul><ul><li>Prolonged 2 nd stage- O2 deprivation causes necrotic changes. Ms , paravaginal tissue severely atrophied or dysfunctional. </li></ul><ul><li>Pudendal neuropathy following delivery . </li></ul>VDP
  14. 14. <ul><li>Macrosomia </li></ul><ul><li>Epidural analgesia </li></ul><ul><li>Instrumental deliveries & </li></ul><ul><li>Oxytocin, PG augmentation </li></ul><ul><li>Age- risk increases 8% at 40yrs,11% at 50yrs. Due to hypoestrogenism, degenerative and organic diseases related to aging. </li></ul><ul><li>Genetic predisposition- weak fascia,collagen (type 3) or muscle(type 1). </li></ul>VDP “ Good mid-wifery is the essence of preventive gynaecology” (Novak)
  15. 15. <ul><li>Chronic increased intra abdominal pressure - obesity, constipation, COPD,Hypothyroidsism, lifting heavy weight. </li></ul><ul><li>Following hysterectomy , secondary hypotrophy of the cardinal- uterosacral ligament complex .(iatrogenic) </li></ul>VDP
  16. 16. <ul><li>Separation of pubocervical fascia from </li></ul><ul><li>rectovaginal fascia causes apical enterocoele, commonly seen in post-hysterectomy patients, hence, essential to get them together with the vaginal muscularis and the uterosacral ligs. </li></ul>VDP
  17. 17. PRESENTING SYMPTOMS <ul><li>Apical VP </li></ul><ul><li>More anterior vaginal wall prolapse </li></ul><ul><li>Enterocele with posterior vaginal wall prolapse </li></ul><ul><li>All of above with lax perineum </li></ul><ul><li>All of above with laxity of introitus (puborectalis or bulbocavernous) </li></ul>VDP
  18. 18. Site Specific Prolapse Repair <ul><ul><li>CYSTO/RECTOCOELE </li></ul></ul><ul><li>- Dislocation - Overdistention </li></ul><ul><li> CAUSE </li></ul><ul><li>Damage to lateral Destruction of fibr </li></ul><ul><li>connective tissue omuscular elasticity support with increase total length & width of vag wall & fornices </li></ul><ul><li>CORRECTION </li></ul><ul><li>Restoration of vaginal Reduction of width </li></ul><ul><li>depth, axis and </li></ul><ul><li>support. </li></ul><ul><li>Inverted ‘T’ Repair Parachute Repair </li></ul>VDP
  19. 19. ENTEROCOELE WITH VP VDP Type Location Treatment Congenital Btwn post vag wall & ant rectal wall Excision of sac with high ligation & approximation of USL Pulsion Eversion of vault Culdoplasty if ligs strong If poor support then do sacrospinous fixation Traction Cysto & recto pulling vault into eversion In addition anterior and posterior colporrhaphy . Iatrogenic Change in axis of vag Obliterate sac & restore axis.
  20. 20. Classification of Vault Prolapse <ul><li>1 st degree – vaginal apex is visible </li></ul><ul><li>when perineum is depressed. </li></ul><ul><li>2 nd degree – apex extends just </li></ul><ul><li> through the introitus. </li></ul><ul><li>3 rd degree – upper 2/3rds of the </li></ul><ul><li>vagina is outside the introitus. </li></ul><ul><li>4 th degree – entire vagina is outside the introitus </li></ul>VDP
  21. 21. Evaluation <ul><li>Pre-operative assessment of sites of damage. </li></ul><ul><li>Determine pre-operatively whether lower urinary tract dysfunction and defecatory dysfunction co-exist. </li></ul><ul><li>Configuration of – abdominal wall, sacral promontary, ischial spine, depth of pelvis and previous surgery with resultant adhesions. </li></ul><ul><li>Dynamic analysis by MRI. Technical error- patient is evaluated in recumbent rather than standing position. </li></ul><ul><li>Dynamic pelvic floor fluoroscopy . Also accurately </li></ul><ul><li>identifies enterocoele.– Done abroad. </li></ul>VDP
  22. 22. Prediction with reasonable accuracy in VH – who will develop Vault Prolapse - Bonney <ul><li>Pt. in lithotomy posn. </li></ul><ul><li>Reposit procidentia in pelvis </li></ul><ul><li>Ask pt. to bear down or cough. </li></ul><ul><li>Observe what protrudes out first. </li></ul><ul><li>If cervix, uterus or vault appear first- level 1 damage ( card / USL)- Primary Pexy with surgery </li></ul><ul><li>If cystocele , rectocele appear first- level 2/3 damage ( pelvic diaphragm)- VH with AP repair adequate </li></ul>VDP
  23. 23. Choice and Route of Surgery <ul><li>No general consensus on best procedure </li></ul><ul><li>Choice of surgery depends on- </li></ul><ul><li>- Comfort & skill of surgeon </li></ul><ul><li>- Primary or recurrent prolapse </li></ul><ul><li>- Patient factor : age, health status , </li></ul><ul><li>state of tissues, sexual activity. </li></ul><ul><li>Transvaginal route safer- VP aft. Vag hyst </li></ul><ul><li>Transabdominal route for – VP after abdo. </li></ul><ul><li>hyst., lap hyst., harmonic vessel seal </li></ul><ul><li>- Failure of previous vaginal approach </li></ul><ul><li>- Foreshortened vagina. </li></ul>“ Surgery is Anatomy Practically Applied” …Campbell VDP
  24. 24. DIFFICULTIES DURING SURGERY <ul><li>VAGINAL APPROACH </li></ul><ul><li>Post menopausal atrophic vagina </li></ul><ul><li>Skimpy Pubovesical fascia and absence of support to bladder base (as uterus absent)- difficult to take buttressing sutures during A repair. </li></ul><ul><li>Incomplete receding of bladder bulge even after repair (Surgeon does not have satisfaction of doing a complete repair). </li></ul>“ ABILITY AND NECESSITY DWELL NEAR EACH OTHER “ …. Pythagoras VDP
  25. 25. <ul><li>VAGINAL APPROACH </li></ul><ul><li>DIFFICULTIES….. </li></ul><ul><li>‘ Hypoestrogenic vagina , attenuated uterosacral ligaments - enterocele sac separation difficult </li></ul><ul><li>Occasional impaction of intestine with adhesion in POD , - difficult and dangerous to approach sac - difficult in enterocoele repair - often incomplete </li></ul><ul><li>Thinned out Dennonvillers fascia makes buttressing sutures of rectocele repair untenable. </li></ul>VDP
  26. 26. <ul><li>VAGINAL APPROACH DIFFICULTIES… </li></ul><ul><li>Sacrospinopexy </li></ul><ul><li>Obesity, ATROPHIC vagina, para vagina loose </li></ul><ul><li>areolar tissue and coccygeal sacrospinal complex– </li></ul><ul><li>increase chances of failure. </li></ul><ul><li>osteoporosis (old age) of ischial spines- </li></ul><ul><li>periosteitis. </li></ul><ul><li>malpositioning of pudendal /gluteal vessels and </li></ul><ul><li> nerves. </li></ul><ul><li>- Anatomy relatively unexplored </li></ul>VDP
  27. 27. ABDOMINAL APPROACH DIFFICULTIES <ul><li>Old age High risk for anesthesia & surgery </li></ul><ul><li>Obesity , pendulous abdomen </li></ul><ul><li>Loss of abdominal muscle tone </li></ul><ul><li>Venous stasis & vascular impedence – </li></ul><ul><li>increased Oozing in Retroperitoneal space </li></ul><ul><li>Osteoporosis – periosteitis at site of sacropexy </li></ul>VDP
  28. 28. <ul><li>ABDOMINAL APPROACH DIFFICULTIES… </li></ul><ul><li>Bladder and rectum adherent to </li></ul><ul><li>vagina and overhang the vault– difficulty </li></ul><ul><li>in locating the vaginal vault and dissecting </li></ul><ul><li> the anterior and posterior vaginal walls. </li></ul><ul><li>Ureters –medial ,close to apex with fibrosis of adjacent fascia-chances of ureteric damage when passing sling needle. </li></ul><ul><li>Uterosacral ligaments attenuated & shortened. </li></ul><ul><li>Posterior peritoneum puckered , needle difficult to pass. </li></ul><ul><li>Round ligament shortened and bladder overhanging – </li></ul><ul><li>pexy difficult </li></ul>VDP
  29. 29. PREVENTION <ul><li>Preoperative Bonneys Assessment </li></ul><ul><li>Paracolpium (endo.Fascia +vag. Mus </li></ul><ul><li>supports vault following hysterectomy provided it is effectively attached to the vault. </li></ul><ul><li>Thorough reassessment of sites of damage prior to hysterectomy achieves a more perfect RECONSTRUCTION . </li></ul><ul><li>Keep Adequate vaginal length . </li></ul>“ The operative treatment of prolapse has been the mirror of our knowledge of pelvic anatomy”….George Noble VDP
  30. 30. <ul><li>Adequate Repair of cystocoele/rectocoele and vault hook up. </li></ul><ul><li>Anterior vagina sits and derives support from an adequate posterior wall. Anterior colporrhaphy should be followed by repair of demonstrable damage to posterior wall . Failure to do so- reoperation in later years. </li></ul><ul><li>Take care during non descent hysterectomy </li></ul><ul><li>When vessel seal/ harmonic opted for do not forget buttressing vault . </li></ul><ul><li>In Lap. hyst , suture uterosacrals to vaginal vault. </li></ul>VDP P R E V E N T I O N
  32. 32. VAGINAL <ul><li>McCall’s culdoplasty </li></ul><ul><li>Sacrospinous ligament fixation </li></ul><ul><li>High Uterosacral ligament suspe- </li></ul><ul><li>- nsion with fascial reconstruction </li></ul><ul><li>Iliococcygeus fascia suspension </li></ul><ul><li>Meshplasty </li></ul>VDP
  33. 33. ABDOMINAL <ul><li>Abdominal sacral colpopexy </li></ul><ul><li>High uterosacral ligament suspension </li></ul><ul><li>Laproscopic approach </li></ul>VDP
  34. 34. OBLITERATIVE <ul><li>LeFort’s Partial Colpocleisis </li></ul><ul><li>Introital tightening </li></ul><ul><li>Colpectomy </li></ul>VDP
  35. 35. McCall Culdoplasty <ul><li>A wedge of posterior vaginal wall </li></ul><ul><li>and peritoneum removed </li></ul><ul><li>Enterocole sac freed and excised </li></ul><ul><li>Two internal sutures (permanent) placed </li></ul><ul><li> approximating both USL and posterior </li></ul><ul><li>peritoneum. </li></ul><ul><li>One external suture thru USL , post peritoneum </li></ul><ul><li>& brought out thru post vaginal wall. </li></ul><ul><li>This obliterates cul-de-sac, supports vaginal apex </li></ul><ul><li>& lengthens posterior vaginal wall. </li></ul>VDP
  36. 36. High USL fixation with fascial reconstruction (Richardson ) <ul><li>Identifying defect in endopelvic fascia </li></ul><ul><li>Reducing enterocoele sac </li></ul><ul><li>Closing fascial defect </li></ul><ul><li>Resuspension of vagina to original level 1 support </li></ul><ul><li>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 anchored </li></ul><ul><li>Absorbable sutures are used to suspend ant. And post. Vaginal walls to the USL ridge. </li></ul><ul><li>These are tied to suspend vagina in the hollow of sacrum </li></ul><ul><li>Perform cystoureteroscopy to evaluate ureteral integrity. </li></ul>VDP
  37. 37. Sacrospinous ligament fixation <ul><li>Principles to follow while dissecting to reach sacrospinous lig- work lateral to rectal wall </li></ul><ul><li>- go posterior to uterosacral ligs </li></ul><ul><li>- start dissecting cranial to levator belly, </li></ul><ul><li>pierce pararectal ligament. Locate SSL. </li></ul><ul><li>Taking sutures thru SSL </li></ul><ul><li>Suspending the vault with pulley stitch or placing sutures thru full thickness of vagina. </li></ul><ul><li>Other Pexy : vagina to pelvic fasc: Shull, </li></ul><ul><li>Vagina to sacrotuberous : Amreich </li></ul><ul><li>Vagina to arcus tendinous : White </li></ul><ul><li>Vagina to sacrospinous lig: Richter </li></ul>VDP
  38. 38. Iliococcygeus fascia suspension (Inmon) <ul><li>Repair any anterior compartment defect </li></ul><ul><li>Iliococcygeus ms identified lateral to </li></ul><ul><li>rectum & anterior to ischial spine </li></ul><ul><li>Sutures placed anterior to ischial spine </li></ul><ul><li>Passed thru vaginal apex </li></ul>VDP
  39. 39. Meshplasty <ul><li>MRI and CT delineation of defects in the fascial planes causing anterior or posterior defects – precise positions of defects which are difficult to correct, </li></ul><ul><li>Hence, proponents feel meshes are ideal </li></ul><ul><li>Apogee : for posterior defect </li></ul><ul><li>Perigee : for anterior defect </li></ul><ul><li>PROLIFT and likes: for vault prolapse </li></ul><ul><li>Is beset with its own problems and complications </li></ul>VDP
  40. 40. <ul><li>Apex of vault held with Allis and pushed up. </li></ul><ul><li>Incision -Infraumbilical midline incision taken </li></ul><ul><li>Preparation of vaginal vault – </li></ul><ul><li>- Peritoneum over vault incised </li></ul><ul><li>- Plane developed between </li></ul><ul><li>posterior wall & rectum </li></ul><ul><li>- Bladder base dissected off the </li></ul><ul><li>superior aspect of anterior vagina </li></ul><ul><li>Preparation of sacrum – </li></ul><ul><li>- sigmoid pushed to left - peritoneum over promontary & 1 st 3 sacral vertebrae incised & continued to vaginal incision. </li></ul>Abdominal Sacral Colpopexy VDP
  41. 41. <ul><li>Placement of mersilene tape / mesh – </li></ul><ul><li>- length 3X15cms. </li></ul><ul><li>- tape/ mesh sutured to vaginal tissues using full </li></ul><ul><li>thickness interrupted non-absorbable sutures . </li></ul><ul><li>- continue anteriorly taking care </li></ul><ul><li> of any cystocoele </li></ul><ul><li>- tape/ mesh turned back towards </li></ul><ul><li>apex & then towards the sacrum </li></ul><ul><li>- secured to sacrum </li></ul><ul><li>Reperitonealisation done. </li></ul>VDP
  42. 42. High USL fixation with fascial reconstruction <ul><li>Reducing enterocoele sac by multiple sutures through USL </li></ul><ul><li>Closing fascial defect </li></ul><ul><li>Resuspension of vagina to original level 1 support </li></ul>VDP
  43. 43. Laparoscopic approach <ul><li>Rise in adoption of laparoscopic approach. </li></ul><ul><li>Advantages - Improved haemostasis </li></ul><ul><li>improved visualization of anatomy </li></ul><ul><li>Reduced hospital stay, post-operative pain </li></ul><ul><li>Reduced overall cost </li></ul><ul><li>Disadvantages - technical difficulty in retroperitoneal dissection </li></ul><ul><li>steep learning curve </li></ul><ul><li>Increased operative room time increasing cost. </li></ul><ul><li>Risk of injury to vital structures. </li></ul>VDP
  44. 44. LeFort Colpocleisis / Colpectomy <ul><li>Small Kelly’s Repair —SUI </li></ul><ul><li>Marking out rectangular / triangular flaps on </li></ul><ul><li>Anterior and posterior vaginal walls </li></ul><ul><li>Repeated sucessive stitches to invert </li></ul><ul><li>the tissues </li></ul><ul><li>Suturing of uppermost horizontal part </li></ul><ul><li>of rectangular flaps to each other with </li></ul><ul><li>delayed absorbable sutures. </li></ul><ul><li>Small P repair , if necessary </li></ul><ul><li>To supplement , do introital tightening if </li></ul><ul><li>extreme laxity </li></ul>VDP
  45. 45. COMPARATIVE STUDY of 56 CASES (23-A, 33-V) VDP FAILURE ABSOLUTE: RECURRENCE OF V.P. ….. 3 (5.35%) AP REPAIR enterocele correction and USL pli in SACROSPINO PEXY with/ out AP Repair ABDOMINAL SACROCOLPO PEXY with/out AP Repair Kelly’s + COLPO CLEISIS with introital tightening INDICATION Ant. & post. Defect , apex pulled up Following VH , good vag length Following abdo/ lap. Hyst. Aged pt. high risk NUMBER OF PTS 17 12 15 12 DIFFICULTY IN SURGERY 0 4 8 0 SUBJECTIVE RESPONSE Fair Good Good Good COMPLICATIONS to look out for <ul><li>bleeding </li></ul><ul><li>Incompl repair </li></ul><ul><li>Hunt for atten USL </li></ul><ul><li>Pudendal vs injury </li></ul><ul><li>Sciatic nerve injury </li></ul><ul><li>Bleeding </li></ul><ul><li>Anatomical distortion </li></ul><ul><li>Adhesions </li></ul><ul><li>Difficult fixation (sacral and vaginal) </li></ul><ul><li>Minimal bleeding </li></ul><ul><li>Prevent over correction </li></ul>FAILURE SUBJECTIVE 12.2% 9.6% 8.3% 9.1%
  46. 46. Pointers to successful surgery <ul><li>Age </li></ul><ul><li>Proper counselling </li></ul><ul><li>High risk factors </li></ul><ul><li>Previous surgeries performed </li></ul><ul><li>No. of attempts at repair </li></ul><ul><li>Symptoms and signs </li></ul><ul><li>Type of vault prolapse </li></ul><ul><li>Defects in supports identified </li></ul><ul><li>Skill, knowledge and experience of surgeon </li></ul><ul><li>Comfort, confidence with particular surgery </li></ul>VDP
  47. 47. <ul><li>THE BEST DEFENCE IS A GOOD </li></ul><ul><li>SURGICAL OFFENSE </li></ul><ul><li>No stereotyping patients, - INDIVIDUALISATION - the NEED ! </li></ul><ul><li>SURGERY SHOULD FIT THE PATIENT , THE PATIENT SHOULD NOT FIT THE SURGERY. - Michael Smith </li></ul>VDP THANK YOU