Operations For Nulliparous Prolapse And Vaginal Vault Prolapse

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Operations For Nulliparous Prolapse And Vaginal Vault Prolapse

  1. 1. OPERATIONS FOR NULLIPAROUS PROLAPSE AND VAGINAL VAULT PROLAPSE Dr. Pradeep Garg Assistant Professor Obstetrics & Gynaecology, All India Institute of Medical Sciences New Delhi-110029
  2. 2. Incidence <ul><li>In India nulliparous prolapse cases constitutes 1.5-2% cases of genital prolapse. </li></ul><ul><li>J Obstet Gynaecol India 1992 </li></ul>
  3. 3. Etiology <ul><li>Connective tissue disorders </li></ul><ul><li>Congenital defect of pelvic floor muscle for eg. Exstrophy of bladder </li></ul><ul><li>Congenital spine defect- spina bifida occulta </li></ul>
  4. 4. Operations for nulliparous prolapse <ul><li>1. Sling </li></ul><ul><li>Abdominal </li></ul><ul><li>Laparoscopic </li></ul><ul><li>2. Transvaginal sacrospinous fixation </li></ul>
  5. 5. Aim/Advantages of conservative surgery <ul><li>To relieve the symptoms </li></ul><ul><li>To restore the anatomy to normal </li></ul><ul><li>To restore the functions to normal </li></ul><ul><li>To prevent recurrence in future </li></ul><ul><li>To maintain child bearing potential </li></ul><ul><li>To maintain menstrual function </li></ul>
  6. 6. Conservative surgery <ul><li>The operative treatment of prolapse in young women in the childbearing age poses three important problems. </li></ul><ul><li>1. Repair of prolapse should not in any way, hamper the fertility of the patients. </li></ul><ul><li>2. The surgery must not hamper the course of normal labour and delivery. </li></ul><ul><li>3. Most importantly, the repair must not give way and cause recurrence of the prolapse after the childbirth </li></ul>
  7. 7. Abdominal Sling operations <ul><li>Indicated when the ligaments are extremely weak. </li></ul><ul><li>Preserves reproductive function. </li></ul><ul><li>Principle-With a fascial strip / prosthetic material the cervix is fixed to the abdominal wall / sacrum / pelvis. </li></ul><ul><li>Cystocele/Rectocele repair if needed can be done vaginally before or after. </li></ul><ul><li>Enterocele repair can also be done abdominally. </li></ul>
  8. 8. Abdominal Sling operations <ul><li>Types-. </li></ul><ul><ul><li>Shirodkar’s posterior sling. </li></ul></ul><ul><ul><li>Purandare’s anterior cervicopexy. </li></ul></ul><ul><ul><li>Khanna’s sling. </li></ul></ul><ul><ul><li>Virkud’s composite sling. </li></ul></ul><ul><ul><li>Joshi’s sling </li></ul></ul><ul><ul><li>Sacrocervicopexy </li></ul></ul>
  9. 9. Shirodkar’s sling <ul><li>Dr. V.N. Shirodkar (Pioneer ) used fascia lata femoris to strengthening the uterosacral ligaments and fixation to the sacral promontary retroperitoneally, now replaced by mersilene tape. </li></ul><ul><li>Mersilene tape has a definite advantage over fascia lata as it is inert material, non-absorbable, non-irritant with predictable tensile strength. </li></ul>
  10. 10. Shirodkar’s sling <ul><li>Tape is fixed to the posterior aspect of isthmus & sacral promontory </li></ul><ul><li>Anatomically correct but difficult to perform </li></ul>
  11. 11. SHIRODKAR’S SLING OPERATION (1960)
  12. 12. Purandare’s cervicopexy <ul><li>Fascial strips are anchored to the ant. aspect of isthmus </li></ul><ul><li>Advantages </li></ul><ul><li>Easy to perform </li></ul><ul><li>Dynamic support </li></ul><ul><li>Minimum blood loss </li></ul><ul><li>Disadvantages </li></ul><ul><li>Alters pelvic anatomy by obliterating U-V fold </li></ul><ul><ul><li>Vagina is being Pulled forward so increased chances of </li></ul></ul><ul><ul><li>enterocele formation </li></ul></ul>
  13. 13. PURANDARE’s CERVICOPEXY (1965)
  14. 14. Khanna’s sling operation <ul><li>Tape is anchored to ant aspect of isthmus & ant. sup. iliac spine. </li></ul><ul><li>Easier to perform and safer . </li></ul>
  15. 15. Khanna’s Posterior sling operation (1972)
  16. 16. Joshi’s Sling <ul><li>Anterior surface of uterus at the level of internal os is suspended to the pectineal ligament on both sides with mersilene tape. </li></ul>
  17. 17. Joshi’s Sling 1993
  18. 18. Virkud’s composite sling operation <ul><li>Tape is anchored from the post aspect of isthmus to sacral promontory on the Rt. side & ant. abdominal wall on the left Side </li></ul><ul><li>Uterosacral ligament is plicated </li></ul>
  19. 19. Virkud’s Sling <ul><li>One end of mersilene Tap- is attached to sacral promontory </li></ul><ul><li> </li></ul><ul><li>Subperitoneally on right pelvic wall then Broad ligament and fixed to post surface of isthmus. </li></ul><ul><li> </li></ul><ul><li>Then passed between left broad ligament through left internal inguinal ring </li></ul><ul><li> </li></ul><ul><li>Turned medially- and sutured to rectus sheath. </li></ul><ul><li>Plication of left uterosacral ligament to correct dextro-rotation. </li></ul>
  20. 20. Virkud’s Sling 1999 S P S C
  21. 21. Soonawala’s Sling <ul><li>Anterior longitudinal ligament on S1 vertebra  along right uterosacral ligament of isthmus of uterus  retraced extra-peritoneally to S1 vertebra. </li></ul>
  22. 22. Soonawala’s Sling
  23. 23. Ureter Video To see videos on laparoscopic gynae surgeries please logon to www .youtube.com and type Pradeep aiims
  24. 24. Sacrocervicopexy Video To see videos on laparoscopic gynae surgeries please logon to www .youtube.com and type Pradeep aiims
  25. 25. Sacrocervicopexy Video <ul><li>Abdominal </li></ul>To see videos on laparoscopic gynae surgeries please logon to www .youtube.com and type Pradeep aiims
  26. 26. Sacrocervicopexy <ul><li>Advantages </li></ul><ul><li>Effective correction of descent </li></ul><ul><li>Anteversion </li></ul><ul><li>No compression on rectum or ureter </li></ul>
  27. 27. Nulliparous Prolapse Shirodker’s + Khanna’s Cervicopexy Video To see videos on laparoscopic gynae surgeries please logon to www .youtube.com and type Pradeep aiims
  28. 28. Laparoscopic Cervicopexy/sling Operations <ul><li>All types of sling operations can be better performed by laparoscopy </li></ul><ul><li>Associated vaginal prolapse can also be repaired laparoscopically ( Paravaginal repair) </li></ul><ul><li>Vaginal Ant./Post. colporrhaphy can be done before / after laparoscopy </li></ul>
  29. 29. Laparoscopic surgery prolapse <ul><li>Advantages- Small incision, better view, no packing, minimal tissue & bowel handling, short recovery, less pain, insignificant scar </li></ul><ul><li>Expertise is needed </li></ul>
  30. 30. <ul><li>OPERATIONS FOR VAGINAL VAULT PROLAPSE </li></ul>
  31. 31. Vaginal vault prolapse <ul><li>Defect in the endopelvic fascia in the area of vaginal apex after hysterectomy </li></ul>
  32. 32. Incidence <ul><li>2-3.6/1000 women years post abdominal and vaginal hysterectomy. </li></ul><ul><li>(J Reprod Med 1999;44) </li></ul>
  33. 33. Etiology <ul><li>The most common cause of prolapse is previous hysterectomy with failure to reattach the cardinal – uterosacral complex to the pubocervical fascia and rectovaginal fascia at the vaginal cuff. </li></ul>Fig-1 Fig-2
  34. 34. Symptoms <ul><li>Feeling of “something coming down” </li></ul><ul><li>Dragging </li></ul><ul><li>Backache </li></ul><ul><li>Urinary symptoms </li></ul><ul><li>Stress incontinence, difficulty – initiating micturation, Post micturation dribble </li></ul><ul><li>Bowel symptoms </li></ul><ul><li>Constipation, Defecation difficulties </li></ul><ul><li>Sexual dysfunction </li></ul>
  35. 35. Management Prolifit and Apogee Mesh Sacrocolpopexy Uterosacral suspension Sacrospinous fixation Paravaginal repair Laparoscopic Posterior intravaginal singplasty Tape Zacharin’s procedure Abdominoperineal Abd Uterosacral suspension Sacrocolpopexy Rectus sheath colpopexy Abdominal Sacrospinous/iliococcygeous fixation Uterosacral suspension Le fort operation Colpocliesis/colpectomy/vaginectomy Vaginal
  36. 36. Laparoscopic sacrocolpopexy
  37. 37. Mesh <ul><li>Polypropylene </li></ul><ul><li>Non-absorbable </li></ul><ul><li>Monofilament </li></ul><ul><li>Choice of most experts </li></ul>
  38. 38. Final position of the Mesh in Pelvis
  39. 39. Final position of the Mesh in Pelvis (Side view) Video
  40. 40. Advantages of Laparoscopic approach <ul><li>Improving visualization, decreased blood loss, Avoid laparotomy, less postoperative pain, Shorter hospital stay, shorter recovery time </li></ul><ul><li>In addition to this other advantages of this approach are as follows: </li></ul><ul><li>Suspension of vaginal vault to the anterior surface of sacrum restores the normal axis of vagina. </li></ul><ul><li>Maximal vaginal depth can be preserved </li></ul><ul><li>Mesh provides additional source of strength to the weaker pelvic tissue. </li></ul>
  41. 41. Complications of Laparoscopic Approach <ul><li>Lower urinary tract injuries </li></ul><ul><li>Bowel injuries </li></ul><ul><li>Vascular injuries </li></ul><ul><li>Mesh erosion </li></ul>
  42. 42. <ul><li>Lower Urinary Tract Injury </li></ul><ul><li>HOW TO PREVENT? </li></ul><ul><li>Foley’s catheter </li></ul><ul><li>Identify the right ureter at brim before dissection on the sacral promontary. </li></ul><ul><li>Careful placement of suture </li></ul><ul><li>Cystoscopy ± </li></ul>Complications of Laparoscopic Approach…
  43. 43. <ul><li>Bowel Injury </li></ul><ul><li>HOW TO PREVENT? </li></ul><ul><li>Good bowel preparation </li></ul><ul><li>Anaesthesia </li></ul><ul><li>Patient position </li></ul><ul><li>Nasogastric tube </li></ul><ul><li>Deflate tube </li></ul>Complications of Laparoscopic Approach…
  44. 44. <ul><li>Vascular Injury </li></ul><ul><li>How to prevent? </li></ul><ul><li>Thorough knowledge of vascular pelvic anatomy and vasculature </li></ul><ul><li>Patient position </li></ul><ul><li>Identify vessel free area on sacrum for mesh fixation </li></ul><ul><li>Rapid conversion to laparotomy if bleeding occurs . </li></ul>Complications of Laparoscopic Approach…
  45. 45. Vascular pelvic anatomy Video To see videos on laparoscopic gynae surgeries please logon to www .youtube.com and type Pradeep aiims
  46. 46. Are laparoscopic procedure recommended ? <ul><li>Laparoscopic sacrocolpopexy appear to be as effective as open sacrocolpopexy. B </li></ul><ul><li>The ureters are at risk during laparoscopic uterosacral ligament suspention. B </li></ul><ul><li>There is insufficient evidence to judge the value of other laparoscopic technique. C </li></ul>
  47. 47. Sacrospinous Ligament Suspension <ul><li>Sacrospinous ligament fixation entails attachment of the vaginal apex to the sacrospinous ligament , the tendinous component of the coccygeus muscle </li></ul>
  48. 48. Vaginal Sacrospinous fixation Video To see videos on laparoscopic gynae surgeries please logon to www .youtube.com and type Pradeep aiims
  49. 49. Abdominal sacrocolpopexy Vs Sacrospinous fixation <ul><li>Abdominal scrocolpopexy is an effective operation for post hysterectomy vaginal vault prolapse, sacrospinous fixation may have higher failure rate but has less post operative morbidity [A] </li></ul>
  50. 50. Unilateral Vs bilateral Sacrospinous fixation <ul><li>There is no evidence to recommend Unilateral Vs bilateral Sacrospinous fixation [C evidence level 4] </li></ul>
  51. 51. Abdominal sacrocolpopexy Vs Sacrospinous fixation <ul><li>What criteria should be used to determine which procedure to use ? [B] </li></ul><ul><li>Vaginal sacrospinous fixation </li></ul><ul><li>adequate vaginal length </li></ul><ul><li>more suitable for physically frail women </li></ul><ul><li>Abdominal sacrocolpopexy </li></ul><ul><li>more suitable for sexually active women because vaginal sacrospinous fixation can cause shortening and/or narrowing leading to dyspareunia </li></ul>
  52. 52. Laparoscopic uterosacral suspension Video To see videos on laparoscopic gynae surgeries please logon to www .youtube.com and type Pradeep aiims
  53. 53. Iliococcygeal vaginal suspension <ul><li>Iliococcygeal vaginal suspension involves attachment of vaginal apex to the iliococcygeus muscle and fascia, usually bilaterally </li></ul>
  54. 54. Iliococcygeus fixation <ul><li>Iliococcygeus fixation does not reduce the incidence of ant vaginal wall prolapse associated with vaginal sacrospinous fixation and should not be routinely recommended [B Evidence level 2b] </li></ul>
  55. 55. Vault suspention to ant abd wall <ul><li>Technique included fixation of vault to rectus sheath or pectineal (Cooper’s ligament) </li></ul><ul><li>Simple procedure, there are not enough studies to judge its value. B </li></ul><ul><li>Disadvantages </li></ul><ul><ul><li>Higher failure rate </li></ul></ul><ul><ul><li>Unphysiological axis of vagina </li></ul></ul>
  56. 56. Colpocleisis <ul><li>Colpocleisis is a safe and effective procedure can be considered for those women who do not wish to retain sexual function [B] </li></ul>
  57. 57. Time has come for Laparoscopic Surgery for Prolapse So move with the times. Practice laparoscopy. This is the Surgery of the future today.
  58. 58. Prevention of vault prolapse at the time of hysterectomy <ul><li>McCall culdoplasty at the time of VH </li></ul><ul><li>Suturing the cardinal and uterosacral ligament to the vaginal cuff </li></ul><ul><li>Sacrospinous fixation at the time of hysterectomy [A] </li></ul><ul><li>Prevention is better than cure </li></ul>
  59. 59. <ul><li>For queries mail me at </li></ul><ul><li>pkgarg_in2004@yahoo.com </li></ul>
  60. 60. Thank You

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