LAPAROSCOPIC MANAGEMENT OF VAULT PROLAPSE BY DR SHASHWAT JANI

1. Lap. Mx. Of
Vault Prolapse
Dr. Shashwat Jani.
M. S. ( Obs – Gyn ) , FIAOG
Diploma in Advance Laparoscopy.
Consultant Assistant Professor,
Smt. N.H.L. Municipal Medical College.
Sheth V. S. General Hospital , Ahmedabad.
Mobile : +91 99099 44160.
E-mail : drshashwatjani@gmail.com

2. It is most distressing to find a
patient coming back with
complaints of SCOPV after a
hysterectomy…!!! 
2/15/2018
Dr Shashwat Jani.
+91 99099 44160.
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3.  Tackling of vault prolapse (VP) is relatively
rare and uncommon .
 Knowing the aftermaths of hysterectomy
it takes time for a Gynecologist to mentally
get tuned to the fact that patient requires
repeat surgery …!!!
2/15/2018
Dr Shashwat Jani.
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4. Definition
Post - hysterectomy Vaginal Prolapse
“ Descent of the vaginal cuff scar,
below a point that is 2 cm less,
than the total vaginal length ,
above the plane of the hymen. “
*International Continence Society
2/15/2018
Dr Shashwat Jani.
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5.  It’s a common complication following
hysterectomy with negative impact on
women's quality of life due to associated
urinary, anorectal and sexual dysfunction.
 A clear understanding of the
supporting mechanism for the uterus
and vagina is important in making the
right choice of corrective procedure.
2/15/2018
Dr Shashwat Jani.
+91 99099 44160.
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6. Age
Poor tissue condition,
Scar tissue,
Increased abdominal pressure
Neuropathies
Obesity
Previous pelvic surgery
 Associated Medical condition
2/15/2018
Dr Shashwat Jani.
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7. Why Post Hysterectomy …???
Hysterectomy causes:
 The attenuation of the cardinal/uterosacral
ligament complex when they are excised during
hysterectomy.
 The separation of the pubocervical fascia
from the rectovaginal fascia.
 The separation of the pubocervical fascia,
rectovaginal fascia from the cardinal/
uterosacral ligament complex
2/15/2018
Dr Shashwat Jani.
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8. Symptoms
 Pelvic heaviness.
 Backache.
 A mass bulging into the vaginal canal or out
of the vagina that may make standing and
walking difficult.
 Involuntary release of urine (incontinence ).
 Vaginal bleeding.
2/15/2018
Dr Shashwat Jani.
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9. Description
 Most vaginal cuff prolapses include apical
enterocele where the pubocervical and
rectovaginal fascia have separated.
 The peritoneum becomes stretched and
comes in direct contact with the vaginal
epithelium creating a true hernia.
 The vaginal epithelium is stretched and
becomes very smooth without rugae.
 There is always some degree of high
cystocele formation and high rectocele
formation associated with the vaginal vault
prolapse.
2/15/2018
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10. Classification of Vault
Prolapse
• 1st degree – vaginal apex is visible
when perineum is depressed.
• 2nd degree – apex extends just
through the introitus.
• 3rd degree – upper 2/3rds of the
vagina is outside the introitus.
• 4th degree – entire vagina is outside the
introitus
2/15/2018
Dr Shashwat Jani.
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11. Conservative Mx
• Pelvic floor exercises
( No strong evidence )
• Pessaries: Ring and shelf pessaries.
( limited use .
- Unfit for Surgery )
2/15/2018
Dr Shashwat Jani.
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12. Surgical Mx
 Repair of vaginal vault prolapse remains a
surgical challenge.
 Abdominal, vaginal & Laparoscopic
procedures have been described.
 As an extension of the abdominal
approach, laparoscopy continues to gain favor as
an access method and as a surgical advancement.
 Recent studies highlight a number of
laparoscopic techniques for restoration of apical
support that demonstrate feasibility and
encouraging results.
2/15/2018
Dr Shashwat Jani.
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13. Laparoscopic Mx
Laparoscopic vaginal vault suspension is
performed to treat apical enteroceles and vault
descensus and to reposition the vaginal vault
after hysterectomy.
2/15/2018
Dr Shashwat Jani.
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14. Methods
1. Uterosacral ligament
suspension
2. Sacrocolpopexy.
3. Pectopexy
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Dr Shashwat Jani.
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15. Laparoscopic
Uterosacral
Ligament Fixation
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16. Steps
• Under G.A.
• Trendelenburg position
• Using a rectal sizer placed in the vaginal
vault, the vault is inverted so that the
peritoneal lining overlying the separated
rectovaginal and pubocervical fascia is
visible in the pelvic cavity
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• Unbroken portion of Uterosacral ligaments ( near
the Sacrum ) identified & tagged with sutures
bilaterally.

18. • Pubocervical & Rectovaginal fascia are
identified and dissected with sharp dissection
& excess of vaginal wall is excised.
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19. • Corner stitches are then placed on each side
that approximate the edges of the pubocervical
to the rectovaginal fascia overlying the vaginal
mucosa.
• The corner stitch is then incorporated into
the ipsilateral uterosacral ligament, which had
been previously tagged.
2/15/2018
Dr Shashwat Jani.
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20. • Now, the Rectovaginal – Pubocervical complex
is sutured to the unbroken portion of the
uterosacral ligament on both the sides,
forming a very secure attachment of the
vaginal apical corner.
2/15/2018
Dr Shashwat Jani.
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21. • The rectovaginal fascia is then
approximated to the pubocervical fascia
across the center of the vaginal vault with
interrupted sutures.
• Reinforcing sutures from the uterosacral
ligaments to the posterior rectovaginal fascia
are then placed bilaterally.
• Thus, they provide an appropriate
anatomic connection to the rectovaginal
septum and maintain the maximum possible
transverse dimension of the upper portion of
the vagina.
2/15/2018
Dr Shashwat Jani.
+91 99099 44160.
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22. 2/15/2018
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Cystoscopy
• Check Ureteral Orifices
• Ureter Kinking

23. Laparoscopic
Sacrocolpopexy
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Laparoscopic sacrocolpopexy represents the
adaptation of abdominal sacrocolpopexy to
different instrumentation

24. Steps…
• Once the operative ports have been placed,
the vagina is elevated with Sponge on holder.
• The peritoneum overlying the vaginal apex
is dissected anteriorly approximately one third to
one half the way down the anterior wall. , exposing
the apex of the pubocervical fascia.
• Similarly, Rectovaginal fascia dissected down
to within 3 cm of perineal body.
• This confirms an enterocele at the apex
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Dr Shashwat Jani.
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26. • A large enterocele should be resected
and the cuff re-approximated with absorbable
sutures so the excessive vaginal epithelium is
not used as a point of mesh attachment.
• The peritoneum overlying the sacral
promontory is incised longitudinally and this
peritoneal incision is extended to the cul-de-
sac.
• Ant. Ligament of Sacral promontary is
exposed by blunt dissection.
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Dr Shashwat Jani.
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27. Dissection on Sacral Promontary
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28. • The peritoneum on the sidewall is
incised and freed up beneath the ureter so
that the mesh can be retroperitonealized at
the end.
• A 15 X 15 cm Soft polypropylene mesh
graft is fashioned into a "Y" shape , so there
is an anterior and posterior leaf of the mesh.
• Typically, the anterior leaf is approximately
3 cm to 4 cm long and the posterior leaf is
longer at 5 cm to 6 cm so that it can be
brought down deeper into the rectovaginal
space.
2/15/2018
Dr Shashwat Jani.
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29. Y shape mesh
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30. • Vaginal apex is directed anterior & cephalad.
• The anterior leaf of the mesh is then sutured
to the pubocervical fascia with three pairs of 2-0
nonabsorbable sutures beginning distally and
working toward the rectovaginal fascia apex.
• The first suture is placed through the mesh
and then through the pubocervical fascia, being
careful to avoid the bladder edge.
• Once the anterior leaf is sutured in place,
the posterior leaf is then released and sutured in
place in a similar fashion.
2/15/2018
Dr Shashwat Jani.
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31. Anteriorly Sutured to
Pubocervical fascia
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32. • The surgeon should attempt to take
stitches through the entire thickness of the
vaginal wall, excluding the vaginal epithelium.
• Now, the free end of the Y shaped mesh is
sutured to the anterior longitudinal ligament of
the sacrum using two No. 0 nonabsorbable
sutures.
• The mesh should be attached with minimal
tension on the vagina.
2/15/2018
Dr Shashwat Jani.
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34. • After reducing intra-abdominal
pressure and inspecting the presacral
space for hemostasis, the peritoneum
is reapproximated with 2-0 polyglactin
sutures .
• Cystoscopy for bladder &
Ureter injury .
2/15/2018
Dr Shashwat Jani.
+91 99099 44160.
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35. LAPAROSCOPIC
PECTOPEXY
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36. The iliopectineal ligament is an extension of
the lacunar ligament that runs on the pectineal
line of the pubic bone, and is significantly
stronger than the sacrospinous ligament and the
arcus tendineus of the pelvic fascia.
2/15/2018
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37. • Opening of peritoneal layer along the right
round ligament towards the pelvic wall in the
medial & caudal direction.
• Approx. 4 cm of Rt. Iliopectineal ligament
adjacent to iliopsoas muscle is exposed.
• This is at S2 level so avoid injury to
obturator nerve.
• Same procedure on left side.
• The incisions on both sides were connected
by opening the peritoneal layer toward the
vaginal apex.
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Dr Shashwat Jani.
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39. • Now, The mesh ends were attached to
both iliopectineal ligaments using
multifilament nonabsorbable synthetic
suture material. ( Ethibond 2 – 0 )
• Vaginal apex is elevated to the intended
tension free position & fixed with suture.
• A hammock-like fixation of the vaginal
apex is created.
• Finally , mesh is covered with peritoneum.
2/15/2018
Dr Shashwat Jani.
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41. Complications…
 Lower Urinary tract injury
 Bowel injury
 Vascular / Nerve injury
 Haemorrhage
 Infection
 Fistula
 Mesh Erosion / Protrusion
 DVT
 Recurrence
2/15/2018
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Dr Shashwat Jani.
+91 99099 44160.