This document discusses various classifications and conservative surgical treatments for pelvic organ prolapse. It begins by describing the normal anatomical supports that prevent prolapse, including the bony scaffolding, endopelvic fascia, and pelvic musculature. It then covers several classification systems for prolapse, including the Baden-Walker and POP-Q systems. Conservative surgeries discussed include abdominal sling operations, various sling procedures, anterior and posterior colporrhaphies, paravaginal defect repairs, and perineorrhaphies. Newer procedures like vaginal sacrospinous cervico-colpopexy and posterior intravaginal slingplasty are also mentioned. The document emphasizes that hyster

1. Classification & conservative
surgeries for prolapse
Presenter:- Dr. Indraneel Jadhav
MBBS, DGO, DNB
Consultant Gynecologist and IVF
Indira IVF, Kolhapur

2. Mechanisms preventing prolapse
Bony
scaffolding
Endopelvic
fascia
Pelvic
musculature

3. De Lancey’s supports – 1990’s

4. Shaw’s classification of prolapse

5. Baden walker Classification of
prolapse

6. POP - Q Classification of prolapse
Aa Ba C
gh pb tvl
Ap Bp D

7. Stages of pelvic organ prolapse
 Stage 0
 no prolapse
- Aa,Ba,Ap,Bp are all at -3
- C or D between tvl and < tvl -2
 Stage I
 most distal portion > 1cm above level of hymen
 Stage II
 <1cm proximal to or distal to the plane of hymen
 Stage III
 >1cm below the plane of the hymen
 Stage IV
 complete eversion, distal portion at least (tvl -2 cm)

8. Abdominal Sling operations
Indicated in nullipara & young women.
Preserves reproductive function.
Objective
• Buttress the weakened support Mackenrodts
and uterosacral ligaments

9. Selection criteria
First or second degree Uterine prolapse
Uterocervical length less than 5 inches
No infravaginal elongation of cervix
Cystocele or rectocele if present should be repaired
before the surgery

10. Purandare’s cervicopexy
Rectus sheath is anchored
to Anterior part of isthmus
through ASIS and the
leaves of broad ligament
Purandare and Mhatre ‘s
modification
•Tape is fixed posteriorly to
isthmus below uterosacrals

11. Shirodkar’s sling
Principle
Tape is fixed to the posterior
aspect of isthmus & sacral
promontory
Anatomically most correct
but difficult to perform
In cases of
Defective rectus sheath
Poor abdominal muscle tone
Failed purandare’s
cervicopexy

12. Shirodkar’s sling operation
 Right side
 Shirodkars needle is passed through
retroperitoneal space and tape is attached
posteriorly to isthmus
 Left side
 Peritoneum over psoas muscle exposed
 Psoas loop made
 Knot is placed lateral
 Shirodkars needle is passed through
retroperitoneal space and tape is attached
posteriorly to isthmus

13. Khanna’s sling
 Support is from bony point
 Tape is fixed to the posterior
aspect of the isthmus to the
anterior superior iliac spine

14. Virkud’s composite sling operation
 End of mersilene tape - sacral
promontory to posterior surface
of isthmus - sutured to rectus
sheath
 Plication of left side uterosacral
ligament to correct
dextrorotation

15. Virkud’s composite sling operation
Advantages
 Easy to perform
 Double support- bony + dynamic
 Tape is posterior-no risk during
LSCS
 No enterocele
 No injury to sigmoid colon

16. Joshi’s sling
Anterior surface of the
uterus at the level of the
internal os is suspended to
the pectineal ligament on
both side with merciline
tape

17. Soonawala’s sling
Anterior longitudinal ligament on S1
vertebra
Along right side uterosacral ligament of
isthmus
Retracted extraperitoneally to S1 vertebra

18. Fothergill operation / Manchester operation
Principle steps
 Anterior colporrhaphy
 Plication of Mackenrodts ligaments in front of the
cervix using fothergills stitch
 Partial amputation of the cervix
 Amputated cervix covered with vaginal flap using
sturmdorff suture
 Posterior colpoperineorrhaphy

19. Manchester (Fothergill) repair

20. Manchester (Fothergill) repair

21. Shirodkar’s modification
of Fothergill’s operation
Amputation of cervix is not done
Plication of uterosacral ligaments
Nadkarni’s sleeve
operation
• Modification of Fothergill’s
operation
• Supravaginal portion is
excised
• Fertility is not affected

22. LeFort’s Operation/ Partial colpocleisis
Old age and unfit for surgery
Uterine pathology to be ruled out
Pap smear to be done

23. Complete colpocleisis/ colpectomy
Entire vaginal mucosa is
excised
High risk of post
operative stress urinary
incontinence

24. Grafts
Types
1. Autologous grafts
Fascia lata
Rectus sheath
2. Synthetic
Macroporous
>75microns
Mersilene,
Marlex , Prolene
Gynemesh
Pore size < 75microns
• Complications
• Mesh erosion
• Infection
Prosthetic repair

25. Tension-free vaginal mesh (TVM) systems
Prolift,
Apogee/Perigee
Avaulta
 all of which vary in
terms of mesh size,
shape and surgical
technique

26.  This system has four main characteristics:
Mesh -replacement for defective visceral pelvic
fascia
Bridge between the left and right arcus tendineus
fascia pelvis (white line, or ATFP)
Large-size mesh is held in place by passing
cannulas through the obturator fascia (anterior wall)
or the sacrospinous ligament (SSL) to attach the
arms of the mesh graft
Bladder neck is preserved
Mesh repair-principles

27. Laparoscopic
surgery
 Vaginal length must be
maintained
 Ureters must be
identified and dissected
 Requires great skill and
expertise
Newer conservative
surgeries
• Vaginal sacrospinous cervico-
colpopexy/sacrospinous
hysteropexy
• Posterior intravaginal slingplasty
• Abdominal /laparoscopic
sacrocolpopexy
• Posterior mesh repair

28. Hysterectomy should not be the prime treatment and fixing of the cervix to
strong ligament such as sacrospinous ligament could give a more
successful result and conservation of the uterus in young women

29. Anterior colporrhaphy
• To correct cystocele and urethrocele
• The underlying principles are to excise a portion of the
relaxed anterior vaginal wall
• To mobilize the bladder and push it upwards after cutting
the vesicocervical ligament
• The bladder is then permanently supported by plicating
the endopelvic fascia and the pubocervical fascia
under the bladder neck in the midline

30. Anterior colporrhaphy

31. Paravaginal defect repair
Abdominal method
Entering the retropubic space
To correct detachment between vagina and arcus
tendinus
Repair is done by fixing (reattaching) the
endopelvic fascia to the arcus tendineus fascia
(white line) of the pelvis.
Done retropubically through the space of Retzius
or vaginally.

32. Paravaginaldefectrepair

33. Perineorrhaphy/
Colpoperineorrhaphy
Repair the prolapse
of posterior vaginal wall
Relaxed perineum-
approximation of superficial
and deep perineal muscles
/levator in midline
Rectocele - tightening the
pararectal fascia.

34. Abdominal sacrohysteropexy is a safe, efficient surgical technique for the
treatment of uterine prolapse in women who desire to preserve the uterus
Khunda A, et al., New procedures for uterine prolapse, Best Practice &
Research Clinical Obstetrics and Gynaecology (2013),
http://dx.doi.org/10.1016/j.bpobgyn.2012.12.004

35. Laparoscopic uterine suspension techniques seem
promising. Advantages are improved visualisation of pelvic
anatomy, shorter hospitalisation, less postoperative pain, and
a quicker return to normal activities

36. References
 Rock, John A.; Jones, Howard W.Te Linde's Operative Gynecology, 10th
Edition:Lippincott Williams & Wilkins 2008 section VII chapter 36A
 Schorge et al -Williams gynaecology 1st edition 2008 Section III Chapter 24 ,Page
no- 1023-53
 Khunda A, et al., New procedures for uterine prolapse, Best Practice &
Research Clinical Obstetrics and Gynaecology (2013)
 Jonathan S Berek , Emil Novak :Berek and Novak’s Gynecology 15th edition
Lippincott Williams & Wilkins, 2007:Page no-1211-29
 Practical Obstetrics and gynecology , Virkud, 3rd Edition,Chapter 18 : Page no-
323-47

37. Thank you