1. Vault prolapse is a distressing complication that can occur after hysterectomy where the top of the vagina descends. 2. There are various surgical options to correct vault prolapse including vaginal approaches like sacrospinous ligament fixation or abdominal approaches like abdominal sacral colpopexy. 3. Factors like parity, age, and previous pelvic floor damage affect the risk of vault prolapse. Thorough understanding of pelvic anatomy and meticulous repair of cystoceles and rectoceles can help prevent future prolapse.

1. VAULT PROLAPSE DR.V.D.PATKAR EMERITUS PROF. , LTMGH & LTMMC, SION VDP

2. INTRODUCTION It is most distressing to find a patient coming back with complaints of SCOPV after a hysterectomy The first reaction of the doctor is to disbelieve the symptom and give it a short shrift 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 VDP

3. The dilemma faced is whether to go abdominally or vaginally ( million dollar question.) Pelvic floor disorders continue to become even more prevalent as women lead longer lives. Lifetime risk of surgery for pelvic organ prolapse is 11%. Re-operation rate for failure is 29%. Thorough understanding of the pelvic anatomy and relationship of vagina is imperative. VDP

4. evolution From quadriped to biped with loss of tail------ Loss of muscle in iliococcygeus, pyriformis and coccygeus. Change in type of muscles of levator ani Change in configuration of endopelvic fascia. VDP

5. Relevant Anatomy Pelvis is divided into false and true pelvis. In upright position angle between inlet and outlet is 15-20 degrees. Bony landmarks of importance — - Ischial spines and tuberosity - Sacral promontary - S1-S2 VDP

6. Pelvic Ligaments – condensation of visceral connective tissue that assume special supportive role. - Sacrospinous lig. - Sacrococcygeus lig. - Arcus Tendinous Fascia Pelvis - Arcus Tendinous Levator Ani - Cardinal / Utero-sacral ligament VDP

7. Levator Ani Muscle – forms pelvic floor - predominantly type 1 muscle fibres - are in a state of constant Contraction. - flap-valve effect - by normal tone of ms and adequate depth of vagina. During periods of increased abdominal pressure,upper vagina is compressed against levator plate. “ The Posterior Pelvic Floor is the Achilles heel of the Pelvic diaphragm because of its vulnerability during Child Birth & Aging . ….Max Bloom VDP

8. Urogenital diaphragm - Is a dense fibromuscular tissue that spans the opening of the anterior pelvic outlet - it consists of – Perineal body and 2 strap muscles – compressor urethrae, sphincter urethrae VDP

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. Fascia – - Pubovescico-cervical - Paravaginal fascia - Rectovaginal fascia - Recto-vaginal septum VDP

11. De Lancey vaginal supports . 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. “ Pelvic Organ Prolapse is often a reflection of our Obstetrical Incompetence” ……Lean Van Dongen ETIOLOGY: Increasing parity - 1.2 times risk with each vaginal delivery. - 8.4 times with 2 vaginal deliveries (Oxford Family Planning – Mant 1997) - 11.4 times with 4 vaginal deliveries (Turkish study – Erata 2002) VDP

13. In vaginal delivery pelvic floor exposed to compressive and expulsive forces. 238 – 403 mmHg. Prolonged 2 nd stage- O2 deprivation causes necrotic changes. Ms , paravaginal tissue severely atrophied or dysfunctional. Pudendal neuropathy following delivery . VDP

14. Macrosomia Epidural analgesia Instrumental deliveries & Oxytocin, PG augmentation Age- risk increases 8% at 40yrs,11% at 50yrs. Due to hypoestrogenism, degenerative and organic diseases related to aging. Genetic predisposition- weak fascia,collagen (type 3) or muscle(type 1). VDP “ Good mid-wifery is the essence of preventive gynaecology” (Novak)

15. Chronic increased intra abdominal pressure - obesity, constipation, COPD,Hypothyroidsism, lifting heavy weight. Following hysterectomy , secondary hypotrophy of the cardinal- uterosacral ligament complex .(iatrogenic) VDP

16. Separation of pubocervical fascia from 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. VDP

17. PRESENTING SYMPTOMS Apical VP More anterior vaginal wall prolapse Enterocele with posterior vaginal wall prolapse All of above with lax perineum All of above with laxity of introitus (puborectalis or bulbocavernous) VDP

18. Site Specific Prolapse Repair CYSTO/RECTOCOELE - Dislocation - Overdistention CAUSE Damage to lateral Destruction of fibr connective tissue omuscular elasticity support with increase total length & width of vag wall & fornices CORRECTION Restoration of vaginal Reduction of width depth, axis and support. Inverted ‘T’ Repair Parachute Repair VDP

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. Classification of Vault Prolapse 1 st degree – vaginal apex is visible when perineum is depressed. 2 nd degree – apex extends just through the introitus. 3 rd degree – upper 2/3rds of the vagina is outside the introitus. 4 th degree – entire vagina is outside the introitus VDP

21. Evaluation Pre-operative assessment of sites of damage. Determine pre-operatively whether lower urinary tract dysfunction and defecatory dysfunction co-exist. Configuration of – abdominal wall, sacral promontary, ischial spine, depth of pelvis and previous surgery with resultant adhesions. Dynamic analysis by MRI. Technical error- patient is evaluated in recumbent rather than standing position. Dynamic pelvic floor fluoroscopy . Also accurately identifies enterocoele.– Done abroad. VDP

22. Prediction with reasonable accuracy in VH – who will develop Vault Prolapse - Bonney Pt. in lithotomy posn. Reposit procidentia in pelvis Ask pt. to bear down or cough. Observe what protrudes out first. If cervix, uterus or vault appear first- level 1 damage ( card / USL)- Primary Pexy with surgery If cystocele , rectocele appear first- level 2/3 damage ( pelvic diaphragm)- VH with AP repair adequate VDP

23. Choice and Route of Surgery No general consensus on best procedure Choice of surgery depends on- - Comfort & skill of surgeon - Primary or recurrent prolapse - Patient factor : age, health status , state of tissues, sexual activity. Transvaginal route safer- VP aft. Vag hyst Transabdominal route for – VP after abdo. hyst., lap hyst., harmonic vessel seal - Failure of previous vaginal approach - Foreshortened vagina. “ Surgery is Anatomy Practically Applied” …Campbell VDP

24. DIFFICULTIES DURING SURGERY VAGINAL APPROACH Post menopausal atrophic vagina Skimpy Pubovesical fascia and absence of support to bladder base (as uterus absent)- difficult to take buttressing sutures during A repair. Incomplete receding of bladder bulge even after repair (Surgeon does not have satisfaction of doing a complete repair). “ ABILITY AND NECESSITY DWELL NEAR EACH OTHER “ …. Pythagoras VDP

25. VAGINAL APPROACH DIFFICULTIES….. ‘ Hypoestrogenic vagina , attenuated uterosacral ligaments - enterocele sac separation difficult Occasional impaction of intestine with adhesion in POD , - difficult and dangerous to approach sac - difficult in enterocoele repair - often incomplete Thinned out Dennonvillers fascia makes buttressing sutures of rectocele repair untenable. VDP

26. VAGINAL APPROACH DIFFICULTIES… Sacrospinopexy Obesity, ATROPHIC vagina, para vagina loose areolar tissue and coccygeal sacrospinal complex– increase chances of failure. osteoporosis (old age) of ischial spines- periosteitis. malpositioning of pudendal /gluteal vessels and nerves. - Anatomy relatively unexplored VDP

27. ABDOMINAL APPROACH DIFFICULTIES Old age High risk for anesthesia & surgery Obesity , pendulous abdomen Loss of abdominal muscle tone Venous stasis & vascular impedence – increased Oozing in Retroperitoneal space Osteoporosis – periosteitis at site of sacropexy VDP

28. ABDOMINAL APPROACH DIFFICULTIES… Bladder and rectum adherent to vagina and overhang the vault– difficulty in locating the vaginal vault and dissecting the anterior and posterior vaginal walls. Ureters –medial ,close to apex with fibrosis of adjacent fascia-chances of ureteric damage when passing sling needle. Uterosacral ligaments attenuated & shortened. Posterior peritoneum puckered , needle difficult to pass. Round ligament shortened and bladder overhanging – pexy difficult VDP

29. PREVENTION Preoperative Bonneys Assessment Paracolpium (endo.Fascia +vag. Mus supports vault following hysterectomy provided it is effectively attached to the vault. Thorough reassessment of sites of damage prior to hysterectomy achieves a more perfect RECONSTRUCTION . Keep Adequate vaginal length . “ The operative treatment of prolapse has been the mirror of our knowledge of pelvic anatomy”….George Noble VDP

30. Adequate Repair of cystocoele/rectocoele and vault hook up. 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. Take care during non descent hysterectomy When vessel seal/ harmonic opted for do not forget buttressing vault . In Lap. hyst , suture uterosacrals to vaginal vault. VDP P R E V E N T I O N

31. SURGERIES FOR VAULT PROLAPSE VDP

32. VAGINAL McCall’s culdoplasty Sacrospinous ligament fixation High Uterosacral ligament suspe- - nsion with fascial reconstruction Iliococcygeus fascia suspension Meshplasty VDP

33. ABDOMINAL Abdominal sacral colpopexy High uterosacral ligament suspension Laproscopic approach VDP

34. OBLITERATIVE LeFort’s Partial Colpocleisis Introital tightening Colpectomy VDP

35. McCall Culdoplasty A wedge of posterior vaginal wall and peritoneum removed Enterocole sac freed and excised Two internal sutures (permanent) placed approximating both USL and posterior peritoneum. One external suture thru USL , post peritoneum & brought out thru post vaginal wall. This obliterates cul-de-sac, supports vaginal apex & lengthens posterior vaginal wall. VDP

36. High USL fixation with fascial reconstruction (Richardson ) Identifying defect in endopelvic fascia Reducing enterocoele sac Closing fascial defect Resuspension of vagina to original level 1 support 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 Absorbable sutures are used to suspend ant. And post. Vaginal walls to the USL ridge. These are tied to suspend vagina in the hollow of sacrum Perform cystoureteroscopy to evaluate ureteral integrity. VDP

37. Sacrospinous ligament fixation Principles to follow while dissecting to reach sacrospinous lig- work lateral to rectal wall - go posterior to uterosacral ligs - start dissecting cranial to levator belly, pierce pararectal ligament. Locate SSL. Taking sutures thru SSL Suspending the vault with pulley stitch or placing sutures thru full thickness of vagina. Other Pexy : vagina to pelvic fasc: Shull, Vagina to sacrotuberous : Amreich Vagina to arcus tendinous : White Vagina to sacrospinous lig: Richter VDP

38. Iliococcygeus fascia suspension (Inmon) Repair any anterior compartment defect Iliococcygeus ms identified lateral to rectum & anterior to ischial spine Sutures placed anterior to ischial spine Passed thru vaginal apex VDP

39. Meshplasty MRI and CT delineation of defects in the fascial planes causing anterior or posterior defects – precise positions of defects which are difficult to correct, Hence, proponents feel meshes are ideal Apogee : for posterior defect Perigee : for anterior defect PROLIFT and likes: for vault prolapse Is beset with its own problems and complications VDP

40. Apex of vault held with Allis and pushed up. Incision -Infraumbilical midline incision taken Preparation of vaginal vault – - Peritoneum over vault incised - Plane developed between posterior wall & rectum - Bladder base dissected off the superior aspect of anterior vagina Preparation of sacrum – - sigmoid pushed to left - peritoneum over promontary & 1 st 3 sacral vertebrae incised & continued to vaginal incision. Abdominal Sacral Colpopexy VDP

41. Placement of mersilene tape / mesh – - length 3X15cms. - tape/ mesh sutured to vaginal tissues using full thickness interrupted non-absorbable sutures . - continue anteriorly taking care of any cystocoele - tape/ mesh turned back towards apex & then towards the sacrum - secured to sacrum Reperitonealisation done. VDP

42. High USL fixation with fascial reconstruction Reducing enterocoele sac by multiple sutures through USL Closing fascial defect Resuspension of vagina to original level 1 support VDP

43. Laparoscopic approach Rise in adoption of laparoscopic approach. Advantages - Improved haemostasis improved visualization of anatomy Reduced hospital stay, post-operative pain Reduced overall cost Disadvantages - technical difficulty in retroperitoneal dissection steep learning curve Increased operative room time increasing cost. Risk of injury to vital structures. VDP

44. LeFort Colpocleisis / Colpectomy Small Kelly’s Repair —SUI Marking out rectangular / triangular flaps on Anterior and posterior vaginal walls Repeated sucessive stitches to invert the tissues Suturing of uppermost horizontal part of rectangular flaps to each other with delayed absorbable sutures. Small P repair , if necessary To supplement , do introital tightening if extreme laxity VDP

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 bleeding Incompl repair Hunt for atten USL Pudendal vs injury Sciatic nerve injury Bleeding Anatomical distortion Adhesions Difficult fixation (sacral and vaginal) Minimal bleeding Prevent over correction FAILURE SUBJECTIVE 12.2% 9.6% 8.3% 9.1%

46. Pointers to successful surgery Age Proper counselling High risk factors Previous surgeries performed No. of attempts at repair Symptoms and signs Type of vault prolapse Defects in supports identified Skill, knowledge and experience of surgeon Comfort, confidence with particular surgery VDP

47. THE BEST DEFENCE IS A GOOD SURGICAL OFFENSE No stereotyping patients, - INDIVIDUALISATION - the NEED ! SURGERY SHOULD FIT THE PATIENT , THE PATIENT SHOULD NOT FIT THE SURGERY. - Michael Smith VDP THANK YOU