Dr. V.D. Patkar discusses surgical techniques for vault prolapse

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

INTRODUCTION ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],VDP

[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],VDP

evolution ,[object Object],[object Object],[object Object],[object Object],VDP

Relevant Anatomy ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],VDP

[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],VDP

[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],“ The Posterior Pelvic Floor is the Achilles heel of the Pelvic diaphragm because of its vulnerability during Child Birth & Aging . ….Max Bloom VDP

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

[object Object],[object Object],[object Object],[object Object],[object Object],VDP

[object Object],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.

“ Pelvic Organ Prolapse is often a reflection of our Obstetrical Incompetence” ……Lean Van Dongen ,[object Object],[object Object],[object Object],[object Object],VDP

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[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],VDP “ Good mid-wifery is the essence of preventive gynaecology” (Novak)

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PRESENTING SYMPTOMS ,[object Object],[object Object],[object Object],[object Object],[object Object],VDP

Site Specific Prolapse Repair ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],VDP

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.

Classification of Vault Prolapse ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],VDP

Evaluation ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],VDP

Prediction with reasonable accuracy in VH – who will develop Vault Prolapse - Bonney ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],VDP

Choice and Route of Surgery ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],“ Surgery is Anatomy Practically Applied” …Campbell VDP

DIFFICULTIES DURING SURGERY ,[object Object],[object Object],[object Object],[object Object],“ ABILITY AND NECESSITY DWELL NEAR EACH OTHER “ …. Pythagoras VDP

[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],VDP

ABDOMINAL APPROACH DIFFICULTIES ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],VDP

PREVENTION ,[object Object],[object Object],[object Object],[object Object],[object Object],“ The operative treatment of prolapse has been the mirror of our knowledge of pelvic anatomy”….George Noble VDP

[object Object],[object Object],[object Object],[object Object],[object Object],VDP P R E V E N T I O N

SURGERIES FOR VAULT PROLAPSE VDP

VAGINAL ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],VDP

ABDOMINAL ,[object Object],[object Object],[object Object],VDP

OBLITERATIVE ,[object Object],[object Object],[object Object],VDP

McCall Culdoplasty ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],VDP

High USL fixation with fascial reconstruction (Richardson ) ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],VDP

Sacrospinous ligament fixation ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],VDP

Iliococcygeus fascia suspension (Inmon) ,[object Object],[object Object],[object Object],[object Object],[object Object],VDP

Meshplasty ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],VDP

[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Abdominal Sacral Colpopexy VDP

High USL fixation with fascial reconstruction ,[object Object],[object Object],[object Object],VDP

Laparoscopic approach ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],VDP

LeFort Colpocleisis / Colpectomy ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],VDP

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 ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],FAILURE SUBJECTIVE 12.2% 9.6% 8.3% 9.1%

Pointers to successful surgery ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],VDP

[object Object],[object Object],[object Object],[object Object],VDP THANK YOU

Dr. V.D. Patkar discusses surgical techniques for vault prolapse

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Dr. V.D. Patkar discusses surgical techniques for vault prolapse