This document discusses laparoscopic techniques for treating vault prolapse, which is the descent of the vaginal cuff after a hysterectomy. It begins by defining vault prolapse and discussing risk factors and symptoms. It then describes three main laparoscopic procedures for vault suspension: uterosacral ligament suspension, sacrocolpopexy, and pectopexy. For each procedure, it provides details on the surgical steps including dissection, mesh placement, and suturing to reattach the vaginal cuff to supportive tissues. The goal of these laparoscopic procedures is to restore apical support of the vagina with minimal tension in order to treat symptoms from vault prolapse.
Selective progesterone receptor modulators (SPRMs)
Stimulates growth :
Up regulating epidermal growth factor (EGF)
Down regulating tumour necrosis factor-alpha expression
Inhibits growth :
Downregulating insulin-like growth factor-1 (IGF-1) expression
NO EFFECT ON ESTRADIOL LEVELS
Mifepristone : 5 or 10 mg per day for 1 year
Ulipristal acetate: 5-10mg/day for 13 weeks
Pro apoptotic and anti-proliferative effects on fibroid cells
Uterus Transplantation Utx (obstetric and gynecology) D.A.B.M
Is the surgical procedure whereby a healthy uterus is transplanted into an organism of which the uterus is absent or diseased.
As part of normal mammalian sexual reproduction, a diseased or absent uterus does not allow normal embryonic implantation, effectively rendering the female infertile.
This phenomenon is known as Absolute Uterine Factor Infertility (AUFI).
Uterine transplant is a potential treatment for this form of infertility.
Uterus is a dynamic, complex organ. It is hugely blood-flow dependent.
More than 116,000 Number of men, women and children on the national transplant waiting list as of August 2017.
33,611 transplants were performed in 2016.
20 people die each day waiting for a transplant.
every 10 minutes another person is added to the waiting list.
Selective progesterone receptor modulators (SPRMs)
Stimulates growth :
Up regulating epidermal growth factor (EGF)
Down regulating tumour necrosis factor-alpha expression
Inhibits growth :
Downregulating insulin-like growth factor-1 (IGF-1) expression
NO EFFECT ON ESTRADIOL LEVELS
Mifepristone : 5 or 10 mg per day for 1 year
Ulipristal acetate: 5-10mg/day for 13 weeks
Pro apoptotic and anti-proliferative effects on fibroid cells
Uterus Transplantation Utx (obstetric and gynecology) D.A.B.M
Is the surgical procedure whereby a healthy uterus is transplanted into an organism of which the uterus is absent or diseased.
As part of normal mammalian sexual reproduction, a diseased or absent uterus does not allow normal embryonic implantation, effectively rendering the female infertile.
This phenomenon is known as Absolute Uterine Factor Infertility (AUFI).
Uterine transplant is a potential treatment for this form of infertility.
Uterus is a dynamic, complex organ. It is hugely blood-flow dependent.
More than 116,000 Number of men, women and children on the national transplant waiting list as of August 2017.
33,611 transplants were performed in 2016.
20 people die each day waiting for a transplant.
every 10 minutes another person is added to the waiting list.
Ureters are retroperitoneal structues which run anterior to psoas muscle and cross lateral to medial.4sites are prone where ureter can be injured and its management
In cases of Nulliparous prolapse or even patients deserving child bearing uterus preserving surgeries are done.
Recently even for prolapse if women want to preserve uterus for variety of reasons ,with newer minimally invasive methods it is now gaining popularity.Larger studies and longer followup is required.
THIS WAS PRESENTED AT SAFOG MOGS "SMART CONFERENCE "IN MUMBAI
PREPARED WITH HELP OF DR SUCHITRA PANDIT,DR CN PURANDARE AND DR ALPESH GANDHI.....VIDEOS CAN BE SEEN AT U TUBE
Urinary Tract Fistulas -(VVF) Etiology, Diagnosis, ManagementVikas V
Urinary Tract Fistulas - Etiology, Diagnosis, Management
Surgical and Relevant Anatomy, Classification, eitiology, VVF in Detail, Examination and Diagnosis, Management of VVF - Both Conservative And Surgical Management - Steps of Surgical Management, Post operative Management.
Anatomy of anal sphincter and perineal bodyJuhi Rathi
Hi...this presentation was created for better understanding of anatomy of perineal muscles and perineal body...to aid better understanding of episiotomies.
PANEL DISCUSSION ON ENDOMETRIOSIS IN ADOLESCENTS (2018 )Lifecare Centre
PANEL DISCUSSION ON ENDOMETRIOSIS IN ADOLESCENTS (2018 ) MODERATOR
DR SHARDA JAIN
DR ILA GUPTA
DR DIPTI NABH
panelist
UMA RAI
RAJ BOKARIA
JYOTI AGARWAL
JYOTI BHASKER
RENU CHAWLA
DIPTI NABH
VANDANA GUPTA
NEW USES OF LASER IN GYNECOLOGY
International Society for the Study of Vulvovaginal Disease (ISSVD)
International Continence Society (ICS)
2019 Guidelines
Ureters are retroperitoneal structues which run anterior to psoas muscle and cross lateral to medial.4sites are prone where ureter can be injured and its management
In cases of Nulliparous prolapse or even patients deserving child bearing uterus preserving surgeries are done.
Recently even for prolapse if women want to preserve uterus for variety of reasons ,with newer minimally invasive methods it is now gaining popularity.Larger studies and longer followup is required.
THIS WAS PRESENTED AT SAFOG MOGS "SMART CONFERENCE "IN MUMBAI
PREPARED WITH HELP OF DR SUCHITRA PANDIT,DR CN PURANDARE AND DR ALPESH GANDHI.....VIDEOS CAN BE SEEN AT U TUBE
Urinary Tract Fistulas -(VVF) Etiology, Diagnosis, ManagementVikas V
Urinary Tract Fistulas - Etiology, Diagnosis, Management
Surgical and Relevant Anatomy, Classification, eitiology, VVF in Detail, Examination and Diagnosis, Management of VVF - Both Conservative And Surgical Management - Steps of Surgical Management, Post operative Management.
Anatomy of anal sphincter and perineal bodyJuhi Rathi
Hi...this presentation was created for better understanding of anatomy of perineal muscles and perineal body...to aid better understanding of episiotomies.
PANEL DISCUSSION ON ENDOMETRIOSIS IN ADOLESCENTS (2018 )Lifecare Centre
PANEL DISCUSSION ON ENDOMETRIOSIS IN ADOLESCENTS (2018 ) MODERATOR
DR SHARDA JAIN
DR ILA GUPTA
DR DIPTI NABH
panelist
UMA RAI
RAJ BOKARIA
JYOTI AGARWAL
JYOTI BHASKER
RENU CHAWLA
DIPTI NABH
VANDANA GUPTA
NEW USES OF LASER IN GYNECOLOGY
International Society for the Study of Vulvovaginal Disease (ISSVD)
International Continence Society (ICS)
2019 Guidelines
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
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Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
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These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
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.
2
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.
+91 99099 44160.
3
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.
+91 99099 44160.
4
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.
5
6. Age
Poor tissue condition,
Scar tissue,
Increased abdominal pressure
Neuropathies
Obesity
Previous pelvic surgery
Associated Medical condition
2/15/2018
Dr Shashwat Jani.
+91 99099 44160.
6
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.
+91 99099 44160.
7
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.
+91 99099 44160.
8
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
Dr Shashwat Jani.
+91 99099 44160.
9
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.
+91 99099 44160.
10
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.
+91 99099 44160.
11
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.
+91 99099 44160.
12
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.
+91 99099 44160.
13
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
2/15/2018
Dr Shashwat Jani.
+91 99099 44160.
16
17. 2/15/2018
Dr Shashwat Jani.
+91 99099 44160.
17
• 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.
2/15/2018
Dr Shashwat Jani.
+91 99099 44160.
18
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.
+91 99099 44160.
19
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.
+91 99099 44160.
20
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.
21
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
2/15/2018
Dr Shashwat Jani.
+91 99099 44160.
24
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.
2/15/2018
Dr Shashwat Jani.
+91 99099 44160.
26
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.
+91 99099 44160.
28
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.
+91 99099 44160.
30
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.
+91 99099 44160.
32
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.
34
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
Dr Shashwat Jani.
+91 99099 44160.
36
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.
2/15/2018
Dr Shashwat Jani.
+91 99099 44160.
37
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.
+91 99099 44160.
39