1) The document discusses the anatomy related to urinary continence and pelvic support. It describes the various muscles, ligaments and fascia that provide support to the pelvic organs.
2) Key anatomical structures that contribute to continence include the urethral sphincters, intact vaginal support, and levator ani muscles. Damage or weakness to these structures can lead to conditions like stress urinary incontinence.
3) Surgical techniques to treat incontinence like retropubic colposuspension and pubovaginal slings are aimed at restoring the hammock-like support of the pelvic organs to improve urethral closure and continence.
This document provides an overview of the pelvic floor anatomy and MRI evaluation of pelvic floor weakness and prolapse. Key points include:
- The pelvic floor is divided into 3 compartments supported by muscles, fascia and ligaments. Weakness can result in prolapse.
- MRI allows visualization of all compartments and pelvic floor muscles to assess for prolapse and weakness seen as increased H/M lines or abnormal organ positioning/shapes.
- Specific abnormalities provide clues to underlying causes - cystocele from bladder neck descent indicates anterior compartment weakness for example.
Practical Aspects about Urogenital Fistula Repair GrothuesmannDr Dirk Grothuesmann
Each year between 50 000 to 100 000 women worldwide are affected by obstetric fistula. I share here practical aspects of my personal experiences dealing with this complex issue mainly affecting the weak and the poor.
During the last two decades huge international interest towards this problem has been raised up in the global medical arena. One might think anyone equipped with abilities to adjust to resource poor settings, armed with comprehensive surgical skills fulfill essentials to learn how to repair fistulas. This is definitely not enough to be a part of the solution!
Regardless surgeons must understand both their own limitations as well as the limitations given by the environment in place as precondition to deal with this problem. Sharing my experiences I hope to contribute to make this understood.
Vaginal approach for Stress Urinary Incontinence surgeryRohan Sharma
This document discusses various surgical approaches for stress urinary incontinence (SUI), including pubovaginal slings and midurethral slings. It provides details on the operative technique for pubovaginal sling surgery, including patient positioning, incisions, dissection, sling placement, and postoperative care. Complications like erosion, extrusion, and voiding dysfunction are also reviewed. The document also discusses the anatomical basis for midurethral slings and how they work to treat SUI.
The document discusses techniques for performing a hysterectomy, including:
1) Identifying ligaments like the round ligament and infundibulopelvic ligament before division.
2) Dissecting the retroperitoneal space to identify the ureter and external iliac artery.
3) Dividing the peritoneum to access the utero-ovarian pedicle or uterine vessels for clamping/ligation.
MANAGEMENT OF VAULT PROLAPSE BY DR SHASHWAT JANIDR SHASHWAT JANI
This document discusses the management of vault prolapse, which is the descent of the vaginal cuff after a hysterectomy. It defines vault prolapse and lists risk factors. Conservative management includes pessaries but surgery is often needed. Surgical options include vaginal approaches like sacrospinous ligament fixation or abdominal approaches like sacral colpopexy. The document compares techniques and factors to consider in surgical planning like prolapse severity and patient factors. Prevention techniques like culdoplasty at time of hysterectomy are also discussed.
This document provides information about rectal prolapse including its anatomy, causes, clinical presentation, and surgical treatment options. It begins with a description of the rectal anatomy including its blood supply, lymphatic drainage, and curves. It then discusses the causes and types of rectal prolapse and explains how factors like pelvic floor weakness can lead to its development. Common signs and symptoms are outlined. Both perineal and abdominal surgical approaches are described in detail including the Thiersch, Delorme, Altemeier, and Wells procedures. Postoperative care is also reviewed. The document provides a comprehensive overview of rectal prolapse.
This document provides information on various gynecological surgical procedures including:
- Hysterectomy - removal of the uterus, described are abdominal and vaginal hysterectomy approaches.
- Myomectomy - removal of uterine fibroids, leaving the uterus intact to preserve fertility.
- Dilation and curettage (D&C) - dilating the cervix and scraping the uterine lining, used diagnostically and therapeutically.
- Anterior and posterior colporrhaphy - procedures to repair vaginal wall defects and prolapse.
- Fothergill's operation - vaginal procedure to correct uterine prolapse while preserving the uterus.
Pre-operative, intra-operative and
This document provides an overview of the pelvic floor anatomy and MRI evaluation of pelvic floor weakness and prolapse. Key points include:
- The pelvic floor is divided into 3 compartments supported by muscles, fascia and ligaments. Weakness can result in prolapse.
- MRI allows visualization of all compartments and pelvic floor muscles to assess for prolapse and weakness seen as increased H/M lines or abnormal organ positioning/shapes.
- Specific abnormalities provide clues to underlying causes - cystocele from bladder neck descent indicates anterior compartment weakness for example.
Practical Aspects about Urogenital Fistula Repair GrothuesmannDr Dirk Grothuesmann
Each year between 50 000 to 100 000 women worldwide are affected by obstetric fistula. I share here practical aspects of my personal experiences dealing with this complex issue mainly affecting the weak and the poor.
During the last two decades huge international interest towards this problem has been raised up in the global medical arena. One might think anyone equipped with abilities to adjust to resource poor settings, armed with comprehensive surgical skills fulfill essentials to learn how to repair fistulas. This is definitely not enough to be a part of the solution!
Regardless surgeons must understand both their own limitations as well as the limitations given by the environment in place as precondition to deal with this problem. Sharing my experiences I hope to contribute to make this understood.
Vaginal approach for Stress Urinary Incontinence surgeryRohan Sharma
This document discusses various surgical approaches for stress urinary incontinence (SUI), including pubovaginal slings and midurethral slings. It provides details on the operative technique for pubovaginal sling surgery, including patient positioning, incisions, dissection, sling placement, and postoperative care. Complications like erosion, extrusion, and voiding dysfunction are also reviewed. The document also discusses the anatomical basis for midurethral slings and how they work to treat SUI.
The document discusses techniques for performing a hysterectomy, including:
1) Identifying ligaments like the round ligament and infundibulopelvic ligament before division.
2) Dissecting the retroperitoneal space to identify the ureter and external iliac artery.
3) Dividing the peritoneum to access the utero-ovarian pedicle or uterine vessels for clamping/ligation.
MANAGEMENT OF VAULT PROLAPSE BY DR SHASHWAT JANIDR SHASHWAT JANI
This document discusses the management of vault prolapse, which is the descent of the vaginal cuff after a hysterectomy. It defines vault prolapse and lists risk factors. Conservative management includes pessaries but surgery is often needed. Surgical options include vaginal approaches like sacrospinous ligament fixation or abdominal approaches like sacral colpopexy. The document compares techniques and factors to consider in surgical planning like prolapse severity and patient factors. Prevention techniques like culdoplasty at time of hysterectomy are also discussed.
This document provides information about rectal prolapse including its anatomy, causes, clinical presentation, and surgical treatment options. It begins with a description of the rectal anatomy including its blood supply, lymphatic drainage, and curves. It then discusses the causes and types of rectal prolapse and explains how factors like pelvic floor weakness can lead to its development. Common signs and symptoms are outlined. Both perineal and abdominal surgical approaches are described in detail including the Thiersch, Delorme, Altemeier, and Wells procedures. Postoperative care is also reviewed. The document provides a comprehensive overview of rectal prolapse.
This document provides information on various gynecological surgical procedures including:
- Hysterectomy - removal of the uterus, described are abdominal and vaginal hysterectomy approaches.
- Myomectomy - removal of uterine fibroids, leaving the uterus intact to preserve fertility.
- Dilation and curettage (D&C) - dilating the cervix and scraping the uterine lining, used diagnostically and therapeutically.
- Anterior and posterior colporrhaphy - procedures to repair vaginal wall defects and prolapse.
- Fothergill's operation - vaginal procedure to correct uterine prolapse while preserving the uterus.
Pre-operative, intra-operative and
Urinary tract injury during female pelvic surgery occurs in 0.3-1% of procedures but can be as high as 2.4%. Risk factors include prior pelvic surgery, endometriosis, and pelvic masses. The ureters pass through the pelvis and can be injured at various points, most commonly when ligating the ovarian or uterine vessels. Identifying and isolating the ureters and bladder during surgery is important to prevent injury from other surgical maneuvers.
The document provides information about rectal prolapse including its definition, types, classification, causes, clinical features, pathogenesis, differential diagnosis, complications and treatment. It discusses partial (mucosal) prolapse and complete (full thickness) prolapse. For treatment, it describes both medical management and surgical procedures for rectal prolapse including perineal procedures like Delorme's procedure and Altemeier's procedure as well as abdominal procedures like Wells operation and Ripstein sling operation. It also lists several homeopathic medicines commonly indicated in the treatment of rectal prolapse such as Podophyllum, Aesculus, Sulphur, Ferrum metallicum, Ruta, Ignatia, Muriaticum
This document discusses sacrohysteropexy surgery for the treatment of nulliparous uterine prolapse. It begins with an overview of the prevalence and risk factors for nulliparous prolapse in India. It then discusses the evolution of prolapse surgeries including Fothergill's operation, sling operations, and sacrohysteropexy. Sacrohysteropexy involves lifting the prolapsed uterus using a synthetic mesh attached between the uterus and sacral promontory. The document reviews studies on sacrohysteropexy and presents outcomes from the author's cases. It concludes with information on pectopexy, a newer technique that attaches the uterus to the pel
Genital prolapse is common, affecting up to 30% of multiparous women, where the uterus, bladder, rectum, or intestines protrude through the vagina. It is usually caused by childbirth weakening the pelvic floor muscles and connective tissues. Symptoms include a feeling of something coming down and pressure. Examination involves assessing the degree of organ descent during straining. Treatment options include pessaries, anterior and posterior vaginal wall repairs, enterocele repair, hysterectomy with vault support, or sacrohysteropexy depending on the site and severity of prolapse and patient preferences.
This document provides an overview of the anatomy of the pelvic floor. It describes the bones that form the pelvis, ligaments such as the sacrotuberous and sacrospinous ligaments, and openings such as the sciatic foramina. It then discusses the muscles that comprise the pelvic floor, including the levator ani muscles, as well as fasciae such as the parietal pelvic fascia. Finally, it briefly touches on materials that are commonly used for midurethral slings.
This document discusses pubovaginal sling procedures for stress urinary incontinence. It provides background on the historical use of autologous materials for urethral suspension dating back to the early 1900s. Specific indications for fascial slings include loss or weakness of proximal urethral closure due to conditions like neurogenic bladder dysfunction or prior failed surgeries. The document describes patient evaluation, sling materials including autologous, allograft and xenograft tissues, and the surgical technique for pubovaginal sling placement including abdominal and vaginal dissection, sling passage and fixation, and post-operative care.
The document discusses the exstrophy-epispadias complex, which results from abnormal cloacal development. It is caused by failure of the cloacal membrane to be reinforced by mesodermal ingrowth. The complex includes classic bladder exstrophy and other variants. Reconstruction involves bladder, abdominal wall, and urethral closure in newborns. Osteotomies may be required to approximate the pubic bones. Epispadias repair is usually done later, along with bladder neck reconstruction and antireflux procedures to achieve urinary control.
This document discusses vaginal vault prolapse and vault suspension. It begins by introducing vaginal prolapse and its causes. It then describes the relevant anatomy of vaginal support, including the three levels of connective tissue. Next, it covers the problem, frequency, etiology, presentation, and evaluation of vaginal vault prolapse. The evaluation section emphasizes identifying the apical support structures and assessing the degree of prolapse. It stresses that accurately identifying and correcting vault prolapse is important to prevent recurrence after surgery.
techniques, methods, indications and complications of various fusion techniques for subaxial cervical spine. comparison of anterior versus posterior techniques, their indications and complication.
Assisting in lower segment cesarean sectionPrakat Aryal
This document provides information on assisting in a lower segment cesarean section (LSCS). It describes the LSCS technique which involves a transverse incision above the bladder that results in less blood loss and easier repair compared to a classic vertical incision. Common indications for LSCS are listed such as previous C-section, fetal distress, breech presentation, and dystocia. The procedure steps are outlined including abdominal incision, uterine incision, baby delivery, placenta removal, uterine repair and closure. The roles and responsibilities of the assistant surgeon during pre-op, intra-op and post-op are also summarized.
The document describes a study of 63 patients who underwent a novel laparoscopic posterolateral rectopexy procedure for treatment of full-thickness rectal prolapse. The procedure involves posterior and unilateral right lateral rectal dissection, fixation of the rectum to the sacral promontory using a polypropylene mesh, and preservation of the mesorectal fascia propria. Short term outcomes were positive, with no reported recurrences and high patient satisfaction. A few patients reported postoperative complications but these were managed conservatively. The procedure aims to provide firm rectal fixation while avoiding issues like constipation seen with other techniques.
This document provides an overview of the history and techniques for orthotopic neobladder urinary diversion. Some key points:
- Orthotopic diversion was pioneered in the 1950s as an alternative to ureterosigmoidostomy and ileal conduit diversion due to complications of those procedures.
- Patient selection considers oncologic factors like risk of urethral recurrence and tumor stage, as well as patient factors like age, renal function, manual dexterity, and prior treatments.
- Surgical techniques aim to optimize continence by preserving the rhabdosphincter and its innervation during cystectomy. For males the urethra is detached in a retrograde
Classification & conservative surgeries for prolapseIndraneel Jadhav
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
This document discusses operative management of cervical degenerative disease. It covers indications and contraindications for various surgical approaches including anterior, posterior, and combined approaches. Anterior approaches like anterior cervical discectomy and fusion are used for single or two level disease anteriorly. Posterior approaches like laminectomy and laminoplasty are used for multilevel disease or posterior compression. Factors like location of compression, number of levels, alignment, and instability are considered in surgical planning. Complications of each approach and factors affecting prognosis are also summarized.
RGU and MCU by capt alauddin, MD phase A.pptxAlauddin Md
The document discusses Micturating Cystourethrography (MCU) and Retrograde Urethrography (RGU), which are imaging techniques used to evaluate the lower urinary tract. MCU involves filling the bladder with contrast dye and imaging the urethra during voiding. It can detect vesicoureteral reflux, bladder abnormalities, and anomalies of the bladder outlet. RGU involves retrograde injection of contrast through the urethra. Both procedures provide information about the urethra and any abnormalities like strictures. The document outlines the anatomy, procedures, indications, complications and advantages/limitations of MCU and RGU.
Spondylolisthesis is the forward displacement of one vertebra over another. It is graded from 0-4 based on the Meyerding grading system. Surgical options for spondylolisthesis include decompression without fusion, non-instrumented fusion, instrumented fusion using pedicle screws, and interbody fusions like anterior lumbar interbody fusion (ALIF) or lateral lumbar interbody fusion (LLIF). ALIF provides the advantage of a greater discectomy and sparing of posterior elements but has risks of visceral, ureteral, and vascular injury. LLIF avoids risks to retroperitoneal structures but may require supplemental posterolateral fusion.
unexplained infertility BY DR REJI MOHAN.pptxReji Mohan
The document provides an overview of unexplained infertility. It begins by defining unexplained infertility and noting that it accounts for 15-30% of infertility cases. The prognosis is best when the female partner is under 35 years old and the duration of infertility is less than two years. Treatment options discussed include expectant management, ovarian stimulation with medications like clomiphene citrate or letrozole with or without intrauterine insemination (IUI), and in vitro fertilization (IVF). Ovarian stimulation and IUI are generally recommended as first-line treatments before moving to IVF, but success rates decline with female age. The cause of unexplained infertility is likely multiple subtle factors that combine to reduce fertility
pcos other than ART.pptx for mbbs and mdReji Mohan
This document provides an overview of ovulation induction in PCOS other than for ART (assisted reproductive technology). It begins with a brief history of PCOS and discusses its epidemiology. It then covers various treatment options for ovulation induction in PCOS, including aromatase inhibitors like letrozole, clomiphene citrate, insulin-lowering medications like metformin, gonadotropins, and laparoscopic ovarian drilling. Key points are emphasized for each treatment approach and their effectiveness, safety, and side effects are compared. Lifestyle modifications focusing on diet and exercise are also highlighted as an important aspect of PCOS management.
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This document provides an overview of the anatomy of the pelvic floor. It describes the bones that form the pelvis, ligaments such as the sacrotuberous and sacrospinous ligaments, and openings such as the sciatic foramina. It then discusses the muscles that comprise the pelvic floor, including the levator ani muscles, as well as fasciae such as the parietal pelvic fascia. Finally, it briefly touches on materials that are commonly used for midurethral slings.
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The document discusses the exstrophy-epispadias complex, which results from abnormal cloacal development. It is caused by failure of the cloacal membrane to be reinforced by mesodermal ingrowth. The complex includes classic bladder exstrophy and other variants. Reconstruction involves bladder, abdominal wall, and urethral closure in newborns. Osteotomies may be required to approximate the pubic bones. Epispadias repair is usually done later, along with bladder neck reconstruction and antireflux procedures to achieve urinary control.
This document discusses vaginal vault prolapse and vault suspension. It begins by introducing vaginal prolapse and its causes. It then describes the relevant anatomy of vaginal support, including the three levels of connective tissue. Next, it covers the problem, frequency, etiology, presentation, and evaluation of vaginal vault prolapse. The evaluation section emphasizes identifying the apical support structures and assessing the degree of prolapse. It stresses that accurately identifying and correcting vault prolapse is important to prevent recurrence after surgery.
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2) Conditions that may require transport of an obstetric patient include pregnancy-related complications as well as medical issues aggravated by pregnancy. Timely transfer to a higher-level facility that can provide specialized care for both mother and baby is important.
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Gemma Wean- Nutritional solution for Artemiasmuskaan0008
GEMMA Wean is a high end larval co-feeding and weaning diet aimed at Artemia optimisation and is fortified with a high level of proteins and phospholipids. GEMMA Wean provides the early weaned juveniles with dedicated fish nutrition and is an ideal follow on from GEMMA Micro or Artemia.
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PELVIC FLOOR ANATOMY AND REPAIR.pptx FOR TEACHING
1. ANATOMY OF CONTINENCE AND
PELVIC SUPPORT.
POP-Q SITE SPECIFIC REPAIR
DR REJI MOHAN,MD,DNB,FELLOW in RM
ASSISTANT PROFESSOR
DEPT. OF REPRODUCTIVE MEDICINE AND SURGERY
SREE AVITTOM THIRUNAAL HOSPITAL
GOVT MEDICAL COLLEGE
THIRUVANANTHAPURAM
3. Surgery is anatomy practically
applied-
Campell
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4. Basic Facts of Anatomy do not Change
But our understanding does…
Evolution is a basic rule
PRIMUM NON CERE
Better understanding of anatomy,sharper diagnosis,targetted surgery ,best
possible surgery with best possible results and less iatrogenic injuries
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7. The Anatomical Components of
Urinary Continence
• Three things are needed for effective urethral closure and
continence at rest and during periods of increased intra-
abdominal pressure :
Properly functioning striated (external)and Smooth
(internal) urethral sphincters
A well-vascularised urethral mucosa submucosa
An intact vaginal support
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8. • Striated external urethral
sphincter (EUS) -Two parts
1.superior, horseshoe- or omega-
shaped part that covers the
urethra and an inferior part that
covers the anterolateral aspect of
the urethra and the lateral aspect
of the vagina.
2.The inferior part is also known
as the urethrovaginal sphincter
Internal urethral sphincter (IUS)
• The smooth muscle is
described completely circular
in females
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9. An intact vaginal support
• Support for the urethra is maintained by the anterior
vagina
These structures provide a hammock-like support system
for the urethra on the anterior wall of the vagina.
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10. Continence mechanism
• The urethral closure by contraction of the EUS and IUS
form the intrinsic continence mechanism.
• The extrinsic continence mechanism is formed by the
pelvic floor muscles, organs, and support structures
surrounding the urethra and urethral sphincter muscles.
• Contraction of the levator ani compresses the urethral
lumen when contraction of the levator ani muscle pulls the
vaginal wall anteriorly against the posterior surface of the
urethra .
So laxity of the vaginal wall
dissipates the effect of contraction of
the LAM and leads to stress urinary
incontinence (SUI)
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11. Anatomy of SUI
• Defects that result in SUI can be repaired surgically with
techniques
Retropubic
colposuspension
Pubovaginal sling
Via minimally invasive RF
bladder neck suspension
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12. Retropubic Colposuspension
• Surgeons use this surgical technique to lift the tissues
near the patient's bladder neck and proximal urethra and
to attach them with sutures to either the ileopectineal line
or the obturator shelf.
• Three variations of this procedure are
The Burch Approach,
The Marshall-marchetti-krantz Approach,
The Paravaginal Defect Repair
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13. Burch procedure
• The Burch procedure has been
the gold standard for surgical
treatment of SUI
• Elevates and fixes the patient's
anterior vaginal wall and
paravesical tissues to the
ileopectineal line of the pelvic
side wall
Vagina and associated structures become a broad sling that supports and
elevates the bladder neck, thus preventing leakage of bladder contents
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14. Pubovaginal Sling
• An artificial support for the
urethra through the use of
a narrow band of either
autologous or synthetic
material, which suspends
the patient's urethra and
helps to prevent leakage of
bladder contents.
• The tension-free vaginal
tape (TVT) procedure
• The transobturator
suburethral tape (TOT)
procedure are the usual
techniques.
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15. RF Bladder Neck Suspension
• Tissue that is targeted with RF thermal energy becomes
denatured and remodeled. This remodeling causes a
decrease in the dynamic compliance of the anatomic
region targeted.
• After RF treatment, elastic fascia is replaced at a
histologic level by stiff fibrotic tissue that improves support
for the bladder neck.
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16. Surgical Anatomy of the Pelvic Floor
Bony Scaffolding
Muscular Supports
of Pelvic Floor
Endopelvic Fascia
and Connective
Tissue Supports.
Supporting Structures
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17. Bony Scaffolding.
• The bones of the pelvis
provide the scaffold on
which the soft-tissue
supports (muscles,
ligaments, and fascia) are
anchored.
• Paired innominate bones
on both sides of the
sacrum comprise the
pelvic girdle.
• The innominate bones are
further divided into the
ileum, the ischium, and
the pubis.
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18. Ischial spine
• The ischial spine provides attachment
• The arcus tendineus fasciae pelvis
• The sacrospinous ligament (SSL)
• The coccygeus muscle
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19. Muscular Supports of Pelvic Floor
• The pelvic floor is a
three-dimensional
structure that functions
as a unit-muscles
ligaments fascia
• The pelvic diaphragm is
composed of the
levator ani muscles
Pubococcygeus
Iliococcygeus a
Coccygeus
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20. Coccygeus
• The coccygeus is also
termed the
ischiococcygeus
muscle
• It is attached medially
to the lateral margins
of the coccyx and fifth
sacral segment and
laterally to the ischial
spine.
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21. lliococcygeus
• The iliococcygeus is
attached to the ischial
spine and the arcus
tendineus levator ani
laterally and the tip of
the sacrum and coccyx
posteriorly.
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22. The pubococcygeus
• The pubococcygeus is
attached to the back of
the pubis, and it
courses lateral to the
urethra in females and
forms a sling around
the vagina, it is termed
the pubovaginalis.
• Fibers of the
pubococcygeus attach
to the perineal body
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23. Pubococcygeus
• The pubococcygeus
compresses the visceral
canals, which cross the
pelvic floor.
• The puborectalis portion of
the pubococcygeus helps
to create the anorectal
angle.
• Contraction of the
puborectalis causes the
rectoanal junction to move
toward the pubic
symphysis, which is
critical in maintaining
fecal continence.
Although the muscles are referred to separately, like other structures of the
pelvic floor, the boundaries are often difficult to delineate and they perform
similar physiologic functions.
Normal defecography
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24. Levator plate
• The posterior levator ani group
(iliococcygeus, pubococcygeus,
and puborectalis muscles) fuses
in the midline and attaches to
the coccyx. The complex formed
by this fusion is the levator
plate, which serves as a
supporting structure for the
upper vagina and cervix,
• Levator plate stabilizes the
upper vagina in a horizontal
plane
• Provides a protective
mechanism and prevents
downward forces onto the
perineal body
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26. Urogenital diaphragm
• Beneath the pelvic diaphragm is
the diamond-shaped
• The boundaries are the pubic
symphysis anteriorly, the tip of
the coccyx posteriorly and
laterally, and the ischiopubic
rami on either side.
• It can be further divided
anteriorly and posteriorly by
imagining a line between the
ischial tuberosities.
• This results in the urogenital
triangle anteriorly and the
anorectal triangle posteriorly.
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27. Perineal membrane
• The deep transversus perinei muscle
or perineal membrane, is contained by
the urogenital triangle, in which the
urethra and vagina traverse.
• The perineal membrane in females has
a dorsal and ventral region
• The ventral region is contiguous with
the paraurethral and paravaginal
connective tissues. This portion
contains the compressor urethrae and
urethrovaginal sphincter muscles of the
distal urethra
• The dorsal region is attached to the
perineal body and the lateral wall of the
vagina via the ischiopubic rami..
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28. • External to the
urogenital triangle are
bulbospongiosus,
ischiospongiosus, and
superficial transversus
perinei.
• The hymen is located
just inside of the labia
minora
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29. Anorectal triangle
• The anorectal triangle
contains the external
anal sphincter, which
attaches to the
anococcygeal ligament
and fuses to the
superficial transversus
muscle.
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30. The urogenital hiatus
• The urogenital hiatus is the
opening within the levator ani
muscle through which the urethra
and vagina pass. Because the
rectum is attached directly to the
muscles at this level, it is not
within the urogenital hiatus.
• The hiatus is supported anteriorly
by the pubic bones and levator
ani muscles and posteriorly by
the perineal body and external
anal sphincter.
• The urogenital hiatus elongates
and descends with POP.
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31. Endopelvic Fascia and Connective Tissue Supports.
• The endopelvic fascia is a
network of fibromuscular
tissue located between
the peritoneum and the
levator muscles.
• The parametrium (broad,
cardinal, and uterosacral
ligaments) attach the
uterus and upper vagina
to the pelvic sidewall.
• The paracolpium (the
arcus tendineus levator
ani and the ATFP) attach
the vagina to the pelvic
sidewalls.
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32. Endopelvic fascia
• Three parts: parietal,visceral and deep
• Parietal : covers muscles namely
obturator,levator,coccygeus(sacrospinous ligament) and
pyriformis
• Visceral covers all the pelvic organs except tubes and
ovaries-no supportive function but distensibility
• Deep : is the most important and in continnum with the
retroperitonial connective tissue.
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33. Deep endopelvic fascia
• 6 ligaments-uterosacrals,cardinals and pubocervicals
• 2 septa-pubocervical provides support to ant.vaginal wall
and bladder
• Rectovaginal septum stabilises and suspends rectum and
perinium
• 1 ring-pericervical-connects all the components of EPF-
stabilies cervix @the level of ischial spines
• Main function is suspends cervix away from UG hiatus
places vagina over levator plate thus acts like a flap valve
closes vagina against the anococcygeal raphae when
there is pressure from above.
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34. Uterosacrals
• S234 to cervix @ 5’ 7’O clock
• Primary proximal suspensory element
Cardinals
• Lateral abd and pelvic wall to cervx@
3&9’O clock
• Lateral stabilisation @the level of
ischial spines
Pubocervicals
• Pubic ramus and AFTP to cervix @ 11
& 1’O clock
• Cervical stabilisation and ant.vaginal
wall support
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35. De Lancey
• The supports of the vagina and conceptually divided them
into three parts according to the region of vaginal support
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36. LEVEL I-Suspensory axis
• The cardinal-uterosacral
ligament complex
• These structures
supports the uterus and
cephalad 2 to 3 cm of
the vagina
• The fibers are primarily
vertical in their
orientation and are the
longest fibers of the
endopelvic fascia.
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38. Level II-Attachment axis
• Level II support is at the midvagina.
• These fibers are shorter than level I
support but longer than those at
level III.
• The orientation of the attaching
fibers is lateral, and they are denser
than the cardinal-uterosacral
complex.
• The endopelvic fascia splits at this
level to encompass the bladder and
urethra such that the abdominal leaf
is still named the endopelvic fascia
and the vaginal leaf is termed the
pubocervical (or perivesical ) and
periurethral fascia.
• Posteriorly, the endopelvic fascia,
which attaches laterally to the
superior fascia of the levator ani
muscles, is the rectovaginal fascia.
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40. Level III-Fusion axis strongest support
• Level III support of the vagina
starts at the introitus and
extends 2 to 3 cm above the
hymenal ring.
• In this most distal location there
is no intervening paracolpium
and the vagina is fused directly
to the urethra and is embedded
in the connective tissue of the
perineal membrane (urogenital
diaphragm.)
• Laterally, it blends into the
medial margins of the levator ani
muscles, and posteriorly it
blends into the perineal body.
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42. Posterior and anterior suspensory axis
Perineal body
Rectovaginal
septum
Pericervical
ring
Uterosacral
ring
Presacral
periosteum
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45. POP-Q
Aa
Ba
Aa-3cm proximal to hymen
Ba-Most distal portion of upper AW
C-Most distal edge of cervix or vault
D-Posterior fornix
Ap-Post vaginal wall 3cm proximal to hymen
Bp-Most distal portion of upper PW
Gh-From middle of ext urthral meatus to
post.midline hymen
Pb- Posterior margin of GH to middle of anal
opening
Tvl- Depth of vagina when point D or C is
reduced to normal
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53. Three by three grid
(Quantitative description of POP)
Anterior wall
Aa
Anterior wall
Ba
Cervix or cuff
C
Genital hiatus
gh
Perineal body
pb
Total vaginal
length
tvl
Posterior wall
Ap
Posterior wall
Bp
Posterior fornix
D
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54. Staging in POP-Q
Stage 0
All points 3cm above hymen and
points C &D are above the
hymen equal to or within 2cm of
total vaginal length
Stage I
All points >1cm above hymen
(value ≤-1)
Stage II
Leading edge of prolapse within
1cm of hymen (value ≥ -1, ≤+1)
Stage III
Maximum prolapse protrudes
≥1cm beyond hymen, but< 2cm
of the total vaginal length (value
≥+1 to [tvl-2])
Stage IV
Maximal prolapse protrudes to
within 2 cm of total vaginal length
(≥ [tvl -2])
St
0
All points 3cm above hymen
and points C &D are above the
hymen equal to or within 2cm of
total vaginal length
Stage
1
All points >1cm above hymen
(value ≤-1)
Stage
2
Leading edge of prolapse within
1cm of hymen (value ≥ -1, ≤+1)
Stage
3
Maximum prolapse protrudes
≥1cm beyond hymen, but< 2cm
of the total vaginal length (value
≥+1 to [tvl-2])
Stage
4
Maximal prolapse protrudes to
within 2 cm of total vaginal
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58. Support by Compartment-anterior and
repair
The major components
are
• The endopelvic fascia
• The ATFP
• The levator ani
muscles
• At this level, the
endopelvic fascia
surrounds the vagina
and attaches to the
ATFP bilaterally.
• Two types of defects
can lead to cystoceles.
• Central- attenuation or
separation of the
pubocervical fascia
• The lateral cystocele
is as a result of -
Detachment of the
pubocervical fascia
and the pubourethral
ligaments to the ATFP
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59. Correction
• Kelly anterior
colporrhaphy -repairing
the pubocervical fascia
with plication sutures
• Vaginal Paravaginal
Repair-reattaches the
pubocervical fascia to
the ATFP.
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60. Apical Compartment
• Apical compartment
defects involve a
disruption in the
uterosacral-cardinal
ligament complex.
• This defect may lead
to prolapse of the
uterus, the vaginal cuff
after hysterectomy,
and enterocele.
• VH and PFR
• Pexy
• Enterocele correction
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61. Enterocele correction
• Waters described four types of
enteroceles by cause:
• Congenital enteroceles occur
either from the failure of the
peritoneum to fuse with the perineal
body or from reopening of
previously fused structures.
• Pulsion defects occur with
increased intra-abdominal
pressures
• Traction enteroceles occur by a
pulling of the vaginal epithelium
from other prolapsing organs.
• Iatrogenic enteroceles are created
when a surgical procedure is
performed that alters the normal
vaginal axis or when the
pubocervical fascia and the
rectovaginal septum are not
reapproximated after hysterectomy
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63. Posterior Compartment
• Defects in the rectovaginal fascia in the
form of either attenuated fascia or site-
specific tears will result in herniation of the
rectum and sometimes the small bowel into
the vagina.
• Richardson 1993
• High rectocele-Defects in the cardinal-
uterosacral ligament complex
• Mid rectocele-Loss of support in the
midvagina from the lateral attachments to
the arcus tendineus fascia rectovaginalis
• Low rectocele- Separation of the perineal
body at the level of the rectovaginal fascia
results in perineal descent or a low
rectocele.
• If perineal body detachment is left
untreated at the time of rectocele repair, a
perineal rectocele can occur in which the
rectum bulges into the perineal body,
termed a perineal rectocele
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64. POSTERIOR COMPARTMENT
REPAIR-KEY POINTS
• Levator plication not advised
• Mesh to be used with caution
• Repair of perineal body by recreating approximation of
rectovaginal connective tissues to the central tendon of
perineum
• Counsel regarding persistence of constipation even after
rectocele correction
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67. To conclude
• The pelvic floor is a complex web of muscle
and fascia and is important in maintaining
continence and supporting the pelvic organs
• The pelvic floor plays a major role in many
conditions such as pelvic organ prolapse,
stress urinary incontinence, urgency and
urge incontinence, and pelvic pain.
• AIM for accurate diagnosis and tailored
treatment programs.
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68. SURGERY SHOULD FIT THE PATIENT AND THE
PATIENT SHOULD NOT FIT THE SURGERY
-MICHAEL SMITH
THANK YOU AND GOD BLESS YOU
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