Classification & conservative surgeries for prolapseIndraneel Jadhav
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)
Classification & conservative surgeries for prolapseIndraneel Jadhav
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)
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 a lecture delivered during the 15th Postgraduate Course of the Jose R Reyes Memorial Medical Center- Department of Obstetrics and Gynecology on June 9, 2021. This is intended for Obstetrician-gynecologists in training and/or in practice.
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
Robson classification Dr. Iqra Malik.pptJawad Awan
Cesarean section (CS) was introduced to obstetrical practice as a lifesaving procedure both for mother and her child. It gives an opportunity to evaluate the prevalence of CSs among various groups of women, to compare data between institutions, learn from each other and to create strategies for better results.
Based on the available knowledge, the Robson classification (the Ten-group classification system) meets the current needs the best.
Caesarean section (CS) rates have been increasing worldwide and have caused concerns. For meaningful comparisons to be made World Health Organization recommends the use of the Ten-Group Robson classification as the global standard for assessing CS rates.
Adherent placenta occurs when there is a defect in the decidua basalis, Resulting in an abnormal invasion of the placenta directly into the substance of the uterus
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 a lecture delivered during the 15th Postgraduate Course of the Jose R Reyes Memorial Medical Center- Department of Obstetrics and Gynecology on June 9, 2021. This is intended for Obstetrician-gynecologists in training and/or in practice.
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
Robson classification Dr. Iqra Malik.pptJawad Awan
Cesarean section (CS) was introduced to obstetrical practice as a lifesaving procedure both for mother and her child. It gives an opportunity to evaluate the prevalence of CSs among various groups of women, to compare data between institutions, learn from each other and to create strategies for better results.
Based on the available knowledge, the Robson classification (the Ten-group classification system) meets the current needs the best.
Caesarean section (CS) rates have been increasing worldwide and have caused concerns. For meaningful comparisons to be made World Health Organization recommends the use of the Ten-Group Robson classification as the global standard for assessing CS rates.
Adherent placenta occurs when there is a defect in the decidua basalis, Resulting in an abnormal invasion of the placenta directly into the substance of the uterus
Consolidated guidelines on
the Use of Antiretroviral
Drugs for Treating and
Preventing HIV Infection
Summary of key features and recommendations
JUNE 2013
Vaginal prolapse is a condition in which structures such as the uterus, rectum, bladder, urethra, small bowel, or the vagina itself may begin to prolapse, or fall out of their normal positions.
Genital prolapse is the descent of one or more of the genital organ (urethra, bladder, uterus, rectum or Douglas pouch or rectouterine pouch”) through the fasciomuscular pelvic floor below their normal level.
PELVIC ORGAN PROLAPSE, uterine prolapse , cystocele, rectocele, urethrocele, supports of uterus, sling surgeries, pessaries, grades of prolapse, uterine preserving surgery for pop, pelvic floor repair, vaginal hysterectomy, ward mayos surgery, pop q grading, grading of prolapse, laproscopic surgeries for prolapse, peregee, apogee , mesh repair, tot, tvt, colpo suspension, colpoclysis, SUI management, epidemiology of prolapse, decubitus ulcer, best ppt for pelvic organ prolapse, better understanding of pelvic organ prolapse and pelvic floor.
PELVIC ORGAN PROLAPSE, uterine prolapse , cystocele, rectocele, urethrocele, supports of uterus, sling surgeries, pessaries, grades of prolapse, uterine preserving surgery for pop, pelvic floor repair, vaginal hysterectomy, ward mayos surgery, pop q grading, grading of prolapse, laproscopic surgeries for prolapse, peregee, apogee , mesh repair, tot, tvt, colpo suspension, colpoclysis, SUI management, epidemiology of prolapse, decubitus ulcer, best ppt for pelvic organ prolapse, better understanding of pelvic organ prolapse and pelvic floor. dr . m. gokul reshmi, dr. gokulreshmi m
Pelvic organ prolapse
Etiology of pelvic organ prolapse
Vaginal vault prolapse
Etiological factors of vault prolapse
Signs and symptoms of vaginal vault prolapse
Diagnosis of vaginal vault prolapse
Treatment measures
MANAGEMENT OF ATRIOVENTRICULAR CONDUCTION BLOCK.pdfJim Jacob Roy
Cardiac conduction defects can occur due to various causes.
Atrioventricular conduction blocks ( AV blocks ) are classified into 3 types.
This document describes the acute management of AV block.
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
Factory Supply Best Quality Pmk Oil CAS 28578–16–7 PMK Powder in Stockrebeccabio
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Hot Selling Organic intermediates
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
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.
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
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
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
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
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.
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.
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
6. • Pelvic Ligaments –
condensation of visceral connective
tissue that assume special
supportive role.
- Sacrospinous lig.
- Sacrococcygeus lig.
- ArcusTendinous Fascia Pelvis
- ArcusTendinous Levator Ani
- Cardinal / Utero-sacral ligament
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
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
9. 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
11. De Lancey vaginal supports.
Level Support Defect
1
Proximal(upper)
Paracolpium ligs
USL & Cardinal.
.UV prolapse
.vault prolapse
.enterocole
2
Mid-Vaginal
Lat attachment to pelvic
side wall to ATFP, ATLA
Anterior & post wall
defects & SUI.
3
DistalVaginal
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)
13.
14. •In vaginal delivery pelvic floor exposed to
compressive and expulsive forces. 238 – 403
mmHg.
•Prolonged 2nd stage- O2 deprivation causes necrotic
changes. Ms , paravaginal tissue severely atrophied
or dysfunctional.
•Pudendal neuropathy following delivery.
15.
16. • 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).
“Good obstetrician is the essence of preventive
gynaecology” (Novak)
17. • Chronic increased intra abdominal pressure- obesity, constipation,
COPD,Hypothyroidsism, lifting heavy weight.
• Following hysterectomy , secondary hypotrophy of the cardinal-
uterosacral ligament complex .(iatrogenic)
18. •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.
19.
20. 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)
24. Stages of POP–Q system measurement
Stage 0 no prolapse is demonstrated
Stage 1 the most distal portion of the prolapse is > 1 cm above the
level of the hymen
Stage 2 the most distal portion of the prolapse is 1 cm or less proximal
or distal to the hymenal plane(> -1 but <1 cm)
Stage 3 the most distal portion of the prolapse protrudes more than 1
cm below the hymen but protrudes no farther than 2 cm less
than the total vaginal length [>+1 but <+(tvl-2cm)]
Stage 4 vaginal eversion is essentially complete [≥+(tvl-2)]
25. Site Specific Prolapse
Repair
CYSTO/RECTOCOELE
- Dislocation - Overdistention
CAUSE
• Damage to lateral Destruction of fibromuscular elasticity
support with increase total
length & width of
vag wall & fornices
connective tissue
CORRECTION
• Restoration of vaginal Reduction of width
depth, axis and
support.
Inverted ‘T’ Repair Parachute Repair
26. Cont. Evaluation
• 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.
27. ENTEROCOELE WITH VP
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.
28. 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
29. 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
30. 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
31. 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
32. 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.
33. 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
34. 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
35. 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
36. 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
37. • 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.
P
R
E
V
E
N
T
I
O
N
42. P1000701.jpg
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
P1000701.jpgP1000701.jpg
43. 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.
44. 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
45. 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
46. 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
47. • 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 & 1st 3 sacral
vertebrae incised & continued to vaginal incision.
Abdominal Sacral Colpopexy
48. • 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.
49. 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
50. 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.
51. 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
52. COMPARATIVE STUDY of 56 CASES (23-A, 33-V)
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%
FAILURE ABSOLUTE: RECURRENCE OFV.P. ….. 3 (5.35%)
53. 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
54. •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