1-Pelvic Organ Prolapse atf.pdf obg and gyn

Prolapse surgeries and their detailed description of the procedure of choice. Moschcowitz and meckel s cul do plasty.

1. Dr. Shiralee Runwal MSAfraTafreeh.com
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2. •Definition
•Pathophysiology
•Classification/quantification
•Clinical presentation
•Conservative management
•Surgical management
•Recent advancesAfraTafreeh.com
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3. POP is a condition characterized
by descent ofpelvic structures
from their anatomical location.
It is defined as the descent of one or
more of the vaginal walls orcervix:
oanterior vaginal wall prolapse
(cystocele, urethrocele, paravaginal
defect),
oPosteriorvaginal wall prolapse
(rectocele or enterocele),
outerine/cervicalprolapse
ovaginal vault prolapse (after
hysterectomy, often with an
enterocele)AfraTafreeh.com
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4. SUPPORTS OF UTERUSAfraTafreeh.com
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5. TRAMPOLINE THEORYAfraTafreeh.com
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6. Imagine there is a boat tied to a dock.
The pelvic organs (i.e., bladder, uterus, and rectum) are
the boat. The ropes holding the boat to the dock are the
ligaments.
The water is the pelvic floor muscle.
■If the water level drops (i.e. weakness of the pelvic
floor muscles), the boat (organs) hangs on the ropes
(ligaments). Eventually the
ropes stretch out and break, resulting in the boat
(organs) falling down (i.e., prolapse).
■If you pull the boat back up by replacing the ropes (i.e.
organ suspension surgery) without raising the water level
(i.e., pelvic floor muscles strengthening) (C), the boat will
continue to hang on the ropes and eventually falls down
again (i.e., prolapse). Falling happens quicker if you jump
on the boat (i.e., increase pressure in the abdomen from
cough, sneeze, lift, or improper exercise).
“BOAT IN THE DOCK” ANALOGYAfraTafreeh.com
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7. THE HAMMOCK HYPOTHESISAfraTafreeh.com
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8. This theory states that tears in different sites of the
“endopelvicfascia” surrounding the vaginal wall allow
herniation of the pelvic organs.
Specifically, attenuation of the vaginal wall without loss
of fascialattachments is called a distention cystocele or
rectocele With distention-type prolapse, the vaginal wall
appears smooth and without rugae, due to abdominal
contents pressed against the vagina from within.
In contrast, anterior and posterior wall defects due to
loss o the connective tissue attachment of the lateral
vaginal wall to the pelvic sidewall are described as
displacement (paravaginal) cystocele or rectocele. With
displacement-type prolapse, vaginal rugaeare visible.
DEFECT THEORY OF POPAfraTafreeh.com
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9. POP is common in multiparous women.
Pelvic support structure defects are often associated
with:
1.vaginal childbirth–related injury (either neuropathy or
muscularinjury),
2.stress and strainfrom heavylifting,
3.agingprocess(postmenopausal state).AfraTafreeh.com
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10. Symptoms can include vaginal bulging,
pelvic pressure, vaginal bleeding or discharge,
low backache, and the need to replace the
prolapse (splint) in order to void ordefecate
POP can beasymptomatic.
Symptoms are more common when the
prolapse extends beyond thehymenAfraTafreeh.com
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12. Normal support of pelvic organs is provided by several
key anatomicstructures:
•Level I support of the vaginal apex and cervix
is provided by the uterosacraland cardinal
ligaments and associated connectivetissue
•Level II support of the mid-vagina is provided
by connective tissue attachments to the
arcus tendineus fasciae pelvis on the lateral
pelvicside walls
•Level III support of the distal (inferior) vagina
is provided by the perineal membrane and
muscles, and all ofthe attachments are
connected through endopelvic connective
tissue.AfraTafreeh.com
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14. Asymptomatic
The classic symptoms of prolapse include vaginal heaviness
and pressure, a vaginal bulge, pelvic pain, or vaginal
bleeding (from erosions of exposed vaginal epithelium).
Back pain and pelvic pain, the former due to uterosacral
strain.
If a woman with objective prolapse does not have any
symptoms or evidence of associated medical risks such as
urinary retention or renal impairment from urethral or
ureteral kinking, she does not needtreatmentAfraTafreeh.com
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15. Urinary symptoms: urinary incontinence,
difficulty in voiding, slow urinary stream, or
a sensation of incomplete bladderemptying.
Bowel symptoms: constipation, straining,
incomplete evacuation, fecal incontinence, or
splinting (reducing the prolapse) to achieve bowel
movements
Sexual symptoms: discomfort, irritation, and
decreased sexualdesire.AfraTafreeh.com
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17. SHAW’S CLASSIFICATIONAfraTafreeh.com
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18. BADEN & WALKER CLASSIFICATIONAfraTafreeh.com
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19. In 1996, the International Continence Society, the American
UrogynecologicSociety, and the Society of Gynecologic
Surgeons adapted a standardized terminology for the
description of female pelvic organ prolapse and pelvic floor
dysfunction.
This is an objective, site-specific system for describing,
quantifying, and staging pelvic support and was developed to
enhance both clinical and academic communication with
respect to individual patients and populations ofpatients.
The terminology replaces such terms as cystocele, rectocele,
enterocele, and urethrovesical junctions with precise
descriptions relating to specific anatomiclandmarks.AfraTafreeh.com
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20. Point Aa is a point located inthe
midline of the anterior wall 3 cm
proximal to the urethral meatus and
is roughly the location of the
urethrovesicalcrease.
Point Ba represents the most
distal position of any part ofthe
anterior vaginalwall.
Point C represents either the most
distal edge of the cervixor the
leading edge (apex) of the vagina if
a hysterectomy has been
performed.AfraTafreeh.com
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21. Point D represents the location of the
posterior fornix (pouch of Douglas) ina
woman with acervix.
Point Bp is a point most distal of any part
of the upper posterior vaginalwall,
Point Ap is a point located in the
midline of the posterior vaginal wall3
cm proximal to thehymen.AfraTafreeh.com
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22. PB -length of the perineal body between the
posterior vaginaand rectum
GH -genital hiatusmeasurement from the
urethra to the posterior vagina
TVL –Total vaginal length, taken after
reposition of the prolapse
•Theseexcept tvl,are measuredduring
straining
•The most severe prolapse measurement
on any of the vaginal walls can then be
used to assign the stage ofprolapseAfraTafreeh.com
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25. Loss of anterior vaginal wall support is the
most common site of primaryPOP.
Normal support of the anterior vaginal wall
depends on level I apical support and level
II support from the endopelvic connective
tissue and its attachments to the bony
pelvis and pelvic muscles.
Anterior vaginal wall prolapse can be
associated with stress urinary incontinence
from urethral hypermobility or urinary
retention from urethral kinking that causes
obstructionAfraTafreeh.com
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26. Cystocele is the protrusion of the bladder into
the vagina, signifying the relaxation of fascial
supports of the anterior vaginalwall.
Fascial breaks:
•Lateral breaks correspond to
paravaginaldefects;
•Apical detachments from the pubocervical
fascia of the cervix or vaginal apex are
transversecystoceles
•Distal detachments from near the pubic
symphysis appear as urethroceles or
urethralhypermobility.AfraTafreeh.com
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27. 1.sensationof
fullness
2.pelvicpressure
3.vaginalbulge
4.feeling that organs are fallingout
5.feeling of incomplete emptyingwith voiding
6.slow urinarystream
7.urinaryurgency.
Signs:
Soft, bulging mass of the anterior vaginalwall.
In some patients this mass must be replaced manually before
the patient canvoid.
Strain, cough, or prolonged standingoftenaccentuates the
bulge.
Often POP symptoms are less bothersome in the morning
and worsen later in the day after uprightactivities.
Symptoms:AfraTafreeh.com
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28. Theurethrocoele and cystocele are bestdemonstrated with a
patient in the lithotomyposition.
A retractor or posterior wall blade of a Graves speculum is
used to depress the posterior vaginalwall.
The patient is then asked to strain, and the degree of
cystocele or urethrocele isnoted.
The physician should palpate the bladder neck and feel
whether it is wellsupportedAfraTafreeh.com
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29. Best performed with the bladder at least
partially filled (100 to 250mL).
Also perform supine stress test to
demonstrate SUI.
A standing exam with Valsalva often
allows the physician to see the maximal
descent of the POP.
CLINICAL EXAMINATION AfraTafreeh.com
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30. ESTIMATION OF STRENGTH OF THE PELVIC FLOOR
Laycock developed the Modified Oxford Grading System to
evaluate the strength of the pelvic floor muscles by using
vaginal palpation.AfraTafreeh.com
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31. Apply PERFECT scheme :--
P: power/strength
E: endurance up to 8 seconds
R: repetitions up to 10 times
F: fast 10 fast squeezes
E: elevation observe elevation of clitoris
C: co-contraction of pelvic floor
T: timed can they cough and squeeze
The “PERFECT” scaleAfraTafreeh.com
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32. First, the bulbocavernosusreflex is elicited by
tapping or stroking lateral to the clitoris and
observing contraction of the bulbocavernosus
muscle bilaterally.
Second, evaluation of anal sphincter innervation
is completed by stroking lateral to the anus and
observing a reflexive contraction of the anus,
known as the anal wink reflex.
Intact reflexes suggest normal sacral pathways.
Role of ReflexesAfraTafreeh.com
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33. Vulval cyst and Gartner cyst tumour can be easily
differentiated from prolapse. The cyst of the
anterior vaginal wall is usually tense with well-
defined margins and cannot be reduced on
pressure.
Urethral diverticula are rare, always small and are
situated low down in the anterior vaginal wall.
Urethroscopyhelps in the diagnosis.
Congenital elongation of the cervix can be
differentiated from prolapse because it is the
vaginal portion of thecervix that is elongated and
there is no accompanying vaginal prolapse. The
fornices are deep.
Differential Diagnosis AfraTafreeh.com
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34. Cervical fibroid polyps can be easily identified as
the cervix is high up in its normal anatomical
position.
Chronic inversion can be recognized because the
cervix is further up, and the uterus cannot be
defined. The uterine sound will confirm the
diagnosis. Ultrasound and laparoscopy will
identify the fundal depression and absence of
uterine fundus in the pelvis.
Differential Diagnosis AfraTafreeh.com
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35. Antenatal physiotherapy, relaxation exercises
Proper supervision and management of the second stage of labour is needed.
A generous episiotomy in all complicated labour, for example, breech delivery
should be considered.
Low forceps delivery should be readily resorted to if there is delay in the
second stage of labour.
A perineal tear must be immediately and accurately sutured after delivery.
Postnatal exercises and physiotherapy are beneficial.
Early postnatal ambulation.
Provision of adequate rest for the first 6 months after delivery.
A reasonable inter-pregnancy interval
Avoiding multiparity
Prophylactic hormone replacement therapy (HRT)
Prophylaxis of ProlapseAfraTafreeh.com
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36. Treatment of anterior vaginal wall prolapse may
undergo non-operative or operative
management. depending on patient preferences
andgoals.
If the patient is not bothered by the prolapse, it
is betterleft alone and managed expectantly
unless it is causing urinary retention or renal
hydronephrosis.
Women with mild (e.g., Stage 2) POP may elect
for non-operative management with pelvic floor
physical therapy and KegelexercisesAfraTafreeh.com
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37. Non-operative treatment
consists of supporting the
herniation of the anterior
vaginal wall with the use of:
1.Smith-Hodgering
2.Cube
3.inflatablepessary
4.Intermittent use of a largetampon.
5.Kegel exercises -help to strengthenthe
pelvic floor musculature and thereby may
relieve some of the pressure symptoms
produced by thecystocele.AfraTafreeh.com
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38. Operative repair of a cystocele is generally
performed in conjunction with the repair of all
other pelvic support defects.
Repair consists of:Anterior colporrhaphy&
Correction of uterine descensus or apicaldefect
Cystoscopy should be performed to assess
bladder and ureteral integrity after the
procedure iscompleted.
Buttressing of the pubovesicocervicalfascia is
also known as A-repair.
Urethrocele& Cystocele
ManagementAfraTafreeh.com
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39. Rectocoele: signs andsymptoms
heavy pelvic pressure or “fallingout”feeling in thevagina.
May complain of constipation and occasionally may need to splint the
vagina with her fingers to affect a bowel movement.
May also have a feeling of incomplete emptying of the rectum at the
time of the bowelmovement.
Protrusion of the prolapse may worsen later in the day and be
aggravated by prolonged standing orexertion.AfraTafreeh.com
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40. Identified by retracting the anterior vaginal wall upward with
one half of a Graves or Pederson speculum and having the
patientstrain.
The rectum will bulge into the vagina, and this bulgemay
protrude through theintroitus
The physician should then place one finger in the rectum and one
in the vagina and palpate thedefect(tenting).
Often the rectovaginal septum is paper thin, andthe
rectocele can be palpated to its uppermargin.AfraTafreeh.com
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41. Herniation of the pouch of Douglas (cul-desac) between
the uterosacral ligaments into the rectovaginal septum and
usually contains smallbowel.
It frequently occurs after an abdominal or
vaginalhysterectomy
Generally is the result of a weakened support for the pouch
of Douglas and the loss of vaginal apical support by the
uterosacralligaments.
True hernia of the peritoneal cavity emanating from POD
between the uterosacral ligaments and into the rectovaginal
septumAfraTafreeh.com AfraTafreeh.com

42. Enterocoele is noticed as a separate bulge above
the rectocele, and at times it may be large enough
to prolapse through the vagina
Transilluminatethe bulge and seeing small bowel
shadows within thesac.
Gurgling sound may be appreciated
The classical “Double hump sign” in presence of
both enterocoele& rectocoele.AfraTafreeh.com
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43. Enterocelesmay be reduced transabdominally(as aprimary
procedureor at the time of other abdominal procedures).
Moschowitzor Halbanrepair is made use of.
In the primary procedure the sac should be reduced upward if
possible and dissected free from the bladder andrectum.If the
uterosacral ligaments are present, these may be brought together in
the midline and attached to the vaginal cuff after closing the
anterior and posterior fascia of the vaginalapex.
Concentric purse-string sutures/multiple A-P suturesin the
endopelvicfascia may obliterate thecul-de-sac.AfraTafreeh.com
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44. McCall’s Culdoplasty
In 1957, Milton McCall, MD, described a technique to
manage the cul-de-sac at the time of vaginal
hysterectomy.
The McCall technique of posterior culdoplasty differs from
other approaches by omitting dissection and excision of
the hernia sac, or excess cul-de-sac peritoneum.
The original McCall culdoplasty begins with the placement
of several rows (average of 3) of non-absorbable suture
(“internal” McCall sutures), starting at the left uterosacral
ligament about 2 cm above its cut edge, and proceeding
across the redundant cul-de-sac to terminate in the right
uterosacral ligament.
Each subsequent row is placed superior to the first, by
applying traction to the previously placed sutures.AfraTafreeh.com
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45. McCall’s Culdoplasty
Prior to the tying of these sutures, 3 “external” absorbable
sutures are placed.
These sutures incorporate posterior vaginal epithelium, each
uterosacral ligament, and the contralateral vaginal epithelium
in a mirror image of the first pass through the vagina.
Again, several rows are placed, each more superior to the
last, to move the newly created vaginal apex to the highest
point on the uterosacral ligaments once all the sutures are
tied.
Tying the internal sutures not only creates a firm, shelf-like
midline structure, but obliterates the redundant cul-de-sac.
The external sutures move the vaginal apex to the uterosacral
bridge and are tied at the conclusion of the procedure.AfraTafreeh.com
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46. Associated with injuries of the
endopelvic fascia, including the
cardinal and uterosacral ligaments,
as well as injury to the
neuromuscular unit with relaxation
of the pelvic floor muscles,
particularly the levator animuscles
Occasionally, prolapse is the result of
increased intraabdominal pressure
(acites or large pelvic or intraabdominal
tumors) superimposed on poor pelvic
supportsAfraTafreeh.com
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47. Stage I uterine prolapse does not require
therapy unless the patient is very
uncomfortable
For stages 2-4, operative repair for
prolapse of the uterus and cervix generally
involves a vaginal hysterectomy with pelvic
floor repair (Ward Mayo operation)
accompanied bya vaginal vaultsuspension.AfraTafreeh.com
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48. NON-SURGICAL MANANGEMENTAfraTafreeh.com
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49. Pessariesin play !
Pessariesare divided into two broad categories: support
and space-filling.
Support pessaries, such as the ring pessary, use a spring
mechanism that rests in the posterior fornix and against
the posterior aspect of the symphysis pubis
In contrast, space-filling pessariesmaintain their
position by creating suction between the pessary and
vaginal walls (cube), by creating a diameter larger than
the genital hiatus (donut), or by both mechanisms
(Gellhorn).
Ideal in pregnancy, puerperium & moribund patients.AfraTafreeh.com
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50. Generally, a patient is fitted with a pessary
while in the lithotomy position after she has
emptied both her bladder and rectum.
A digital examination is performed to assess
vaginal length and width, and an initial
estimation of pessary size is made.
Lubricant is placed on either the vaginal
introitus or the pessary’sleading edge. While
holding the labia apart, the pessary is inserted
by pushing in a cephaladdirection and against
the posterior vaginal wall.
Procedure & MechanismAfraTafreeh.com
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51. Next an index finger is directed into the posterior
vaginal fornix to ensure that the cervix is resting
above the pessary.
The pessary should fit snugly but not tightly against
the symphysis pubis and the posterior and lateral
vaginal walls.
Following pessary placement, a woman is prompted
to perform a Valsalva maneuver, which might
dislodge an improperly fitted pessary. She should be
able to stand, walk, cough, and urinate without
difficulty or discomfort.
Procedure & MechanismAfraTafreeh.com
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52. In some women the cervix is hypertrophied and
elongated to the area of the introitus, but the
supports of the uterus itself areintact.
A cystocele and rectocele may be present, and
operative repair can consist of a Manchester (Donald
or Fothergill)operation.
Combines an anterior and posterior colporrhaphy with the
amputation of the cervix and the use of the cardinalligaments
to support the anterior vaginal wall andbladder(Sturmdorf
suture).
Ideal for women who have an elongated cervix and well-
supported uterus becauseit is technically easier and has a
shorter operative time than the vaginalhysterectomyAfraTafreeh.com
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53. In elderly women who are no longer sexually
active, a simple procedure forreducing prolapse
is an obliterative procedure called a colpocleisis
(Le Fortprocedure)
The classic partial colpocleisis procedure was
described by Le Fort in1877
It involves the removal of a strip of anterior
and posterior vaginal wall,withclosure of the
margins of the anterior and posterior wall to
eachother.
The vaginal cavity is nearly completely closed,
with small vaginal canals on either side of the
opposed vaginal walls to allow drainage of any
fluid from the cuff oruterus.AfraTafreeh.com
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54. Goodall-Power modification of the Le Fort operation
allows for the removal of a triangular piece of vaginal
wall beginning at the cervical reflection or 1 cm above
the vaginal scar at the base of the triangle, with the
apex of the triangle just beneath the bladder neck
anteriorly and just at the introitusposteriorly.
The cut edge of vaginal wall making up the base of the
triangle anteriorly is sutured to the similar wall
posteriorly, and the vaginal incision is then closed with a
row of interrupted sutures beginning beneath the
bladder neck and carried side to side to the area of the
introitus.
Ideal for relatively small prolapses, whereas the Le Fort is
best for largerones.AfraTafreeh.com
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55. How to manage apical defects ?
One of the most widely performed transvaginal suspension
procedures is the sacrospinous fixation in which the coccygeus
sacrospinous ligament is attached to the vaginal apex.
Advantages include avoiding the morbidity of an abdominal
incision, achieving a functional vagina, and the ability to
repair coexisting anterior and posterior compartment defects
using a single surgical site.
However, because the technique displaces the vaginal axis
posteriorly, it can often lead to the development of new
anterior compartment defects.
Associated complications that have been reported include
intraoperative hemorrhage due to laceration of the pudendal
artery, vaginal shortening, sexual dysfunction, and injury to
the pudendal nerveAfraTafreeh.com
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56. The uterosacral suspension is an alternative transvaginal
approach in which the plication of the uterosacral ligaments
across the midline is preformed and attached to the vaginal
cuff. Disadvantages to consider in this approach is the
proximity of the uterosacral ligaments to the ureters.
In recent years, the procedure of choice has become the
abdominal sacrocolpopexy, which can be done by either
laparotomy, laparoscopy, or robotic-assisted. Since the initial
delineation of the procedure by Lane in 1962, the procedure
has gone through many modifications. Birnbaum has
advocated anchoring the suspensory mesh to the sacrum.
However, there is a high risk of hemorrhage from laceration
of the presacralvessels.
How to manage apical defects ?AfraTafreeh.com
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57. MESH --A miracle or mess ?
The use of biologic grafts or synthetic mesh has expanded rapidly and
in the absence of supporting long-term safety and efficacy data.
Selective use may include:
(1)the need to bridge space
(2) weak or absent connective tissue
(3) connective tissue disease
(4) high risk or recurrence (obesity, chronically increased intra-
abdominal pressure, and young age)
(5) shortened vagina
Type I Macroporousmesh is ideal.
Mesh erosion, extrusion & scarring are known complications.AfraTafreeh.com
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58. APOGEE/PERIGEE/PROLIFT REPAIRAfraTafreeh.com
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59. NULLIPAROUS PROLAPSE
Since India has the largest prevalence of nulliparous prolapse, it is no
surprise that Indian gynecologists have devised most of the
conservative operations for genital prolapse.
The various conservative sling operations for genital prolapse in young
women who want to preserve fertility are:--
•Shirodkar sling
•Purandare cervicopexy
•Khanna sling
•Soonawallasling
•Joshi sling
•Virkudsling
•Mangeshkar’slaparoscopic technique
•Neeta Warty’slaparoscopic modification of Shirodkar’s operationAfraTafreeh.com
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60. Shirodkar’s Sling Operation
VN Shirodkar was the first to describe a conservative sling
operation.
His aim was to recreate the uterosacral ligaments because he
realized that they have a more important role in prevention
of genital prolapse that the cardinal ligaments.
In his sling operation one end of tape is attached to the
anterior longitudinal ligament and then passed
subperitoneallyalong the right pelvic wall between the two
leaves of broad ligament and transfixed to isthmus
posteriorly.
It passes posteriorly through left broad ligament; it is then
passed through a psoas loop, through the sigmoid mesentery
back to the sacral promontory where it is fixed.AfraTafreeh.com
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61. Shirodkar’s Sling Operation
Shirodkar sling has following advantages:
•Anatomically it is the most correct
operation as it maintains the uterus in its
correct anatomical position.
•It provides a strong static bony support.
•No tendency to enterocele formationAfraTafreeh.com
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62. Shirodkar’s Sling Operation
Disadvantages of the sling operation are:
Technically very difficult to perform
The degree of difficulty is more on the left side
where the sling has to pass through the Psoas
loop and then under the sigmoid mesentery
There is risk of injuring the nerves passing
through the psoas muscle while making the Psoas
loop.
Since it is a closed loop sling, should it become
tight, there is a risk of bowel obstruction.AfraTafreeh.com
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63. Purandare’s Sling Operation
Purandare cervicopexy was first described
by Dr. B. N. Purandare in 1965.
He used rectus sheath strips as sling
material. Purandare cervicopexy was later
modified by Dr. V. N. Purandare and
PravinMhatre; they used Mersilenetape
and attached the tape to the isthmus
posteriorly instead of anteriorly.AfraTafreeh.com
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64. Purandare’s Sling Operation
Advantages of Purandare’s sling are:
•Technically very easy to perform
•Provides dynamic support to uterus
Disadvantages are:
•The uterus becomes retroverted
•There is a tendency to enterocele
•Since the tape is anchored to the isthmus anteriorly, it may
be damaged at subsequent cesarean section (LSCS) operation.
•Advancement of bladder on uterus may make exposure of
lower uterine segment difficult.
•Since it is a closed loop sling, should it become tight, there is
a risk of bowel loops being trapped between uterus and
anterior abdominal wallAfraTafreeh.com
AfraTafreeh.com

65. Khanna’s Sling Operation
Brigadier SD Khanna propounded this technique
for conservative treatment of nulliparous prolapse.
The principle aim of the sling is to strengthen the
cardinal ligaments. The ends of the tape are
attached to the anterior superior iliac spines.
Disadvantages are:
If the tape is very superficial, it can be very easily
felt by the patient
If skin wound gets infected, periosteitisresults
which is very painful and there is a risk of the tape
getting detached.AfraTafreeh.com
AfraTafreeh.com

66. Virkud’s Sling Operation
Here the tape is fixed to anterior longitudinal ligament,
passed subperitoneallyalong right side, and then
transfixed to isthmus posteriorly at the level of the
uterosacral ligaments.
The tape is then passed between two leaves of left broad
ligament, it then pierces the transversals fascia in the
internal inguinal ring and passes medially between the
anterior rectus sheath and rectus muscle where it is
fixed to the rectus compartment.
This operation has the advantages of Shirodkar and
Purandare sling operations, and at the same time, it
avoids the disadvantages of both these operationsAfraTafreeh.com
AfraTafreeh.com

67. Virkud’s Sling OperationAfraTafreeh.com
AfraTafreeh.com

68. Advantages are:
•Provides double support: Bony (sacral
promontory)+Dynamic (rectus sheath)
•Uterus remains anteverted
•No tendency to enterocele formation
•No risk of injury to sigmoid mesentery/colon or the
genitofemoralnerve
•No risk of bowel obstruction (open sling)
•No difficulty in subsequent LSCS: as tape is posterior
Only disadvantage is that it tends to dextrortoatethe
uterus: This is the reason why it is advised to do
plication of the left uterosacral ligament.
Virkud’s Sling OperationAfraTafreeh.com
AfraTafreeh.com

69. Soonawala’sSling Operation
Dr. RP Soonawalaadvises only a right sided
posterior sling as in Shirodkar’s sling operation
to avoid the risks of passing the sling on the
left side.
Advantages of Soonawalasling are:
No risk of bowel obstruction (open sling)
No risk of injury to sigmoid mesentery/colon
or the genitofemoralnerve
Disadvantages are:
Position of uterus may be distortedAfraTafreeh.com
AfraTafreeh.com

70. Joshi’s Sling Operation
A technique described by Dr. VivekJoshi from Pune is
an extraperitonealsling operation where the uterus is
suspended from the pectinealligaments on either side
with Mersilenetape.
Advantages of Joshi sling are:
Gives good static support.
No risk of injuring the ureters, rectosigmoid, median
sacral vessels.
Disadvantages are:
Operating in the retropubic space requires experience
Risk injury to vessels in the retropubic spaceAfraTafreeh.com
AfraTafreeh.com

71. “Rule of 11”
11% lifetime risk of POP surgery
11%risk of re-operation after primary surgery
Within next 11years, it tends to recur at a different siteAfraTafreeh.com
AfraTafreeh.com

72. THANK YOUAfraTafreeh.com
AfraTafreeh.com