Classification & conservative surgeries for prolapse

Stage 0
no prolapse
- Aa,Ba,Ap,Bp are all at -3
- C or D between tvl and 1cm above level of hymen
Stage II
1cm below the plane of the hymen
Stage IV
complete eversion, distal portion at least (tvl -2 cm)

1. Classification & conservative surgeries for prolapse Presenter:- Dr. Indraneel Jadhav MBBS, DGO, DNB Consultant Gynecologist and IVF Indira IVF, Kolhapur

2. Mechanisms preventing prolapse

3. De Lancey’s supports – 1990’s

4. Classification of prolapse

5. Shaw’s classification of prolapse

6. Baden walker Classification of prolapse

7. POP - Q Classification of prolapse Aa Ba C gh pb tvl Ap Bp D

8. Stages of pelvic organ prolapse 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)

9. Per speculum examination

10. The operative treatment of prolapse in childbearing age posses 3 different problems Repair of prolapse should not hamper fertility of patients Should not hamper course of normal labour Should not give away following child birth or cause recurrence

11. Abdominal Sling operations Indicated in nullipara & young women. Preserves reproductive function. Objective Buttress the weakened support Mackenrodts and uterosacral ligaments

12. Selection criteria First or second degree Uterine prolapse Uterocervical length less than 5 inches No infravaginal elongation of cervix Cystocele or rectocele if present should be repaired before the surgery

13. Purandare’s cervicopexy Rectus sheath is anchored to Anterior part of isthmus through ASIS and the leaves of broad ligament Purandare and Mhatre ‘s modification Tape is fixed posteriorly to isthmus below uterosacrals

14. Shirodkar’s sling Principle Tape is fixed to the posterior aspect of isthmus & sacral promontory Anatomically most correct but difficult to perform In cases of Defective rectus sheath Poor abdominal muscle tone Failed purandare’s cervicopexy

15. Shirodkar’s sling operation Right side Shirodkars needle is passed through retroperitoneal space and tape is attached posteriorly to isthmus Left side Peritoneum over psoas muscle exposed Psoas loop made Knot is placed lateral Shirodkars needle is passed through retroperitoneal space and tape is attached posteriorly to isthmus

16. Khanna’s sling Support is from bony point Tape is fixed to the posterior aspect of the isthmus to the anterior superior iliac spine

17. Virkud’s composite sling operation End of mersilene tape - sacral promontory to posterior surface of isthmus - sutured to rectus sheath Plication of left side uterosacral ligament to correct dextrorotation

18. Virkud’s composite sling operation Advantages Easy to perform Double support- bony + dynamic Tape is posterior-no risk during LSCS No enterocele No injury to sigmoid colon

19. Joshi’s sling Anterior surface of the uterus at the level of the internal os is suspended to the pectineal ligament on both side with merciline tape

20. Soonawala’s sling Anterior longitudinal ligament on S1 vertebra Along right side uterosacral ligament of isthmus Retracted extraperitoneally to S1 vertebra

21. Fothergill operation / Manchester operation Principle steps Anterior colporrhaphy Plication of Mackenrodts ligaments in front of the cervix using fothergills stitch Partial amputation of the cervix Amputated cervix covered with vaginal flap using sturmdorff suture Posterior colpoperineorrhaphy

22. Manchester (Fothergill) repair

23. Manchester (Fothergill) repair

24. Shirodkar’s modification of Fothergill’s operation Amputation of cervix is not done Plication of uterosacral ligaments Nadkarni’s sleeve operation Modification of Fothergill’s operation Supravaginal portion is excised Fertility is not affected

25. LeFort’s Operation/ Partial colpocleisis Old age and unfit for surgery Uterine pathology to be ruled out Pap smear to be done

26. LeFort’s repair Principle- Rectangular flaps of anterior and posterior vaginal wall are denuded Apposition of vaginal walls Two channels are left for drainage Complication: Bleeding from raw area during surgery UTI Urinary stress incontinence Enterocele

27. LeFort’s repair

28. Complete colpocleisis / colpectomy Entire vaginal mucosa is excised High risk of post operative stress urinary incontinence

29. Grafts Types 1. Autologous grafts Fascia lata Rectus sheath 2. Synthetic Macroporous >75microns Mersilene , Marlex , Prolene Gynemesh Pore size < 75microns Complications Mesh erosion Infection Prosthetic repair

30. Tension-free vaginal mesh (TVM) systems Prolift , Apogee/Perigee Avaulta all of which vary in terms of mesh size, shape and surgical technique

31. This system has four main characteristics: Mesh -replacement for defective visceral pelvic fascia Bridge between the left and right arcus tendineus fascia pelvis (white line, or ATFP) Large-size mesh is held in place by passing cannulas through the obturator fascia (anterior wall) or the sacrospinous ligament (SSL) to attach the arms of the mesh graft Bladder neck is preserved Mesh repair-principles

32. Laparoscopic surgery Vaginal length must be maintained Ureters must be identified and dissected Requires great skill and expertise Newer conservative surgeries Vaginal sacrospinous cervico-colpopexy / sacrospinous hysteropexy Posterior intravaginal slingplasty Abdominal /laparoscopic sacrocolpopexy Posterior mesh repair

33. Hysterectomy should not be the prime treatment and fixing of the cervix to strong ligament such as sacrospinous ligament could give a more successful result and conservation of the uterus in young women

34. Anterior colporrhaphy To correct cystocele and  urethrocele The underlying principles are to excise a portion of the relaxed anterior vaginal wall To mobilize the bladder and push it upwards after cutting the vesicocervical ligament The bladder  is then permanently supported by plicating the  endopelvic fascia and the pubocervical fascia under  the bladder neck in the midline

35. Anterior colporrhaphy

36. Paravaginal defect repair Abdominal method Entering the retropubic space To correct detachment between vagina and arcus tendinus Repair is done by fixing (reattaching) the endopelvic fascia to the arcus tendineus fascia (white line) of the pelvis. Done retropubically through the space of Retzius or vaginally.

37. Paravaginal defect repair