MANAGEMENT OF VAULT PROLAPSE BY DR SHASHWAT JANI

MANAGEMENT OF VAULT PROLAPSE BY DR SHASHWAT JANI

1. Management Of V ault P rolapse Dr. Shashwat K. Jani. M. S. ( Obs – Gyn ) Diploma in Advance Laparoscopy. Consultant Assistant Professor , Smt. N.H.L. Municipal Medical College. Sheth V. S. General Hospital , Ahmedabad. Mobile : [phone]. E-mail : [email protected]

2. It is most distressing to find a patient coming back with complaints of SCOPV after a hysterectomy…!!! 

3. Tackling of vault prolapse (VP ) is relatively rare and uncommon . Knowing the aftermaths of hysterectomy it takes time for a Gynecologist to mentally get tuned to the fact that patient requires repeat surgery …!!!

4. Definition Post - hysterectomy Vaginal Prolapse “ Descent of the vaginal cuff scar, below a point that is 2 cm less, than the total vaginal length , above the plane of the hymen. “ *International Continence Society

5. A common complication following vaginal hysterectomy with negative impact on women's quality of life due to associated urinary, anorectal and sexual dysfunction. A clear understanding of the supporting mechanism for the uterus and vagina is important in making the right choice of corrective procedure. 

6. Age Poor tissue condition, Scar tissue, Increased abdominal pressure Neuropathies Obesity Previous pelvic surgery Associated Medical condition

7. Why Post Hysterectomy …??? Hysterectomy causes: The attenuation of the cardinal/ uterosacral ligament complex when they are excised during hysterectomy. The separation of the pubocervical fascia from the rectovaginal fascia. The separation of the pubocervical fascia, rectovaginal fascia from the cardinal/ uterosacral ligament complex

8. Symptoms Pelvic heaviness. Backache. A mass bulging into the vaginal canal or out of the vagina that may make standing and walking difficult. Involuntary release of urine (incontinence ). Vaginal bleeding.

9. Description Most vaginal cuff prolapses include apical enterocele where the pubocervical and rectovaginal fascia have separated. The peritoneum becomes stretched and comes in direct contact with the vaginal epithelium creating a true hernia . The vaginal epithelium is stretched and becomes very smooth without rugae . There is always some degree of high cystocele formation and high rectocele formation associated with the vaginal vault prolapse.

10. Conservative Mx Pelvic floor exercises ( No strong evidence ) Pessaries: Ring and shelf pessaries. ( limited use . - Unfit for Surgery )

11. Surgical Mx MILLION DOLLAR QUESTION The dilemma faced is whether to go abdominally or vaginally …???

12. Transvaginal route safer – - VP after Vaginal hyst Transabdominal route for – - VP after abdominal hyst ., lap hyst ., harmonic vessel seal - Failure of previous vaginal approach - Foreshortened vagina .

13. Things to consider… Prolapse pathology Patient’s age Patient’s lifestyle Presence of co morbidities Sexual function Patient’s expectations Expertise of surgeon

14. De Lancey vaginal supports . Level Support Defect 1 Proximal (upper) Paracolpium ligs USL & Cardinal. .UV prolapse .vault prolapse . enterocole 2 Midvaginal Lat attachment to pelvic side wall to ATFP, ATLA Anterior & post wall defects & SUI. 3 Distal vaginal Pubocx fascia & RVS fusion to UGD , PB Lax perineum, low rectocoele , anal incontinence.

15. Classification of Vault Prolapse 1 st degree – vaginal apex is visible when perineum is depressed. 2 nd degree – apex extends just through the introitus . 3 rd degree – upper 2/3rds of the vagina is outside the introitus . 4 th degree – entire vagina is outside the introitus

16. Evaluation Pre-operative assessment of sites of damage. 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 . VDP

17. VAGINAL McCall’s culdoplasty Sacrospinous ligament fixation High Uterosacral ligament suspension with fascial reconstruction Iliococcygeus fascia suspension Meshplasty

18. ABDOMINAL Abdominal sacral colpopexy High uterosacral ligament suspension Laparoscopic approach

19. OBLITERATIVE LeFort’s Partial Colpocleisis Introital tightening Colpectomy

20. 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 & lengthens posterior vaginal wall.

21. 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 The biggest risk is injury to the ureters (up to 10.9%) due to its proximity to the anterior border of the uterosacrals , especially at the level of the cervix. 

22. 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.

23. 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

24. 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 & 1 st 3 sacral vertebrae incised & continued to vaginal incision. Abdominal Sacral Colpopexy

25. 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.

26. A Mersilene mesh exposure through the posterior vaginal wall at the perineal body and posteriorly at the vaginal vault.

27. 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

28. 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.

29. Lap. Sacrocolpopexy (a) A Y-shaped mesh with one proximal arm and two distal arms. (b) The bladder and bowel has been dissected from the vaginal vault (arrow). (c) The distal arm was sutured to the posterior vaginal wall (arrow). (d) The proximal arm was sutured to the sacral promontory (arrow). (e) Re- peritonisation was completed to prevent bowel adhesion to the mesh from vaginal vault (white arrow), along pelvis (arrowheads) and sacrum (black arrow).

30. 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

31. Prevention McCall culdoplasty at the time of vaginal hysterectomy is a recommended measure to prevent enterocele formation. Grade A RCOG 2011

32. Prevention Suturing the cardinal and uterosacral ligaments to the vaginal cuff at the time of hysterectomy is a recommended measure to avoid vault prolapse— Grade B Sacrospinous fixation at the time of vaginal hysterectomy is recommended when the vault descends to the introitus during closure- Grade B

33. Remember “ SURGERY SHOULD FIT THE PATIENT , THE PATIENT SHOULD NOT FIT THE SURGERY. “ - Michael Smith .

34. THANK YOU…!!!