Recurrent prolapse RVF Inversion OCPT rectovaginal fistula.ppt

Recurrent prolapse RVF Inversion OCPT

1. Recurrent prolapse

2. Incidence:
5-10% (usually occurs in the first year)

3. Causes:
Pre-operative:Pre-operative:
1.Bad preparation ( bronchial asthma or pre-
operative infection)
2.Bad timing of operation (best is post-
menstrual).
3.Missing diagnosing level of support defects

5. Operative:Operative:
1.Bad choice of operation.
2.Bad technique of operation.
3.Missing an operation e.g. enterocele, cervical
elongation.

6. Post-operative:Post-operative:
1.Bad care (infection, hemorrhage)
2.Bad spacing of pregnancies.
3.Missing treatment of predisposing factors e.g.
chronic cough.

7. Clinical Picture:
History of previous operation for repair of
prolapse.
Presence of symptoms which depend upon
the type of prolapse.
Examination reveals the nature of prolapse,
and scar of previous operation.
The cause of recurrence has to be
determined as chronic cough and obesity.

8. Treatment:
Treat the cause of recurrence.
The operation depends upon the type of
prolapse and patient general condition.
Operation is done at least 3-6 months after
the previous repair to allow absorption of
scar tissue. Fibrous tissue resulting from the
previous operation makes the second
operation more difficult.

9. Retroversion-flexed
(RVF)

10.  Normally the uterus is anteverted anteflexed.
 In about 20% of females the uterus is retroverted or
retroflexed or both i.e. retroverted-flexed
Normal position: Normal position:
Anteverted:Anteverted:
The cervix bends forward on
the vagina forming an
angle of 90 degrees.
Anteflexed: Anteflexed:
The body of uterus bends
forwards on the cervix
forming an angle of 160
degrees.

11. Abnormal position:Abnormal position:
Retroverted:Retroverted:
The cervix is bends
backwards on the
vagina.
Retroflexed:Retroflexed:
The body of uterus is
bends backwards on
the cervix.

12. Causes:
(A) Congenital: (A) Congenital:
The uterus may be of normal size or slightly hypoplastic.
(B) Acquired: (B) Acquired:

Puerperal R.V.F.:Puerperal R.V.F.:
Occurring after abortion or labour, due to:
1.Laxity of the supporting ligaments of uterus, allowing it
to rotate backwards.
2.Increased bulk and weight of uterus.
3.Distended bladder, pushing the uterus backwards.
4.Prolonged stay in bed in the dorsal position

13. 
Pelvic lesions: Pelvic lesions:
1.Tumors lying in front of uterus pushing it
backwards.
2.Adhesions behind the uterus pulling it
backwards.

Genital prolapse:Genital prolapse:
Before uterine prolapse, the long axis of
uterus lies on the long axis of vagina. i.e.
retroversion.

14. Types:
Mobile RVF
Fixed RVF

15. Degrees:
First degree: First degree:
The fundus is directed
towards the sacral
promontory.
Second degree: Second degree:
The fundus of uterus is
directed towards the sacral
concavity.
Third degree: Third degree:
The fundus of uterus is
directed towards the tip of
sacrum.

16. Clinical picture:
(A) Symptoms:(A) Symptoms:

Asymptomatic (50%)Asymptomatic (50%)

Symptoms related to pelvic congestion: Symptoms related to pelvic congestion:

Congestive dysmenorrhea,

Heavy menstrual bleeding

Polymenorrhea (Congestion of the ovaries),

Leucorrhea.

17. 
Symptoms related to abnormal position of Symptoms related to abnormal position of
uterus: uterus:

Low Backache: Due to pressure of uterus Low Backache: Due to pressure of uterus
on the sacral ligaments.on the sacral ligaments.

Spasmodic dysmenorrheaSpasmodic dysmenorrhea

Dyspareunia:Dyspareunia: Due to:
a.Prolapsed ovaries on the douglas pouch.
b.Direct pressure on the uterine fundus.
c.Pelvic congestion.

18. 
Infertility: Due to ; Infertility: Due to ;
The cervix is directed forwards away from
the seminal pool.
Kinking of the cervical canal.
Congestion of endometrium interfering with
ovum implantation.
Kinking of fallopian tubes.
Congestion of ovaries  Anovulation.

Complications during pregnancyComplications during pregnancy
Miscarriage
Incarceration
Anterior sacculation

19. (B) Signs:(B) Signs:
1.The posterior lip of cervix is first felt.
2.The external os is directed downwards and
forwards.
3.Bimanual examination: The fundus of
uterus is felt through the posterior fornix.
4.Adnexa is felt through the posterior fornix.
5.Uterine sound diagnoses the direction of
uterine cavity.

20. Pessary test
It is done before any surgical
treatment to be sure that the
symptoms are due to retroversion and
so will be cured by operation.
The uterus is corrected and a Hodge
pessary is inserted to keep it
anteverted.
The patient is examined after 1
month, if symptoms are relived, then
the cause was due to retroversion
and operation can be performed.

21. Treatment
(A) Prophylactic:(A) Prophylactic:
This is carried out after labour and includes:

Frequent emptying of the bladder as a full
bladder pushes the uterus backwards

Pelvic floor exercise

The patient is asked to lie on her abdomen for
1 hour daily to encourage anteversion

If the uterus is found retroverted during
puerperium, it should be corrected and a
Hodge pessary is inserted for 3 months.

22. (B) Pessary treatment:(B) Pessary treatment:
Indications:Indications:
1.Retroversion detected in puerperium.
2.Early pregnancy with retroversion, when the
patient gives history of abortions when no
other causes were detected.
3.Symptomatic retroversion and the patient is
surgically inoperable.

23. Technique: Technique:
A Hodge or Smith pessary is
made of plastic or vulcanite
used to correct retroversion by
introducing into the uppermost
of vagina.

24. The broader part stretches
the posterior fornix and the
utero-sacral ligaments to
maintain the anteverted
position of uterus, while the
lower end behind the
symphysis pubis to maintain
the pessary in position.

25. (C) Surgical treatment:(C) Surgical treatment:
Indications: Indications:
1.Mobile retroversion with marked symptoms
relived by pessary test.
2.Fixed retroversion producing symptoms.

26. Operations: Operations:
Ventro-suspension:Ventro-suspension:

Modified Gilliam operation:Modified Gilliam operation:
Done by pliation and suturing of the round Done by pliation and suturing of the round
ligament to the anterior rectus sheath. A loop ligament to the anterior rectus sheath. A loop
of each round ligament is brought out through of each round ligament is brought out through
the internal inguinal ring and sutured to the the internal inguinal ring and sutured to the
anterior rectus sheath. This leads to anterior rectus sheath. This leads to
shortening of the round ligament and pulling of shortening of the round ligament and pulling of
the uterus forwards.the uterus forwards.

28. 
Alexander Adam’s operationAlexander Adam’s operation
Round ligaments are dissected in the inguinal Round ligaments are dissected in the inguinal
canal, pulled through the internal inguinal ring canal, pulled through the internal inguinal ring
to shorten them (even cut part of each) thus to shorten them (even cut part of each) thus
the uterus is pulled forwards.the uterus is pulled forwards.

30. 
Baldy-Webster’s (sling) operationBaldy-Webster’s (sling) operation
Opening in the posterior leaflet of the broad Opening in the posterior leaflet of the broad
ligament on each side and loops of round ligament on each side and loops of round
ligaments are sutured together behind the ligaments are sutured together behind the
uterus through these openings below the level uterus through these openings below the level
of their insertion into the uterus.of their insertion into the uterus.

32. Ventro-fixationVentro-fixation::
The body of uterus is fixed to The body of uterus is fixed to
the anterior abdominal wall the anterior abdominal wall
by non-absorbable material by non-absorbable material
as silk. This interferes with as silk. This interferes with
the growth of the uterus the growth of the uterus
during pregnancy and so during pregnancy and so
cannot be applied except in cannot be applied except in
sterile women and in women sterile women and in women
after menopauseafter menopause..

33. RVF with uterine PROLAPSERVF with uterine PROLAPSE
Is corrected by suturing the Mackenrodt’s Is corrected by suturing the Mackenrodt’s
ligaments in front of the cervix.ligaments in front of the cervix.
Operation done AS an added step to other Operation done AS an added step to other
operation:operation:
As myomectomy to keep the uterus anteverted
Plication of the round ligaments
Plication of uterosacral ligaments

34. Chronic inversion

35. Definition:Definition:
The uterus is turned inside out through the
cervix.
It may be acute or chronic.
Acute inversion: it occurs during or
immediately after delivery of the fetus. It is
called acute puerperal inversion

36. Degrees: Degrees:
11
stst
degree: degree:
The fundus is within
the endometrial
cavity (Cupping of
the fundus).

37. 22
ndnd
degree: degree:
The fundus
protrudes through
the cervical os

38. 33
rdrd
degree: degree:
The fundus protrudes
to or beyond the
introitus

39. 44
thth
degree: degree:
Both the uterus and
vagina are inverted

41. Causes:Causes:
Chronic puerperal inversion: it is the result
of acute puerperal inversion which was not
recognized at labour.
Fundal tumors: Attempts of the uterus to
expel intra-cavitary tumors

Fundal myoma pulling the uterine fundus
downwards.

Malignant tumors of the body of uterus.
Senile inversion: Due to weakness of uterine
muscles and laxity of circular muscle fibers of
cervix.

42. Clinical picture:Clinical picture:
Symptoms:
Contact or irregular vaginal bleeding due to
ulceration of the endometrium.
Vaginal discharge
Chronic pelvic pain
Dyspareunia
Mass protruding through the vulva.

43. Signs:
Abdominal examination:

In 1
st
and 2
nd
degrees cupping of the fudus is felt

IN 3
rd
and 4
th
degree the uterus is not felt per
abdomen.
Vaginal examination:

In 2
nd
, 3
rd
and 4
th
degrees, there is a large mass
in the vagina covered by dark red infected
endometrium.

A sound cannot passed through the cervix or is
introduced for a short distance.

44. Differential diagnosis:Differential diagnosis:
A mass protruding in the vagina:
Uterine prolapse
Fibroid polyp
Cauliflower carcinoma or sarcoma arising from
cervix or vagina.

46. Treatment
(I) Chronic puerperal (I) Chronic puerperal
inversion:inversion:
Conservative treatment:Conservative treatment:
By applying continuous
pressure using the Aveling’s
repositor.
It may be used if the patient
is unfit for surgery.

48. Surgical treatment: Surgical treatment:

(A) Abdominal (A) Abdominal
operations: operations:
1. Huntington’s 1. Huntington’s
operation:operation:

Traction on the
depressed fundus by
vulsellum.

49. 2. Dobbin’s operation: 2. Dobbin’s operation:

Division of the cervical ring
anteriorly and pulling the
fundus.
3. Haultain’s operation: 3. Haultain’s operation:

Division of the cervical ring
posteriorly and pulling the
fundus.
4. Abdominal 4. Abdominal
hysterectomy: hysterectomy:

If the patient above 40 years
and complete her family.

50. 
(B) Vaginal operations:(B) Vaginal operations:
1. Spinelli’s operation: 1. Spinelli’s operation:

Division of the cervical ring anteriorly and
correction of inversion.
2. Kustner’s operation: 2. Kustner’s operation:

Division of the cervical ring posteriorly and
correction of inversion.
3. Vaginal hysterectomy.3. Vaginal hysterectomy.

51. (II) Inversion due to fundal tumors:(II) Inversion due to fundal tumors:

Fundal myoma: Fundal myoma:
If the woman is above 40 years, hysterectomy is
done.
If the patient is young, vaginal myomectomy is
done with correction of uterine inversion.

Malignant tumors: Malignant tumors:
The treatment is according to the malignant
condition.
(III) Senile inversion: (III) Senile inversion:
Treated by hysterectomy.

52. Old Complete Perineal
Tear

53. Perineum:
Is formed by the soft tissues inferior to the
pelvic diaphragm (levator ani muscles)
ending with the skin.

54. Bounded by :
Anterior: the lower border of the symphysis
pubis
And inferior pubic ligament.
On either side: pubic arches, ischial tuberosity
and sacrotuberous ligament
Posterior: Tip of coccyx
Superiorly: pelvic floor
Inferiorly: skin and fascia

55. Two Triangles
Urogenital
triangle
(anterior)
Anal triangle
(posterior)

56. The perineal membrane

57. The perineal body
is a triangular
fibromuscular
mass located
between the anal
canal and the
perineal
membrane

58. Muscles attached to
perineal body:
-Levator ani m.
-Deep transverse
perineal m.
-Super. Transverse
per. m.
-Bubospongiosis m.
-Ext. anal sphincters

59. External/Internal Anal Sphincter
Internal anal
sphincter
(circular smooth
muscle)
External anal
sphincter
(striated
voluntary
muscle)

60. Perineal tears
PERINEAL TEARS:
Gross Injury due to mismanaged 2
ND
stage of
labour
ETIOLOGY:
1.Over stretching of perineum
2.Rapid stretching of perineum
3.Inelastic perineum

61. DEGREES:
 First-degree: injury to
perineal skin, and
vaginal mucosa only

62. Second-degree: injury
to the perineum
involving perineal
muscles

63. Third-degree: ( complete)
injury to perineum
involving the anal
sphincter complex:
< 50% of EAS thickness
torn
> 50% of EAS thickness
torn
Both EAS and IAS torn

64. A fourth-degree
(complete): injury to
perineum involving the
anal sphincter complex
(EAS and IAS) and ano-
rectal mucosa.

66. Old Complete perineal tear
Complete perineal tear
not sutured immediately
after labour and the
wound healed by
granulation tissues

67. Diagnosis:
Symptoms:
-Anal incontinence
-2ry vaginitis
-2ry vulvitis
-Sexual dysfunction

68. Signs:
-Tear is seen extending
to the anus
-Dimple on each side of
the anus?
-Absence of corrugations
anteriorly?
-PR/ Examine
- resting tone ?
- squeeze pressure?

69. Treatment:
Preoperative preparation:
-6
th
months after labour is proper time
-Treatment of any genital infections (ex,
vaginitis)
-Patient admitted 5 days before operation
for colonic preparation:
Non residue diet,
laxatives, Neomycin ,Falgyl,
lastly enema, Ensure rectum is clear

70. Operation: layered method of repair
Dissection of posterior vaginal wall from
rectum
The anal epithelium is repaired by
interrupted 3/0 polyglactin Vicryl, with the
knots lying within the anal canal
The torn ends of the external anal sphincter
is identified and sutured together by the
overlap technique or end-to-end repair using
polydioxanone PDS or polyglactin Vicryl.

71. The levator muscles are approximated in
front of the rectum.
The vagina, superficial muscles and skin
are sutured as before.

73. Postoperative:
-Folys catheter with vaginal packing
-Antiseptic after each micturation (keep wound
dry and clean)
-Postoperative antibiotics , analgesics, colonic
antisepsis
-Continue NPO for 2 days, oral fluids I day, non
residue diet for 2 days, then usual diet on the
5
th
day with stool softners.
-No intercourse for 3 months, no pregnancy for
2 years.

74. Recto-vaginal Fistula

75. Etiology:
Congenital (very rare)
Traumatic:
Obstetric:
Incomplete healing of 3
rd
or 4
th
degree
laceration occurring during labour
(commonest cause)
Necrotic obstetric fistula due to obstructed
labour causing prolonged compression,
ischemia and necrosis of the recto-vaginal
septum.
Traumatic obstetric fistula caused by
instrumental deliveries or with destructive
procedures.

76. Surgical
Direct
Inflammatory:
A pelvic abscess may open into the vagina
and rectum
T.B., Syphilis and bilharziasis of the vagina or
rectum are rare causes
Neoplastic in advanced vaginal, rectal and
cervical cancer
Post irradiation

77. Diagnosis
Symptoms:
-Depends upon the size of the fistula
-Large:
-Anal incontinence (flatus, liquid and solid
stool)
-Small
-Anal incontinence (flatus and liquid stool)
-2ry vaginitis
-2ry vulvitis
-Sexual dysfunction

78. Signs:
Inspection of posterior vaginal wall
-Small probe may pass through fistula
-Methylene blue test
-Proctoscopy

79. Treatment:
Preoperative: the same as old complete perineal
tear
Operative: according to site of fistula
-Fistula in lower third……, is converted to
complete perineal tear,…… layered method of
repair
-Fistula in middle third: excision with layerd
closure… Dedoublement (flap-splitting) operation
-Fistula in upper third:
Abdominal repair….. If the fistula is large a
temporary colostomy is done 2 weeks before
the operation and the closed after healing of
the fistula (at least 6 weeks after operation).

81. Postoperative:
-The same as old complete perineal tear.