Vault Prolapse, Pelvic organ Prolapse, Supports Of Uterus

1. VAULT PROLAPSE
DR. JOGRAJIYA

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)

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.

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.

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)

21. Evaluation
• Pre-operative assessment of sites of damage by POPQ.

22. POPQ

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.
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38. SURGERIES FOR
VAULT
PROLAPSE

39. VAGINAL
•McCall’s culdoplasty
•Sacrospinous ligament fixation
•High Uterosacral ligament suspe-
- nsion with fascial reconstruction
•Iliococcygeus fascia suspension
•Meshplasty

40. ABDOMINAL
• Abdominal sacral colpopexy
• High uterosacral ligament suspension
• Laproscopic approach

41. OBLITERATIVE
•LeFort’s Partial Colpocleisis
•Introital tightening
•Colpectomy

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