vaginal prolapse 1568
TRANSCRIPT
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Management Of Genital ProlapseManagement Of Genital Prolapse
Associate Professor Semyatov S.M.Department of Obstetrics and Gynecology
with course PerinatologyPeoples’ Friendship University of Russia, Moscow
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DEFINITION
Prolapse/Procidentia is downward decent of uterus &/or vagina.(Procidentia is from Latin procidere - to fall). It is a state of pelvic relaxation due to a disorder of pelvic support structures that is, the endopelvic fascia.It is not a disease but a disabling condition.
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CAUSE
• WEAKNESS OF THE SUPPORTS OF THE UTERUS & VAGINA
• Precipitating / Exaggerating / Unmasking Causes -– INCREASED INTRA ABDOMINAL PRESSURE
• Chronic cough• Chronic Constipation• Heavy Wt.Lifting / domestic Work• Obesity, Ascitis
– WEAKNESS OF THE SUPPORTS & MUSCLES• Chronic ill health, malnutrition dysentery, anemia • Inadequate rest during pureperium • Menopause
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TYPES OF PROLAPSE
• Vaginal• Anterior –cystocele &
urethrocele • Posterior - Enterocele &
Rectocele• Vault Prolapse - a
special term applied to the prolapse of upper vagina
• Uterine/Utero-vaginal- Acquired or Congenital.– First degree.– Second degree &.– Third degree-(total
Prolapse / complete procidentia).
• However Procidentia is often used only to denote third degree uterine prolapse.
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EFFECTS OF PROLAPSE
• NO SYMPTOM- mild & moderate prolapse.• Discomfort & disability.• Sexual Dysfunction.• URINARY- Frequency, Dysuria, Stress
incontinence, infection.• Incomplete emptying of rectum.• Discharge.• Backache.• Ulceration & Infection.
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WHEN TO TREAT ?
• Should be treated only when it is symptomatic (Be certain symptoms are due to Prolapse )
• Interferes with the normal activity of the woman
• The patient seeks treatment
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HOW TO TREAT ? • NON-SURGICAL Methods: -Limited Role
– PELVIC FLOOR REHABILITATION (pelvic muscle exercises, galvanic stimulation, physiotherapy, rest in the purperium).
– HORMONE REPLACEMENT, both systemic and local.
– PESSARY TREATMENT for temporary relief• During Pregnancy, Puerperium & Lactation• When Operation is Unsafe due to Extreme
Senility/Debility and Diseases• Preoperatively • For therapeutic test
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HOW TO TREAT ? • SURGICAL TREATMENT: -
RECONSTRUCTIVE SURGERY is invariably needed and has to be a COMBINATION OF PROCEDURES to correct the multiple defects.
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SURGICAL TREATMENT• It is the definitive & curative treatment of
Prolapse.• It is a cold operation. So complete
investigation should be done & all existing diseases & disorders should be treated first.
• Pre operative pessary/tampoon & or Hormone treatment should be given as indicated.
• Meticulous and through examination under anaesthesia should be done before deciding the surgery.
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SURGICAL TREATMENT• Depending on the type & extent of Prolapse, surgery
should be tailor made not only to rectify the defect but also to suit the individual patient’s requirement.
• Absolute haemostasis is mandatory. Diathermy should be liberally used.
• Vaginal suturing should be with interrupted stitches. Synthetic absorbable fine sutures are preferable.
• Catheter for more than 48 hrs should be exceptional.• Strict antibiotic prophylaxis is essential
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VAGINAL OPERATIONS FOR PROLAPSE
• Anterior colporrhaphy
• Posterior colporrhapry- High / Low
• Enterocele repair
• Perineorrhaphy
• Amputation of cervix
• Paravaginal repair
• Hysterectomy with or without Colporrhaphy / Perineorrhaphy
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VAGINAL OPERATIONS FOR PROLAPSE
• Manchester/ Fothergill’s operation & Shirodkar’s modification
• Uterus/Cervix suspension/fixation
• Vaginal vault suspension/fixation
• Retro-rectal levatorplasty and post. anal repair for associated rectal prolapse
• Vaginectomy ?
• Colpocleisis ?
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Anterior colporrhaphy & Urethroplasty
• For correction of Cystocele & Urethrocele
• Incision- Midline / Inv.T / Elliptical
• Excision of vagina according to the size & site of laxity
• Avoid shortening &/or narrowing of vagina
• Closure with interrupted sutures
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Posterior colporrhaphy & Enterocele repair
• For correction of Enterocele & Rectocele• Enterocele repair can be done either by
vaginal or abdominal route depending on the associated procedures.
• Approximation of uterosacral ligaments for enterocele & prerectal fasciae and levator for rectocele with interrupted sutures is essential
• Excision of vagina should be tailor made• Perineorrhapy to be done only if perineal body
is torn
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Perineorrhaphy• Not an Operation for prolapse, but Indicated
only for associated old 2nd degree perineal tear
• Performed along with posterior colporrhaphy • Aim-Reconstruction of the Perineal body and
reduction of gaping introitus.• Can cause Dyspareunea• Essential steps - Excision of the scar tissue &
approximation of levator ani & superficial perineal muscles
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Vaginal Hysterectomy with/without Vaginal repair
• Indicated when uterus needs removal, in old age & in total prolapse.
• Patient’s consent is mandatory knowing that there are alternatives to hysterectomy.
• Usually combined with Ant. & Posterior colporrhaphy.
• Perineorrhaphy is not mandatory but case specific.• Vault suspension is an essential step.• If sexual function is not needed narrowing of vaginal
canal should be done.
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Amputation of cervix• Not for Prolapse.Indicated only for cervical
elongation (Uterocervical length >12.5 Cm )• To be done only as a part of Fothergill’s
repair/sling operations.• Adequate cervical dilatation - a prerequisite• Bladder displacement is a must • Excision of cervix should not exceed 2 cm• Likely to affect reproductive life• Long-term complications are real risks
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Fothergill’s operation
• It is the operation of choice in uncomplicated Utero-vaginal prolapse when uterus is to be preserved but NO future child bearing is required.
• It is a combination of, Amp. of Cx., Fixation of the Meconrodt’s ligament to the anterior of Cx. & Ant. Colporrhaphy. D&C is a must.
• Post. Colporrhaphy to be performed only if Ent/Rectocele is present
• Perineorrhaphy is usually not required
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Fothergill’s operation• Not useful if ligaments are weak & Uterus is of
normal size. Purandare’s modification may help.
• Technically difficult operation, requiring high degree of surgical skill.
• Threat of short-term complications. • Real possibilities of long term complications.• Recurrence/Failure.• Sling operations are better alternatives• HAS A BLEAK FUTURE
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ABDOMINAL OPERATIONS FOR PROLAPSE
• Sling operations
• Closure or repair of enterocele
• Sacrocolpopexy
• Anterior Colpopexy
• Colposuspension
• Paravaginal repair
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Abdominal Sling operations• Indicated when the ligaments are extremely weak as
in nullipara & young women.• Preserves reproductive function.• Principle - With a fascial strip / prosthetic material
(Merselene tape or Dacron) the Cx is fixed to the abdominal wall / sacrum / pelvis.
• Amp.of Cx should also be done if Utereocervical length >12.5cm.
• Cystocele/Rectocele repair if needed can be done vaginally before or after.
• Enterocele repair can also be done abdominally.
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Abdominal Sling operations• It is a major abdominal operation & Synthetic
material is costly & not widely available in India.
• Types-.– Shirodkar’s posterior sling.– Purandare’s anterior cervicopexy.– Khanna’s sling.– Virkud’s composite sling.
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Shirodkar’s sling• Tape is fixed to the post. Aspect of isthmus &
sacral promontory
• Anatomically most correct but difficult to perform
• Risks of complication
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Purandare’s cervicopexy• Tape is anchored to the ant.aspect of isthmus
and ant. abd. Wall
• Easy to perform
• Dynamic support
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Virkud’s composite sling operation• Tape is anchored from the post aspect of
isthmus to sacral promontory on the Rt. side & ant. abd. Wall on the Lt. Side
• Utrosacral ligament is plicated
• Technically easy
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Khanna’s sling operation• Tape is anchored to ant aspect of isthmus &
ant. sup. Iliac spine
• Easier to perform and safer
• But tape is superficial
• Risk of infection
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Abdominal Colpopexy / Colposuspension
• Indicated when vault prolapse occurs after hysterectomy or vaginal laxity is to be corrected at abdominal hysterectomy.
• Major abdominal operation & technically difficult.
• Sexual function is preserved.• Methods-.
– Sacrocolpopexy.– Ant.Colpopexy.– Colposuspension.
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Sacrocolpopexy
• Vault is fixed to 3rd & 4th sacral vertebrae with a facial strip / proline mesh under the peritoneum to the right of rectum
• Enterocele repair can be done if required
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Ant.Colpopexy• Corrects ant. vag laxity & stress inc.
• Useful at abdominal hysterectomy / for vault prolapse.
• Extra peritoneal supra pubic approach if done alone.
• Enterocele repair if required.
• Vagina stitched to the ileo-pectineal ligaments.
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Vault / Colposuspension
• Vault is fixed to the abdominal wall by a facial strip or merseline tape
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LAPAROSCOPIC SURGERY PROLAPSE
• Advantages of M I S-small incision, better view, haemostasis, no packing, minimal tissue & bowel handling, short recovery, less pain, insignificant scar
• Can all types of prolapse be treated?- Yes.• Ant. / Post. Lower vaginal repairs if needed can also
be done vaginally before or after lap.Surgery• However extended period of rest is essential • Expertise is needed• Presently cannot be widely practised• This is the surgery of the future today
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LAPAROSCOPIC SURGERY PROLAPSE
• PROCEDURES:- – Cervicopexy / Sling operations with/without
Lap.Paravaginal repair / Vaginal repair – VH / LAVH / LH / TLH + Colposuspension – VH / LAVH /LH/TLH+ Lap.Pelvic reconstruction– Rectocele repair & levatorplasty – Enterocele repair with suturing of uterosacral
ligaments– Colpopexy- Ant / Post
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Laparoscopic Cervicopexy/sling Operations
• All types of sling operations can be better performed by laparoscopy
• Associated vaginal prolapse can also be repaired laparoscopically (Lap.Paravaginal repair)
• Vaginal Ant./Post. colporrhaphy can be done before / after laparoscopy
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Laparoscopic Vault suspension/ Culdoplasty)
• Can be done with VH / LAVH / LH / TLH
• Corrects mild laxity
• Prevents vault prolapse
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Laparoscopic Pelvic Reconstruction
With VH / LAVH / LH / TLH • An alternative to Ward-Mayo’s operation• Before Hys., Lap.Ureteral dissection is done
and suture placed in uterosacral ligament near sacrum & left long, for latter vaginal vault suspension
• Lap. levator plication if needed • Enterocele repair and suturing of uterosacral
ligaments if needed • Retro pubic Colposuspension (Bruch) if required
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Laparoscopic Rectocele repair & Levatoroplasty
• Rectovaginal space is opened & rectum dissected
• Interrupted sutures given in the levator in the midline
• Enterocele repair done if indicated
• Vaginal vault suspension done
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Laparoscopic Enterocele repair • Rectovaginal space is opened, sac excised
and purse string suture given
• Uterosacral ligament sutured
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Laparoscopic Post Colpopexy / Sacrocolpopexy
• Indicated for vault prolapse
• Enterocele if present is first repaired
• Prolene mesh is fixed to the vault & 3rd-4th sacral vertebrae, under the peritoneum in the Rt.para rectal space
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Time has come for Laparoscopic Surgery for Prolapse
So move with the times. Practice laparoscopy.
This is the Surgery of the future today.