Prevention of vault prolapsed, needs some understanding on pelvic organ support system. De Lancey’s 3 Levels of Pelvic Support ( Delancey JOL: Am J Obstet Gynecol 166: 1717, 1992 ) is one of the essential components in preventing PHVP. The method & techniques’ for prevention depends on the type of hysterectomy carried out ( Abdominal as well as Vaginal). If the Abdominal Hysterectomy, one can Re-anchor uterosacral ligament pedicles to vaginal vault during vault closure / pelvic peritonisation or pericervical tissues ( Level B evidence), Moscowitz sutures (Circumferential sutures to obliterate a deep cul-de-sac) & Halban cul-de-sac closure are some other procedures to prevent PHVP. When doing vaginal hysterectomy, one can do peritoneal closure of the cul-de-sac, a vaginal Moschowitz operation, McCall’s culdoplasty. However The authors found significantly fewer cases of posterior-apical vaginal prolapse (stage 2) at three years following the McCall’s culdoplasty 2/32 (6%) than with either peritoneal closure 13/33 (39%) or the vaginal Moschowitz procedure 10/33 (30%) (p=.004)* (Stephen H Cruikshank, Am J 427 Obstet Gynecol 1999;180:859-65). Therefore McCall Culdoplasty at the time of vaginal hysterectomy is effective in preventing subsequent PHVP (Level B evidence). Sacrospinous ligament fixation (SSF) & abdominal sacral colpopexy are not recommended for the prevention of prolapse at the time of hysterectomy for non-related disease (Level C). SSF can be added to a post vaginal hysterectomy and McCall culdoplasty if the cuff (point C) is ≥ Stage 2 to prevent vault prolapse. Subtotal hysterectomy is not recommended for the prevention of PHVP (Level A). In cases of total Laparoscopic hysterectomy (TLH). The only study evaluating 22 laparoscopic uterosacral ligament suspension in comparison to 96 vaginal uterosacral ligament suspension retrospectively found no significant difference in recurrent apical prolapse (6% in the vaginal group vs 0% in the laparoscopic group. This study identified no statistical significance in the ureteral compromise recognized intraoperatively 4% in the vaginal group, 0% in the laparoscopic group (Rardin CR, Erekson EA, Sung VW, Ward RM, Myers DL. Comparison of laparoscopic and vaginal.Uterosacral colpopexy at the time of vaginal hysterectomy's J Reprod Med 2009: 54: 273-80). Of course there are other confounding factors involved in the success in preventing the PHVP which include surgeon factor, patient factors, materials & techniques used.
Below is AN technique which is the modification of Mc Culdoplasty to address vault prolapse after Vaginal Hysterectomy.
METHODS OF PREVENTION OF PHVP
Abdominal Hysterectomy
- Peritonisation of pelvis- transfixing anterior leaf of peritoneum, round ligament, ovarian ligaments, uterosacral ligaments and vaginal wall of vault. This is repeated on both sides.
- Richardson's cuff angle closure, in-cooperating broad ligaments, uterosacral ligament & vaginal vault ( most gynaecologist do this during abdominal hysterectomy)
- Moschowitz Suturing ( usually done if there concurrent enterocele)
- Halbans Cul do sac closure ( Done if there is concurrent enterocele)
Abdominal / Total Laparoscopic Hysterectomy
- Pericervical And Uterosacral plication ( most laparoscopic surgeons do this technique at the time of TLH
- Mc Call Culdoplasty ( very effective operation, has small risk of ureteric injury esp with regards to high suture placement)
- Vaginal approach Moschowitz ( most vaginal surgeon like this technique, in cooperating all the ligaments-round, ovarian and uterosacral ligaments and in-cooperating them as purse string closure )
- AN (Aruku Naidu) modified Mc Call ( In-cooperation of low-mid uterosacral and anchored to vaginal vault ipsilaterally and brought to centre) = provide goo vault support & reduce post vaginal skin bleeding
The above are some of the technique, which can be used to prevent vault prolapse during hysterectomy after abdominal, laparoscopic or vaginal approach.
No comments:
Post a Comment