REPAIR OF VAGINAL APICAL SUPPORT DEFECTS

Apical support defects can occur alone but usually one or more of the following segmental prolapses coexist:

      ·        Uterine prolapse when a uterus is in place

·      vaginal vault prolapse is reserved to apical support defect when a hysterectomy was performed previously

·       Cystocele

·        Rectocele

·        Enterocele

These defects should be recognized prior to surgery and their repair carried out at the same time.

Several surgical procedures have been described for the correction of apical support defects. The repair can be performed transvaginally, transabdominally, or laparoscopically. Surgical procedures available include as day care procedure include:

Abdominal Appraoch

 Abdominal sacral colpopexy (Open/  laparoscopic)

This approach is usually preferred when a preservation of cervical length to allow sexual intercourse is desired or when vaginal approach failed. The bladder, rectum and ureters can be directly visualized; hence the chances of injury to these structures is minimized. This procedure aims at supporting the vaginal apex to the sacral promontory using a synthetic or facial bridge.

Procedure:

 ·         The patient is in frog-leg like position with a foley catheter inside the bladder.

 ·         Three port or single port technique can be employed.

 ·         The peritoneal cavity is entered and the bowel is displaced out of the field.

 ·         A sponge stick introduced into the vagina is helpful in identification of the vagina. The peritoneum overlying the vagina is then dissected of the vaginal wall.

 ·      A synthetic graft polypropelene mesh are used are sutured to the vaginal apex using permanent suture material using 3/0 daflon or prolene sutures. 

 ·         The peritoneum covering over the sacrum is opened from the sacral promontory to the level of S3. Permanent sutures are passed through the periosteum of the sacral promontory, alternatively protex tagger/ bone anchors can be used to fix the free end of the graft.

 ·      Once the sutures are tied, the vaginal apex is approximated to the sacral promontory. The graft material should be tension free. 

 ·         The peritoneum is then closed with absorbable suture material.

Complications

·         Injuries to bowels, bladder, ureter, and vessels

·         Bleeding

·         Infection

·         Mesh related complication like erosion, irritations to bowels

·         Chronic pelvic pain, defecation pain

·         Herniation

Vaginal Apparoach

Vaginal sacrospinous fixation ( TVSSF)

This procedure aims at suspension of vaginal apex to the sacrospinous ligament (SSL) or the coccygeous-sacrospinous ligament that extend from the ischial spine to the lower portion of the sacrum and coccyx.

The surgeon should be aware of the close proximity of the pudendal nerve and vessels running directly posterior to the ischial spine and the sciatic nerve that runs superior and laterally to the ligament.

Procedure:

·       The patient is put in the dorsal lithotomy position. 

·       The ischial spine and sacrospinous ligament should be identified by palpation before surgery begins.

·      The apex of the vagina is grasped and fully retracted out of the vagina to evaluate the extent of the defect. Stay sutures are put to mark the apex of the vagina and then the apex is reduced to verify its relationship to the SSL. At times, the vagina is too short to reach the SSL so that the fixation is dependant on the sutures connecting the two structures (vaginal apex and SSL).

·      Cystocele repair, +/- bladder neck suspension or a sling procedure, if needed, is usually performed at this point. 

·         A midline longitudinal posterior vaginal wall incision is performed from the vaginal intoitus to 2cm caudal to the vaginal apex previously marked.

·    An enterocele sac, when present, should be dissected free from the posterior vaginal wall and reduced as discussed separately (see enterocele repair).

·       The plane between rectocele and posterior vaginal wall is developed as in any rectocele repair, this dissection is extended, however, usually on the right side of the patient, to the perirectal space. 

·       The perirectal space at the level of the ischial spine is entered by blunt and sharp dissection of the fibroareolar tissue medial to the rectum until the SSL can be palpated. 

·     The SSL is further dissected clean. Briesky-Navratil retractors (long straight retractors) are used by the assistant to allow easy approach to the deeply situated SSL and medial retraction of the rectum. A Deschamps ligature carrier and a nerve hook or a Miya hook ligature carrier are traditionally used to pass 2 sutures through the SSL 3-4 cm medial to the ischial spine, 1 cm apart. Passing the sutures more laterally can cause injury to the underlying pudendal nerve and internal pudendal vessels which course posteriorly to the ischial spine. Other commercially available kits ( Capio applicators) for passing the sutures are also available. An Allis or a Babcock clamp can be used to hold the SSL, during this sometimes difficult to perform step. 

·      The sutures are then passed through vaginal apex. A pulley stitch can be used so that the knot is buried between the vaginal wall and the SSL. 

·      The vaginal apex incision is closed. Only then, the stitches passed through the SSL and the vaginal apex are tied so that the vaginal apex is approximated to the SSL. Tying these sutures beforehand will cause difficulty in closing the vaginal apex. 

·      The posterior vaginal wall is closed as in posterior colporraphy.

·        Check cystoscopy & PR are performed to exclude any injuries to the bladder or bowels

This are two main appoach to support in my practice, there are other options like Uterosacral ligament plication and others 

 

 

 The above are perrecatal dissection & placement of sutures to SSL and vault

 Consent Has been Taken from Patient to publish this Pictures ( For Teaching Purpose)