Conservative Surgeries For Genital Prolapse : Conservative Surgeries For Genital P rolapse Presented by :- Dr Nikhil Bansal J.N.M.C.,Wardha Operative Treatments of Prolapse: Operative Treatments of Prolapse The type of surgery offered to the patient with prolapse depends on the – Age of the patient H er desire to retain the uterus either for reproductive or menstrual reasons H er menstrual history Her general condition Degree of uterine prolapse List of conservative surgeries: List of conservative surgeries Conservative procedures are which preserves the menstural and childbearing functions. Colporrhaphy ( anterior/ posterior) Fothergill’s repair(Manchester operation) Shirodkar’s procedure Abdominal sling operation a) Abdominocervicopexy b) S hirodkar’s abdominal sling operation c) Khanna’s abdominal sling operation Anterior colporrhaphy: Anterior colporrhaphy Principle -An anterior repair is a vaginal surgery to correct a cystocele , when the "upper" wall of the vagina that is in contact with the bladder is sagging down, or coming outside of the vaginal opening. Indications – a) cystocele b) Cystourethrocele PowerPoint Presentation: Steps – a)Traction is given to the cervix to expose the anterior vaginal wall. b) An inverted T- shaped incision is made , starting with a transverse incision in the bladder sulcus and through its mid point ,vertical incision extended up to the urethral opening. c) The vaginal walls are reflected to either side to expose the bladder and vesicovaginal fascia. d) The overlying vesicovaginal fascia is tightened and the excess vaginal wall excised to correct the laxity, and vaginal wall sutured. PowerPoint Presentation: Complications - Risks of colporrhaphy include potential complications associated with- 1.Anesthesia, 2.Infection, 3.Bleeding, 4.Injury to other pelvic structures, 5.Dyspareunia (painful intercourse), 6.Recurrent prolapse, 7. Failure to correct the defect. Posterior colporrhaphy : Posterior colporrhaphy Principle – A posterior repair is a vaginal surgery to correct a rectocele , when the "lower" wall of the vagina that is in contact with the rectum is bulging into the vagina, or coming outside of the opening of the vagina. Indications – a) Rectocele b) Repair of deficient perineum PowerPoint Presentation: Steps – This is done by making a triangular or diamond-shaped incision, and removing some of the extra skin of the wall of the vagina After this skin is removed, the strong tissues underneath are brought together with strong stitches. The lax vagina over the rectocele is excised , and the rectovaginal facia repaired after reducing the rectocele . The approximation of the medial fibers of the levator ani helps to restore the caliber of the haitus urogenitalis , restore the perineal body and provide an adequate prenium . PowerPoint Presentation: Complications- One possible risk of this surgery is that the vaginal opening may become narrow with scar tissue, and there may be some discomfort with sexual activity. The rest of the complications are same as that of Anterior Colporrhaphy. Shirodkar’s procedure: Shirodkar’s procedure Principle – Cervical cerclage , also known as a cervical stitch , is used for the treatment of cervical incompetence ,a condition where the cervix has become slightly open and there is a risk of miscarriage because it may not remain closed throughout pregnancy and may even cause prolapse. Indications – a)To avoid miscarriage and preterm delivery b)Prolapse of uterus c) Prolapse of vagina d) Maintainence of fertility PowerPoint Presentation: Steps – Anterior colporrhaphy is performed as usual Attachment of mackenrodt ligament to the cervix on each side is exposed The vaginal incision is then extended posteriorly round the cervix The pouch of douglus is opened , uterosacral ligaments identified and devide close to the cervix The stumps of these ligaments are crossed and stiched together in front of cervix A high closure of the peritonium of the pouch of douglus is carried out. PowerPoint Presentation: Complications- Cervical Dystocia with failure to dilate requiring Cesarean Section D isplacement of the cervix I njury to the cervix or bladder C ervical rupture (may occur if the stitch is not removed before onset of labor) I nfection of the cervix I nfection of the amniotic sac ( chorioamnionitis ) Fothergill’s repair: Fothergill’s repair Principle – A vaginal operation for prolapsed uterus consisting of cervical amputation and parametrial fixation of the cervical ligaments of the uterus. Also called M anchester O peration . I ndications – a)Cervical elongation b)2 nd and 3 rd degree Prolapse c)Preservation of menstrual and childbearing capabilities. PowerPoint Presentation: Steps – a)The surgeon combines an anterior colporraphy with amputaion of cervix b) Then sutures the cut ends of the meckenrodt ligament in front of the cervix c) Covers the raw area of the amputed cervix with vaginal mucosa d) Follows it up with a colpoperineorrhaphy (suture of the ruptured vagina and perineum) Complications- 1) Incompetent cervical os . 2)Habitual abortion or preterm deliveries 3) Excessive fibrosis may lead to cervical stenosis and distocia during labour 4) Heamatometra 5) Recurrence of prolapse may occur following vaginal deliveries in some cases Abdominal sling operations : Abdominal sling operations Principle- the objective of this operation is to buttress the weakened supports ( mackenrodt and uterosacral ligaments) of the uterus by providing a substitute in the form of nylon or dacron tapes , used a slings to support the uterus Indications- 3 rd or 4 th degree uterine prolapse Women who are desirous of retaining their childbearing and menstrual functions Enterocele Operation in common practice include – 1) Abdomino cervicopexy 2) S hirodkar’s abdominal sling operation 3) K hanna’s abdominal sling operation PowerPoint Presentation: Steps - 1)Opening of the abdominal wall through a low transverse supra pubic incision deepened down up to the rectus sheath 2)Two musculofascial slings are elevated from the midline outwards and laterally up to the lateral border of the rectus abdominus muscle on either side 3) The peritoneum is opened in the mid line , and the uterus brought up into view 4)The uterovesical fold is incised ,and the bladder mobilised from the front of the uterine isthmus 5)Presently the surgeons uses a 12” long mersilene /nylon tape to provide a new artificial suppport for the uterus 6) The tape is fixed at its mid point to the uterine isthmus anteriorly , and its lateral ends brought out retropritoneally between the two leaves of the broad ligament 7) The ends of the tape are now fixed to the aponeurosis of the external oblique muscle of the abdominal wall PowerPoint Presentation: Complications- I ntraoperative bladder or urethra injury I nfections associated with screw or staple points R ejection of sling material from a donor or erosion of synthetic sling material Infection, 5) Bleeding, 6) Injury to other pelvic structures, 7) Dyspareunia (painful intercourse Thank you!!!: Thank you!!!