by simply plicating the uterosacral-cardinal ligaments ?
Are we lousy surgeons ?
Can’t we go a step further after a big operation so as to plicate the uterosacrals?
The step can be a ”shotgun” to increase the problem rather than preventing it.
Although the chances of vault prolapse after hysterectomy are less but one must know the basic anatomy and actual causes of the vault prolapse rather than blindly following the plication of uterosacrals and cardinals.
- Is a patient ‘destined’ to prolapse her vaginal vault after hysterectomy due to her genetic makeup or can this problem be avoided.?
- First we have to understand the Anatomy and Pathophysiology :
- Do any of these intraoperative factors truly affect the incidence of prolapse?
- Iatrogenic factors potentially leading to prolapse can be :
- Preventive measures :
- Can vault prolapse be prevented?
- Are we lousy surgeons ?
- Can’t we take a step further by plicating the uterosacrals to the lateral aspect of vagina.?
- Do not play with the normal anatomy until and unless indicated.Whether or not the hysterectomy itself increases the risk of subsequent pelvic floor…
- Prophylactic procedures at the time of operation may be the ” shotgun” approach to the problem which has not yet occured.Since vaginal support is…
pure in itself,
perpetual in its applicability and
a worthy product of heaven
‘‘From inability to leave well alone;
From so much zeal for what is new and contempt for what is old;
From putting knowledge before wisdom,
Science before an art,cleverness before commonsense;;
From treating patients as cases; and
From making the cure of a disease more grevious than its endurance,
Good Lord Deliver us”
Huthinson , 1871-1960
Cited in Bailey and love’s ”A short practice of surgery”
Is a patient ‘destined’ to prolapse her vaginal vault after hysterectomy due to her genetic makeup or can this problem be avoided.?
First we have to understand the Anatomy and Pathophysiology :
RELATIONSHIP OF GENITAL STRUCTURES TO BLADDER , RECTUM , URETER AND OTHERS STRUCTURES
Sacrum, coccyx,Ileum, Ischium,Pubis
Levators , Obturator,Piriformis,Coccygeus muscles
- Identifying and reapproximating the endopelvic fascia.
- Reattaching remnants of the uterosacrals to the vagina.
- Securing the vault to other pelvic structures with mesh or permanent suture material.
Do any of these intraoperative factors truly affect the incidence of prolapse?
Iatrogenic factors potentially leading to prolapse can be :
- Poor surgical technique resulting in excessive damage to vessels and nerves in the endopelvic fascia.
- Failure to support the vagina after removal of cervix.
- Excessive shortening of vagina.
- Failure to employ a prophylactic step prior to closure of the vault.
- Failure to recognise and repair pelvic floor defects during hysterectomy.
PELVIC KIDNEY IN POUCH OF DOUGLAS
Preventive measures :
- Plication of the uterosacrals obliteration of cul de sac.
- Has these procedures provided any protective effect?
- It could even be argued that these prophylactic procedures might actually increase the risk of pelvic floor defects by increasing the amount of tissue damage to the very support structures one is trying to reinforce.
Can vault prolapse be prevented?
Are we lousy surgeons ?
Can’t we take a step further by plicating the uterosacrals to the lateral aspect of vagina.?
- Do not play with the normal anatomy until and unless indicated.
- Whether or not the hysterectomy itself increases the risk of subsequent pelvic floor defect is unknown.
- Defect in the support structures of vagina occur in a variety of anatomical locations and present differently in each patient.
- Treatment must be individualized for every patient after careful evaluation of the each anatomic defect.
- Prophylactic procedures at the time of operation may be the ” shotgun” approach to the problem which has not yet occured.
- Since vaginal support is dependent on other anatomical structures as well so plication of the uterosacrals will not prevent the subsequent vault prolapse.
- These defects might be lateral vaginal wall herniation or a small asymptomatic enterocele.
- Prior to surgery , surgeon must thoroughly examine the vagina for the defects in the support.
- When uterus is removed they must be evaluated further in the abdomen and must be corrected.
- The role of ‘preventive’ measure for vault prolapse is unclear.It is certain, however that careful identification and correction of subtle defects at the time of hysterectomy is more likely to prevent the vault prolapse than any prophylactic measure.
- D A JOHNS
- MC call postr culdoplasty; surgical corection of enterocele during vaginal hysterectomy, obstet gynecol 1957;10;592
- Patrick O’Connor Department of Biomedical Sciences College of Osteopathic Medicine Ohio University Athens, OH 45701
- Emge LA , Durfee RB. pelvic organ prolapse;4000 years of treatment.cin obstet gyneco;1996;9:997
- Te Linde’s operative Gynec edited by John D.Thompson.John A rock-7th edition.704
- MATTHEW D. BARBER, MD, MHS CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 72 • SUPPLEMENT 4 DECEMBER 2005
- Total laparoscopic hysterectomy (bhagia.wordpress.com)
- What is genital prolapse? (zocdoc.com)
- Pelvic Organ Prolapse (incostress1.wordpress.com)