Can vault prolapse be prevented ?

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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.

Surgery is the first and highest division of the healing art,
pure in itself,
perpetual in its applicability and
a worthy product of heaven

सुश्रुता



‘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”

Pelvic floor defects like cystocoele , enterocele,rectocele, vaginal prolapse are seen by gynecologists in routine practice while doing per vaginal examination.Usually these women are parous and do not require surgical intervention.
Pure vaginal vault prolapse after hysterectomy is rare.Usually it is asociated with ”pelvic floor relaxation” having unidentifiable pelvic floor defects.Pure vaginal prolapse not associated with any other pelvic floor defect is very rare.

Is a patient ‘destined’ to prolapse her vaginal vault after hysterectomy due to her genetic makeup or can this problem be avoided.?

The vagina has been sewn , meshed , spiked , and glued to almost every available pelvic structure after the vault prolapse.But it is the treatment not the prevention.

First we have to understand the Anatomy and Pathophysiology :

The upper portion of vagina and cervix are supported by the uterosacral cardinal ligaments.
They are not ligaments but the condensation of fibroelastic tissue, smooth muscle fibres, vessels, lymphatics and nerves comprising what is known as endopelvic fascia.
The ‘pelvic diaphragm’ and ‘ urogenital diaphragm’,along with pubourethral ligaments , complete the structures supporting the vagina and cervix.
Uterus is not a factor in vaginal vault support.
When support structures are damaged it will prolapse along with vagina.
The Female Pelvis
CORE
Centers for osteopathic research and education
Netter1989
RELATIONSHIP OF GENITAL STRUCTURES TO BLADDER , RECTUM , URETER AND OTHERS STRUCTURES

BOUNDARIES
Sacrum, coccyx,Ileum, Ischium,Pubis
Levators , Obturator,Piriformis,Coccygeus muscles

Netter 1989
PERITONEAL REFLECTIONS
Surgical procedures designed to correct pelvic floor defects , including vaginal vault prolapse, rely on reconstructing those structures normally supporting vagina.
  •  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.
Cause of prolapse may be the conegintal defect in the tissues, trauma from delivery , obesity, COPD resulting in increased abdominal pressure.

Do any of these intraoperative factors truly affect the incidence of prolapse?

Could , possibly , ‘reattaching’ the support structures to vaginal apex actually increase the likelihood of subsequent 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.
Millions of hysterectomies are performed every year worldwide with different techniques , different skills,
variety of instruments and sutures.How can we study the variations in the parameters to know if any of these are related to subsequent prolapse of the vault.
UTERUS POSITIONING
PELVIC KIDNEY IN POUCH OF DOUGLAS
UTEROVAGINAL PROLAPSE
BROAD LIGAMENT
NORMAL VAGINAL  AXIS AND THREE LEVELS OF SUPPORT OF UTERUS AND VAGINA
MATTHEW D. BARBER, MD

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.?

However vagina is not separated from these structures during hysterectomy.
Uterosacral-cardinal ligament complex remains intact and in direct contact with vaginal’ cuff.’
Damage to the complex at the time of hysterectomy may be a factor leading to subsequent vault prolapse.Damage is done to the most distal parts of these structures.
When they are plicated sutures are tried under tension , bringing them in the midline.Anatomically if we see how the plication which is away from the vagina , in the midline , is going to help and give support to vagina.?
Sutures damage the ligaments proximal to their attachment to vagina.Hence the damage may
increase the risk of prolapse rather than decreasing it.
To obliterete the normal cul-de-sac or removal of the peritoneum in order to ‘scar’ the area may damage the vascular and neurological structures and increases risk of vault prolapse .

  •  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.

References

  1. D A JOHNS
  2. MC call postr culdoplasty; surgical corection of enterocele during vaginal hysterectomy, obstet gynecol 1957;10;592
  3. http://knol.google.com/k/-/-/1phs16i73la7p/ss9ofw/pouch-of-douglas.bmp
  4. Patrick O’Connor Department of Biomedical Sciences College of Osteopathic Medicine Ohio University Athens, OH 45701
    http://oconnorp@exchange.oucom.ohiou.edu
  5. http://knol.google.com/k/-/-/1phs16i73la7p/ss9ofw/pelvis.bmp
  6. http://knol.google.com/k/-/-/1phs16i73la7p/ss9ofw/boundaries.bmp
  7. http://knol.google.com/k/-/-/1phs16i73la7p/ss9ofw/pouch.bmp
  8. Emge LA , Durfee RB. pelvic organ prolapse;4000 years of treatment.cin obstet gyneco;1996;9:997
  9. Te Linde’s operative Gynec edited by John D.Thompson.John A rock-7th edition.704
  10. http://knol.google.com/k/-/-/1phs16i73la7p/ss9ofw/prolapse.bmp
  11. MATTHEW D. BARBER, MD, MHS CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 72 • SUPPLEMENT 4 DECEMBER 2005
  12. http://knol.google.com/k/-/-/1phs16i73la7p/ss9ofw/anatomy-female-pelvis.p
  13. http://knol.google.com/k/-/-/1phs16i73la7p/ss9ofw/broad-ligament.bmp
English: lateral anatomy view of the female re...

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  1. MCQs-Gynaec-1 – ObGyn linked to this post.

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