Anterior Colporrhaphy

The excess vaginal epithelium is then trimmed and the incision is closed with use of a 2-0 polyglycolic acid suture. A vaginal pack is then placed for postoperative hemostasis. Cystoscopy should then be performed to ensure bladder and ureteral integrity.

Anterior vaginal prolapse resulting from a central defect is best corrected through a transvaginal approach. The anterior colporrhaphy was popularized by Howard Kelly in 1912,2 and although no longer an acceptable treatment for stress urinary incontinence, it remains a commonly used technique for transvaginal correction of anterior vaginal prolapse today.Although many variations of this technique have been described in the last century, the basic approach is still similar to that originally described by Kelly.

In recent years there has been a growing interest in the use of synthetic mesh or biologic grafts in the surgical repair of cystoceles to reduce the risk of prolapse recurrence. The role of mesh or tissue grafts in the surgical correction of prolapse is currently unknown because few randomized trials investigating these techniques exist. However, the limited evidence that is available remains promising. Below we describe both our technique for the traditional anterior colporrhaphy and the mesh or graft patch repair.

Mesh or Graft Patch Repair

A central defect repair using mesh or tissue graft patch begins similarly to the traditional repair. After completion of the vaginal dissection, the cardinal ligaments are isolated and plicated with two 0-polyglycolic acid sutures to correct their separation and laxity. The sutures are placed into the levator fascia on each side, thereby preventing the sliding defect herniation of the bladder base. Additionally, the cardinal ligaments form the base of the cystocele repair and anchor the posterior portion of the patch (Figure 83.1). The vaginal muscularis is plicated over the central defect cystocele which may be reduced with use of an absorbable mesh. The fascia is reapproximated with horizontal mattress sutures of delayed absorbable or permanent suture. The tissue is brought to the midline, over the mesh to facilitate reapproximation without tension and this maneuver also helps to reduce the incidence of ureteric injury. Before this, intravenous indigo carmine dye is administered to ensure patency of the ureters. A separate

Traditional Approach

The patient is placed in dorsal lithotomy position in candy-cane or Allen stirrups. A Foley catheter is placed to dependent drainage. A weighted speculum is placed in the vagina and a midline vaginal incision is made with a scalpel. Sterile saline or local anesthetic can be injected into the anterior vaginal wall before incision if desired. If performed along with a vaginal hysterectomy, it is useful to complete the hysterectomy before beginning the anterior vaginal dissection. Sharp dissection is carried laterally to remove the vaginal epithelium from the vaginal muscularis up to the lateral sulcus. The retropubic space is entered sharply with the curved Mayo scissors to allow palpation of the pubic bone if simultaneous pubovaginal sling is required. Alternatively, it can be preserved if a tension-free or other mid urethral sling is to be performed. Also, one may curtail the incision immediately below the bladder neck to allow a tension-free mid urethral sling to be placed through a separate incision.

After completing the dissection, the vaginal muscularis is plicated in the midline using several interrupted stitches of delayed absorbable or permanent suture thereby repairing the central defect and elevating the bladder base and anterior vagina. If a sling is not performed, the bladder neck can be preferentially supported by placating the peri-urethral tissue underneath the bladder neck (Kelly plication). After completing the anterior colporrhaphy, repair of lateral and/or apical support defects is then performed.

Figure 8-3.1. Cystocele repair.The vaginal muscularis is reapproximated with horizontal mattress sutures of delayed absorbable or permanent suture. (Reprinted with the permission of The Cleveland Clinic Foundation.)
Anterior Colporrhaphy

Figure 8-3.2. A segment of allograft, xenograft, or synthetic mesh is then fashioned such that the width spans from the obturator fascia to the contralateral side.The sutures are placed in the corners of the patch 5 mm from the edge. (Reprinted with the permission of The Cleveland Clinic Foundation.)

Figure 8-3.2. A segment of allograft, xenograft, or synthetic mesh is then fashioned such that the width spans from the obturator fascia to the contralateral side.The sutures are placed in the corners of the patch 5 mm from the edge. (Reprinted with the permission of The Cleveland Clinic Foundation.)

set of polyglycolic acid sutures is placed into the levator fascia distally at the level of the bladder neck to support the distal portion of the patch. A segment of allograft, xenograft, or synthetic mesh is then fashioned such that the width spans from the obturator fascia to the contralateral side. The sutures are placed in the corners of the patch 5 mm from the edge. The length of the patch segment is dependent on the size of the cystocele and the distance between the pubic bone and the cardinal ligaments. We routinely trim a 5- to 7-cm segment to fit this distance appropriately. The lower set of sutures (through the cardinal ligaments) is placed through the patch segment in a similar manner (Figure 8-3.2). The excess vaginal epithelium is then trimmed and the incision is closed with use of a 2-0 polyglycolic acid suture incorporating the underlying mesh to prevent any dead space for fluid accumulation. A vaginal pack is then placed for postoperative hemostasis.

Constipation Prescription

Constipation Prescription

Did you ever think feeling angry and irritable could be a symptom of constipation? A horrible fullness and pressing sharp pains against the bladders can’t help but affect your mood. Sometimes you just want everyone to leave you alone and sleep to escape the pain. It is virtually impossible to be constipated and keep a sunny disposition. Follow the steps in this guide to alleviate constipation and lead a happier healthy life.

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