Paravaginal Defect Repair

The object of the paravaginal defect repair is to reattach, bilaterally, the anterolateral vaginal sulcus with its overlying endopelvic fascia to the pubococcygeus and obturator internus muscles and fascia at the level of the arcus tendineus fasciae pelvis. The retropubic space is entered and the bladder and vagina are depressed and pulled medially to allow visualization of the lateral retropubic space, including the obturator internus muscle, and the fossa containing the obturator neurovascular bundle. Blunt dissection can be carried dorsally from this point until the ischial spine is palpated. The arcus tendineus fasciae pelvis is frequently visualized as a white band of tissue running over

Figure 6-5.1. Technique of Burch colposuspension.After the two sutures are placed on each side, they are passed through the pectineal (Cooper's) ligament, so that all four suture ends exit above the ligament to facilitate knot tying. Inset: In placing the sutures, one should take a full thickness of vaginal wall,excluding the epithelium,with the needle parallel to the urethra.This maneuver is best achieved by suturing over the vaginal finger.

(Reprinted from Urogynecology and Reconstructive Pelvic Surgery, 2nd ed, MD Walters, MM Karram, page 161,© 1999 Mosby,with permission from Elsevier.)

Figure 6-5.1. Technique of Burch colposuspension.After the two sutures are placed on each side, they are passed through the pectineal (Cooper's) ligament, so that all four suture ends exit above the ligament to facilitate knot tying. Inset: In placing the sutures, one should take a full thickness of vaginal wall,excluding the epithelium,with the needle parallel to the urethra.This maneuver is best achieved by suturing over the vaginal finger.

(Reprinted from Urogynecology and Reconstructive Pelvic Surgery, 2nd ed, MD Walters, MM Karram, page 161,© 1999 Mosby,with permission from Elsevier.)

the pubococcygeus and obturator internus muscles from the back of the lower edge of the symphysis pubis toward the ischial spine. A lateral paravaginal defect representing avulsion of the vagina off the arcus tendineus fasciae pelvis or of the arcus tendineus fasciae pelvis off the obturator internus muscle may be visualized (Figure 6-5.2).

The surgeon's nondominant hand is inserted into the vagina. While gently retracting the vagina and bladder medially, the surgeon elevates the anterolateral vaginal sulcus. Starting near the vaginal apex, a suture is placed, first through the full thickness of the vagina (excluding the vaginal epithelium), and then into the obturator internus and levator fascia or arcus tendineus fasciae pelvis, 1 to 2 cm anterior to its origin at the ischial spine. After this first stitch is tied, additional (four or five) sutures are placed through the vaginal wall and overlying fascia and then into the levator muscle and fascia at about 1-cm intervals toward the pubic ramus (Figure 6-5.2). The most distal suture should be placed as close as possible to the pubic ramus, into the pubourethral ligament. We use No. 2-0 non-absorbable suture on a medium-sized, tapered needle for the paravaginal repair. If a Burch procedure is combined with a paravaginal defect repair, it is easier to place and tie the most cephalad paravaginal sutures first, then place the Burch colposuspension sutures at the level of the urethra and bladder neck.

The procedure leaves free space between the symphysis pubis and the proximal urethra,but secures support so that rotational descent of the proximal urethra and bladder base is prevented with sudden increases in intraabdominal pressure. The paravaginal defect repair avoids overcor-rection and fixation of the paraurethral endopelvic fascia, which might compromise the functional movements of the urethra and bladder base and lead to obstruction and voiding difficulty. This principle may explain why the paravaginal defect repair usually results in spontaneous voiding on the first or second postoperative day.

Figure 6-5.2. Lateral paravaginal defect and technique of paravaginal defect repair. Four to six sutures are placed,first through the full thickness of the vagina (excluding the vaginal epithelium), and then into the obturator internus and levator fascia or arcus tendineus fasciae pelvis, 3 to 4 cm below the obturator fossa. (Reprinted from Urogynecol-ogy and Reconstructive Pelvic Surgery, 2nd ed,MD Walters,MM Karram, page 162,© 1999 Mosby,with permission from Elsevier.)

Figure 6-5.2. Lateral paravaginal defect and technique of paravaginal defect repair. Four to six sutures are placed,first through the full thickness of the vagina (excluding the vaginal epithelium), and then into the obturator internus and levator fascia or arcus tendineus fasciae pelvis, 3 to 4 cm below the obturator fossa. (Reprinted from Urogynecol-ogy and Reconstructive Pelvic Surgery, 2nd ed,MD Walters,MM Karram, page 162,© 1999 Mosby,with permission from Elsevier.)

Constipation Prescription

Constipation Prescription

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