Surgical Approaches

The goals of vaginal vault prolapse surgery include restoration of vaginal apical support and maintenance of normal vaginal length, axis, and caliber. To achieve a long-term successful outcome, correction of all pelvic floor defects should be achieved at the time of a vaginal vault suspension. Care must thus be taken to achieve integrity of the fascial envelope of the anterior and posterior vaginal walls and reattaching any fascial tears off of the vaginal apex during the surgical procedure.

Vaginal vault support procedures are divided into abdominal approaches and vaginal approaches, as well as reconstructive and obliterative procedures as shown below:

Vaginal

McCall culdoplasty Ileococcygeus suspension Sacrospinous fixation Uterosacral ligament suspension Posterior intravaginal slingplasty (IVS) vault suspension Abdominal

Abdominal sacrocolpopexy Reattachment of uterosacral ligaments Laparoscopic

Abdominal sacrocolpopexy Reattachment of uterosacral ligaments Obliterative vaginal Le Fort colpocleisis Colpectomy

Choice of the surgical approach to a patient's vault suspension procedure is dependent on multiple individual

Figure 8-2.1. The vaginal cuff or the cervix act as a central attachment site for suspensory ligaments (uterosacral and cardinal) and anterior and posterior vaginal wall endofascial layers. 1, Vaginal apex. 2, perineal body. (Reprinted with the permission of The Cleveland Clinic Foundation.)

variables. We will typically perform an abdominal sacro-colpopexy in a patient with advanced prolapse in which the vaginal apex reaches significantly above the ischial spines on vaginal examination, for whom maintaining normal sexual activity is very important, someone who will require another abdominal procedure for their vaginal prolapse such as an abdominal paravaginal repair, and someone with significant vaginal wall scarring, large apical fascial defects, or significant foreshortening of the vaginal canal. Vaginal approaches are typically performed in post-menopausal women for whom sexual activity may not be as important and in whom other reconstructive procedures can be appropriately performed vaginally. Obliterative procedures are performed in elderly women who are not, and will not, be sexually active, and who request the least invasive procedure for advanced vaginal prolapse. Laparo-scopic approaches are reserved for surgeons request laparoscopic skills adequate enough to safely achieve a good anatomic result. At our center, we restrict our laparo-scopic surgeries to those patients who are good candidates for reattachment of the uterosacral ligaments to the vaginal apex or shortening of the uterosacral ligaments in enhancing vaginal vault support.

The importance of prevention of posthysterectomy vaginal vault prolapse cannot be overemphasized. Performance of a McCall culdoplasty at the time of a vaginal hysterectomy has proven value in maintaining vaginal vault support. We encourage surgeons to perform this procedure at the time of any vaginal hysterectomy and to be very methodical in restoration of vaginal vault support by reattaching uterosacral and cardinal ligaments to the vaginal apical fascia and mucosa. This is of special importance in women who are undergoing vaginal hysterectomy for pre existing vaginal vault prolapse. We perform a McCall culdoplasty by using a permanent suture (i.e., 0-silk) to incorporate both uterosacral ligaments to full thickness of the apical vaginal wall. It is important to tag the uterosacral ligaments during the hysterectomy procedure, so as to be able to easily identify the ligaments for suture placement. In women with vault prolapse,we measure the number of centimeters the vault has prolapsed [pelvic organ prolapse quantitation (POP-Q) TVL minus point D], and place the sutures that same distance up each ligament from the vaginal cuff. In addition, during cuff closure, we approximate the cardinal and uterosacral ligaments to each other in the midline with individual figure-of-8 sutures. A McCall culdoplasty will prevent the development of an enterocoele unless a posterior fascial separation from the cervix was preexistent. Such a defect may be identified during a posterior colporrhaphy dissection, and the fascia should be reattached to the newly formed cuff.

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