In the period between May 2002 and July 2008, 51 cases of vaginal vault prolapse were treated with the innovative technique described hereunder.88.23% (n = 45) had had undergone vaginal hysterectomy for genital prolapse and the remaining 11.77% (n = 6) had apical prolapse developing after abdominal hysterectomy for the indication of leiomyoma uteri in 4 cases and dysfunctional uterine bleeding in the other 2 cases. The mean time elapsed from the previous surgery was 29 months with the shortest being 13 months and the longest being 50 months. Two of the cases of vaginal hysterectomy group had undergone prior surgery for the vault prolapse- one had sacrocolpopexy 13 months back, and the other had some vaginal procedure 27 months back, record of which was not available but both these patients developed recurrence.
Mean age of our patients was 59.3 years with the youngest & oldest being 37.0 & 69.5 years respectively.
Written informed consent was taken and the Departmental Ethical Committee approved the study.
Based on the quality of life, complaints, history and clinical examination- a questionnaire proforma was filled for each patient. Nine of the patients had stress incontinence (all after vaginal hysterectomy).
Previous history of one patient was that of Pulmonary Tuberculosis for which she had had a full course of anti-tubercular treatment and at the time of admission was symptom free. Prior to taking up the patient for surgery, presence of chronic cough & chronic constipation complaints were clearly addressed to.
Clinical examination was re-conducted for the presence of enterocoele (n = 9), cystocoele (n = 17), rectocoele (n = 23), genuine stress incontinence (n = 9).
Initially, bladder cathetrisation with 16 French indwelling foley's and tight vaginal packing done pre-operatively.
Technique employed included: transverse skin incision (Pfannenstiel) about 8 cm long at the level of anterior superior iliac spine. Rectus sheath was exposed by separating the subcutaneous adipose tissue from its surface for the entire length of the incision and about 2 cm in breadth.
About 1 cm longitudinal incision was given on the rectus sheath in the midline and laterally this incision extended transversely about 3-4 cm on either side superiorly as well as inferiorly beyond the lateral margin of the rectus muscle. Now that two strips of the rectus fascia were devised (figure- 1 and 2) with free medial margins which were secured with silk no.1 with the thread kept long on both the sides.
Diagramatic representation showing Rectus fascia strips.
Peritoneal cavity was approached in the usual way followed by abdominal packing. Vault (figure- 3) identified (easy because of initial vaginal packing) and held with Allis' forceps at both of its angles. Peritoneum between these Allis' forceps over the vault was incised.
vault (easily identified because of pre-op. vaginal packing).
A long curved artey forceps was used to make a track retroperitoneally, parallel to the erstwhile round ligament exercising utmost care so as to avoid ureter on the way. On reaching lateral to the rectus muscle the medial margin of the ipsilateral already carved rectus sheath strip was held and brought to the angle of the vault ensuring that no twisting occurred. Similar procedure was performed on the opposite side. Once done, the silk threads kept long earlier, were tied on to the vault with optimal tension (figure-4 and 5) so that rectus fascia strips after fixation were neither too taut nor so lax as to defeat the purpose of surgery.
pulled-up vault after fixation of the rectus fascia strips.
Diagramatic representation showing fixation of the rectus fascia strips.
Re-peritonisation accomplished by suturing the incised peritoneum on the vault with chromic catgut no. 1-0.
Patients having enterocoele were treated with Moschowitz operation. In those nine patients having stress incontinence, concomitant pubovaginal sling repair was carried out.
Abdomen was closed in layers after securing haemostasis and removing the sponge pack.
Sub-cuticular sutures were applied in all the cases.
Vaginal packing done prior to surgery, removed.
In cases with rectocele, perineorrhaphy with levator myorrhaphy was done followed by vaginal packing for 24 hrs in such cases.
Intra venous fluids continued for about 24 hrs and injectable antibiotics for 36 hours. Oral fluids were offered after the bowel sounds appeared (on an average after 24 hours). Patient was made ambulatory 24-36 hours following surgery.
Catheter was removed after 24 hours except in patients who underwent anti-incontinence repair alongwith, where it was taken out after 5 days post-operatively.
Mean operating time was approximately 52 minutes: those cases in whom only anterior abdominal wall colpopexy was done the procedure was accomplished in 47 minutes but in those cases in whom additional surgical procedures were required like
Moschowitz/Burch/perineorrhaphy, extra 15 minutes were taken but operating duration never extended beyond 70 minutes.
Intraoperative difficulties encountered were not much annoying: 7 cases (13.73%) had omental and 3 (5.88%) had small gut adhesions on the vault.
Amount of intra operative blood loss was between 200 to 450 ml (more loss in cases where perineorrhaphy was done alongwith); nevertheless, no blood transfusion was required in any of the cases neither during surgery nor post-operatively.
In the post-operative period two patients (3.92%) had vomiting on the 2nd day, another two (3.92%) had fever. 25.49% (n = 13) patients felt slight tightness in the abdomen but not amounting to discomfort of concern.
Two patients (3.92%) who had simultaneous urinary anti-incontinence operation had urinary retention following removal of the indwelling catheter on the 5th post-operative day and had to be re-catheterised for another 48 hrs and toning-up of the bladder done.
One patient (1.96%) had bleeding from the perineorrhaphy wound on removal of the vaginal pack but not too alarming to be of concern. 42 (82.35%) patients were discharged 3 days after surgery, eight of those nine cases (15.68%) who had concomitant pubo-vaginal sling for stress incontinence were discharged 5 days after surgery; one of these patients had urinary retention following catheter removal and was discharged after 3 more days. Another patient had retention of urine after discharge from the hospital but was re-admitted for 72 hrs.
Sub-cuticular abdominal wound stitches were removed on the7th day of surgery in all the patients.
At discharge, per-speculum examination was conducted and the success criteria considered was that on straining the vault, which was prolapsing pre-operatively, was seen being pulled up/retracted.
39 patients (76.47%) are under regular follow-up, (longest follow-up-5 yrs 3 months and the patient with the shortest follow-up of 14 months), 12 patients (23.53%) were lost after initial one or two follow-ups. Another questionnaire proforma was filled after one year of regular postoperative visits of these 39 patients. All the patients on regular follow-up confirm the success of the procedure as none of these have reported recurrence of the symptoms.