DOCSLIB.ORG

Abdominal Techniques for Surgical Management of Vaginal Vault Prolapse

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
Abdominal Techniques for Surgical Management of Vaginal Vault Prolapse SURGICAL TECHNIQUES William Irvin, MD Abdominal techniques Associate Professor Division of Gynecologic Oncology for surgical management University of Virginia Health System of vaginal vault prolapse Charlottesville, Va Kathie Hullfish, MD Indications, techniques, and evidence-based rationale Director, Division of Reconstructive Pelvic Surgery and Urogynecology University of Virginia Health System range of clinical conditions can sug- Technique Charlottesville, Va gest an abdominal approach for Identify and tag the remnants of the utero- A vaginal vault prolapse procedures. sacral ligaments at the level of the ischial These include, but are not limited to: spines. Once the ureters are identified and • prior unsuccessful vaginal attempts ® isolated,Dowden address Healththe enterocele Media by obliterat- • obligate need for adnexal access ing the cul-de-sac via Halban’s culdoplasty • markedly foreshortened vagina or abdominal McCall’s culdoplasty. • pelvic bony architecturalCopyright limitationsFor personalOpen the peritoneum use only over the vaginal • high risk for surgical failure (eg, athleti- apex and trim it back to the level of the cism, obesity, chronic obstructive pul- endopelvic fascia of the vaginal wall. After monary disease, congenital connective excising the redundant peritoneum of the tissue disorder) vaginal apex, identify and reapproximate IN THIS ARTICLE • desire for uterine preservation the pubocervical fascia of the anterior In Part 1 (November 2005) of this 2- vaginal wall and the rectovaginal fascia of S Abdominal part article, we reviewed the most widely the posterior vaginal wall using interrupt- sacral colpopexy used and the newest vaginal techniques. ed or running nonabsorbable suture. technique Part 2 focuses on the abdominal approach, Then use nonabsorbable sutures to Page 20 and compares vaginal and abdominal suspend each corner of the prolapsed vagi- approaches. na from its respective ipsilateral utero- S sacral ligament. Why correct all defects at once? Page 22 T High uterosacral ligament suspension T Abdominal sacral colpopexy Surgical technique for this procedure for Abdominal sacral colpopexy was first pop- mild to moderate vaginal vault prolapse ularized by Addison and Timmons in the (stage I or II), using a vaginal approach, 1980s, and is the abdominal standard of was described in Part 1, in the November apical prolapse repair due to its long-term issue of OBG MANAGEMENT. Abdominal durability. repair involves the same concepts; like the Abdominal sacral colpopexy can be vaginal approach, it is applicable only to performed with or without uterine extirpa- the patient with mild to moderate vault tion. When a hysterectomy is performed prolapse. It will be less successful if it is per- concomitantly, some surgeons prefer a formed to address complete vault prolapse. supracervical approach, provided there is www.obgmanagement.com December 2005 • OBG MANAGEMENT 19 For mass reproduction, content licensing and permissions contact Dowden Health Media. L Surgical management of vaginal vault prolapse FIGURE 1 no history of cervical dysplasia, because, Abdominal sacral colpopexy technique theoretically, the cervical stump serves as a firm and substantial point of fixation for the INCISION synthetic mesh that will be used to perform the repair. This in turn may diminish the likelihood of postoperative mesh erosion. Technique Reflect the sigmoid colon as far as possible into the left lateral pelvis to expose the sacral promontory. If it has not already been done, free all adhesions between the colon and pelvic peritoneum to fully mobi- lize the colon and permit its maximal A longitudinal incision in the peritoneum overlying the sacral promontory retraction out of the pelvic field prior to is extended 6 cm into the cul-de-sac, opening the retrorectal space. making the peritoneal incision. Also make it a point to identify all MESH ATTACHMENT structures at risk during this portion of the procedure—namely, the common iliac ves- sels, ureters, and middle sacral artery and vein. The left common iliac vein is medial to the left common iliac artery and is par- ticularly susceptible to injury during this phase of the procedure. Make a longitudinal incision in the peri- toneum overlying the sacral promontory and extend it approximately 6 cm from the promontory dorsally into the cul-de-sac, The mesh is attached through the fibromuscular thickness of the opening the retrorectal space (FIGURE 1, anterior vaginal wall, excluding the mucosa, with multiple interrupted TOP). Using a fine tonsil forceps and sutures. Though the diagram suggests the use of 2 separate pieces of mesh (one for the anterior and one for the posterior walls), doubling cautery, very gently dissect the retroareolar a single piece of mesh and “fishmouthing” the end to be attached to filmy tissue overlying the anterior longitu- the vagina will accomplish the same goal. dinal ligament away from S1 in thin layers Reprinted from Addison WA, Cundiff GW, Bump RC, Harris RL. Sacral colpopexy is the until the white periosteum of the anterior preferred treatment for vaginal vault prolapse. J Gynecol Tech. 1996;2:69-74. ©1996, with permission from Elsevier. longitudinal ligament overlying S1 is clear- ly exposed. It now becomes very easy to CLOSING THE INCISION visualize the course of the middle sacral artery and vein. With these vessels under direct visualization, place 2 permanent #0 sutures through the periosteum of S1. Do not attempt to place these sutures deeper in the presacral space than the S1 vertebral body, or life-threatening and uncontrollable bleeding may result. If there is no uterus, insert a probe such as an end-to-end anastomotic sizer or handheld Harrington retractor into the vagina and extend it, elongating and elevat- The 6-cm incision is closed over the top of the mesh, retroperitonealizing the prosthesis. ing the vaginal cylinder. It now becomes much easier to identify the interface 20 OBG MANAGEMENT • December 2005 Surgical management of vaginal vault prolapse L between the bladder and vagina prior to sacral promontory are threaded through making the peritoneal incision. the apex of the mesh prosthesis at a point If the interface remains indistinct, that will allow the vagina to rest comfort- instill 150 cc of saline into the bladder to ably within the pelvis, without undue ten- delineate its boundaries. Then elevate and sion or traction once the sutures are tied incise the vesicouterine peritoneum overly- into place (FIGURE 1, MIDDLE). ing the junction between the bladder and Trim any excess mesh, and close the 6- vaginal apex; this provides access to the cm longitudinal peritoneal incision previ- vesicocervical space. Dissect the bladder ously created in the cul-de-sac. Close the off the anterior vaginal wall in a caudal incision over the top of the mesh, direction until the pubocervical fascia can retroperitonealizing the mesh prosthesis be identified. Do not dissect away the peri- (FIGURE 1, BOTTOM). toneum over the posterior vaginal wall, but leave it intact. Reconstructive materials T Paravaginal defect repair Although many different materials have The bladder base is intimately associated been described, none have undergone rig- with the anterior vaginal wall via a trian- orous comparisons. In our institution, we gular sheet of pubocervical fascia attached use soft polypropylene (Surgipro; US to and extending from the arcus tendineus Surgical, Norwalk, Conn). fascia pelvis bilaterally. When the apex of Fold a piece of 5-inch mesh over onto the vagina prolapses through the introitus, itself and suture the layers together to cre- as in total vault prolapse, the base of the ate a double-thickness configuration. Then bladder is torn free from these fascial attach- “fishmouth” the caudal end of this mesh ments in the pelvis and herniates through the prosthesis, producing both an anterior and introitus along with the vaginal apex. By def- posterior leaf. With the obturator still inition, a bilateral paravaginal defect will within the vaginal cylinder stretching the result. Thus, surgical repair of total vaginal FAST TRACK vaginal apex, secure the posterior leaf of vault prolapse almost invariably requires Surgical repair the mesh to the posterior vaginal wall with paravaginal defect repair as well. 3 to 5 nonabsorbable #0 sutures. The goal of paravaginal defect repair is of total vaginal Suture placement. Thread each suture ini- to reattach, bilaterally, the anterolateral vault prolapse tially through the posterior leaf of the vaginal sulcus and its overlying endopelvic almost always mesh, placed deeply through the fibromus- fascia to the pubococcygeus and obturator cular thickness of the posterior vaginal internus muscles and fascia at the level of requires wall, then bring it back out through the the arcus tendineus fascia pelvis. paravaginal defect mesh at the same point. Place the sutures in repair, as well a transverse line 1 to 2 cm apart and 3 to Technique 4 cm distal to the vaginal apex. Enter and gently develop the retropubic Once all sutures have been placed, tie space of Retzius, taking care not to disrupt each of them, thereby securing the posteri- the myriad venous anastomotic networks of or leaf of the mesh to the posterior vaginal the plexus of Santorini, located on and wall. Now perform a “mirror” procedure around the bladder. Bluntly mobilize the to secure the anterior leaf of the mesh pros- bladder bilaterally, exposing the lateral thesis to the anterior vaginal wall. Then retropubic spaces, the pubococcygeus and
Load more

Recommended publications
  • The Subperitoneal Space and Peritoneal Cavity: Basic Concepts Harpreet K
    ª The Author(s) 2015. This article is published with Abdom Imaging (2015) 40:2710–2722 Abdominal open access at Springerlink.com DOI: 10.1007/s00261-015-0429-5 Published online: 26 May 2015 Imaging The subperitoneal space and peritoneal cavity: basic concepts Harpreet K. Pannu,1 Michael Oliphant2 1Department of Radiology, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA 2Department of Radiology, Wake Forest University School of Medicine, Winston-Salem, NC, USA Abstract The peritoneum is analogous to the pleura which has a visceral layer covering lung and a parietal layer lining the The subperitoneal space and peritoneal cavity are two thoracic cavity. Similar to the pleural cavity, the peri- mutually exclusive spaces that are separated by the toneal cavity is visualized on imaging if it is abnormally peritoneum. Each is a single continuous space with in- distended by fluid, gas, or masses. terconnected regions. Disease can spread either within the subperitoneal space or within the peritoneal cavity to Location of the abdominal and pelvic organs distant sites in the abdomen and pelvis via these inter- connecting pathways. Disease can also cross the peri- There are two spaces in the abdomen and pelvis, the toneum to spread from the subperitoneal space to the peritoneal cavity (a potential space) and the subperi- peritoneal cavity or vice versa. toneal space, and these are separated by the peritoneum (Fig. 1). Regardless of the complexity of development in Key words: Subperitoneal space—Peritoneal the embryo, the subperitoneal space and the peritoneal cavity—Anatomy cavity remain separated from each other, and each re- mains a single continuous space (Figs.
    [Show full text]
  • A Simplified Fascial Model of Pelvic Anatomical Surgery: Going Beyond
    Anatomical Science International https://doi.org/10.1007/s12565-020-00553-z ORIGINAL ARTICLE A simplifed fascial model of pelvic anatomical surgery: going beyond parametrium‑centered surgical anatomy Stefano Cosma1 · Domenico Ferraioli2 · Marco Mitidieri3 · Marcello Ceccaroni4 · Paolo Zola5 · Leonardo Micheletti1 · Chiara Benedetto1 Received: 13 March 2020 / Accepted: 5 June 2020 © The Author(s) 2020 Abstract The classical surgical anatomy of the female pelvis is limited by its gynecological oncological focus on the parametrium and burdened by its modeling based on personal techniques of diferent surgeons. However, surgical treatment of pelvic diseases, spreading beyond the anatomical area of origin, requires extra-regional procedures and a thorough pelvic anatomical knowl- edge. This study evaluated the feasibility of a comprehensive and simplifed model of pelvic retroperitoneal compartmen- talization, based on anatomical rather than surgical anatomical structures. Such a model aims at providing an easier, holistic approach useful for clinical, surgical and educational purposes. Six fresh-frozen female pelves were macroscopically and systematically dissected. Three superfcial structures, i.e., the obliterated umbilical artery, the ureter and the sacrouterine ligament, were identifed as the landmarks of 3 deeper fascial-ligamentous structures, i.e., the umbilicovesical fascia, the urogenital-hypogastric fascia and the sacropubic ligament. The retroperitoneal areolar tissue was then gently teased away, exposing the compartments delimited by these deep fascial structures. Four compartments were identifed as a result of the intrapelvic development of the umbilicovesical fascia along the obliterated umbilical artery, the urogenital-hypogastric fascia along the mesoureter and the sacropubic ligaments. The retroperitoneal compartments were named: parietal, laterally to the umbilicovesical fascia; vascular, between the two fasciae; neural, medially to the urogenital-hypogastric fascia and visceral between the sacropubic ligaments.
    [Show full text]
  • Understanding the Anatomy of the Denonvilliers Fascia: Review Article Compreendendo a Anatomia Da Fáscia De Denonvilliers: Artigo De Revisão Mohammed Yousef Alessa1
    THIEME Review Article 193 Understanding the Anatomy of the Denonvilliers Fascia: Review Article Compreendendo a anatomia da fáscia de Denonvilliers: Artigo de revisão Mohammed Yousef Alessa1 1 King Faisal University Surgery, Hofuf, Eastern Province, Saudi Arabia Address for correspondence Mohammed Yousef Alessa, King Faisal University Surgery, Hofuf, Eastern Provience, Saudi Arabia J Coloproctol 2021;41(2):193–197. (e-mail: [email protected]). Abstract The postoperative outcome of rectal cancer has been improved after the introduction of the principles of total mesorectal excision (TME). Total mesorectal excision includes resection of the diseased rectum and mesorectum with non-violated mesorectal fascia (en bloc resection). Dissection along the mesorectal fascia through the principle of the “holy plane” minimizes injury of the autonomic nerves and increases the chance of preserving them. It is important to stick to the TME principle to avoid perforating the tumor; violating the mesorectal fascia, thus resulting in positive circumferential resectionmargin(CRM);orcausinginjuryto the autonomic nerves, especially if the tumor is located anteriorly. Therefore, identifying the anterior plane of dissection during TME is important because it is related with the autonomic nerves (Denonvilliers Keywords fascia). Although there are many articles about the Denonvilliers fascia (DVF) or the ► anatomy of anterior dissection plane, unfortunately, there is no consensus on its embryological denonvilliers fascia origin, histology, and gross anatomy. In the present review article, I aim to delineate ► understanding and describe the anatomy of the DVF in more details based on a review of the literature, anatomy in order to provide insight for colorectal surgeons to better understand this anatomical ► review article feature and to provide the best care to their patients.
    [Show full text]
  • Surgery for Urogenital Prolapse ARTÍCULOS DE REVISIÓN
    MoenARTÍCULOS MD DE REVISIÓN REV MED UNIV NAVARRA/VOL 48, Nº 4, 2004, 50-55 Surgery for urogenital prolapse M.D. Moen, M.D., FACOG, FACS Director, Division of Urogynecology. Advocate Lutheran General Hospital. Park Ridge, Illinois, USA. Correspondencia: Department of Obstetrics and Gynecology Advocate Lutheran General Hospital 1775 Dempster Street Park Ridge, IL 60068, USA. ([email protected]) Resumen Summary El prolapso urogenital puede tener un impacto significativo en la Urogenital prolapse can have a significant impact on quality of life. calidad de la vida. A medida que la población continúa envejeciendo, As the population continues to age, the prevalence of urogenital prolapse el predominio del prolapso urogenital está aumentando, y el riesgo is increasing, and the lifetime risk of requiring surgery for urogenital de requerir cirugía para el prolapso urogenital o para la incontinen- prolapse or incontinence is now approximately 11%. The majority of cia urogenital es, aproximadamente, 11%. La mayoría de mujeres women presenting with symptomatic prolapse suffer from multiple que presentan prolapso sintomático sufre de defectos múltiples de la defects of pelvic support and require comprehensive repair to relieve estructura pélvica y requiere de una reparación adecuada para ali- symptoms. An understanding of normal pelvic support structures viar losr síntomas. Una comprensión de las estructuras pélvicas provides the basis for the anatomic approach to repair. Many normales de soporte proporciona la base para el acercamiento ana- appropriate options exist for surgical correction of urogenital prolapse. tómico a la reparación. Existen muchas opciones apropiadas para la Procedures to reestablish apical support include culdoplasty corrección quirúrgica del prolapso urogenital.
    [Show full text]
  • Management of Rectal Prolapse –The State of the Art
    Central JSM General Surgery: Cases and Images Bringing Excellence in Open Access Review Article *Corresponding author Adrian E. Ortega, Division of Colorectal Surgery, Keck School of Medicine at the University of Southern California, Los Angeles Clinic Tower, Room 6A231-A, Management of Rectal Prolapse LAC+USC Medical Center, 1200 N. State Street, Los Angeles, CA 90033, USA, Email: sccowboy78@gmail. – The State of the Art com Submitted: 22 November 2016 Ortega AE*, Cologne KG, and Lee SW Accepted: 20 December 2016 Division of Colorectal Surgery, Keck School of Medicine at the University of Southern Published: 04 January 2017 California, USA Copyright © 2017 Ortega et al. Abstract OPEN ACCESS This manuscript reviews the current understanding of the condition known as rectal prolapse. It highlights the underlying patho physiology, anatomic pathology Keywords and clinical evaluation. Past and present treatment options are discussed including • Rectal prolapsed important surgical anatomic concepts. Complications and outcomes are addressed. • Incarcerated rectal prolapse INTRODUCTION Rectal prolapse has existed in the human experience since the time of antiquities. References to falling down of the rectum are known to appear in the Ebers Papyrus as early as 1500 B.C., as well as in the Bible and in the writings of Hippocrates (Figure 1) [1]. Etiology • The precise causation of rectal prolapse is ill defined. Clearly, five anatomic pathologic elements may be observed in association with this condition:Diastasis of Figure 1 surrounded by circular folds of rectal mucosa. the levator ani A classic full-thickness rectal prolapse with the central “rosette” • A deep cul-de-sac • Ano-recto-colonic redundancy • A patulous anus • Loss of fixation of the rectum to its sacral attachments.
    [Show full text]
  • Clinical Anatomy of the Female Pelvis 1
    Clinical Anatomy of the Female Pelvis 1 Clinical Anatomy of the Female Pelvis 1 Helga Fritsch CONTENTS 1.1 Introduction 1.1 Introduction 1 1.2 Morphological and The pelvic fl oor constitutes the caudal border of the Clinical Subdivision of the Female Pelvis 1 human’s visceral cavity. It is characterized by a com- plex morphology because different functional systems 1.3 Compartments 7 join here. A clear understanding of the pelvic anatomy 1.3.1 Posterior Compartment 7 1.3.1.1 Connective Tissue Structures 7 is crucial for the diagnosis of female pelvic diseases, for 1.3.1.2 Muscles 10 female pelvic surgery as well as for fundamental mech- 1.3.1.3 Reinterpreted Anatomy and anisms of urogenital dysfunction and treatment. Clinical Relevance 12 Modern imaging techniques are used for the diag- 1.3.1.4 Important Vessels, Nerves and Lymphatics of the Posterior Compartment: 13 nosis of pelvic fl oor or sphincter disorders. Further- 1.3.2 Anterior Compartment 14 more, they are employed to determine the extent of 1.3.2.1 Connective Tissue Structures 14 pelvic diseases and the staging of pelvic tumors. In 1.3.2.2 Muscles 15 order to be able to recognize the structures seen on 1.3.2.3 Reinterpreted Anatomy and CT and MRI as well as on dynamic MRI, a detailed Clinical Relevance 16 1.3.2.4 Important Vessels, Nerves and Lymphatics knowledge of the relationship of the anatomical enti- of the Anterior Compartment: 16 ties within the pelvic anatomy is required. 1.3.3 Middle Compartment 17 The Terminologia Anatomica [15] contains a mix- 1.3.3.1 Connective Tissue Structures 17 ture of old and new terms describing the different 1.3.3.2 Muscles 17 structures of the pelvis.
    [Show full text]
  • The Female Pelvic Floor Fascia Anatomy: a Systematic Search and Review
    life Systematic Review The Female Pelvic Floor Fascia Anatomy: A Systematic Search and Review Mélanie Roch 1 , Nathaly Gaudreault 1, Marie-Pierre Cyr 1, Gabriel Venne 2, Nathalie J. Bureau 3 and Mélanie Morin 1,* 1 Research Center of the Centre Hospitalier Universitaire de Sherbrooke, Faculty of Medicine and Health Sciences, School of Rehabilitation, Université de Sherbrooke, Sherbrooke, QC J1H 5N4, Canada; [email protected] (M.R.); [email protected] (N.G.); [email protected] (M.-P.C.) 2 Anatomy and Cell Biology, Faculty of Medicine and Health Sciences, McGill University, Montreal, QC H3A 0C7, Canada; [email protected] 3 Centre Hospitalier de l’Université de Montréal, Department of Radiology, Radio-Oncology, Nuclear Medicine, Faculty of Medicine, Université de Montréal, Montreal, QC H3T 1J4, Canada; [email protected] * Correspondence: [email protected] Abstract: The female pelvis is a complex anatomical region comprising the pelvic organs, muscles, neurovascular supplies, and fasciae. The anatomy of the pelvic floor and its fascial components are currently poorly described and misunderstood. This systematic search and review aimed to explore and summarize the current state of knowledge on the fascial anatomy of the pelvic floor in women. Methods: A systematic search was performed using Medline and Scopus databases. A synthesis of the findings with a critical appraisal was subsequently carried out. The risk of bias was assessed with the Anatomical Quality Assurance Tool. Results: A total of 39 articles, involving 1192 women, were included in the review. Although the perineal membrane, tendinous arch of pelvic fascia, pubourethral ligaments, rectovaginal fascia, and perineal body were the most frequently described structures, uncertainties were Citation: Roch, M.; Gaudreault, N.; identified in micro- and macro-anatomy.
    [Show full text]
  • Dynamic MRI of the Pelvic Floor
    Dynamic Magnetic Resonance Imaging of the Pelvic Floor Sindhura Alapati, MD,* and Kedar Jambhekar, MD Pelvic floor dysfunction is a widespread condition affecting up to 50% of elderly women. It markedly compromises the quality of life owing to various disabling symptoms such as pelvic pain, pelvic organ prolapse, and urinary and fecal incontinence. Although age and female sex are the main risk factors, others include multiparity, obesity, and connective tissue disorders. Pelvic floor dysfunction is frequently multicompartmental, and failure to diagnose it accurately often leads to treatment failure. Dynamic pelvic floor magnetic resonance imaging is a robust tool that enables simultaneous visualization of the 3 pelvic floor compartments and is indispensable for precise preoperative evaluation. Semin Ultrasound CT MRI 38:188-199 C 2017 Elsevier Inc. All rights reserved. Introduction of one or more pelvic organs through the hiatus secondary to ineffective support structures. This disorder can manifest as elvic floor dysfunction is an umbrella term for a spectrum prolapse of any of the following anatomical structures either in P of functional disorders affecting the 3 compartments of isolation or in combination with one another: urethra the pelvic floor, caused by impairment of the support (urethrocele), urinary bladder (cystocele) or both (cystoureth- ligaments, fasciae, and muscles. It is a prevalent disorder rocele), vaginal vault and cervix (vaginal prolapse), uterus 1 affecting up to 50% of women older than 50 years of age. It (uterine prolapse), rectum (anterior or posterior rectocele), affects 23.7% of women in the United States with a prevalence small bowel (enterocele), and peritoneum (peritoneocele). On 2,3 of 9.7%-49.7%, that increases with age.
    [Show full text]
  • Laparoscopic Surgery for Pelvic Support Defects John R
    ~ Laparoscopic surgery for pelvic support defects John R. Miklosa, Robert D. Mooreb and Neeraj Kohlia Reconstructive pelvic surgery for the treatment of vaginal Introduction prolapse continues to evolve as surgeons continue their quest The anatomy, pathophysiology,and treatment of pelvic for definitive surgical cure. Though there are three primary organ prolapse has significantly evolved over the last routes of access to reconstructive pelvic surgery (abdominal, decade with increasing understanding of anatomy and vaginal and laparoscopic) it is the laparoscopic approach that development of minimally invasive surgical procedures. appears to be the least utilized. This is in part due to the great Although support for the pelvic viscera,the vagina, and degree of technical difficulty associated with laparoscopic neighboring structures involves a complex interplay suturing. This paper reviews the general principles and between muscles, fascia,nerve supply, and appropriate functional anatomy associated with normal vaginal support as anatomic orientation, the endopelvic faiscia and pelvic well as the laparoscopic surgical approach to pelvic floor floor musclesprovide most of the support function in the support defects. female pelvis. Laparoscopicreconstructive pelvic surgery requires a thorough knowledge of pelvic floor anatomy CUff Opin Obstet Gynecol 14:387-395. @ 2002 Lippincott Williams & Wilkins. and its supportive componentsbefore repair of defective anatomy is attempted. This review examines contem- porary conceptsin pelvic support anatomy,describes the Urogynecology and Reconstructive Pelvic Surgery, "Atlanta Urogynecology Associates, Atlanta, Georgia and bHarvard Medical School, Cambridge, various laparoscopicsurgical techniques currently avail- Massachusetts, USA able for reconstructive pelvic surgery, and summarizes Correspondence to John R. Miklos MD, Atlanta Urogynecology Associates, 3400-C currently published results of laparoscopicreconstructive Old Mi~on Parkway, Suite 330, Alpharetta, GA 30005, USA pelvic surgery.
    [Show full text]
  • Practical MR Imaging of Female Pelvic Floor Weakness1
    EDUCATION EXHIBIT 295 Practical MR Imaging of Female Pelvic Floor Weakness1 CME FEATURE Julia R. Fielding, MD See accompanying test at http:// www.rsna.org Pelvic floor weakness is common in middle-aged and elderly parous /education women and is often associated with stress incontinence, uterine pro- /rg_cme.html lapse, constipation, and incomplete defecation. Most patients with in- continence and minimal pelvic floor weakness can be treated based on LEARNING OBJECTIVES physical examination and basic urodynamic findings. However, in FOR TEST 5 women with symptoms of multicompartment involvement for whom a After reading this complex repair is planned or who have undergone previous repairs, article and taking the test, the reader magnetic resonance (MR) imaging can be a useful preoperative plan- will be able to: ning tool. The MR imaging evaluation is performed with the patient in Ⅲ Use commercially the supine position, without contrast agents, and within 15 minutes. A available MR imagers and software to suc- multicoil array and a rapid half-Fourier T2-weighted imaging sequence cessfully image the are used to obtain sagittal images while the patient is at rest and during female pelvic floor. Ⅲ Recognize the ap- pelvic strain, followed by axial images. On these images, the radiologist pearance of the nor- identifies the pubococcygeal line (which represents the level of the pel- mal female pelvic vic floor), the H and M lines (which are helpful for confirming pelvic floor. Ⅲ Identify MR imag- floor laxity), and the angle of the levator plate with the pubococcygeal ing markers of signifi- line (which is helpful for identifying small bowel prolapse).
    [Show full text]
  • Pelvic Pain Due to Placement of the Vaginal Cuff After Hysterectomy
    FORUM FOR OSTEOPATHIC THOUGHT TRADITION SHAPES THE FUTURE VOLUME 16 NUMBER 4 DECEMBER 2006 Pelvic Pain Due to Placement of the Vaginal Cuff after Hysterectomy page 11 December 2006 The AAO Journal/1 Instructions to Authors The American Academy of Osteopathy® Editorial Review Abstract (AAO) Journal is a peer-reviewed publication Papers submitted to The AAO Journal may be Provide a 150-word abstract that summarizes for disseminating information on the science submitted for review by the Editorial Board. the main points of the paper and it’s conclu- and art of osteopathic manipulative medicine. Notification of acceptance or rejection usually sions. It is directed toward osteopathic physicians, is given within three months after receipt of students, interns and residents and particularly the paper; publication follows as soon as pos- Illustrations toward those physicians with a special interest sible thereafter, depending upon the backlog 1. Be sure that illustrations submitted are in osteopathic manipulative treatment. of papers. Some papers may be rejected clearly labeled. because of duplication of subject matter or The AAO Journal welcomes contributions in the need to establish priorities on the use of 2. Photos and illustrations should be submit- the following categories: limited space. ted as a 5” x 7” glossy black and white print with high contrast. On the back of each photo, Original Contributions Requirements clearly indicate the top of the photo. If photos Clinical or applied research, or basic science for manuscript submission: or illustrations are electronically scanned, research related to clinical practice. they must be scanned in 300 or higher dpi Manuscript and saved in .jpg format.
    [Show full text]
  • NOTES from GUTMAN LECTURE 10/26 Use This Outline to Study From
    NOTES FROM GUTMAN LECTURE 10/26 Use this outline to study from. As you go through Gutman’s lecture, fill in the topics. Anatomy above the arcuate line below the arcuate line Skin Skin Camper’s fascia Camper’s fascia Scarpa’s fascia Scarpa’s fascia External oblique aponeurosis External oblique aponeurosis Internal oblique aponeurosis Internal oblique aponeurosis Rectus muscle Rectus muscle Internal oblique aponeurosis Transversus abdominis muscle Transversus abdominis muscle Transversalis fascia Transversalis fascia peritoneum peritoneum Anterior Abdominal Wall landmarks Median umbilical folds- Medial umbilical folds – Lateral umbilical folds– Bones of pelvis Sacrum Coccyx Innominate bones Pubis Ischium Ilium Sacrotuberous – ischial tuberosity Æsacrum Sacrospinous – ischil spine Æ sacrum Anterior longitudinal ligament (ASC) Anal coccygeal ligament Pectineal ligament = Cooper’s ligament - along pectin pubis (Burch retropubic urethropexy) Pelvimetry Inlet true conjugate - AP diameter from superior margin pubic symphysis to sacral promontory (11cm) Obstetric conjugate – AP diameter that runs from back of pubic symphysis to sacral promontory (10cm), smallest conjugate. Diagonal conjugate – AP diameter from inferior margin of pubic symphysis to sacral promontory (11.5cm) Oblique diameter – from sacroiliac joint to contralateral iliopubic eminence (<13cm) Transverse diameter – widest distance across the pelvic brim (13.5cm) Midplane interspinous diameter - (10cm), smallest diameter, very important obstetrically. Site of deep transverse arrest.
    [Show full text]