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A Vaginal Approach to Pelvic Floor Prolapse

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A Vaginal Approach to Pelvic Floor Prolapse 30 O B .GYN. NEWS • December 1, 2007 M ASTER C LASS A Vaginal Approach to Pelvic Floor Prolapse n a recent Master Class the pubic bones and the sacrum. Posterior to the spine is searcher and much-sought-after lecturer. As this year’s sci- (OB.GYN. NEWS, Aug. 1, the sacrospinous ligament with the overlying coccygeus entific program chairman of the American Association I2007, p. 24), abdominal muscle. The sacrospinous ligament marks the posterior of Gynecologic Laparoscopists’ Global Congress of Min- sacral colpopexy via a laparo- limit of the pelvic diaphragm. imally Invasive Gynecology, I invited Dr. Sand to present scopic approach was featured Because he is a nationally recognized expert in the vagi- a surgical tutorial on the vaginal approach to prolapse. for the treatment of vaginal nal approach to pelvic floor prolapse, I have asked Dr. Pe- Just as the participants found his discussion interesting and vault prolapse. However, for ter Sand to discuss vaginal vault suspension, the evolu- informative, I am sure our readers will feel the same. ■ the gynecologic surgeon who tion of the procedure, and the prevailing literature that BY CHARLES E. is more adroit with vaginal compares this technique with abdominal sacral colpopexy. DR. MILLER is clinical associate professor, University of MILLER, M.D. surgery, sacrospinous vaginal Dr. Sand is currently a professor of ob.gyn. at North- Chicago and University of Illinois at Chicago and President vault suspension also offers a western University, Chicago, and the director of urogy- of the AAGL. He is a reproductive endocrinologist in private safe and effective remedy for this disorder. As a review, necology and reconstructive pelvic surgery at Evanston practice in Schaumburg, Ill., and Naperville, Ill., and the the ischial spine is located approximately halfway between (Ill.) Northwestern Healthcare. Dr. Sand is a prolific re- medical editor of this column. Sacrospinous Vaginal Vault Suspension: Variations on a Theme aginal vaginal vault suspension involves a poste- sacrospinous liga- Vvault pro- rior vaginal incision, perforation of the ment. lapse is one of rectal pillars, and blunt dissection of the A short Breisky- the most fre- pararectal space anterior to the ligament. Navratil retractor quently occur- In the original posterior approach de- can then be placed ring types of scribed by Dr. Nichols, two Allis clamps at the 10 o’clock pelvic organ are placed at the level of the hymenal ring, position, resting on prolapse, and approximately 1 cm from the midline, the ischial spine. By BY PETER with our aging and a dilute vasopressin solution can be maintaining your SAND, M.D. population, it used to infiltrate underneath the posteri- right index finger AND S is a problem or vaginal wall to within 1 cm of the apex against the ischial for which increasing numbers of women of the vagina. The scalpel is used to make spine, you can then ETER . P R likely will seek treatment. Dr. Christo- a transverse incision between the Allis insert a long D pher F. Maher and his associates have es- clamps, and then the Metzenbaum scissors Breisky-Navratil re- timated the incidence of posthysterecto- are used to dissect underneath the vaginal tractor directly op- OURTESY my vaginal vault prolapse requiring epithelium in the midline, vertically to posing the short re- C surgery to be 36 per 10,000 person-years. within 1 cm of the apex of the vagina. tractor over the Metzenbaum scissors are used to free the endopelvic A variety of operations now exists for The Metzenbaum scissors can be used ventral surface of connective tissue from the vaginal epithelium. the treatment of vaginal vault prolapse to spread beneath the vaginal epithelium your finger, against and the reestablishment of apical sup- and smooth muscle to free the underlying the ischial spine with its posterior edge just bilized, the Deschamps ligature carrier port—from abdominal sacral colpopexy endopelvic connective tissue from its at- anterior to the coccygeus muscle. can be rotated counterclockwise—in an and abdominal uterus sacral suspensions, tachments on the undersurface of the Sweeping this long retractor counter- arc exactly opposite to that in which it was to sacrospinous vaginal vault suspensions, vaginal epithelium and smooth muscle. clockwise immediately across the coc- placed—to withdraw the posterior end of sacrospinous hysteropexies, and iliococ- (See photo.) The scissors can then be used cygeus muscle, keeping its posterior blade the suture. cygeal vaginal vault suspensions. to make a vertical incision in the posteri- in contact with the muscle throughout, Care should be taken to identify the All options have been described in the or vaginal wall to about 1-2 cm away from will mobilize the rectal and pararectal fat posterior end of the suture and differen- literature as being effective operations the vaginal apex. medially and expose the coccygeus mus- tiate it from the anterior end. This may be with minimal complications and varying Placement of Allis clamps—or self-re- cle and sacrospinous ligament. This re- accomplished through the use of a degrees of success, but the optimal ap- straining retractor hooks—on the incised tractor should be held at approximately straight hemostat on one end and the proach for vaginal vault prolapse remains edges of the vaginal epithelium and the 2 o’clock position, creating a 60- to 90- placement of a curved hemostat across a subject of debate. Unfortunately, many smooth muscle can allow for exposure and degree angle with the other Breisky- both ends of the suture. surgeons are not comfortable with vaginal resection of the endopelvic connective Navratil retractor. (The exact angle will de- (When we perform the surgery, we use surgery, despite the safety, speed, and ef- tissue from the undersurface of the vagi- pend on the angle of the pubic arch.) a straight hemostat to identify the poste- fectiveness that sacrospinous vaginal vault nal epithelium and smooth muscle later- At this point, the right-angle Haney re- rior end of suture on the patient’s right suspension and its modifications can pro- ally to the level of the rectal pillars. This tractor can be placed at approximately side, or the lateral suture, and a straight vide in experienced hands. may be facilitated by countertraction from the 7 o’clock position over the coccygeus Kocher clamp to identify the posterior Sacrospinous vaginal vault suspension your assistant, using tissue forceps on the muscle and then, with posterior traction, end on the patient’s left side.) was originally described by Dr. Paul endopelvic connective tissue. withdrawn distally until it pops down in The Breisky-Navratil retractors can then Zweifel in Germany in 1892. It was “re- Once this dissection is complete, the is- front of the coccygeus muscle, exposing be slowly withdrawn one at a time to al- discovered” in 1951 by Dr. I.A. Amreich in chial spine on the patient’s right side may this muscle and sacrospinous ligament. low for observation of the entire para- Austria, modified by Dr. J. Sederl, and be palpated, and—with either sharp dis- A Deschamps ligature carrier then can vaginal space and assessment for any then studied and described extensively in section with the tips of the Metzenbaum be inserted through the middle of the bleeders, which can be easily grasped and 1968 by fellow Austrian Dr. K. Richter. scissors or blunt dissection with the oper- coccygeus muscle and rotated clockwise to electrocoagulated or sutured. The operation received more attention ator’s right index finger—the endopelvic expose its tip around the sacrospinous lig- The suture can then be placed on the when Dr. C.L. Randall and Dr. D.H. connective tissue can be swept from ante- ament. The initial bite should be placed 1 undersurface of the apex of the vagina by Nichols reported on it (Obstet. Gynecol. rior-lateral to medial of the ischial spine cm medial to the ischial spine to avoid the use of a free Mayo needle. The anterior 1971;38:327-32). Since then, the posterior across the coccygeus muscle to remove the pudendal complex. A second suture can arm of the lateral suture can be placed ap- approach to sacrospinous vaginal vault fatty tissue that overlies the ischial spine then be placed 1-2 cm medial to the first, proximately 1-2 cm away from the right suspension that was described by Dr. and the sacrospinous ligament. again with care taken to place it through apex of the vagina in a figure-eight fash- Nichols has been modified, and an alter- The entire coccygeus muscle with its an- the middle of the coccygeus muscle and ion, and this one arm of the suture can be native approach through the anterior com- terior sacrospinous ligament should be not posterior to this muscle, where it tied to itself with a loose surgeon’s knot. partment of the vagina has been devel- palpated, and the rectum and pararectal at- could injure the vessel and nerve of the The same process can be followed with oped and described. Several newer devices, tachments mobilized bluntly with the in- pudendal complex. the left or medial anterior arm of the sec- in the meantime, have offered improved dex finger from lateral to medial. This is When the Deschamps ligature carrier is ond sacrospinous suture, 1-2 cm away safety and simplicity. a relatively blood-free plane, and such a brought through the muscle, a colpotomy from the left apex of the vagina, and tied maneuver is possible with minimal bleed- or nerve hook can be used to mobilize one down in the same fashion. Care needs to The Original Posterior Approach ing so long as the affecting finger remains end of the suture and withdraw it back out be taken on the patient’s left side to place The posterior approach to sacrospinous anterior to the ischial spine and into the operative field.
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