Surgical TechniQueS Step by step: Obliterating the vaginal canal to correct pelvic organ prolapse Very elderly age, comorbidity, and disinterest in maintaining sexual function make a woman an ideal candidate for having POP corrected by surgery to close the vaginal canal, detailed here Mickey Karram, MD, and Janelle evans, MD s women live longer, on average, pel- for them less than an ideal solution. vic floor disorders are, as a whole, be- Instead, surgical procedures that obliter- A coming more prevalent and a greater ate the vaginal canal can alleviate their health and social problem. Many women symptoms of POP. entering the eighth and ninth decades of life In this article, we provide a step-by-step display symptomatic pelvic organ prolapse description of: In thIs (POP)—often after an unsuccessful trial of a • leFort partial colpocleisis in a woman Article pessary or even surgery. who still has her uterus in place Total colpectomy These elderly patients often have other • partial or complete colpectomy and and colpocleisis concomitant medical issues and are not colpocleisis in a woman who has post- page 32 sexually active, making extensive surgery hysterectomy prolapse • levator plication and perineorrhaphy, as es- sential concluding steps in these procedures. Distal levatoroplasty Dr. Karram is Director of the and perineorrhaphy Fellowship Program in Female Pelvic page 35 Medicine and Reconstructive Pelvic Surgery, University of Cincinnati/The leFort partial colpocleisis Christ Hospital, Cincinnati, Ohio; Co-Editor in Chief of the International An obliterative procedure in the form of a Questions about Academy of Pelvic Surgery (IAPS); LeFort partial colpocleisis is an option when outcomes and and Course Director of the Pelvic a patient 1) has her uterus and 2) is no lon- Anatomy and Gynecologic Surgery Symposium complications (PAGS) and the Female Urology and Urogynecology ger sexually active. Because the uterus is re- page 40 Symposium (FUUS), both co-sponsored by OBG tained in this procedure, however, keep in ManageMent. mind that it will be difficult to evaluate any Dr. Evans is a Urogynecology Fellow uterine bleeding or cervical pathology in the at The Christ Hospital, Cincinnati, Ohio. future. Endovaginal ultrasonography or an endometrial biopsy, and a Pap smear, must be done before LeFort surgery. The ideal candidate for LeFort partial On the Web colpocleisis is a woman who has complete The authors report no financial relationships relevant to this uterine prolapse, or procidentia (FIGURE 1), Dr. Karram shares article. his techniques in This article, with accompanying video footage, is presented with which is characterized by symmetric ever- 3 videos, at the support of the International Academy of Pelvic Surgery. sion of the anterior and posterior vaginal obgmanagement.com walls. 30 OBG Management | MarchFebruary 2010 2012 | Vol. | Vol. 22 24 No. No. 3 2 obgmanagement.com leFort partial colpocleisis: Key step FIGURE 1 Pelvic organ prolapse, by key step preoperatively 1 Begin by placing the cervix on traction to evert the vagina. Inject the vaginal mucosa with either bupivacaine or 2% lidocaine with 1:200,000 epinephrine, just below the vagi- nal epithelium. Place a Foley catheter with a 5-mm balloon into the bladder so that you can identify the bladder neck. 2 Use a marking pen to mark out the rec- tangular areas of the vaginal epithelium that are to be removed anteriorly and posteri- orly. Extend the anterior rectangle from ap- proximately 2 cm from the tip of the cervix to WATCH THE VIDEO 4 or 5 cm below the external urethral meatus. Mark out a mirror image on the posterior LeFort partial aspect of the cervix and vagina. Extend the colpocleisis by Mickey Karram, MD rectangle on the posterior vaginal wall from approximately 2 cm below the level of the tip of the cervix to 4 or 5 cm inside the posterior fourchette. 3 Incise the previously marked areas and utilize sharp dissection to remove the vagi- nal epithelium from both the anterior and 4 ways to watch this video: posterior vaginal walls. Leave the maximum 1. go to the Video Library at www.obgmanagement.com amount possible of vaginal muscularis on 2. use the QR code to download the underlying bladder and the rectum. the video to your smartphone* Hemostasis is an absolute must. When you 3. text OBLTECH to 25827 remove the posterior vaginal flap, avoid en- 4. visit www.OBGmobile.com/ Top: Uterine procidentia. A patient who has OBLTECH tering the peritoneum; if you do enter it in- this condition is an ideal candidate for LeFort *By scanning the QR code with a advertently, close the defect with interrupted partial colpocleisis. bottom: Asymmetric anterior QR reader, the video will download delayed absorbable suture. vaginal prolapse. to your smartphone. Free QR readers are available at the iPhone 4 App Store, Android Market, and Sew together the cut edges of the anterior based on preoperative assessment for poten- BlackBerry App World. and posterior vaginal walls with interrupted tial or occult urinary stress incontinence. For delayed absorbable sutures. When possible, more discussion, see QuestiOn 7 in “Ques- turn the knot into the epithelium-lined tun- tions we’re asked (and answers we give) nels that you have created bilaterally. Turn about obliterative surgery,” page 40. the uterus and vaginal apex gradually in- ward. After the vagina has been inverted, su- 6 Perform levator plication and perineor- ture the superior and inferior margins of the rhaphy as a matter of routine. Key steps in rectangle together. these procedures are provided in the final section of the article (page 35). 5 Our opinion is that a support proce- dure—at either the bladder neck (Kelly pli- 7 Postoperatively, the patient is mobilized cation) or midurethra (synthetic midurethral early, although she should avoid heavy lifting sling)—should be performed on all patients, for at least 6 weeks to prevent recurrence of obgmanagement.com Vol. 24 No. 2 | February 2012 | OBG Management 31 Surgical TechniQueS / cOlpocleiSiS FIGURE 2 Steps: leFort partial colpocleisis a b c (3RD EDITION, 2011; SAUNDERS/ELSEVIER) WITH PERMISSION OF THE PUBLISHER D e the prolapse secondary to breakdown of the repair. FIGURE 2 shows key steps in perform- ing LeFort partial colpocleisis. See ViDeO #1 at www.obgmanagement.com for demon- ATLAS OF PELVIC ANATOMY AND GYNECOLOGIC SURGERY strations of how to perform LeFort partial colpocleisis. Total colpectomy and colpocleisis: Key step by key step In a patient who has post-hysterectomy F prolapse and is not interested in continued sexual function, total colpectomy and colpo- a Denude the anterior vaginal epithelium. b Plicate the neck of the bladder. c Next, denude cleisis provide a highly minimally invasive, the posterior vaginal epithelium. D Approximate durable option to correct her prolapse. most proximal surfaces. e Place lateral sutures to If there is complete eversion of the va- allow for drainage canals. F The uterus has been gina then, truly, total colpectomy and colpo- replaced and most of the distal incisions closed. cleisis is the procedure of choice. If there is ILLUSTRATIONS, FIGURES 2-4: JOE CHOVAN. REPRINTED FROM 32 OBG Management | February 2012 | Vol. 24 No. 2 obgmanagement.com Surgical TechniQueS / cOlpocleiSiS FIGURE 3 Steps: Total colpectomy and colpocleisis b c at the base of the prolapse. Using a marking pencil, mark out quadrants in the segments of the vagina that will be removed sharply. Completely remove the vaginal epithelium (FIGURES 3a and 3b); a your goal is to leave most of the muscularis of the vaginal wall on Denude the anterior vaginal epithelium (a) and then the posterior epithelium (b). the prolapse. c Place sequential purse-string sutures. Avoid the peritoneal cavity if at D The completed colpocleisis, in cross- all possible; when the main portion section. D of the prolapse is secondary to an en- terocele and the vaginal epithelium is significant prolapse of only one segment of very thin, however, formal excision of the en- the pelvic floor, however—for example, the terocele sac, with closing of the defect, may anterior vaginal wall (FIGURE 1)—then ag- be required. gressive repair of this variant with a narrow- ing down of the genital hiatus accomplishes 3 Subsequently, place a series of 2-0 de- the same result without requiring complete layed absorbable sutures in purse-string removal of what appears to be fairly well sup- fashion, inverting the vagina by sequentially ported vaginal mucosa. tying down the sutures (FIGURE 3c). Ideally, Here are key steps for performing partial you should take these sutures through the or complete colpectomy and colpocleisis. vaginal muscularis that has been left on the prolapse. 1 Grasp the most prominent portion of If at all possible, avoid the peritoneum the prolapse with two Allis clamps. Inject and the wall of the viscera, whether bladder the vaginal mucosa with either bupivacaine or bowel. Invert the apex of the soft tissue, or 2% lidocaine with 1:200,000 epinephrine, using the tip of forceps, as each purse-string just below the vaginal epithelium. suture is tied. There is a variation of this procedure: 2 Circumscribe the vagina with an inci- Perform a separate anterior and posterior sion several centimeters from the hymen colporrhaphy, with two purse-string sutures 34 OBG Management | February 2012 | Vol. 24 No. 2 obgmanagement.com used to approximate the anterior and pos- FIGURE 4 Steps: Distal levatoroplasty terior segments, thus obliterating any dead with high perineorrhaphy space. 4 Perform distal levatoroplasty and exten- sive perineorrhaphy (described in the next section of the text). 5 The patient is usually kept overnight. She is discharged with instructions similar to what are given to patients who have had a LeFort partial colpocleisis: Early mobiliza- tion but no heavy lifting for at least 6 weeks— again, to prevent recurrence of the prolapse secondary to breakdown of the repair.