Vaginal prolapse repair

Vaginal repairs

Anterior colporrhaphy

  1. Position in lithotomy, place foley, weighted speculum, and lone star retractor
  2. Inject saline to hydrodissect anterior vaginal wall
  3. Create midline incision on anterior vaginal wall (do not go distally over urethra)
  4. Grasp each wing with allis clamps x2, use Metz to incise attachments holding prolapsed bladder to vaginal wall without creating buttonholes
  5. Place figure-of-8 2-0 vicryl sutures in perivesical tissue to close at midline (do not place too far lateral), place each stitch immediately below the prior
  6. Cystoscopy to assess for bladder injury and confirm ureteral efflux (can insert ureteral stent if concerned for obstruction)
  7. Trim redundant vaginal edges
  8. Close vagina with 2-0 vicryl running locking suture
  9. Place foley and vaginal packing

Posterior colporrhaphy

  1. Position in lithotomy, place foley, weighted speculum, and lone star retractor
  2. Inject saline to hydrodissect posterior vaginal wall
  3. Make midline incision from mid-vagina to hymenal ring and cut out diamond-shaped piece of epithelium for perineorraphy
  4. Grasp each wing with allis clamps x2, use Metz to incise posterior attachments to vaginal wall without creating buttonholes
  5. Place figure-of-8 2-0 vicryl sutures in perirectal tissue to reapproximate
  6. Trim redundant vaginal tissue
  7. Close vaginal mucosa with locking 2-0 vicryl starting proximally to distally
  8. On reaching perineum, run stitch in subepithelial tissue to distal point then backtrack through epithelium to close completely
  9. Place foley and vaginal packing

Uterosacral ligament suspension with vaginal hysterectomy

  1. Position patient in high lithotomy position, prep/drape, give cefazolin or alternative antibiotic
  2. Place foley, lone star retractor (large circle inferiorly), vaginal speculum
  3. Grasp cervix with tenaculum, hydrodissect circumferentially, and perform circumscribing incision 1-2cm proximal to cervix, incise through superficial layers
  4. Enter posterior peritoneum by using curved Mayo scissors to cut through peritoneum, confirm no bowel injury
  5. Use Heaney clamp to clamp, cut, and ligate uterosacrals with 0 vicryl, tag for later retraction
  6. Incise anterior peritoneum sharply and confirm no bladder entry
  7. Continue clamp/cut/ligate to remove further peritoneal attachments until broad ligament removed completely, remove uterus and send for pathology
  8. Optional: remove fallopian tubes (can cause ovarian cancer), do not remove if difficult to access (can avulse from lateral wall), usually do not remove ovaries (benefit to hormones even postmenopause)
  9. Obtain hemostasis on posterior vaginal wall edge and peritoneum with a running 2-0 vicryl locking stitch
  10. Pack away bowel and examine peritoneum, use already placed distal uterosacral stitch to identify deep uterosacral ligament, expose with Breisky-Navratil retractors, clamp uterosacral proximally with long allis (avoid ureters)
  11. Place 0 PDS into deep uterosacral ligament x2 and tag (straight hemostat for lateral, curved hemostat for medial), don't cut off needle (use later)
  12. Perform anterior repair if necessary
  13. Place uterosacral stitch through vaginal wall, using attached needle posteriorly and free needle anteriorly, clamp (do not tie down yet)
  14. Place interrupted 2-0 vicryl stitches to close vaginal cuff, then tie down uterosacral stitches - perform cystoscopy before cutting
  15. Perform posterior colporraphy to reduce risk of recurrent prolapse
  16. Place foley and vaginal packing

Sacrospinous ligament fixation

  1. Position patient in high lithotomy position, prep/drape, give cefazolin or alternative antibiotic
  2. Place foley, lone star retractor (large circle inferiorly), vaginal speculum
  3. Mark location of new apex (just distal to cuff on posterior wall) with silk stitch
  4. Hydrodissect posterior wall at midline and sides (mainly right), then make midline incision, also incise diamond over perineum for perineorrhaphy
  5. After developing sides, perforate right perirectal space to access sacrospinous ligament
  6. Use Breisky-Navratil retractors x3 to expose ischial spine and sacrospinous ligament
  7. Place 0 PDS x2 through sacrospinous ligament at least 2cm medial to ischial spine, do not cut off needle (straight hemostat for lateral, curved hemostat for medial)
  8. Perform anterior/posterior repair as needed but do not close epithelium
  9. Place sacrospinous stitches through vaginal epithelium (use needle posteriorly, free needle anteriorly) but do not tie down
  10. Trim redundant vaginal edges and close vaginal epithelium using locking 2-0 vicryl stitch
  11. Tie down sacrospinous stitches to create new apex
  12. No need to perform cystoscopy if no anterior repair was performed (no risk for bladder/ureteral injury)
  13. Place foley and vaginal packing

Colpocleisis

  1. Place patient in dorsal lithotomy position, ensure far enough down on bed to place weighted speculum, give cefazolin for prophylaxis, prep/drape genital area
  2. Grasp apex of prolapse with allis clamps, demarcate extend of prolapse in 4 quadrants with cautery
  3. Hydrodissect with lidocaine
  4. Dissect vaginal epithelium from underlying connective tissue with Metzenbaum in all 4 quadrants, leaving adequate connective tissue behind
  5. Place 2-0 PDS pursestring sutures circumferentially at prolapse apex, tie down to reduce prolapse
  6. Continue placing sutures more distally, reducing prolapse further until it is reduced to level of the bladder neck