Pessary:
- Estrogen (0.25-0.5mg) 2-3x weekly.
- Remove and clean pessary for the night every 1-2 weeks.
Lawrence:
* Before prolapse surgery, pre-treat with vaginal estrogen if atrophy is present.
Sacrospinous ligament suspension:
*Combined with posterior repair (see below) - Start posterior repair, then continue dissection to right ischial spine.
- Palpate right ischial spine, the place allis clamp on sacrospinus ligament 3cm from spine (2 finger breadths).
- Place deschamps ligature carrier threaded with #1 vicryl and #1 gortex suture just behind allis clamp to ensure bite of sacrospinous ligament.
- Use nerve hook to pull suture out of carrier before removing carrier.
- Complete apical half of posterior repair - both mattress sutures and vaginal epithelium half way down the length of the repair, then tie down first vicryl, then the gortex SSL sutures. Then, continue remainder of posterior repair.
Posterior Repair:
- Place allis clamps at 5 and 7 o'clock. Use bovie to cut perineal triangle with corners at allis clamps and pointing down toward anus (adjust size based on desired size of introitus).
- Cut incision in midline of vaginal epithelium at base of triangle.
- Find plane between vaginal epithelium and rectum. Use blunt and sharp dissection to dissection this plane toward the apex and laterally to vaginal walls.
- Create this plane with one finger in the rectum to ensure no perforation is made.
- Place horizontal mattress sutures with 0 vicryl as lateral as possible to plicate posterior defect.
- Close vaginal epithelium in running locked fashion with 3-0 vicryl to level of hymen.
- Plicate perineal body with 0 vicryl use two vertical mattress sutures. (similar to deep sutures placed during second degree repair.
- Using 3-0 or 4-0 vicryl, place anchor suture at hymen, then pass suture behind hymen to come out at perineum and close in same fashion as second degree repair, with deep vertical mattress sutures down to apex, then subcuticular back up to hymen.
Anterior Repair:
- Allis clamp 1-2cm below urethral meatus. Then place second allis in the midline, as far back as the defect goes. Inject 5-10ml local with epinephrine between allis'. Use scalpel to make an incision between allis'. Place allis' along edges of vaginal epithelium, and with one finger on vaginal epithelium, use metzembaum scissors and blunt dissection with ray-tec to dissect defect away from epithelium. Trim epithelium (but leave slightly loose). Close defect with interrupted horizontal mattress sutures of 2-0 vicryl, then close epithelium in running locked fashion with 2-0 vicryl.
*Pack with kerlix (with bacitracin) for 1-2 hours postop after prolapse surgery. Remove foley with packing.
- Lawrence wants PVR <100ml for patient to avoid straight cath.
Bennett:
- Offer every prolapse (just anterior?) surgery patient a mid urethral sling - 30% of patients without previous incontinence will develop incontinence after prolapse surgery.
Anterior repair:
- Place allis at least 1 cm below urethral meatus. Then place second allis in the midline, as far back as the defect goes. Use scalpel to make an incision between allis'. Grasp edges with 4 adairs, place finger in vaginal and use metz to dissection plane away from vaginal epithelium bilaterally. Identify where the defect is, and use interrupted mattress sutures (2-0 vicryl) to imbricate over defect. Then remove excess vaginal epithelium (but leave slightly loose to avoid over tightening) and close with 3-0 vicryl.
Posterior repair:
- Place allis' at 5 and 7 o'clock of introitus. if introitus is enlarge, then cut triangle incision on perineum to complete perineorrhaphy at end of procedure. Make a midline incision at the introitus with the scalpel, carry incision down midline of posterior vagina as far as the defect goes.
Colpocleisis:
For pt with hysterectomy:
- Excise posterior and anterior vaginal epithelial squares. Perform plication with mattress sutures of 2-0 vicryl in the same fashion as anterior and posterior repair if needed. Then bring the squares together for the colpocleisis (around a red rubber catheter to create tunnel with remaining vaginal epithelium).
- for large genital hiatus, perform perineorrhaphy.
- foley until next AM.
Vandermark:
Uterosacral Ligament suspension (at time of LAVH):
- Identify uterosacral ligaments and ureters. Perform ureterolysis by using laparoscopic scissor to cut along the lateral edge of each USL (for most of the length of the USL) to allow the ureters to fall away from the USL.
- Grasp USL with laparoscopic allis or babcock, then with a laparoscopic needle driver, pass 2-0 PDS approx. 1.5-2cm lateral to distal (cervical) end of USL. The needle should pass just behind the USL. If the grasper is on the USL at the area the suture should pass, place the needle just under the grasper.
- In a similar fashion, place two additional sutures of 2-0 ethibond just behind the USL, each approx. 1-2cm proximal to the previous placed suture. Now, there is one PDS and two ethibond sutures through each USL.
- Hysterectomy is completed laparoscopic except for cuff closure.
- USL suture ends are all passed to a ring forcep that is inserted through the vaginal to pull the suture ends out the vaginal and stats are placed on suture ends that are hanging out of vagina.
- Leave trocars in abdomen during vaginal portion of the case to allow for laparoscopic viewing after USL suspension is completed vaginally.
- Free needle is used to attach USL suture to vaginal cuff.
- PDS is sutured through-and-through anterior and posterior cuff edges (corners) and tied down.
- Ethibond permanent suture is passed through peritoneal edge and fibromuscular layer of the anterior and posterior vaginal cuff and tied down - do not pass permanent suture through the vaginal epithelium.
- The middle USL suture is placed medial to the PDS suture, and the USL suture closest to the sacral is placed medial to the first ethibond suture. Tie each suture down securely.
- Perform cystoscopy to ensure bilateral ureteral jets are visualized.
- Close the vaginal cuff vaginally (not laparoscopically) with either interrupted or running 0 vicryl.
- Consider viewing pedicles laparoscopically before ending case.
Uterosacral Ligament Suspension:
- After TVH, use uterosacral pedicle tags to ID USLs.
- Palpate ureters, then place Allis clamps on uterosacral ligaments.
- Place prolene through vaginal cuff (avoiding vaginal epithelium), behind Allis clamps and back through cuff in a purse string fashion.
- Repeat purse string in same path with 0 vicryl, but passing through complete cuff including epithelium.
- Pass sutures through uterosacral ligaments bilaterally and tag ends (hanging out of the vagina) with clamps/stats.
- Tie off USLS sutures, then close cuff.
- Perform anterior/posterior repair if needed.
- After completing anterior/posterior repair, then tie down uterosacral ligaments.
- Close vaginal cuff.