Paravaginal Repair The paravaginal or “lateral defect” repair involves reattachment of the anterior lateral vaginal sulcus to the obturator internus fascia and, in some cases, muscle at the level of the arcus tendineus pelvis (“white line”) (82,83). It is usually performed as a bilateral procedure via transvaginal or retropubic (abdominal or laparoscopic) access. The procedure essentially restores normal anatomy; however, because it is not practical to rebuild the defective endopelvic–fascial bridge to the pelvic sidewall, it attaches the vaginal wall itself. Observational studies have reported good success with this procedure (80%–95%); however, long-term data on durability and function are lacking (12,84–88). Most women with anteriolateral detachments usually have separation of the upper vaginal fornices from the arcus tendineus immediately adjacent to the ischial spine (Fig. 27.13) (89). Thus, it is important to resuspend those specific areas.
It is difficult to achieve optimal results when the paravaginal repair is used in combination with traditional central repairs because of the creation of tension on opposing suture lines. A repair that removes a weakened central vaginal wall may decrease the side-to-side dimensions of the anterior vaginal wall, making it difficult to suspend its lateral points more laterally. When large central defects coexist with lateral defects, one option is an extensive central repair accompanied by an apical support procedure. This changes the shape of the vagina to a more cylindrical structure. Another choice is placement of a graft to span the entire anterior rhomboid-shaped plate, thus augmenting anterior paravaginal tissue strength. The graft with tension adjusted may be anchored to the arcus tendineus along with the adjacent vaginal wall from the level of the pubic rami to the ischial spine (88).
Figure 27.13 Schematics illustrating normal attachments of the anterior fibromuscular vaginal plane (A and C) and bilateral detachments of that plane from the arcus tendineus up to the level of the ischial spines (B and D). Note: For B and D to occur, there will either be concurrent apical descent or a detachment of the upper fibromuscular plane from the apical structures. (From Delancey JO. Fascial and muscular abnormalities in women with urethral hypermobility and anterior vaginal wall prolapse. Am J Obstet Gynecol 2002;187:93–98, with permission.)
Although most reports indicate that repair of anterior defects with all of these procedures relieves symptoms directly related to prolapse, there are very few data on patient satisfaction and qualityof-life improvement over time (88).
as much of this tissue as possible attached laterally to the levator fascia. After obvious defects in the rectal muscularis are repaired, the fascia is then plicated in the midline with interrupted or continuous sutures. The authors prefer delayed absorbable sutures for this plication. Permanent nonbraided suture material also can be used. Braided permanent suture material is associated with a greater incidence of stitch infection and formation of granulation tissue (91). The vaginal epithelium is trimmed and closed with absorbable sutures.