6.
Closure of the cul-de-sac lateral to the sigmoid on the left and approximation of the distal presigmoid fat to the distal edge of the posterior graft is accomplished with box stitches of 0-delayed absorbable sutures. It is thought that these procedures and the retroperitonealization of the graft through the right side of the cul-de-sac will prevent posterior enterocele and sigmoidocele as well as a Halban or Moschcowitz procedure.
Figure 27.14 (continued ) 7.
The two “handle” ends of the graft are then brought to the point of sacral attachment, where their length is adjusted to remove any tension on the vaginal sutures and secured to the anterior sacral ligament with no. 1 permanent braided nylon sutures (Fig. 27.14B).
8.
Reperitonealization of the graft is then performed using the right cul-de-sac peritoneum and peritoneal ﬂaps dissected from the vaginal apical area; occasionally presigmoid fat is used.
Following this procedure, adjunctive procedures, such as paravaginal repair, Burch procedure, midurethral sling, and any transvaginal procedure that is indicated, are performed. When rectocele and pelvic ﬂoor defects are present, one option is the sacral colpoperineopexy, as discussed in the posterior compartment section (116). A vaginal pack is inserted for approximately 24 hours to ensure that the graft is well applied to the fibromuscular layer at points other than where sutures are placed.
Colpocleisis or vaginal narrowing procedures may be appropriate choices for debilitated patients who do not desire vaginal function, because complete vaginal reconstructive procedures may last several hours and are associated with potentially higher blood loss and increased morbidity (132,133). Many variations exist, from partial colpocleisis (where some portion of the vaginal epithelium is left to provide drainage tracts for cervical or upper genital discharge) to total colpectomy (where all of the vaginal epithelium is removed from the hymen posteriorly to within 0.5–2 cm of the external urethral meatus anteriorly). If hysterectomy is performed, blood loss is greater and operative time is longer than procedures without hysterectomy (134). These techniques should include a high perineorrhaphy and often a plication of
Management of Urinary Symptoms with Pelvic Organ Prolapse Repair the puborectalis muscles to reinforce posterior support and to reduce the genital hiatus, with the goal of decreasing the chance of recurrent prolapse. Case series have reported success rates as high as 100%, although the population of patients, by nature of their relatively short life expectancy and limited activity, are probably at lower risk for recurrence. In some instances in which most of the defects are anterior and posterior, a modified anterior and posterior colporrhaphy may be performed, whereby relatively large portions of the anterior and posterior vaginal wall are removed and closed, creating a narrow (1–2 cm diameter) cylindrical vagina. As with the colpocleisis, the success of the procedure is augmented by an extensive perineorrhaphy and puborectalis plication. Such a procedure may be performed quickly and with relatively low morbidity. The prevention or treatment of stress incontinence, voiding dysfunction, and colorectal dysfunction in the context of these procedures can be problematic. Careful preoperative history and evaluation, if indicated, is important so that additional conservative therapies or operative techniques such as pubourethral plications or less invasive tension-free slings may be employed.