Surgical Treatment of Vaginal Vault Prolapse and Enterocele

21 Surgical Treatment of Vaginal Vault Prolapse and Enterocele




In recent years, the problem of pelvic organ prolapse has been given much more attention. Many women are living longer, and more interest exists in maintaining self-image of femininity and the capacity of sexual activity beyond menopause.


The management of pelvic organ prolapse can be difficult; several support defects often coexist, and simple anatomic correction of the various defects does not always result in normal function of the vagina and surrounding organs. To accomplish the goals of pelvic reconstruction, the surgeon must thoroughly understand normal anatomic support and physiologic function of the vagina, bladder, and rectum. These goals are to restore anatomy, maintain or restore normal bowel and bladder function, and maintain vaginal capacity for sexual intercourse.


This chapter discusses the pathology and surgical correction of enterocele, uterovaginal prolapse, and posthysterectomy apical prolapse. Normal anatomy of the pelvic diaphragm is discussed in detail in Chapter 2. The evaluation of patients with pelvic organ prolapse, especially regarding their symptoms, physical examination, and diagnostic tests, is discussed in Chapters 5 and 6.



PATHOLOGY OF PELVIC ORGAN PROLAPSE


Pelvic organ prolapse can result when normal pelvic organ supports are subjected chronically to increases in intra-abdominal pressure or when defective genital support responds to normal intra-abdominal pressure. Individual organs that pass through the pelvic floor can lose support singly or in combination, resulting in various degrees and combinations of pelvic organ prolapse. This loss of support occurs as a result of damage to any of the pelvic supportive systems. These systems include the bony pelvis, to which the soft tissues ultimately attach; the subperitoneal retinaculum and smooth muscle component of the endopelvic fascia (the cardinal and uterosacral ligament complex); the pelvic diaphragm, with the levator ani muscles and their fibromuscular attachments to the pelvic organs; and the perineal membrane. The perineal body and the walls of the vagina can lose tone and weaken from pathologic stretching from childbirth and attenuating changes of aging and menopause.


Loss of support or integrity of the anterior and posterior vaginal walls results in cystocele and enterorectocele, respectively. Uterovaginal prolapse occurs with damage or attenuation of endopelvic fascia that supports the uterus and upper vagina over the pelvic diaphragm. Furthermore, when the muscles within the pelvic diaphragm weaken as a result of congenital factors, childbirth injury, pelvic neuropathy, or aging, the levator ani lose resting tone and fail to contract quickly and strongly with increases in intra-abdominal pressure. Muscle atrophy and a wider levator hiatus result; weaker and less rapid muscle contractions with rises in intra-abdominal pressure contribute to related symptoms of urinary and fecal incontinence.


A useful approach to understanding the pathophysiology of prolapse was described by Bump and Norton (1998). They proposed considering risk factors for the development of prolapse as predisposing, inciting, promoting, or decompensating events. Predisposing factors are genetic, race, and gender; inciting factors are pregnancy and delivery, surgery such as hysterectomy for prolapse, myopathy, and neuropathy; promoting factors are obesity, smoking, pulmonary disease, constipation, and recreational or occupational activities; and decompensating factors are aging, menopause, debilitation, and medications. Depending on the combination of risk factors in an individual, prolapse may or may not develop over her lifetime. With further research on the human genome project, risk factors will continue to be identified. Eventually, we may be able to predict those at highest risk for developing prolapse. Modifiable risk factors can be altered to decrease the likelihood of subsequent prolapse. Obesity is one of the modifiable risk factors identified so far. Although increased parity is a risk factor for prolapse, nulliparity does not provide absolute protection against prolapse. Data from the Women’s Health Initiative (Hendrix et al., 2002) noted that almost one fifth of nulliparous women had some degree of prolapse. These data contradict those who enthusiastically promote cesarean delivery for all women to prevent prolapse.


Normally, the vaginal axis in an erect woman is nearly horizontal in the upper half of the vagina, with the uterus and upper 3 or 4 cm of the vagina lying over the levator plate in the hollow of the sacrum (Fig. 21-1). Funt et al. (1978) found that the vagina is directed toward the S3 and S4 vertebras and extends approximately 3 cm past the ischial spines in most nulliparous women. Increases in intra-abdominal pressure compress the vagina anteriorly to posteriorly over the contracted levator muscles in the midline (levator plate). Diminished muscle tone may result in loss of stability of the levator plate, widening of the levator hiatus, and loss of an adequate base to support the upper vagina and uterus in the normal axis. Distortion of the normal vaginal axis during reconstructive pelvic surgery predisposes women to the development of pelvic organ prolapse at an anatomic site opposite to where the repair was performed. Examples of this are the development of posterior vaginal wall prolapse after colposuspension procedures for stress incontinence and the development of anterior vaginal wall prolapse after suspension of the vaginal apex to the sacrospinous ligament.



Connective tissue defects have been found in women with uterine prolapse and stress incontinence. In several studies, Mädakinen et al. (1986), 1987) identified abnormal histologic changes in the pelvic connective tissue in 70% of women with uterine descent, compared with 20% of normal controls. Decreased cellularity (fibroblasts) and an increase in collagen fibers were observed. Ulmsten et al. (1987) reported 40% less total collagen in the skin and round ligaments of women with stress incontinence when compared with that of continent women. These studies and others suggest that abnormal connective tissue may be associated with pelvic organ prolapse and stress urinary incontinence.



PREVALENCE AND DEMOGRAPHICS


Because the prevalence of pelvic organ prolapse increases with age, the changing demographics of the world’s population will result in even more affected women. Based on projections from the U.S. Census Bureau, the number of American women age 65 and over will double in the next 25 years to more than 40 million women by 2030. One study by Luber et al. (2001) noted that the demand for health care services, related to pelvic floor disorders, will increase at twice the rate of the population itself.


Using data from a large U.S. Northwest health maintenance organization database, Olsen et al. (1997) reported the risks of pelvic organ prolapse or urinary incontinence surgery by age 80 as 11.1%. Surgery for pelvic organ prolapse with continence surgery (22%) or without (41%) accounted for 63% of this risk, or a lifetime risk of 7%. Boyles et al. (2003) reported that over a nearly 24-year period reviewed, the rate of procedures to correct prolapse decreased slightly, but not significantly, and that the surgical indication for approximately 7% to 14% of hysterectomies is listed as pelvic organ prolapse. Data from the U.S. National Hospital Discharge Survey (NHDS) indicate that approximately 200,000 women undergo surgery for pelvic organ prolapse annually. A study by Brown et al. (2002), using data from the NHDS for surgical rates, indicated that approximately 22.7 per 10,000 women had some form of pelvic organ prolapse surgery in a year. As expected, surgical rates vary with age peaking in the sixth decade, with an average age of surgery of 55 years. Racial differences were also reported, with Caucasian women having a threefold greater rate of pelvic organ prolapse surgery than African American women. Pelvic organ prolapse is common worldwide. Samuelsson et al. (1999) reported a prevalence of pelvic organ prolapse of 30.8% among Swedish women ages 20 to 59, with 2% having prolapse to the introitus. In the United Kingdom two hospitalizations per 1000 person-years for pelvic organ prolapse occur by age 60 (Mant et al., 1997). Sajan and Fikree (1999) reported that 19.1% of women in Pakistan who were under age 30 reported feeling symptoms of prolapse.



ENTEROCELE



Definition and Types


Enterocele is a hernia in which peritoneum and abdominal contents displace the vagina and may even be in contact with vaginal mucosa. The normal intervening endopelvic fascia is deficient or absent, and small bowel fills the hernia sac.


Generally, enteroceles have been divided into four types: congenital, traction, pulsion, and iatrogenic. Congenital enterocele is rare. Factors that may predispose to the development of congenital enterocele include neurologic disorders, such as spina bifida and connective tissue disorders. Traction enterocele occurs secondary to uterovaginal descent, and pulsion enterocele results from prolonged increases in intra-abdominal pressure. The two latter types of enterocele may coexist with apical vaginal prolapse, cystocele, or rectocele. Iatrogenic enterocele occurs after surgical procedures that elevate the normally horizontal vaginal axis toward a vertical direction; examples include colposuspension and needle urethropexy operations for stress incontinence, or hysterectomy, with or without repair, when the vaginal cuff and cul-de-sac are not managed effectively.


Clinically, enteroceles are best classified based on their anatomic location. Apical enteroceles herniate through the apex of the vagina, posterior enteroceles herniate posteriorly to the vaginal apex, and anterior enteroceles herniate anteriorly to the vaginal apex (Fig. 21-2).





Surgical Repair Techniques


Surgical repair of enterocele can be performed vaginally or abdominally. No data exist comparing the various types of repairs. The approach and type of procedure performed depend on the surgeon’s preference and whether there is concomitant vaginal or abdominal pathology. Vaginal surgical techniques described herein are the traditional vaginal enterocele repair and the McCall culdoplasty, and abdominal approaches discussed include the Moschcowitz procedure, Halban procedure, and uterosacral ligament plication.



VAGINAL ENTEROCELE REPAIR


Patients rarely have an isolated enterocele; hence, concurrent vaginal vault suspension, with or without cystocele and rectocele repair, is often necessary. The technique of vaginal repair of an apical or posterior enterocele is as follows:



2. The enterocele sac should be mobilized from the vaginal walls and rectum. When the enterocele sac is difficult to distinguish from the anterior rectum, differentiation is aided by a rectal examination with simultaneous dissection of the enterocele sac from the anterior rectal wall (Fig. 21-3, B). At times, distinguishing the enterocele sac from a large cystocele may prove difficult. In this situation, placement of a probe into the bladder or transillumination with a cystoscope may prove helpful.

3. After the enterocele sac has been dissected from the vagina and rectum, traction is placed on it with two Allis clamps and the sac is entered sharply (Fig. 21-3, C). The enterocele sac is explored digitally to ensure that no small bowel or omental adhesions are present (Fig. 21-3, D); if encountered, they are dissected to the level of its neck.

4. Under direct visualization, two or three circumferential, nonabsorbable, purse-string sutures are used to close the enterocele sac (Fig. 21-3, E). The cardinal-uterosacral ligaments are incorporated as well. Once placed, the sutures are tied in sequence. Care should be taken to avoid kinking the ureter.




MCCALL CULDOPLASTY


McCall (1957) described the technique of surgical correction of enterocele and a deep cul-de-sac at the time of vaginal hysterectomy. The advantage of the McCall culdoplasty is that it not only closes the redundant cul-de-sac and associated enterocele but also provides apical support and lengthening of the vagina. Many authors advocate using this procedure as part of every vaginal hysterectomy, even in the absence of enterocele, to minimize future hernia formation and vaginal vault prolapse.


The technique is as follows (Fig. 21-4):







The complications as reported by Given (1985) after McCall culdoplasty are shown in Table 21-1. He reported ureteral injury in 1 of 48 McCall culdoplasty procedures. Stanhope et al. (1991) also found that culdoplasty sutures were implicated in ureteral obstruction after vaginal surgery. To ensure ureteral patency, cystoscopy should be routinely considered after the McCall culdoplasty.


Table 21-1 Complications After McCall Culdoplasty*

































Complication Percent of Patients (N = 48)
Removal of silk suture 10
Postoperative cuff infection 4
High rectocele 4
Partial prolapse of vaginal vault 4
Shortened vagina 4
Introital stenosis 2
Pulmonary emboli 2
Nerve palsy 2
Ureteral obstruction 2

* Follow-up was 2 to 22 (average 7) years.


From Given FT. “Posterior culdeplasty”: revisited. Am J Obstet Gynecol 1985;153:135, with permission.


When there is excessive redundancy of the posterior vaginal wall and peritoneum, a modification of the McCall culdoplasty, in which a wedge of posterior vaginal wall and peritoneum is excised, can be considered (Fig. 21-5).




ABDOMINAL ENTEROCELE REPAIRS


Three techniques of abdominal enterocele repair have been described: Moschcowitz and Halban procedures and the uterosacral ligament plication. The Moschcowitz procedure is performed by placing concentric purse-string sutures around the cul-de-sac to include the posterior vaginal wall, the right pelvic side wall, the serosa of the sigmoid, and the left pelvic side wall (Fig. 21-6, A). The initial suture is placed at the base of the cul-de-sac. Usually, three or four sutures completely obliterate the cul-de-sac. The purse-string sutures are tied so that no small defects remain that could entrap small bowel or lead to enterocele recurrence. Care should be taken not to include the ureter in the purse-string sutures or to allow the ureter to be kinked medially when tying the sutures.



Halban described a technique to obliterate the cul-de-sac using sutures placed sagittally between the uterosacral ligaments. Four or five sutures are placed sequentially in a longitudinal fashion through the serosa of the sigmoid, into the deep peritoneum of the cul-de-sac, and up the posterior vaginal wall (Fig. 21-6, B). The sutures are tied, obliterating the cul-de-sac.


Transverse plication of the uterosacral ligaments can be used to obliterate the cul-de-sac (Fig. 21-6, C). Three to five sutures are placed into the medial portion of one uterosacral ligament, into the back wall of the vagina, and into the medial portion of the opposite uterosacral ligament. The lowest suture incorporates the anterior rectal serosa to bring the rectum adjacent to the uterosacral ligaments and vagina. Care must be taken to avoid entrapment or kinking of the ureter. Relaxing incisions can be made in the peritoneum lateral to the uterosacral ligaments to release the ureters, if necessary.



VAGINAL PROCEDURES THAT SUSPEND THE APEX


When mild forms of isolated uterovaginal prolapse (descent of the cervix not beyond the midportion of the vagina) are present, vaginal hysterectomy and culdoplasty, with anterior and posterior colporrhaphy, are usually sufficient to relieve the patient’s symptoms and restore normal vaginal function. However, more severe apical prolapse requires separate operations to re-suspend the apex. In Figure 21-7, A an isolated apical enterocele is shown with a wells-supported anterior and posterior vaginal walls. In such a case, no formal vaginal vault suspension is necessary because simple excision and closure of the enterocele sac will result in a well-supported vagina of adequate length. As more of the anterior and posterior vaginal walls become everted, the more complex the repair becomes (Fig. 21-7, B, C).




Sacrospinous Ligament Suspension



SURGICAL ANATOMY


To perform this procedure correctly and safely, the surgeon must be familiar with pararectal anatomy as well as the anatomy of the sacrospinous ligament and its surrounding structures (Fig. 21-8).



The sacrospinous ligaments extend from the ischial spines on each side to the lower portion of the sacrum and coccyx. Nichols and Randall (1989) described the sacrospinous ligament as a cordlike structure lying within the substance of the coccygeus muscle. However, the fibromuscular coccygeus muscle and sacrospinous ligament are basically the same structure and thus called the coccygeus-sacrospinous ligament (C-SSL). The coccygeus muscle has a large fibrous component that is present throughout the body of the muscle and on the anterior surface, where it appears as white ridges. The C-SSL can be identified by palpating the ischial spine and tracing posteriorly and medially the flat triangular thickening to the sacrum The fibromuscular coccygeus is attached directly to the underlying sacrotuberous ligament.


Posterior to the C-SSL and sacrotuberous ligament are the gluteus maximus muscle and the fat of the ischiorectal fossa. The pudendal nerves and vessels lie directly posterior to the ischial spine. The sciatic nerve lies superiorly and laterally to the C-SSL. Also superiorly lies an abundant vascular supply that includes inferior gluteal vessels and hypogastric venous plexus.



SURGICAL TECHNIQUE


Before this operation is initiated, one should have preoperatively recognized the ischial spine and C-SSL on pelvic examination. Preoperative estrogen replacement therapy should be given liberally, if appropriate. We prefer to use a preoperative vaginal estrogen cream for 4 to 6 weeks.


The performance of this operation almost always requires simultaneous correction of the anterior and posterior vaginal walls and enterocele repair. Displacing the prolapsed vaginal apex to the sacrospinous ligament to see whether the anterior and posterior vaginal wall prolapse disappears with a Valsalva maneuver helps determine whether cystocele and rectocele repairs are needed. The patient should be consented routinely for these repairs because many times it is difficult preoperatively to discern the extent of the various defects.


The technique of unilateral sacrospinous fixation is as follows:









8. Two techniques have been popularized for the actual passage of sutures through the ligament (Fig. 21-9). The first is the technique of Randall and Nichols (1971), using a long-handled Deschamps ligature carrier and nerve hook (Fig. 21-10, A). Long, straight retractors are used to expose the coccygeus muscle. Heaney retractors or Breisky-Navratil retractors (Fig. 21-10, B) are preferred. One must take great care not to let the tip of the retractor be pushed across the anterior surface of the sacrum, risking potential damage to vessels and nerves. If the right sacrospinous ligament is to be used, the middle and index fingers on the left hand are placed on the medial surface of the ischial spine and, under direct vision, the tip of the ligature carrier penetrates the C-SSL at a point two fingerbreadths medial to the ischial spine. When pushing the ligature carrier through the body of the C-SSL, considerable resistance should be encountered; this must be overcome by forceful yet controlled rotation of the handle of the ligature carrier. If visualization of the C-SSL is difficult, the muscle and ligament can be grasped in the tip of a long Babcock or Allis clamp, which helps isolate the tissue to be sutured from underlying vessels and nerves. After suture passage, the fingers of the left hand are withdrawn. The retractor is suitably repositioned, and the tip of the ligature carrier is visualized. The suture is then grasped with a nerve hook (see Fig. 21-10, A). A second suture is similarly placed 1 cm medial to the first. To avoid a second passage of the ligature carrier, the original long suture can be cut in the center and each end of the cut loop paired with its respective free suture. This obtains two sutures through the ligament, with only one penetration of the ligature carrier. To ensure that an appropriate bite of tissue has been obtained, one should be able to gently move the patient with traction of the sutures.


Mar 10, 2016 | Posted by in Reconstructive surgery | Comments Off on Surgical Treatment of Vaginal Vault Prolapse and Enterocele

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