This document discusses various classifications and conservative surgical treatments for pelvic organ prolapse. It begins by describing the normal anatomical supports that prevent prolapse, including the bony scaffolding, endopelvic fascia, and pelvic musculature. It then covers several classification systems for prolapse, including the Baden-Walker and POP-Q systems. Conservative surgeries discussed include abdominal sling operations, various sling procedures, anterior and posterior colporrhaphies, paravaginal defect repairs, and perineorrhaphies. Newer procedures like vaginal sacrospinous cervico-colpopexy and posterior intravaginal slingplasty are also mentioned. The document emphasizes that hyster
6. POP - Q Classification of prolapse
Aa Ba C
gh pb tvl
Ap Bp D
7. Stages of pelvic organ prolapse
Stage 0
no prolapse
- Aa,Ba,Ap,Bp are all at -3
- C or D between tvl and < tvl -2
Stage I
most distal portion > 1cm above level of hymen
Stage II
<1cm proximal to or distal to the plane of hymen
Stage III
>1cm below the plane of the hymen
Stage IV
complete eversion, distal portion at least (tvl -2 cm)
8. Abdominal Sling operations
Indicated in nullipara & young women.
Preserves reproductive function.
Objective
• Buttress the weakened support Mackenrodts
and uterosacral ligaments
9. Selection criteria
First or second degree Uterine prolapse
Uterocervical length less than 5 inches
No infravaginal elongation of cervix
Cystocele or rectocele if present should be repaired
before the surgery
10. Purandare’s cervicopexy
Rectus sheath is anchored
to Anterior part of isthmus
through ASIS and the
leaves of broad ligament
Purandare and Mhatre ‘s
modification
•Tape is fixed posteriorly to
isthmus below uterosacrals
11. Shirodkar’s sling
Principle
Tape is fixed to the posterior
aspect of isthmus & sacral
promontory
Anatomically most correct
but difficult to perform
In cases of
Defective rectus sheath
Poor abdominal muscle tone
Failed purandare’s
cervicopexy
12. Shirodkar’s sling operation
Right side
Shirodkars needle is passed through
retroperitoneal space and tape is attached
posteriorly to isthmus
Left side
Peritoneum over psoas muscle exposed
Psoas loop made
Knot is placed lateral
Shirodkars needle is passed through
retroperitoneal space and tape is attached
posteriorly to isthmus
13. Khanna’s sling
Support is from bony point
Tape is fixed to the posterior
aspect of the isthmus to the
anterior superior iliac spine
14. Virkud’s composite sling operation
End of mersilene tape - sacral
promontory to posterior surface
of isthmus - sutured to rectus
sheath
Plication of left side uterosacral
ligament to correct
dextrorotation
15. Virkud’s composite sling operation
Advantages
Easy to perform
Double support- bony + dynamic
Tape is posterior-no risk during
LSCS
No enterocele
No injury to sigmoid colon
16. Joshi’s sling
Anterior surface of the
uterus at the level of the
internal os is suspended to
the pectineal ligament on
both side with merciline
tape
18. Fothergill operation / Manchester operation
Principle steps
Anterior colporrhaphy
Plication of Mackenrodts ligaments in front of the
cervix using fothergills stitch
Partial amputation of the cervix
Amputated cervix covered with vaginal flap using
sturmdorff suture
Posterior colpoperineorrhaphy
21. Shirodkar’s modification
of Fothergill’s operation
Amputation of cervix is not done
Plication of uterosacral ligaments
Nadkarni’s sleeve
operation
• Modification of Fothergill’s
operation
• Supravaginal portion is
excised
• Fertility is not affected
22. LeFort’s Operation/ Partial colpocleisis
Old age and unfit for surgery
Uterine pathology to be ruled out
Pap smear to be done
25. Tension-free vaginal mesh (TVM) systems
Prolift,
Apogee/Perigee
Avaulta
all of which vary in
terms of mesh size,
shape and surgical
technique
26. This system has four main characteristics:
Mesh -replacement for defective visceral pelvic
fascia
Bridge between the left and right arcus tendineus
fascia pelvis (white line, or ATFP)
Large-size mesh is held in place by passing
cannulas through the obturator fascia (anterior wall)
or the sacrospinous ligament (SSL) to attach the
arms of the mesh graft
Bladder neck is preserved
Mesh repair-principles
27. Laparoscopic
surgery
Vaginal length must be
maintained
Ureters must be
identified and dissected
Requires great skill and
expertise
Newer conservative
surgeries
• Vaginal sacrospinous cervico-
colpopexy/sacrospinous
hysteropexy
• Posterior intravaginal slingplasty
• Abdominal /laparoscopic
sacrocolpopexy
• Posterior mesh repair
28. Hysterectomy should not be the prime treatment and fixing of the cervix to
strong ligament such as sacrospinous ligament could give a more
successful result and conservation of the uterus in young women
29. Anterior colporrhaphy
• To correct cystocele and urethrocele
• The underlying principles are to excise a portion of the
relaxed anterior vaginal wall
• To mobilize the bladder and push it upwards after cutting
the vesicocervical ligament
• The bladder is then permanently supported by plicating
the endopelvic fascia and the pubocervical fascia
under the bladder neck in the midline
31. Paravaginal defect repair
Abdominal method
Entering the retropubic space
To correct detachment between vagina and arcus
tendinus
Repair is done by fixing (reattaching) the
endopelvic fascia to the arcus tendineus fascia
(white line) of the pelvis.
Done retropubically through the space of Retzius
or vaginally.
34. Abdominal sacrohysteropexy is a safe, efficient surgical technique for the
treatment of uterine prolapse in women who desire to preserve the uterus
Khunda A, et al., New procedures for uterine prolapse, Best Practice &
Research Clinical Obstetrics and Gynaecology (2013),
http://dx.doi.org/10.1016/j.bpobgyn.2012.12.004
35. Laparoscopic uterine suspension techniques seem
promising. Advantages are improved visualisation of pelvic
anatomy, shorter hospitalisation, less postoperative pain, and
a quicker return to normal activities
36. References
Rock, John A.; Jones, Howard W.Te Linde's Operative Gynecology, 10th
Edition:Lippincott Williams & Wilkins 2008 section VII chapter 36A
Schorge et al -Williams gynaecology 1st edition 2008 Section III Chapter 24 ,Page
no- 1023-53
Khunda A, et al., New procedures for uterine prolapse, Best Practice &
Research Clinical Obstetrics and Gynaecology (2013)
Jonathan S Berek , Emil Novak :Berek and Novak’s Gynecology 15th edition
Lippincott Williams & Wilkins, 2007:Page no-1211-29
Practical Obstetrics and gynecology , Virkud, 3rd Edition,Chapter 18 : Page no-
323-47
Anteflexion of 170 degrees and anteversion of 90 degrees. Retroversion is the 1st step in POP
When the levator muscles contract forcibly, the genital hiatus narrows as it is pulled posteriorly towards sacrum, this mechanism works when the pressure forces on the uterus are transmitted onto the levator muscle
Michigan, identifies specific structural goals for each of the 3 levels of support of the vagina, defines a set of goals for the pelvic reconstructive surgeon