MANAGEMENT OF VAULT PROLAPSE BY DR SHASHWAT JANI

1. Management Of
Vault Prolapse
Dr. Shashwat K. Jani.
M. S. ( Obs – Gyn )
Diploma in Advance Laparoscopy.
Consultant Assistant Professor,
Smt. N.H.L. Municipal Medical College.
Sheth V. S. General Hospital , Ahmedabad.
Mobile : 99099 44160.
E-mail : drshashwatjani@gmail.com

2. It is most distressing to find a
patient coming back with
complaints of SCOPV after a
hysterectomy…!!! 

3.  Tackling of vault prolapse (VP) is relatively
rare and uncommon .
 Knowing the aftermaths of hysterectomy
it takes time for a Gynecologist to mentally
get tuned to the fact that patient requires
repeat surgery …!!!

4. Definition
Post - hysterectomy Vaginal Prolapse
“ Descent of the vaginal cuff scar,
below a point that is 2 cm less,
than the total vaginal length ,
above the plane of the hymen. “
*International Continence Society

5.  A common complication following
vaginal hysterectomy with negative
impact on women's quality of life due to
associated urinary, anorectal and sexual
dysfunction.
 A clear understanding of the
supporting mechanism for the uterus
and vagina is important in making the
right choice of corrective procedure.

6. Age
Poor tissue condition,
Scar tissue,
Increased abdominal pressure
Neuropathies
Obesity
Previous pelvic surgery
 Associated Medical condition

7. Why Post Hysterectomy …???
Hysterectomy causes:
 The attenuation of the cardinal/uterosacral
ligament complex when they are excised during
hysterectomy.
 The separation of the pubocervical fascia
from the rectovaginal fascia.
 The separation of the pubocervical fascia,
rectovaginal fascia from the cardinal/
uterosacral ligament complex

8. Symptoms
 Pelvic heaviness.
 Backache.
 A mass bulging into the vaginal canal or out of
the vagina that may make standing and
walking difficult.
 Involuntary release of urine (incontinence ).
 Vaginal bleeding.

9. Description
 Most vaginal cuff prolapses include apical
enterocele where the pubocervical and
rectovaginal fascia have separated.
 The peritoneum becomes stretched and
comes in direct contact with the vaginal
epithelium creating a true hernia.
 The vaginal epithelium is stretched and
becomes very smooth without rugae.
 There is always some degree of high
cystocele formation and high rectocele formation
associated with the vaginal vault prolapse.

10. Conservative Mx
• Pelvic floor exercises
( No strong evidence )
• Pessaries: Ring and shelf pessaries.
( limited use .
- Unfit for Surgery )

11. Surgical Mx
MILLION DOLLAR QUESTION
• The dilemma faced is whether to
go abdominally or vaginally …???

12. • Transvaginal route safer –
- VP after Vaginal hyst
• Transabdominal route for –
- VP after abdominal hyst., lap hyst.,
harmonic vessel seal
- Failure of previous vaginal approach
- Foreshortened vagina.

13. Things to consider…
 Prolapse pathology
 Patient’s age
 Patient’s lifestyle
 Presence of co morbidities
 Sexual function
 Patient’s expectations
 Expertise of surgeon

14. De Lancey vaginal supports.
Level Support Defect
1
Proximal
(upper)
Paracolpium ligs
USL & Cardinal.
.UV prolapse
.vault prolapse
.enterocole
2
Midvaginal
Lat attachment to
pelvic side wall to
ATFP, ATLA
Anterior & post
wall defects &
SUI.
3
Distal
vaginal
Pubocx fascia &
RVS fusion to UGD
, PB
Lax perineum,
low rectocoele,
anal
incontinence.

15. Classification of Vault
Prolapse
• 1st degree – vaginal apex is visible
when perineum is depressed.
• 2nd degree – apex extends just
through the introitus.
• 3rd degree – upper 2/3rds of the
vagina is outside the introitus.
• 4th degree – entire vagina is outside the
introitus

16. Evaluation
 Pre-operative assessment of sites of damage.
 Determine pre-operatively whether lower urinary tract
dysfunction and defecatory dysfunction co-exist.
 Configuration of – abdominal wall, sacral promontary, ischial
spine, depth of pelvis and previous surgery with resultant
adhesions.
 Dynamic analysis by MRI. Technical error- patient is
evaluated in recumbent rather than standing position.
 Dynamic pelvic floor fluoroscopy . Also accurately
identifies enterocoele.
VDP

17. VAGINAL
o McCall’s culdoplasty
o Sacrospinous ligament fixation
o High Uterosacral ligament suspension
with fascial reconstruction
o Iliococcygeus fascia suspension
o Meshplasty

18. ABDOMINAL
o Abdominal sacral colpopexy
o High uterosacral ligament suspension
o Laparoscopic approach

19. OBLITERATIVE
oLeFort’s Partial Colpocleisis
oIntroital tightening
oColpectomy

20. McCall Culdoplasty
• A wedge of posterior vaginal wall
and peritoneum removed
• Enterocole sac freed and excised
• Two internal sutures (permanent) placed
approximating both USL and posterior
peritoneum.
• One external suture thru USL , post peritoneum
& brought out thru post vaginal wall.
• This obliterates cul-de-sac, supports vaginal apex
& lengthens posterior vaginal wall.

21. High USL fixation with fascial
reconstruction (Richardson)
• Identifying defect in endopelvic fascia
• Reducing enterocoele sac
• Closing fascial defect
• Resuspension of vagina to original level 1 support
• Non absorbable sutures put through USL at level of ischial spine
and tied across in midline to form a ridge to which vagina is to
be anchored
• Absorbable sutures are used to suspend ant. And post. Vaginal
walls to the USL ridge.
• These are tied to suspend vagina in the hollow of sacrum
• The biggest risk is injury to the ureters (up to 10.9%) due to its
proximity to the anterior border of the uterosacrals, especially
at the level of the cervix.

22. Sacrospinous ligament
fixation
• Principles to follow while dissecting to
reach sacrospinous lig- work lateral to
rectal wall
- go posterior to uterosacral ligs
- start dissecting cranial to levator belly,
pierce pararectal ligament. Locate SSL.
• Taking sutures thru SSL
• Suspending the vault with pulley stitch or
placing sutures thru full thickness of
vagina.

23. Iliococcygeus fascia
suspension (Inmon)
• Repair any anterior compartment defect
• Iliococcygeus ms identified lateral to
rectum & anterior to ischial spine
• Sutures placed anterior to ischial spine
• Passed thru vaginal apex

24. • Apex of vault held with Allis and pushed up.
• Incision-Infraumbilical midline incision taken
• Preparation of vaginal vault –
- Peritoneum over vault incised
- Plane developed between
posterior wall & rectum
- Bladder base dissected off the
superior aspect of anterior vagina
• Preparation of sacrum –
- sigmoid pushed to left - peritoneum over promontary & 1st 3
sacral vertebrae incised & continued to vaginal incision.
Abdominal Sacral Colpopexy

25. • Placement of mersilene tape / mesh –
- length 3X15cms.
- tape/ mesh sutured to vaginal tissues using
full thickness interrupted non-absorbable
sutures.
- Continue anteriorly taking care of any
cystocoele
- Tape/ mesh turned back towards apex &
then towards the sacrum
- Secured to sacrum
• Reperitonealisation done.

26. A Mersilene mesh
exposure through the
posterior vaginal wall
at the perineal body
and posteriorly at the
vaginal vault.

27. High USL fixation with
fascial reconstruction
Reducing enterocoele sac by
multiple sutures through USL
 Closing fascial defect
 Resuspension of vagina to
original level 1 support

28. Laparoscopic approach
• Rise in adoption of laparoscopic approach.
Advantages- Improved haemostasis
• improved visualization of anatomy
• Reduced hospital stay, post-operative pain
• Reduced overall cost
Disadvantages - technical difficulty in retroperitoneal dissection
• steep learning curve
• Increased operative room time increasing cost.
• Risk of injury to vital structures.

29. Lap. Sacrocolpopexy
(a) A Y-shaped mesh with one
proximal arm and two distal arms.
(b) The bladder and bowel has
been dissected from the vaginal
vault (arrow).
(c) The distal arm was sutured to
the posterior vaginal wall (arrow).
(d) The proximal arm was sutured
to the sacral promontory (arrow).
(e) Re- peritonisation was
completed to prevent bowel
adhesion to the mesh from vaginal
vault (white arrow), along pelvis
(arrowheads) and sacrum (black
arrow).

30. LeFort Colpocleisis / Colpectomy
• Small Kelly’s Repair—SUI
• Marking out rectangular / triangular flaps on
Anterior and Posterior vaginal walls
• Repeated sucessive stitches to invert
the tissues
• Suturing of uppermost horizontal part
of rectangular flaps to each other with
delayed absorbable sutures.
• Small P repair, if necessary
• To supplement , do introital tightening if
extreme laxity

31. Prevention
• McCall culdoplasty at the time
of vaginal hysterectomy is a
recommended measure to
prevent enterocele formation.
Grade A
RCOG 2011

32. Prevention
 Suturing the cardinal and uterosacral
ligaments to the vaginal cuff at the time of
hysterectomy is a recommended measure to
avoid vault prolapse—Grade B
 Sacrospinous fixation at the time of
vaginal hysterectomy is recommended when
the vault descends to the introitus during
closure- Grade B

33. Remember
“ SURGERY SHOULD FIT THE PATIENT ,
THE PATIENT SHOULD NOT FIT THE SURGERY. “
- Michael Smith .