Laparoscopic Sling Procedures

The uterus, or womb, is a muscular structure that's held in place by pelvic muscles and ligaments.
 

If these muscles or ligaments stretch or become weak, they're no longer able to support the uterus, causing prolapse.

Uterine prolapse occurs when the uterus sags or slips from its normal position and into the vagina, or birth canal.

Uterine prolapse may be incomplete or complete. An incomplete prolapse occurs when the uterus is only partly sagging into the vagina. A complete prolapse describes a situation in which the uterus falls so far down that some tissue rests outside of the vagina.

 

What is vaginal vault?

The vaginal vault is the expanded region of the vaginal canal at the internal end of the vagina. The vaginal vault may prolapse after a hysterectomy, as there is no uterus supporting the interior end of the vagina. The incidence of vaginal vault prolapse is approximately 15% after hysterectomy due to uterine prolapse, and approximately 1% after hysterectomy due to other reasons.

What is sacrocolpopexy?

Sacrocolpopexy is a procedure to correct prolapse of the vaginal vault (top of the vagina) in women who have had a previous hysterectomy. The operation is designed to restore the vagina to its normal position and function.

How is it done?

Sacrocolpopexy Reconstruction is achieved with an open abdominal technique or with the use of minimally invasive techniques means laparoscopy.

The specific treatment approach is chosen in accordance with the type and degree of pelvic organ prolapse, as well as the severity of symptoms.

The key aspect of sacrocolpopexy is the suspension of the vaginal apex to the sacral promontory in a manner that recreates the natural anatomic support .

What happens during surgery?

Sacrocolpopexy is performed either through an abdominal incision or 'keyholes' under general anesthesia.

The vagina is first freed from the bladder at the front and the rectum at the back.

A graft made of permanent synthetic mesh is used to cover the front and the back surfaces of the vagina. The mesh is then attached to the sacrum (tail bone). The mesh is then covered by a layer of tissue called the peritoneum that lines the abdominal cavity; this prevents the bowel from getting stuck to the mesh. Sacrocolpopexy can be performed at the same time as surgery for incontinence or vaginal repair for bladder or bowel prolapse.

What are the types of prolapse ?

1. Anterior defects with herniation of the urinary bladder creates a cystocele.
2. A rectocele occurs from posterior vaginal wall defects-rectum prolapses.
3. Apical defects include uterine prolapse or uterovaginal prolapse, vaginal cuff prolapse after hysterectomy, and enteroceles.
4. An enterocele is protrusion of the intestines into the apical vaginal wall and can be in either the anterior or posterior compartment.
5. All these types can occur with or without uterine prolapse or can be seen post hysterectomy.

What are Risk factors for pelvic organ prolapse ?

• Increasing age.
• Increasing body mass index (obesity).
• Increasing gravidity/ number of pregnancy.
• Increasing parity.
• Number of vaginal deliveries.
• Macrosomic delivery/bigbaby delivery.
• Chronic obstructive pulmonary disease.
• Constipation.
• Strenuous activity, weight bearing, or strenuous labor.

What are the Symptoms ?

• Vaginal bulge.
• Pelvic pressure.
• Bleeding.
• Infection.
• Splinting or digitation (the need to manually assist in reducing prolapse, often to void or defecate).
• Back pain.

What are the Concomitant symptoms ?

• Urinary incontinence symptoms, such as stress, urgency, or postural incontinence.
• Bladder storage symptoms, such as frequency, urgency, or overactive bladder syndrome.
• Voiding symptoms, such as hesitancy, slow stream, straining, incomplete emptying, or position-dependent voiding.
• Sexual dysfunction symptoms, such as dyspareunia(pain during sex) or obstructed intercourse.
• Anorectal dysfunction, such as fecal incontinence, flatal incontinence, fecal urgency, straining to defecate, constipation, and incomplete evacuation.

What is the principle used?

The key aspect of sacral colpopexy is the use of a graft to support the vaginal wall and suspend the vault to the sacral promontory ( tail bone) to give the anatomic support.

Does the surgery need anaesthesia?

Laparoscopic technique is done under general anaesthesia after thorough examination and keeping in mind all comorbidities if any.

Any advantages of laparoscopy?

laparoscopic approach has less blood loss, less hospital stay, almost similar operative time. Less handling of tissues and no adhesions thus minimizing post surgery pain, better cosmetic results, less morbidity, and shorter postoperative recovery periods.

What are the after surgery care tips?

After surgery -patient can be discharged very next day provided :

1. her recovery is good .
2. tolerating orally .
3. well ambulating.
4. can resume normal activity in days.
5. Any strenuous activity or heavy lifting should be avoided in the immediate postoperative period, usually 6-8 weeks, to allow adequate time for scar tissue formation.
6. Activities that generate perineal strain or trauma, such as bicycle riding, should be prohibited.
7. The patient must refrain from any sexual intercourse during healing.
8. Additionally, the patient should be instructed to not insert tampons or applicators into the vagina.
9. A course of antibiotics is often prescribed at discharge.
10. For postmenopausal patients with significant vaginal atrophy, short-term course of vaginal estrogen therapy is recommended (unless contraindicated) in order to maintain the integrity of pelvic tissues and to maximize surgical success.

What are the Nonsurgical treatments ?

For mild variety of descent-

• losing weight to take stress off of pelvic structures.
• avoiding heavy lifting.
• doing Kegel exercises, which are pelvic floor exercises that help strengthen the vaginal muscles.
• taking estrogen replacement therapy.
• wearing a pessary, which is a device inserted into the vagina that fits under the cervix and helps push up and stabilize the uterus and cervix.

what about sexual life after surgery?

Sexual activity/sexual urge will not be hampered with the surgery with added benefits of correction for incontinence and mass protruding from vagina.

Will I feel weak after surgery?

surgery will not hamper your physical strength or makes you weak with joint pain as thought always and does not deteriorate daily activity .

Laparoscopic sacrocolpopexy is safe cost effective and cosmetic and patient can really consider this option after weighing risks and benefits.

What is LAPAROSCOPIC SACRO CERVICOPEXY ?

1. Sacrocervicopexy is a procedure similar to sacrocolpopexy,done for uterine prolapse ie., when the uterus is still intact , in which a graft material is used to suspend the cervix to the ligament on the pelvic bone(anterior longitudinal ligament Os sacrum).
2. Sacrocervicopexy can be performed either with uterine preservation or after supracervical hysterectomy.
3. Moreover, it preserves the integrity of ligaments, which are the main supports of the vaginal apex.
4. Laparoscopic sacrocervicopexy is an effective option for women with pelvic organ prolapse who desire uterine preservation.

What will be the time period to go back to work ?

2-3 Days

Dietary restrictions if any?

To have a balanced diet.

Any form of exercises to be followed postop ?

Any form of physical activity say yoga,meditation,walking ,sport to keep urself fit n fine.

will there be weight gain later?

Well, Not Exactly. Surgery does not make you put on weight.might be the restriction of physical inactivity self imposed can lead to weight gain.

will there be low back ache after surgery ?

No, not because of surgery. it could be due to loss of bone mineral density which can be tackled with supplementary medicines and physical activity.

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