Pelvic Reconstructive Surgery

Approximately fifty percent of women who have experienced childbirth have varying degrees of pelvic organ prolapse that affect the vagina. Some of these conditions can include:

• Vaginal Prolapse. Where the top of the vagina loses its support and drops, this condition occurs most often with women who have had a hysterectomy. Vaginal Prolapse can cause include difficulty urinating, bowel function, painful intercourse, vaginal pain loss of bladder control and a feeling of heaviness in the vaginal area.
• Small Bowel Prolapse (Enterocele). A condition when the small bowel presses against and moves the upper wall of the vagina causing a bulge or hernia to form.
• Anterior Vaginal Prolapse (Cystocele). A bulge or cystocele forms on the front wall of the vagina and causes a loss of support to the bladder that rests on that area of the vagina. Symptoms can include incontinence, a feeling of pelvic heaviness or back pain.
• Posterior Vaginal Prolapse (Rectocele). A condition when the rectum bulges into or out of the vagina. May cause difficulty with bowel movements.

Proper diagnosis is essential in treating pelvic support conditions. Being open about symptoms with your physician is important in finding the exact cause. Depending upon your symptoms and the type or vaginal prolapse you are diagnosed as having, treatments can include special exercises, lifestyle changes, the use of pessaries, changes in diet and lifestyle, reconstructive surgery and obliterative procedures to narrow and shorten the vagina.

Vaginal Prolapse Treatment

In treating or repairing vaginal prolapsed” apical” suspensions are used to restore the support of the top of the vagina (vaginal vault). Procedures used include:

• Abdominal Sacral Colopexy (ASC – performed through an incision in the abdomen either laparoscopically or robotically, ASC involves the use of graft material to reinforce the walls of the vagina by forming straps that, when attached to the ligaments overlying the sacrum, support and suspend the vagina over the pelvic muscles and backbone.
• Uteroscral or Sacropinous Ligament Fixation – this procedure involves suspending the vagina to a patient’s own uterosacral ligament or sacrospinous ligaments. Graft material can also be added to improve the durability of the repair.

Small Bowel Prolapse (Enterocele) Treatment

The surgical procedure to correct this condition is called a sacral colpopexy. The surgical procedure uses polypropylene or biologic grafts so as to close over the apex of the vagina and correct the bulge or herniation of the small bowel into the vagina. The procedure approaches the vagina intra-abdominally. It is a complicated procedure in which a Y shaped mesh is positioned over the apex of the vagina and re-suspended to the sacrum.

Anterior Vaginal Prolapse (Cystocele) Treatment

A cystocele repair elevates the anterior vaginal wall back into the body to support the bladder. This can be done either vaginally or through an abdominal approach at the time of a sacral colpopexy. In an anterior colporrhaphy, an incision is made in the front wall of the vagina. The vaginal skin is separated from the bladder wall behind it.  The weak or frayed edges of the deep vaginal wall are found and the strong tissue next to edges are sutured to each other lifting the bladder and recreating the strong ”wall” underneath it. 

Since this part of the pelvic floor is subjected to significant pressure with each cough or when picking up heavy items,  up to one third of women will develop recurrent anterior prolapse after an anterior colporrhaphay.  To reduce this recurrence, a surgeon may use graft material over the repair to reinforce it.

Posterior Vaginal Prolapse (Rectocele) Treatment

If muscles at the vaginal opening are stretched or separated at childbirth, this condition can be corrected by a perineorrhaphy. It may also be corrected abdominally during a sacral colpopexy. To correct the vaginal bulge, a surgical procedure called an anterior colporrhaphy is performed to raise the back wall of the vagina back into the body to support the bladder.

A posterior coloporrhaphy is a procedure used to repair the rectal bulge that protrudes through the back wall of the vagina. In this procedure, an incision is made in the back wall of the vagina. The vaginal skin is separated from the rectal wall underneath.  Once the weak or frayed edges of the deep vaginal wall tissue are identified, the strong tissue next to edges is sutured to each other to recreate the wall between the rectum and the vagina. Occasionally, a surgeon will use graft material to provide additional strength to the repair.

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