**8. Abdominal sacrocolpopexy**

The nonabsorbable suture ends from the uterosacral ligaments are now attached to the vaginal apex. One suture end is taken through the lateral aspect of the posterior vaginal wall and the other is attached to the lateral aspect of the anterior vaginal wall. The same is repeated on

Tying these sutures suspends the vagina in the hollow of the sacrum and restores the continu-

The single most careful point in this procedure is prevention of ureteric injury or kinking. It is important to perform an intraoperative cystoscopy to ensure ureteral patency. If the urine spurt is not seen in cystoscopy then the suspension sutures on that side should be removed and ureters reevaluated. Often the anchoring can be achieved by taking a more medial suture

In 1963, Inmon used ileococcygeal fascia in three women for bilateral fixation of vaginal vault in patients with inadequate uterosacral ligaments. In 1993, Schull and colleagues had performed this technique in 42 women. The principle is to identify all fascial defects prior to surgery. Posterior perineal incision is made. The vaginal epithelium is then freed from the rectum and rectovaginalis fascia. The dissection is carried further laterally to the levators and cephalad to the vaginal cuff. The ileococcygeal muscle is identified lateral to the rectum and anterior to the ischial spine. The non-dominant hand is used to depress the rectum away from

ity of the endopelvic fascia of the anterior and posterior vaginal walls [24].

the other side.

66 Pelvic Floor Disorders

the ischial spine.

through the uterosacral ligament.

**7. Ileococcygeous fascia suspension**

**Figure 5.** The abdominal uterosacral ligament suspension.

Post Hysterectomy Vaginal Vault Prolapse always requires a surgical correction. The suspension of vagina in the hollow of sacrum to the anterior longitudinal ligament of first sacral vertebra has been shown to be an effective treatment of vault prolapse.

Peritoneum over vaginal apex is opened to identify the endopelvic fascia. A continuous covering of endopelvic fascia is created around the vaginal epithelium. Nonabsorbable sutures are used to suspend the vagina along with endopelvic fascia to the sacral periosteum [26].

Sacrocolpopexy is an abdominal operation that connects the top of the vagina with a strip of permanent synthetic mesh to the sacrum bone. This operation is sturdy, with many studies showing success rates of over 90%. Cutting and tying the mesh design an "inverted Y" shaped mesh.

The patient is placed in low lithotomy position to allow vaginal manipulation during the surgery. The vagina is packed with a sponge stick or an E sizer, End-to-end anastomosis **sizer** (Auto Suture EEA reusable **sizer**; United States Surgical, Tyco Healthcare Group LP, Norwalk, CT, USA).

The lower limbs of inverted Y are anchored to the full thickness of vagina by multiple interrupted sutures. The mesh is placed around half way down the anterior wall, thereby correcting the undiagnosed, unidentified cystocele.

**9. Corrections of pelvic organ prolapse with mesh systems**

**10. Role of minimally invasive surgery in vaginal vault prolapse**

therefore presumably associated with quicker recovery and less pain.

**11. Recurrent prolapse and stress urinary incontinence**

**12. Operations for complete eversion of vagina**

vaginal evisceration if not treated on time.

Though the operating times are still longer than vaginal surgery, multiple studies of minimally invasive surgery, including the laparoscopic colpopexy, robotic sacrocolpopexy, show shorter hospital stays and less blood loss compared to the open abdominal approach, they are

Randomized trials of Laparoscopic sacrocolpopexy versus robotic sacrocolpopexy showed no difference in anatomical prolapse or bulge symptoms 1 year after surgery, demonstrating that long-term outcomes after these two minimally invasive approaches may be similar [29]. However, robotic assisted laparoscopy is significantly more expensive, mainly because of a longer duration of surgery (265 min for robotic sacrocolpopexy versus 199 for laparoscopic

Vault prolapse and incontinence can develop simultaneously after hysterectomy. Women with prolapse who are continent have an increased risk of developing de novo stress urinary incontinence after surgical prolapse repair. Therefore addressing stress urinary incontinence at the time of surgical intervention for prolapse is an important consideration for improving the quality of life. Performing an anti-incontinence procedure at the time of prolapse repair is

The management is always surgical because the prolapse has a tendency to enlarge gradually due to increased intraabdominal pressure. The vaginal prolapse also carries a rare risk of

effective in reducing the risks of occult stress urinary incontinence postoperatively.

placement [27, 28].

sacrocolpopexy).

Over the last decade, mesh augmented surgical repair is being increasingly used in pelvic organ prolapse. In 2008, the FDA issued a warning against the use of mesh for prolapse and incontinence repair. The warning was repeated in 2011, although narrowing it to vaginal mesh used for correction of pelvic organ prolapse (not for anti-incontinence procedures or when used abdominally). These warnings arose from concerns over mesh erosion through vagina, pain, infection, bleeding, dyspareunia, organ perforation and urinary problems. While many of these complications are common to all pelvic floor repairs, mesh erosion and some type of organ perforation are surely unique to mesh and trocars used for its

Recurrent Pelvic Organ Prolapse

69

http://dx.doi.org/10.5772/intechopen.76669

**Figure 7.** (a) The posterior peritoneum is incised over the sacral promontory and the median sacral artery and vein are identified. (b) Non-absorbable sutures are passed through the presacral fascia. The vaginal vault is elevated with an E-sizer and the bladder is dissected anteriorly and the rectum is dissected posteriorly. (c) The inverted oblique limbs of Y shaped mesh are anchored to the anterior and posterior vaginal wall. The vertical limb is anchored to the presacral fascia.

The vertical limb of inverted Y is now anchored to the periosteum with 2–4 nonabsorbable 0 suture. The peritoneum over the sacrum is sutured carefully taking care to prevent ureteric injury (**Figure 7(a)**–**(c)**). A paravaginal repair to anchor the lateral vaginal wall with arcus tendineus fascia pelvis is done. The abdomen is closed in layers. After this a posterior colporrhaphy procedure is done to correct the laxity of the perineal body.
