**6. Uterosacral vaginal vault suspension**

The anterior approach was developed subsequently to overcome the shortcomings of posterior approach. In the anterior approach a vertical anterior vaginal incision is made for retro pubic entry and paravaginal and paravesical space is dissected. The sacrospinous ligament is identified and the anterior cuff of vagina is anchored with two polytetrafluoroethylene (00) sutures. The two sutures are placed 2 cm apart on sacrospinous ligament. The same proce-

**Figure 3.** (a) The anatomical identification of sacrospinous ligaments as viewed from above and laterally. (b) The vaginal vault is anchored to the sacrospinous ligaments with delayed absorbable or nonabsorbable sutures. (c) The vaginal

The anterior suspension technique positions the vaginal vault in a more capacious anatomic space, in comparison to the relatively narrow pararectal area occupied by the upper vagina after posterior sacrospinous vault suspension (**Figure 4(a)** and **(b)**). After anterior sacrospinous vaginal vault suspension, vaginal length and apical suspension are slightly increased. The axis of the suspended vagina appears more physiological. There are less chances of recurrent anterior compartment prolapse as compared with the posterior sacrospinous vaginal vault suspension procedure. The upper vaginal lumen caliber and sexual function are adequately preserved in both techniques [23]. The posterior vaginal wall laxity, on the contrary,

However, these differences are likely to be influenced by differences in levator muscle tone and degree of perineal support. So a posterior colporrhaphy may be concurrently performed

dure is performed on the contralateral sacrospinous ligament.

mucosa is anchored and closed.

64 Pelvic Floor Disorders

is more common after anterior sacrospinous vault suspension.

In vault prolapse the endopelvic fascia surrounding the vagina is broken at specific points. A site-specific repair and anchoring to the stumps of uterosacral ligaments will restore the suspension. Three principles are identification of the fascia defect, reducing the enterocele sac and closure of the fascia defect. Finally the vagina is anchored to the Level 1 support of uterosacral ligament making the procedure most anatomically close to physiologically correct vaginal axis.

Vaginal apex is grabbed with two Allis clamps. The vaginal mucosa over the enterocele is incised. The enterocele sac is identified and dissected till the base or neck of the sac. The enterocele sac is opened carefully and contents are reduced taking care of adhesions. The excessive peritoneum is excised. A Deaver retractor is placed anteriorly and used to pack the abdominal contents anteriorly.

The uterosacral ligament stumps are identified; remnants are usually believed to be present at 5 0'clock and 7 0'clock position. The ureter position is confirmed by palpating the pelvic sidewall. The ureter is usually placed 2–3 cm lateral and ventral to the ischial spine. A nonabsorbable Prolene 1/0 suture is placed on the uterosacral remnant on left side passing the needle from lateral to medial side to avoid injuring the ureter. The rectum is then deflected away by the non-dominant hand. A second suture is placed further high and medially on the left uterosacral ligament for better anchoring. The peritoneum is included in the stich and now the stich is passed in the opposite uterosacral ligament taking the needle from lateral to medial side. Now these sutures are tied and this obliterates the cul-de-sac (**Figure 5**). Anterior colporrhaphy or sling procedures if required are performed at this stage now.

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

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 the other side.

A suture is placed just anterior to the ischial spine in the fascia covering the ileococcygeous muscle. Both ends of the loop are now passed through the ipsilateral vaginal apex. A similar suture is placed on the contralateral ileococcygeus muscle and vaginal apex is sutured to the opposite ileococcygeus (**Figure 6(a)**-**(c)**). A delayed absorbable suture like Vicryl 1,0, Ethicon,

**Figure 6.** (a) The ileococcygeus muscle anatomical identification. (b) The ileococcygeus fixation of vaginal mucosa and

Recurrent Pelvic Organ Prolapse

67

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

A specific complication is anterior vaginal wall relaxation due to non-physiological axis of the

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

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

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 correct-

used to suspend the vagina along with endopelvic fascia to the sacral periosteum [26].

Somerville, NJ, USA should pass through the entire vaginal thickness.

**8. Abdominal sacrocolpopexy**

closure of vagina after bilateral ileococcygeus fixation.

ing the undiagnosed, unidentified cystocele.

reconstructed vaginal support, which makes the vagina tilt anteriorly [25].

vertebra has been shown to be an effective treatment of vault prolapse.

Tying these sutures suspends the vagina in the hollow of the sacrum and restores the continuity of the endopelvic fascia of the anterior and posterior vaginal walls [24].

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 through the uterosacral ligament.

## **7. Ileococcygeous fascia suspension**

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 the ischial spine.

**Figure 6.** (a) The ileococcygeus muscle anatomical identification. (b) The ileococcygeus fixation of vaginal mucosa and closure of vagina after bilateral ileococcygeus fixation.

A suture is placed just anterior to the ischial spine in the fascia covering the ileococcygeous muscle. Both ends of the loop are now passed through the ipsilateral vaginal apex. A similar suture is placed on the contralateral ileococcygeus muscle and vaginal apex is sutured to the opposite ileococcygeus (**Figure 6(a)**-**(c)**). A delayed absorbable suture like Vicryl 1,0, Ethicon, Somerville, NJ, USA should pass through the entire vaginal thickness.

A specific complication is anterior vaginal wall relaxation due to non-physiological axis of the reconstructed vaginal support, which makes the vagina tilt anteriorly [25].
