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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_202_библиотеки_им_акад_М_И_Перельмана
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additional elevation and support (Fig. 22.4). If GSI is
not present, the vaginal skin edges are then approximated commencing at the cervical end, using a series of
interrupted sutures or a continuous locking suture to
prevent vaginal shortening (Fig. 22.5). The authors
prefer interrupted sutures as these provide maximum
support for the underlying bladder during the postoperative period, and also avoids the development
of haematoma formation by allowing space between
the sutures for any blood to escape. An indwelling
transurethral urinary catheter is inserted if the bladder
neck was not given additional support by the use of
Kelly’s sutures. Alternatively, a suprapubic urinary
catheter, as described in the preceding chapter, should
be inserted. A vaginal pack is not required.
Alternative techniques
A commonly used technique is to identify and excise the
vaginal skin to be removed at the onset of the operation
by demarcating the edges, and excising the redundant
skin from the underlying pubocervical ligament and
BONNEY’S GYNAECOLOGICAL SURGERY
240
Fig. 22.3 Division of the cervicovesical fascia.
Fig. 22.4 Insertion of Kelly’s buttress sutures.
bladder, as shown in Fig. 22.6. Alternatively, the procedure can be commenced by incising a vertical incision
between the urethral meatus and the cervix at the onset
of the operation prior to the development of the subepithelial plane. The authors’ preferred technique is the
one described, as it ensures accurate entry and development of the subepithelial plane, crucial to the performance of an avascular operation, in addition to avoiding
the error of removing too little or too much vaginal
skin.
Posterior colpoperineorrhaphy
The operation is performed for a rectocele with or without an associated enterocele, and for a deficient perineum resulting in a gaping vaginal introitus. The
principles are to excise redundant posterior vaginal
skin, obliterate the enterocele sac, if present, and to
reform the perineal body and perineum. Special care
is required when performing this procedure, as poor
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tion of the most posterior of the carunculae myrtiformes on each side. These two forceps are first approximated to confirm that the calibre of the new introitus
will be adequate; they are then retracted laterally. A solution of 1% xylocaine with adrenaline 1 : 200000 is
now injected to raise the posterior vaginal wall off the
underlying tissues. Drawing the two marginal Kocher’s
forceps laterally and towards the operator, the old scar
is boldly excised with scissors (Fig. 22.7), the only exception being where the perineum is so deficient that
the anus might be injured, in which case a transverse
incision with the scalpel is to be preferred.
Separation of the rectum from vagina
The operator now retracts the distal vagina upwards
with toothed forceps or a Kocher’s forceps and his fingers; by dissecting against the fingers, the plane between rectum and vagina is found (Fig. 22.8). The open
scissors are now inserted into this space laterally to
separate the lower vagina from the superficial perineal
muscles (Fig. 22.9). If the correct plane has been found,
dissection of the rectum from the posterior vaginal wall
surgical technique or surgical misjudgment can result
in considerable dyspareunia and even apareunia, for
the patient. The so-called ‘registrar constriction ring’ is
seen to occur just as commonly after the operation has
been performed by a consultant.
Anaesthesia, patient preparation and instruments
The comments made above should be noted, with the
avoidance of a head-down tilt to the operating table.
The instruments required are those in the gynaecological general set, shown in Chapter 2.
The operation
The incision
The apex of the rectocele is seized by applying a
Kocher’s forceps to the posterior vaginal wall; it is usually found that on drawing this point downwards it will
reach the posterior margin of the introitus. The forceps
is retracted upwards. Two Kocher’s forceps mark the
lateral points of the incision just internal to the junction
of the vaginal and perineal skin and usually at the posi-
PROLAPSE OF THE UTERUS AND VAGINA
241
Fig. 22.5 Insertion of vaginal sutures.
Fig. 22.6 Excising redundant vaginal skin.
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and the margins of the divaricated levator ani muscles is
easy with gauze dissection; this separation reaches the
apical Kocher’s forceps.
Excision of the skin
The redundant vaginal skin is now excised. Care must
be taken to avoid a constriction at the junction of the
upper third and lower two-thirds of the vagina; the anterior repair in the vault region tends to ‘borrow’ from
the posterior vaginal wall, so that if too much vagina is
excised in the upper part of the posterior repair there
will be undue narrowing (Fig. 22.10). The closure of
the posterior vaginal wall is now started using a continuous locking suture.
Reformation of the perineal body
After the first few stitches the muscle sutures are passed
by retracting the vaginal suture upwards and holding
the rectum back with the operator’s left forefinger,
which also stretches the puborectalis muscle. It is best
to insert the highest stitch first; this is at levator ani level.
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242
Fig. 22.7 Excising the perineal scar tissue.
Fig. 22.8 Exposing the plane between vagina and rectum.
Fig. 22.9 Separation of superficial layers laterally.
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wall can be excised first, the rectum separated, and the
repair carried out in similar fashion to that already
described.
Posterior colpoperineorrhaphy with enterocele repair
The previously described procedure is followed except
the incision is continued to the vaginal vault, paying
particular attention not to remove an excessive amount
of vaginal skin. If the correct subepithelial plane is identified, the inferior and the anterior peritoneal margins
of the enterocele sac will be encountered. After continuing the dissection of the peritoneum of the enterocele sac off the vaginal skin, the other attachments to
the enterocele sac are then dissected using a combination of sharp and blunt dissection, until the enterocele
sac is completely mobilized. The enterocele sac is then
opened by incising the peritoneum, paying attention at
this point to avoid injury to the small bowel, which may
be lying within the sac. A minor degree of head-down
tilt to the operating table can be particularly useful in
emptying the sac. The remaining small bowel contents
Taking a good bite of muscle on the right, the needle
is taken through the vaginal wall into the canal and
then back through the vagina to take a good bite of the
left muscle (Fig. 22.11); this binds the vagina to the
muscle and avoids dead space. The two ends of the suture are held in a Spencer Wells forceps which is pulled
upwards and, with the rectum still being retracted posteriorly, another stitch is passed through the two muscles, omitting the vaginal wall this time. A third suture
is usually required, placed in similar fashion. The
Spencer Wells forceps are now allowed to hang downwards and the vaginal closure continues, each muscle
stitch being tied as it is reached by the continuous vaginal suture. The continuous suture can pick up the conjoined muscles in the lower parts of the repair. On
reaching the introital margin, the continuous suture is
completed. The perineum is reconstituted by uniting
the subcutaneous tissue and then the skin with fine
suture material.
Where there is no need for perineorrhaphy, the rectocele can be dealt with similarly but a transverse incision
with the scalpel is indicated. Alternatively, the vaginal
PROLAPSE OF THE UTERUS AND VAGINA
243
Fig. 22.10 Shape of excised vaginal skin.
Fig. 22.11 Reformation of perineal body muscle sutures.
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posterior vaginal walls which normally lie in apposition. Separation of vaginal adhesions may still be required at the first postoperative clinic visit.
The Fothergill or Manchester repair
Although not recommended by the authors, some gynaecologists prefer this procedure for treatment of
uterine prolapse in preference to vaginal hysterectomy;
whilst it may be satisfactory for lesser degrees of uterine
descent, it is not effective in uterine procidentia and is
not satisfactory if an enterocele is present.
The principle of the procedure is to amputate the
elongated cervix and approximate the cardinal ligaments anterior to the cervix to elevate and retract it
backwards so that the uterus is both supported and
anteverted. A curettage is performed at the onset of the
operation to exclude the presence of intrauterine
pathology.
The operation
The incision
This is as described for vaginal hysterectomy and repair. The vaginal skin is reflected from the cervix all
round and the bladder reflected from the cervix.
Ligation of the ligaments and the descending cervical
branch of the uterine artery
The ligaments are usually clamped on each side and the
cervix then amputated (Fig. 22.12). The ligaments and
vessels are ligated and the ligatures held.
Recovering the posterior cervix
A strong absorbable suture is passed through the skin
of the posterior vaginal wall at the 7 o’clock position;
the needle then passes through the wall of the cervix
into the canal from where it is withdrawn to pick up the
centre of the posterior vaginal wall, whence it returns
into the canal and then out through the cervical wall at
the 5 o’clock position and finally through the vaginal
wall. When tied, the Sturmdorff suture covers the posterior half of the amputated cervix (Fig. 22.13).
The Fothergill stitch
This stitch covers the anterior half of the amputated
cervix with vaginal skin and also approximates the
ligaments in front of it. The needle passes through the
are then pushed out of the enterocele sac by use of a
small swab wrapped and held by a sponge holder. The
redundant peritoneum is then excised up to the neck of
the hernial sac, and the new peritoneal edges closed
with a purse-string suture using Vicryl or Dexon. For
severe, complex or recurrent cases, a culdoplasty stitch
can be inserted to provide additional support. Closure
of the vaginal skin is then continued as previously
described, ensuring adequate obliteration of the space
between the vaginal skin and the underlying fascia
to provide additional support, and prevention of
recurrence.
Postoperative care
If care is taken not to over-tighten the sutures at the perineum and the vaginal introitus, then pain is not a
significant feature during the postoperative period.
Routine urinary catheterization is therefore not essential on completion of the procedure. A vaginal pack is
also not required.
Vaginal hysterectomy
Vaginal hysterectomy is frequently required for treatment of uterovaginal prolapse, usually but not always
performed in conjunction with an anterior or posterior
vaginal repair. The procedure is described in detail in
Chapter 10. When all three procedures are required to
deal adequately with the prolapse, the authors’ preference is to perform the vaginal hysterectomy first,
followed by the anterior repair and finally the posterior
repair. The basis of the logic is that performing the posterior repair first can prevent adequate access to the
upper vagina and the anterior vaginal wall; also, after
dealing with the uterine and anterior vaginal wall prolapse, it often becomes apparent that it is unnecessary
to perform the posterior repair for a satisfactory end
result. As many women are post- or perimenopausal,
the performance of a bilateral salpingo-oophorectomy
should be performed at the time of the vaginal hysterectomy. If a bilateral salpingo-oophorectomy is not performed, then at the very least, the ovaries and tubes
should be inspected for normality. When an anterior
and posterior repair have been carried out, the authors’
preference is to insert a bacterostatic soaked vaginal
pack for up to 24 h in an attempt to avoid the development of vaginal adhesions between the anterior and
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244
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vaginal skin under the marking lateral Kocher’s forceps, under the supporting ligaments, and into the cervical canal from which it is withdrawn to be returned
into the canal and out of the anterior wall to pick up the
opposite ligament and through the vaginal wall. A second stitch, passing through vaginal skin, under the ligament, through the anterior cervical wall, under the
opposite ligament and again through skin, supports the
Fothergill stitch (Fig. 22.14). When the Fothergill stitch
is tied, the Kocher’s forceps on the angles of the vagina
have their tips approximated and this allows the cervix
to be covered. After tying the second stitch, the anterior
colporrhaphy is completed.
Vault prolapse (enterocele
following hysterectomy)
Vault prolapse can occur after abdominal or vaginal
hysterectomy. The authors believe it is a myth that ligating the pedicles to the vaginal vault at the time of the
hysterectomy significantly reduces the likelihood of a
vault prolapse subsequently developing. Certainly,
there is no strong evidence to support the practice.
Vault prolapses are often inadequately dealt with by
the inexperienced gynaecologist. Attempts to deal with
it by a combination of anterior or posterior repair, as is
commonly practised, will do nothing to reduce the prolapse and will only shorten and constrict the vagina,
making coitus virtually impossible and subsequent
attempts to deal with the prolapse more difficult.
In fact, vault prolapses can be corrected very simply
using reconstructive techniques that will impress the
trainee surgeon, the patient and also many senior colleagues. Where vaginal access is satisfactory and there
is also the need for a posterior colpoperineorrhaphy, a
sacrospinous colpopexy is recommended performed by
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245
Fig. 22.12 Amputation of the cervix.
Fig. 22.13 The Sturmdorff suture.
Fig. 22.14 The Fothergill stitch.
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Identification and mobilization of the enterocele
The enterocele sac is encountered and dealt with as previously described.
Identification of the sacrospinous ligament and
insertion of the sacrospinous stitch
The patient’s right pararectal space is bluntly dissected
in a posterolateral direction combined with regular palpation of the ischial spine, eventually allowing palpation and visualization of the sacrospinous ligament
within the body of the coccygeus muscle (Fig. 22.16).
The approach is aided by a large Sims’ speculum placed
in the posterior vagina with moderate traction in a
downward direction by the assistant, to keep the rectum out of the operating field. A vaginal retractor
placed along the right vaginal wall applying traction in
an anterolateral direction also allows adequate displacement of the endopelvic fascia, easing access to the
the vaginal route. For more complex, severe or repeat
procedures, an abdominal sacral colpopexy is preferred. Both procedures will relieve symptoms and
re-establish a coitally functional vagina and, with
sufficient experience, can also be performed laparoscopically. In the authors’ opinion, there is no place for
the performance of obliterative procedures such as
colpocleisis, and these will not be discussed further.
Sacrospinous colpopexy
Anaesthesia, patient preparation and instruments
The comments made above should be noted, with the
avoidance of a head-down tilt to the operating table.
The operation
The incision
The posterior repair is commenced as described earlier,
with the incision continued up to the vaginal vault (Fig.
22.15). The redundant vaginal skin is removed.
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246
Fig. 22.15 Posterior vaginal wall incision up to vaginal vault.
Fig. 22.16 Visualization of the sacrospinous ligament.
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the perineal body and perineum. An indwelling
transurethral urinary catheter and bacterostatic
soaked vaginal pack are advisable.
Abdominal sacral colpopexy
Anaesthesia
The addition of an epidural or spinal anaesthesia to the
general anaesthetic is helpful in reducing minor bleeding from the sacrum but is not essential.
Patient preparation
The patient is prepared as for any abdominal procedure. The authors’ preference is also to insert a vaginal
pack prior to commencing the operation to aid dissection of the rectum and bladder from the vaginal vault.
Alternatively, an obturator can be inserted into the
vagina and used to manipulate the vault during the procedure. An indwelling transurethral urinary catheter is
also inserted.
Instruments
The gynaecological general set shown in Chapter 2 is
used.
ischial spine and ligament. A fish-hook needle attached
to a strong absorbable suture is then passed through the
sacrospinous ligament about 2 cm away from the
ischial spine, in a posteromedial direction. Knowledge
that the pudendal vessels and nerve, and the sciatic
nerve lie directly beneath the ischial spine should persuade most surgeons to keep well clear of this area. The
application of firm traction to the suture length will test
the correctness of its placement. Attention should also
be made to insert the stitch through the ligament and
not around it. Using a separate suture length, a second
stitch is inserted for additional strength. Alternatively,
an eyed needle can be used, or as is now becoming common practice, the use of a Miya notched speculum,
needle and retrieval set (Fig. 22.17). The two sutures
are then secured to the upper posterior aspect of the
vaginal skin, allowing the vaginal vault to be drawn
snugly on to the right sacrospinous ligament (Fig.
22.18). If necessary, the procedure can be repeated on
the left side to provide the vaginal vault with additional
support. However, in the editor’s personal practice, to
date, this has not been required.
Closure of the vaginal vault and completion of the
posterior repair
The vaginal skin edges are then approximated as described earlier, in combination with the reformation of
PROLAPSE OF THE UTERUS AND VAGINA
247
Fig. 22.17 The Miya notched speculum, needle and retrieval
set.
Fig. 22.18 Suspension of the vaginal vault to the
sacrospinous ligament.
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tures into the anterior longitudinal ligament or periosteum. The length of mesh used is gauged whereby it adequately holds the vagina in an elevated position, whilst
lying within the hollow of the sacrum, free of any undue
tension (Fig. 22.19). Any excess mesh length can now
be excised and discarded. The area is then reperitonealized to avoid the development of adhesions,
and combined with a Moschowitz or Halban’s culdoplasty stitch if required (Fig. 22.20).
The operation
The incision
The procedure is ideally performed through a subumbilical mid-line incision for ease of access. Entry into
the abdominal cavity is as described in Chapter 6.
Preparation of the vaginal vault
The firm pack within the vagina is easily palpated. The
peritoneum overlying the vaginal vault is incised taking
care to exclude the possibility that the bladder may be
lying within the intervening space. Once the edges of
the vaginal vault are identified and exposed, the plane
between the posterior vaginal wall and rectum is developed as far as is necessary, this step having been made
considerably easier by the insertion of a vaginal pack.
The bladder base is then dissected off the superior aspects of the anterior vaginal wall. Sharp dissection is
usually required as a result of the previous surgical
intervention.
Preparation of the sacrum
With the sigmoid colon pushed over to the left side, the
peritoneum overlying the sacral promontory and the
upper three sacral vertebrae are then incised at the midline. The peritoneal incision is continued to the peritoneal incision overlying the vagina.
Placement of the mesh
A variety of synthetic and natural materials have been
used including Marlex, Teflon, Goretex, Mersilene,
rectus muscle fascia and dura mater. Using two Littlewood’s forceps, traction is applied to the vaginal vault
and the vaginal pack removed. In not removing the
vaginal pack at this stage, the danger will be to suture
the mesh to the pack in addition to the vagina.
Although this may help support the vaginal vault, it is
unlikely that you will be thanked by the patient. An
adequate length of mesh should be made available, ideally 3 ¥ 15 cm. Commencing at the lower aspects of the
posterior vaginal wall and aiming towards the vault,
the mesh is sutured to the vaginal tissues using fullthickness interrupted non-absorbable sutures. Attachment of the mesh to the vagina should continue
sufficiently anteriorly also to deal with any cystocele
which may be present. The mesh is then turned back on
itself, aiming towards the vaginal vault and from there
towards the sacrum, to which it is also secured by way
of transversely placed non-absorbable interrupted su-
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248
Fig. 22.19 Placement of the sacral colpoplexy mesh.
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(a)
(b)
There is considerable doubt concerning the role of
ventrosuspension procedures in the management of infertile patients. The positioning of the cervix and the lie
of the uterus may not be of any significance in either the
subfertile or the infertile.
When a ventrosuspension is performed there
are a number of variations in technique, but as the
indications are relatively few the authors will concentrate on the Gilliam’s ventrosuspension with minor
modifications.
Gilliam’s ventrosuspension
Instruments
The gynaecological general set described in Chapter 2
will be required. The uterine packing forceps are the
ideal instrument for burrowing subperitoneally along
the round ligament.
The operation
Opening the abdominal cavity The low transverse or
Pfannenstiel incision is very suitable for this procedure
(see Chapter 6).
Elevating the uterus The uterus is raised by gently inserting the left hand into the pouch of Douglas and drawing the uterus forward. It is important to determine
whether the retroversion is due to adhesions or the scarring consequent upon endometriosis. Occasionally, an
extensive dissection is necessary in order to mobilize the
uterus and to undo the retroflexion which can occur
after endometriotic scarring. Great care should be taken
to identify the ureter and keep it in full vision.
Plicating the round ligaments Once the uterus is mobilized, the round ligaments are identified and a plication
stitch inserted as shown in Fig. 22.21; nylon may be
used for this stitch. The suture should begin with a firm
bite of the uterine musculature, taking care not to impinge on the entry point of the fallopian tube. The stitch
is then carried along the length of the intra-abdominal
portion of the round ligament, taking a zig-zag course.
The two ends of the stitch are then drawn tight to concertina the round ligament and are tied.
This simple part of the procedure may be all that is
required to elevate and antevert the uterus.
Passing the round ligament forceps The line of cleavage between the edge of the rectus muscle and the
Closure of the abdominal wall
This is as described in Chapter 6.
Operations for the correction of axial
displacement of the uterus
Indications
Operations to correct the position of the uterus have
gone through periods of popularity, interspersed with
equal periods of unpopularity. At the present time,
there appear to be few sound indications for these operations. No longer should an uncomplicated retroversion of the uterus be regarded as pathological, nor
should it be felt that it has any bearing on the ability to
procreate.
The following indications for correction are agreed
by most gynaecologists.
When a retroverted uterus is fixed in the pelvis by
adhesions, endometriosis or infection and is causing
dyspareunia, it is important that a cause for the
dyspareunia is found, and laparoscopy is invaluable.
Occasionally, a prolapsed ovary causing dyspareunia may be preserved and elevated within the pelvis by a
simple suspension procedure.
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249
Fig. 22.20 The Moschowitz culdoplasty.
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