Laparoscopic Repair of Female Organ Prolapse

Introduction:

The goal of laparoscopic repair of female organ prolapse is to restore normal functioning by correcting female organ supporting defects in the pelvis. The supporting system in the female pelvis is quite complex; however, it is dynamic rather than static. There are basically two systems in the pelvis that provides the active and passive support of pelvic organs to their proper places. The active and dynamic support of the female organs comes primarily from a pair of special muscles in the pelvis that is called levator ani muscles. These muscles maintain a certain tone even during the resting phase. The muscle is strong and can contract forcefully when needed. Yet it is quite flexible, resilient, and also renewable. When the levator ani muscles are damaged due to childbirth or to a constant increase in intra-abdominal pressure, as in chronic lung disease, (due to asthma or heavy smoking), constipation, or jobs requiring constant heavy lifting and straining activities, the levator ani muscles are no longer able to maintain their efficient contractility and lose the resting tones to support the female organs in their proper places. A great strain is then placed on the passive support system of the pelvis, which is provided by the endopelvic fascia (a tough fibrous sheet) within the pelvis. Unfortunately, the endopelvic fascia, being a fibrous tissue consisting of collagen, elastin, and smooth muscle fibers, is poorly suited to support the pelvic organs, which are under constant gravitational pull and frequent bouts of increase in intra-abdominal pressure. Exposed to prolonged pressure and tension, the endopelvic fascia will stretch and eventually break, resulting in loss of support to the pelvic organs, resulting vaginal prolapse and urinary and /or fecal incontinence. Because the defect in the pelvic floor support usually is multiple and not limited just to the obvious component, the entire pelvic floor supporting system must be thoroughly evaluated before and during surgery, and all defects must be reconstructed at the same time of surgery. 

The prolapse rarely bothers the patient when she is lying down and resting; it only bothers her when she is up and carrying on her normal daily activities in an erect (either standing or sitting) positions. Any physical stress such as coughing, sneezing, or lifting usually aggravates the prolapse. To accurately evaluate the degree and site of the prolapse, the patient should be examined in an erect position rather than on her back. She must be thoroughly evaluated and the prolapse clearly observed by the physician under different physical stresses (coughing, bearing down, straining), before she is counseled to have reconstructive surgery. 

To restore the normal vaginal depth and axis, to relieve the symptoms of pressure, and to maintain the satisfactory sexual function remains my surgical goals for my patients with uterovaginal or vaginal prolapse.


Advantages of Laparoscopic Surgery

With a bright light directly shining on the deep pelvis and the magnification provided by the laparoscope, a superb view of the pelvic floor can be obtained and the pelvic supporting defects can be clearly identified. The laparoscopic approach differs from the traditional vaginal or even the abdominal surgical approach in that during the laparoscopic repair of prolapse, the surgeon can not only see the supporting defects clearly, he/or she can also feel the defects by performing a vaginal examination under direct laparoscopic view, thereby permitting the surgeon to place the sutures very precisely and effectively. With the traditional vaginal repair surgery for prolapse, the surgeon is almost totally depends entirely on tactile feeling to guide the surgery which unfortunately can result in either over or under repair at the defects. An additional advantage of laparoscopic surgery is that pictures of the surgery can be taken or the entire surgery can be video taped for the future reference and for patient’s own information. With the minimal invasive nature of the laparoscopic surgery, the postoperative pain and discomfort are greatly reduced and the recovery period is much shortened. I have been performing laparoscopic surgery for female organ prolpase for the past 10 years with outstanding results. My experience firmly convinces me that if a surgeon is knowledgeable of the anatomy and pathophysiology of genital prolapse and also possess advanced laparoscopic surgical skills, he or she will be able to provide the patient with a great service.


Laparoscopic Surgery for Uterovaginal and Vaginal Prolapse

The prolapse of uterus and vagina is one of the most frustrating and embarrassing disorders confronting the modern woman, who, with increased life expectancy, is interested in maintaining her femininity and capacity for sexual activity. A prolapsed uterus or vagina is just a manifestation of the break down in the pelvic floor supporting system, and it is nearly coexists with other type of genital prolapse such as cystocele, rectocele, and enterocele. Therefore, the reconstructive surgery for uterovaginal or vaginal prolapse is just a part of the total repair of the pelvic floor, which is necessary for restoration of the normal anatomy and function.

The length of the vagina in a normal adult female is approximately 10 – 12 cm. In a standing female, her lower 1/3 of the vagina is pointing 90 degree to the floor and her upper 2/3 of vagina is in an angle almost parallel to the floor and directly toward her lower backbone. The vagina is basically supported on three different levels in the pelvis. The support of the upper 1/3 of vagina comes from the uterosacral ligaments, a pair of very strong fibromuscular structures that originate from lateral aspects of sacrum (the lowest part of our spine), going around the rectum and attaching to the cervix (the mouth of womb), and upper part of vagina. These ligaments pull the top of vagina and cervix toward the sacrum and form the normal axis of vagina. The middle third of the vagina is held in place by the lateral attachments of the fascia to the pelvic sidewall. The lower third of vagina is blending into and merging with the fibromuscular tissue surrounding the opening of the vagina and anus. It is of utmost importance for the readers to understand that the uterus, per se, has no bearing or effect on the vaginal support. In other words, a hysterectomy should not be considered as part of repair surgery for uterovaginal or vaginal prolapse unless there is distinct pathology of the uterus. In order to restore the vaginal depth and axis, all three levels of support must be attended at the time of surgery.

Surgical Technique

The patient is under general anesthesia and the laparoscope is placed into the abdominal cavity through a small ½ inch incision inside the navel. Additional three or four ¼ inch incisions in the lower abdomen may be needed to place some of the laparoscopic instruments during surgery. The laparoscope is connected to a small, yet very sophisticated and sensitive video camera and the deep pelvic structures are greatly magnified onto three high resolution video monitors positioned in front of the surgeon, the surgical assistant, and the scrub technician; thus the entire surgical team has a superb view of the operative field. Laparoscopic surgery differs greatly from the traditional surgery in a way that the surgery is almost entirely guided by the electronic eyes which can deliver the magnified view of the operative field, the surgeon perform the surgery with his/her eyes focus on the video monitor instead of looking at patient, and the entire surgical team has the same clear view of the surgery. As the individual supporting defects are visualized and reconfirmed by digital vaginal palpation under the view of the laparoscope, the defect is repaired with the placement of permanent non-absorbable sutures precisely through the laparoscope. Frequent digital vaginal examinations are performed throughout the surgery to ensure that all defects are repaired. Because of excellent visibility of the operative field through the laparoscope, the blood vessels in the pelvic area can be either avoided or sealed by electrocautery or suture ligation, thus minimizing the blood loss. There are several laparoscopic surgical techniques that can be used to repair the uterovaginal and vaginal prolapse. My current surgical technique is to use presacral uterosacral ligaments to resuspend the apex of vagina and cervix (if patient still has a uterus) to restore the depth and axis of the vagina. The presacral uterosacral ligament is a very strong fibromuscular tissue, which can withstand great strain. I did one experiment to show the strength of the presacral uterosacral ligaments in an anatomy meeting for physicians, I put in a big suture through the presacral uterosacral ligament and hooked the suture to a 30 pounds weight, it held the weight without any problem. 

For those patients with marked prolapse, a paravaginal repair will usually be necessary at the same time of the surgery to reattach the midvagina to the pelvic sidewalls. 

I have been doing laparoscopic surgery for uterovaginal and vaginal prolapse for the past 10 years with good long-term results. Unlike traditional vaginal surgical repair, there is no or minimal cutting or trimming of the vagina, therefore, there is absolutely no risk of making the vagina too narrow or too short, both of which are the major long-term complications of vaginal surgical repair of prolapse. 

Laparoscopic Surgery for the Repair of Cystocele

Support for the bladder and urethra, (the tube between the bladder and the opening of vagina) is provided by a strong layer of fibromuscular sheet that overlies the linings of the anterior vaginal wall; this is the pubocervical fascia. Superiorly it attaches to the upper part of vagina and cervix of uterus, and laterally it attaches on each side to the pelvic sidewall. The pubocervical fascia supports the bladder and the urethra by forming a shelf, allowing the bladder neck and the proximal part of urethra to be compressed in an anterioposterior fashion during the periods of stress (coughing, sneezing, laughing, or lifting heavy objects). When this supporting mechanism becomes loose due to trauma of childbirth, or for other reasons, the stability of this supportive layer of fascia diminishes and may ultimately fail, leading to the formation of cystocele and the development of stress urinary incontinence if the fascial defects involves the support of the bladder neck and proximal urethra. In 1976, Dr. Richardson of Atlanta, after careful clinical observations and cadaver dissections, proposed and emphasized that the vast majority of cystocele is not caused by the stretching or attenuation of the pubocervical fascia, but that it is a result of a “break” of the pubocervical fascia from its attachments to the pelvic side walls. He called this defect “paravaginal defect” and he strongly advocated the use of paravaginal repair, instead of traditional vaginal anterior repair (anterior colporrhaphy), for the treatment of cystocele. His concept of cystocele and proposed treatment has been accepted endorsed by virtually all the leading urogynecologists in the country. 

Technique of Laparoscopic Paravaginal Repair for Cystocele

The patient is under general anesthesia and a laparoscope is inserted into the abdominal cavity through a small ½ inch umbilical incision. The peritoneum (the lining of the abdominal and pelvic cavity) above the bladder and behind the pubic bone is opened through the laparoscope and the retropubic space (a space in the pelvis where the bladder and its supporting ligaments are located) is entered and dissected. With a bright light shinning directly into the retropubic space and the magnification provided by the laparoscope, a clear view of the retropubic space is projected onto the high resolution TV monitor through a very sensitive video camera that afford the surgeon a superb visualization of the anatomy of retropubic space. The paravaginal defect(s), can be very easily picked up by the surgeon. A digital vaginal examination under the direct observation of the laparoscope is performed to reconfirm the presence and extend of the defects; the defects are then repaired with several interrupted sutures with permanent stitches through the laparoscope. There are three different types of paravaginal defects that can be identified through laparoscope, and each defect should be treated differently according to its own types of defect. 

With positive intra-abdominal pressure, which is created by pneumoperitoneum, during laparoscopic surgery, paraviginal defects become much more apparent. Digital vaginal examination under the direct viewing through laparoscope, afford the surgeon with additional tactile assessment of the defects. Therefore, intraoperative findings of the paravaginal defects not only confirm the preoperative findings, they dictate the ultimate procedures to be performed. At the end of the reconstructive surgery, repeat digital vaginal examination under direct laparosopic view allows the surgeon to be confident that all the defects have been repaired. I have been performing the paravaginal defect repair for the past 10 years with very satisfactory results, I attribute my results to the ability that I can see and identify the defects perfectly and place the sutures very precisely through the laparoscope. As it is said, “If you can not see, you don’t know what you are missing”.