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Vaginal vault suspension

The Australian Centre for Female Pelvic and Vaginal Rejuvenation
The Australian Centre for Female Pelvic and Vaginal Rejuvenation

What is a vaginal vault prolapse?

The vaginal vault is the area at the top of the vagina previously occupied by the cervix of the uterus and what was the anterior and posterior fornix.

Symptoms of vaginal vault prolapse

  • Feeling of pressure within the vagina.
  • Feeling of bulge or a lump.
  • Discomfort during intercourse.
  • Backache – worse when standing.
  • Dragging sensation.
  • Difficulty emptying the bladder or bowel.
  • Movement related urinary urgency.

indications for vaginal vault suspension

Grade 4 vaginal vault prolapse
Grade 4 vaginal vault prolapse

The main indication for vaginal vault suspension is symptomatic prolapse of the vaginal vault

Ulceration of the prolapsed vaginal vault
Ulceration of the prolapsed vaginal vault

Vaginal vault suspension is appropriate for women who have symptomatic vaginal vault prolapse. There are a variety of techniques that are designed to achieve this. The approach can be through open, vaginal and laparoscopic surgery. The procedures described can use permanent sutures or mesh augmentation.

The relevant anatomy

The principle ligamentous supports of the uterus are the utero-sacral ligaments. There is additional support from:

  • The transverse cervical (also known as the Cardinal or McKenrodt’s) ligaments.

Utero-sacral ligaments

A fibrous fascial band on each side of the uterus that passes along the lateral wall of the pelvis from the uterine cervix to the sacrum.

Cardinal ligaments

Attaches the cervix to the lateral pelvic wall by its attachment to the obturator fascia of the obturator internus muscle.

Muscular or active support of the uterus is provided by the:

  • Pelvic diaphragm
  • Perineal body
  • Urogenital diaphragm

Muscular or active support of the uterus is provided by the:

  • Pelvic diaphragm
  • Perineal body

The common features of mesh and non-mesh laparoscopic vaginal vault suspension

Done under general anaesthesia
Bowel preparation prior to surgery
Laparoscopic ('key hole') technique
2-4 nights as an inpatient
IV access, pelvic drain, catheter all used
Recovery and time off work identical

Grade 4 vaginal vault prolapse prior to surgery commencing.

C02 pneumoperitoneum; gas insufflated into abdomen so that the abdominal and pelvic contents can be viewed. The gas pressure fills the vaginal vault from above, distending it like a balloon.

A vaginal probe (metal probe with a round end) is inserted into the vagina from below and used to push the vaginal vault back up into the pelvis.

The vaginal probe in place viewed from above through the laparoscope. The probe is covered by peritoneum, fascia then the muscularis of the vagina.

The recto-vaginal fascia (behind) is dissected from the muscularis of the vagina.

The vesico-vaginal fascia (in front) is dissected from the muscularis of the vagina.

At this point, mesh and non-mesh surgery differ

Laparoscopic non-mesh vaginal vault suspension

The left utero-sacral ligament has been identified and isolated by opening up the peritoneum above it. This protects the left ureter from direct injury or from being kinked as the vault is suspended.

The right utero-sacral ligament has been identified and isolated by opening up the peritoneum above it. This protects the right ureter from direct injury or from being kinked as the vault is suspended.

Permanent sutures are used on the left and right to plicate the utero-sacral ligaments and then to attach the plicated ligaments to the lateral aspect of the vaginal vault.

At the 6 week post surgery check, the vaginal vault is no longer outside of the vagina and is, in fact, high up within the vagina, well supported.

Laparoscopic mesh vaginal vault suspension (Sacrocolpopexy)

The sacral promontory is identified.

The peritoneum over the sacral promontory is opened and extended along the right pelvic sidewall, below the right ureter to the vaginal vault.

The fascia over the sacral promontory is dissected, being careful to avoid the plexus of veins and middle sacral artery.

Identification of the anterior longitudinal ligament over the sacral promontory.

The mesh is prepared: soaked in antibiotic solution, then 2 pieces cut before being sutured together to achieve a Y-shape. The mesh is then introduced into the pelvis.

Delayed absorbable sutures are used to suture the mesh to the anterior vaginal wall.

Delayed absorbable sutures are used to suture the mesh to the posterior vaginal wall.

The tail of the mesh is placed over the sacral promontory.

Shallow metal tackers are used to fix the mesh to the sacral promontory.

An absorbable suture is used to close the peritoneum, thus burying the mesh and keeping it away from the abdominal contents.

The suture is extended to close the peritoneum along the right pelvic sidewall and over the vaginal vault.

In some patients, there is an extra-ordinary amount of redundant vaginal tissue. The tissue at the vaginal vault can be excised.

The vaginal vault is closed with absorbable sutures and then the vault suspension carried out as described above.

Dr Onuma will proceed to correct any other prolapse that you have been consented for. A cystoscopy (inspection of the bladder with a telescope) will be performed before you are woken up.

You will be transferred from the operating theatre to the recovery room where you will spend approximately an hour before being transferred to the ward.

When you first wake up from surgery you will notice a variety of things attached to you. These may (or may not) include a:

  • Catheter
  • Vaginal pack
  • Drain
  • Calf compressor
  • Intravenous access
  • A fluid bag
  • A nasogastric tube or oxygen mask
  • A blood pressure cuff

Risks of surgery

  • Anaesthetic
  • General medical
  • General surgical
  • Specific to laparoscopic surgery
  • Organ injury
  • Dissatisfaction with outcome
Laser Vaginal Rejuvenation Institute of Adelaide
Laser Vaginal Rejuvenation Institute of Adelaide