Anterior & posterior vaginal repair

What is a vaginal repair?
Vaginal repairs are know by various names including prolapse repairs, vaginal rejuvenation and vaginoplasty. The label of the surgery alone does not reveal the exact nature and technique of surgery as even the most basic vaginal repairs are carried out differently by different surgeons.
The aim of surgery
The aim of surgery is to resolve or alleviate the symptoms attributable to the prolapse such as a feeling of pressure, vaginal bulge, presentation of a lump, discomfort, problems with voiding, defaecation and sexual function.
How surgery can differ
Approach:
- Vaginal
- Laparoscopic
- Laparo-vaginal
- Open
Dissecting tool:
- Cold knife
- Laser
- Diathermy
- Scissors
Anaesthesia:
- Local
- Regional
- Sedation
- General
Purpose:
- Correction of defect
- Site-specific repair
- Sexual function approach
- Symptom specific approach
Tissue:
- Native tissue repair
- Biological graft augmentation
- Synthetic graft augmentation
Suture material:
- Absorbable
- Delayed absorbable
- Permanent
Performing an anterior vaginal repair

Anterior vaginal wall defect (Cystocele): Grade 2 with vaginal wall (epithelial) relaxation

Traction on cystocele

Infiltration of the subcutaneous tissue with a local anaesthetic/adrenaline mixture

Tissue tumescence achieved

Midline incision of the anterior vaginal wall

Traction applied to begin dissection of vaginal epithelium away from the bladder fascia

Dissection completed

The first delayed absorbable suture being applied to the apex of the bladder fascia

More sutures are added to achieve a 2 layer facial reduction and closure

The closure technique can utilise either an interrupted or continuous suture technique

Excess anterior vaginal wall epithelium identified

Excess lateral vaginal wall epithelium trimmed

The remaining vaginal wall epithelium is examined to ensure that the length and anticipated tension is correct

Closure of the vaginal epithelium is achieved using absorbable sutures

Inspection of the completed surgery is carried out and a check made that haemostats has been achieved

The surgical field is washed. A vaginal compression pack can be placed at this time
Performing a posterior vaginal repair

Rectocele & enterocele presenting beyond introitus

Dissection reveals a tear in the fascia

Closure of the fascial defect using delayed absorbable sutures

Operation completed after repair of muscle defects and vaginal epithelium
Mesh augmentation surgery
In both the anterior and posterior vaginal walls, the fascial layer can be such that it forms no useful supportive function and cannot be repaired. This can occur when;
- There are extensive and numerous tears.
- Little or no fascia is found after dissection.

Mesh placed in the posterior vaginal wall
Mesh augmentation can be achieved using either biological or synthetic materials. Synthetic materials do not degrade and are permanent. Biological grafts will degrade over time and are not permanent. Mesh augmentation is usually reserved for more severe prolapses or recurrences of prolapses after previous surgical failures. This type of surgery should be done by surgeons experienced in mesh augmentation surgery.

Mesh being prepared for placement in the anterior vaginal wall
How to get the best outcome from surgery
Think about and document the problems that you want help with
Actually discuss those problems with your surgeon – don’t leave anything out
Choose a surgeon with experience in dealing with the problem(s) that you want corrected
Don’t leave things until they have progressed too far
Plan the timing of surgery to allow you to have sufficient recovery before return to work and other activities
Try to improve your general fitness with attention to exercise, diet, cessation of smoking
Work with your local doctor &/or specialist to ensure that any medical conditions you have are managed optimally prior to surgery
Have a realistic expectation about surgical outcomes and don’t rely on other peoples experiences either good or bad