Anterior & Posterior 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 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.

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

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

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

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

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