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Surgical procedures

Laparoscopic surgery.

This form of surgery, for those requiring an operation, is safer than conventional surgery and promises a faster return to normal activities. There has been adverse publicity about serious complications but with 12 years of experience, the risk of these has now been minimised. The hysterectomy may be accompanied with the removal of one or both ovaries and sometimes the appendix. The indications for this surgery would be mainly for bleeding problems, pelvic pain often due to endometriosis, and as part of a more comprehensive procedure for the repair of prolapse. While in the early years this form of surgery would have been regarded as being 'innovative', it is now more 'mainline' and certainly well received by the patient.

Diagnostic/ Operative Laparoscopy.

 

Not all laparoscopy is destructive! There is frequently the need to put in the telescope to see what is going on and make a diagnosis. At the time there may be the need for some minor 'housekeeping' to be done particularly in the younger woman anxious to preserve or even enhance her fertility. An older woman, may be concerned about a cancer risk particularly of the ovaries. She can undergo quite modest surgery with the laparoscope to eliminate this problem. Often the only way to resolve a problem of pelvic pain is to look with the laparoscope.

 

Prolapse.

 

Prolapse is simply a herniation of the vaginal walls down into the vaginal cavity or even outside the vagina. A hernia is a bulging of soft tissue through the normal supports. So for example an inguinal hernia or groin hernia is a weakness in the abdominal wall at the groin that allows the contents of the tummy to extrude through the abdominal wall. The vagina, of course, has its own mechanisms of support and usually prolapse is the result of a weakening of those supports as a result, usually of childbirth, leaving the woman vulnerable later in life to the prolapse problem. Prolapse can occur in woman who have never had babies but that is uncommon and I will refer to that in a moment.

Prolapse occurs in various areas of the vagina. When the bladder neck becomes weakened and descends, this can be felt as a bulge at the entrance to the vagina and is usually accompanied by a form of incontinence, which is such that a woman experiences leakage of urine quite unconsciously when she exerts herself in various ways. This is as opposed to a leaking of urine that is accompanied by a sensation of the need to void and that is quite a different problem and not usually treated by surgery.

Bulging of the front wall of the vagina is a weakness of the bladder base that emerges into the vagina and may be felt as a bulge and there may be some upset with the voiding pattern, usually with ‘split voiding’.

Prolapse of the back wall of the vagina is quite common and this is a weakness of the vaginal supports over the rectum so that again there is a sensation of bulging and particularly when a woman tries to empty her bowel. Evacuation of the stool is assisted in these cases by an upward pressure of the thumb or the hand to support the bulge and give greater strength to the expulsive powers of the rectum.

Then there may be prolapse of both the uterus and cervix (neck of the uterus) so that the uterus descends down the vaginal barrel and the cervix is palpable at the entrance to the vagina. If as I recall you have had, the woman has already has had a hysterectomy, then she may have a weakness of the top of the vagina or vaginal vault and that may come down the vagina and emerge as a palpable lump in the entrance to the vagina.

When assessing prolapse one likes to assess these various areas to assess the degree of severity of the prolapse and to look for symptoms associated with the weakness. While conservative management with physiotherapy assistance, a ring pessary or indeed hormonal treatment may be effective as a stopgap measure; the ultimate and radical solution to the problem is surgery. I think the important point to recognise is that when you are addressing surgically one area of prolapse you should take care to make sure that all the other areas are properly strengthened, otherwise the woman may need to return to hospital for further surgery, when in fact all of the weaknesses could be fixed at one sitting. This is in terms of the observed fact, that if you strengthen one part of the pelvic floor then there follows a relative increase in pressure on other parts of the pelvic floor, which while they may be asymptomatic at the time then may become symptomatic and give cause for the need for further surgery. On many occasions I have been saddened by the inability of my colleagues to recognise this and that they subject a woman to successive operations when all of the problems could be fixed on the initial occasion. While I say this, the repair of prolapse is subject to a failure rate when the repair fails to heal properly and then the woman may need to return to undergo further repair. Recurrent prolapse is a great worry when it recurs on successive occasions and in that woman one may suspect that the quality of the tissues is impaired in terms of a deficiency of collagen (that is the substance that forms scar tissue and thereby gives the repaired tissues their strength). These women present a great problem in that you simply fail with your repair because the tissue quality is lacking.

Turning to the actual treatment of each area of prolapse, if the woman has bladder neck descent with stress incontinence then she should undergo a bladder neck suspension procedure. There are a vast number of procedures that achieve this but in my hands I undertake a laparoscopic bladder neck suspension and get good results. The operation can be done as an open operation or alternatively, usually in the hands of the urologist they perform what is called a ‘sling operation’. In recent times there has been a vogue for so call ‘ambulatory incontinence surgery’ where a small procedure is done around the pipe leading out of the bladder and that is said to give a good result with minimal interference. I have, however, some doubts about these claims.

As for repair of the front wall of the vagina or the cystocoele, if this is giving rise to problems such as a sense of bulge or split voiding then that is simply repaired vaginally and that is a minimal interference. The same general principle would apply to prolapse of the back wall of the vagina overlying the rectum and that is essentially a vaginal operation. Of importance when undertaking these forms of repair is to recognise the engineering principles of the support of the vagina. I will describe this as briefly and simply as I can. It is best to imagine the vagina as being enclosed over its deep surface by a layer of thin tissue that is called the endopelvic fascia. This is like a stocking of thin but strong material that invests the vaginal wall on its deep aspect and it is this fascia that becomes torn at the time of delivery, creating thereby isolated defects. When undertaking repair it is important to recognise these defects and to close them before continuing on to what may be a conventional prolapse repair. The stocking of endopelvic fascia is in turn suspended from the muscles and bones of the pelvis by a series of ligamentous attachments. These ligaments may also become torn and so they also need to be reattached after the endopelvic fascial defects have been closed. To complete the analogy, if you have a hole in your stocking you need to repair that hole and then you need to reattach the stocking to your suspender belt. Of course these days a woman doesn’t bother with this but simply discards the stocking but in the case of the vagina and its supports you don’t have that luxury!

Finally, turning to the question of the vaginal vault prolapse after hysterectomy, there is of course an endopelvic fascial defect in the vaginal vault and the vaginal vault itself is attached before hysterectomy to a strong series of ligaments called the uterosacral ligaments. So not only may there be a weakness in the vaginal vault itself but that it may also have been torn away from its anchoring attachment to the bony pelvis. There is therefore the need for repair and reattachment. For some five or six years now I have been repairing this disruptions using the laparoscope and having now undertaken fifty-two of these procedures, I am satisfied that I get a good result. If you don’t use the laparoscope, then you are faced with a rather nasty and extensive open operation that is accompanied by a prolonged postoperative recovery. Before I started doing these procedures laparoscopically I would send my problem ladies to a colleague who was doing them as open operations and when I saw the extent of the surgery, I found this somewhat appalling. I am now very happy with my technique.

With regard to the general management of prolapse surgery, it is time consuming work when done properly and the duration of stay in hospital is usually about five to six days, to allow time for bladder and bowel function to return to normal. The recovery after surgery is some four to six weeks and I encourage my patients not to lift heavy weights (that is more than five kilograms) for the next three months. This gives the repair the optimum chance of recovery.

Heavy periods.

Hysterectomy is not the only choice for treatment of this problem. Every attempt is made to control the bleeding by non surgical means. Control is achieved either by hormones or by the new intrauterine device (Mirena). For those who need ablative surgery, laparoscopic hysterectomy is a safe and minimally painful way of resolving a disabling condition. A new alternative is to undertake 'ablation of the uterus' using Thermachoice* heat ablation. This is 'day case surgery' and is published as being 100% free of complications. It can be done with or without anaesthetic.