Anatomy of female genital tract - PowerPoint Presentation

Slide1

Anatomy of female genital tractSlide2

SUPPORTS OF UTERUS

Primary Supports

Fibromuscular

supports-

a)

Muscular supports- 1.Pelvic diaphragm

2.Perineal body

3.Urogenital diaphragm

b)

Ligamentary

supports- 1.

Pubocervical

ligament

2.Transverse cervical ligament

3.

Uterosacral

ligament

c)

Fascial

support – 1.endopelvic fascia

2.vesicovaginal fascia

3.rectovaginal fascia

Uterine axis

Round ligamentSlide3

Secondary Supports –

Broad ligament

Uterovesical

fold

Rectovaginal

fold

Mechanical Supports –

Bony supports-

Lordosis

of

lumbosacral

spine

Vertical orientation of inletSlide4
Slide5

Vagina

H-shaped on cross section

It extends upwards and backwards (direction)making an angle 60 degree with the horizontal plane.

Upper 2/3

rd

is horizontal and lower 1/3

rd

is vertical

Anterior wall is 8 -9 cm and the posterior wall is 10 -11 cm.

4-5 cm at lower end & twice as wide at the upper endSlide6
Slide7

Pericervical ringSlide8

Pubocervival

/

Rectovaginal septumSlide9
Slide10

Urogenital diaphragmSlide11
Slide12

Perineal

Body

Anatomical perineum/ Central tendon of perineum.

Pyramidal structure. 3.5-4*4*4cm.

Base covered by skin. Apex attached to

rectovaginal

septum.

Confluence of 9 muscles-

1.Superficial transverse

perinei

2.Deep transverse

pernei

3.Levator

ani

4.Bulbospongiosus

5. External anal sphincterSlide13
Slide14

Levator

Plate

Also known as median

raphe

.

Strong connective tissue band formed by confluence of

levator

muscles in midline.

Vagina and rectum are suspended by

endopelvic

fascia over the

levator

plate.

Situated between coccyx & anus.

Horizontal in erect posture.

Descent occurs due to inherent loss of tone- enlarges

urogenital

hiatus & descent of upper 1/3 of vagina.Slide15
Slide16

POP -Q

Approved by the International Continence Society, the American

Urogynecologic

Society, and the Society of Gynecologic Surgeons for the description of female pelvic organ

prolapse

Ordinal staging system created to make comparative analyses and clinical communications more practical Slide17

Reduce the

prolapse

and mark

Aa

(3cm from external urinary

meatus

) and

Ap

(3cm from hymen on the posterior vaginal wall) points, measure TVL(

forchette

to posterior fornix) , GH (urethra to

forchette

) and PB (

forchette

to midpoint of anus)

At maximal excursion mark

Ba

, Bp, C and D points, now measure all 6 points from hymenSlide18
Slide19
Slide20

ICS CLASSIFICATION:POPQ System

Stage 0 – No

prolapse

Stage 1 - Descent of most distal part of

prolapse

within 1cm above the level of hymen

Stage 2 – Descent between 1cm above and 1cm below the hymen

Stage 3 – Descent beyond stage 2 but not complete < (tvl-2)

Stage 4 – Total / Complete Vaginal

Eversion

≥ (

tvl

-2)Slide21

Principles of genital

prolapse

surgeriesSlide22

General prolapse

All three supports are weak –

Ligaments – sling/mesh/SSF

Fascia – native tissue repair, attachment, mesh

Muscular -

perineorrhaphySlide23

UV prolapse

1

st

and 2

nd

degree – Ligaments are strong

Manchester operation

3

rd

and 4

th

degree – Ligaments are also weak

Sling/mesh/SSFSlide24

Congenital/Nulliparous

prolapse

Severe weakness of connective tissue – congenital

prolapse

Moderate weakness –

Nulliparous

prolapse

Mild weakness –

Nulliparous

prolapse

after easy child birthSlide25

Case 1

Nulliparous

prolapse

28 yr old P1L1 comes with mass per vagina

O/E – III Uterine descent without the descent of vaginal wallSlide26

Defect –

Ligamentary

support is weak

Choice of surgery –

Sacrohysteropexy

– fixing the uterus to the anterior longitudinal ligament at S2 S3 level (simulating

Uterosacrals

)Slide27

Sacral HysteropexySlide28

Sacral HysteropexySlide29

Sling surgeries

Modified

Purandare

– fixing the uterus to the anterior rectus sheath – dynamic sling – works only if tone of the rectus muscle is goodSlide30

Purandhare’s slingSlide31

Shirodkar

– uterus fixed to anterior longitudinal ligament at S2 S3 level (simulating

Uterosacrals

) (static sling)Slide32

Right side – retroperitoneal space created, tape fixed to posterior aspect of isthmus of uterus

Left side –

psoas

loop, elevation of sigmoid colon, posterior aspect of isthmus of uterus

Shirodkar’s

abdominal posterior sling operationSlide33

Virkud

- uterus fixed to anterior longitudinal ligament at S2 S3 level on right side and to the anterior rectus sheath on left side (static and dynamic sling)

Khanna

– Uterus fixed to anterior superior iliac spine (static sling)Slide34

Virkuds composite slingSlide35

Case 2

General

prolapse

23 yr old

nulliparous

lady comes with mass per vagina

O/E – III degree uterine descent without

supravaginal

elongation and

cystocele

,

enterocele

,

rectoceleSlide36

Defect –

ligamentary

and

fascial

support weakness

Surgery –

Sling surgeries

with site specific repair of

fascial

defects

Extended Manchester

– cervix not amputated , uterus is

anteflexed

by fixing the

Mackenrodts

and

uterosacrals

anteriorly

, conventional anterior and posterior

colporrhaphySlide37

Case 3

Uterovaginal

prolapse

A 28 yr old P2L2 comes with mass per vagina

O/E – III degree uterine descent with

supravaginal

elongation,

cystocele

enterocele

and deficient perineumSlide38

Defect –

All three supports

ligamentary

,

fascial

and muscular support

Surgery –

Modified Fothergill’s

- cervix amputated , uterus is

anteflexed

by fixing the

Mackenrodts

and

uterosacrals

anteriorly

, conventional anterior and posterior

colpoperineorrhaphy

Sling surgeries

with site specific repair of

fascial

defectsSlide39

Manchester operation (Fothergill’s operation)

Fothergill’s points – 1 sub

urethral , 2

on either side of the cervix

1 on posterior vaginal wallSlide40

Case 4

Uterovaginal

prolapse

in

peri

and postmenopausal age group

Defect –

All three supports

ligamentary

,

fascial

and muscular support

Surgery –

Vaginal hysterectomy with site specific repair of

fascial

defects,

perineorrhaphy

and SSFSlide41

Site specific repair

Reconstruction of

pericervical

ring

Anchor

vesicovaginal

fascia and

rectovaginal

fascia to the

pericervical

ring

plication

of

vesicovaginal

fascia will detach the fascia from its lateral attachmentSlide42

Vaginal hysterectomySlide43

Vaginal hysterectomySlide44

Vaginal hysterectomySlide45

Vaginal hysterectomySlide46

Vaginal hysterectomySlide47

Vaginal hysterectomySlide48

Cystocele

repair –

- Central – defects in the fascia are closed and

vesicovaginal

fascia is attached to

uterosacrals

- Lateral –

vesicovaginal

fascia is attached laterally to ATFP(

Arcus

tendinous

fascia pelvis) and proximally to

uterosacralsSlide49

Cystocele

repairSlide50

Enterocele

repair –

rectovaginal

fascia is fixed proximally to the

uterosacralsSlide51

Enterocele correction

Abdominal

Moschowitz

procedure

Halban’s

Vaginal

McCaul

culdoplastySlide52

Suture inserted into the pouch of Douglas peritoneum including serosa

of the colon and both

uterosacral

ligaments.Slide53

Three successive sutures in place to obliterate the pouch of Douglas.Slide54

Halban’s

Technique -

antero

posterior

plication

Slide55

Internal

Culdoplasty

External

CuldoplastySlide56

Principles:

Obliterates

cul

de sac

supports vaginal apex

Directs it to hollow of sacrum

lengthens posterior vaginal wall

Attaches

rectovaginal

fascia to

uterosacralsSlide57

Rectocele

Central defects in the

rectovaginal

septum are repaired

Rectovaginal

fascia is

attched

proximally to

uterosacrals

Laterally to ATRV

Distally to PBSlide58

Rectocele repairSlide59

Rectocele repairSlide60

Perineorrhaphy

– approximation of

bulbospongiosus

and transverse

perinnei

muscles (distal attachment of

rectovaginal

septum, narrowing of genital hiatus and horizontal orientation of

levator

plate)Slide61

Perineorrhaphy

Essential because it prevents vault

prolapse

by

Anchoring

rectovaginal

fascia to PB

Making

levator

plate horizontal

Narrowing the genital hiatus

Levator

myorrhaphy

in selected cases

Dumble

shaped vaginaSlide62

Perineal

body reconstruction /

PerineorraphySlide63

Levator

Myorraphy

and High

PerineorraphySlide64

Case 5

General

prolapse

in postmenopausal women

Defects –

All three supports

ligamentary

,

fascial

and muscular support

Surgery –

Vaginal hysterectomy with site specific repair of

fascial

defects and

perineorrhaphy

Sacrospinous

fixation

Iliococcygeous

fixation – easy and safe Slide65

Case 6

Recurrent vaginal wall

prolapse

Defect –

Fascial

support

Management

Prolift

/

Perigie

/

customised

mesh repair of

cystocele

Apogie

for

rectocele

repairSlide66

Needle passes through the groin to enable connection of the anterior wall graft to the pelvic sidewalls.

Final positioning of the Perigee systemSlide67

Apogee needle passage

Final positioning of the Apogee systemSlide68

Posterior

intravaginal

slingoplasty

(

Infracoccygeal

sacropexy

) Slide69

Case 7

Vault

prolapse

Defect –

Ligamentary

support

Surgery –

Abdominal

sacrocolpopexy

Vaginal

sacrospinous

/

iliococcygeous

fixation of the vaultSlide70

Vault Prolapse

Sacrocolpopexy

Sacrospinous

fixation

Green-top Guideline No. 46 RCOG/BSUG Joint Guideline | July 2015Slide71

Surgery? Who?

Surgical treatment should be offered to women with symptomatic PHVP after appropriate

counselling

.

PHVP surgery should be performed by an

urogynaecologist

or

gynaecologists

who can demonstrate an equivalent level of training or experience.Slide72

Postop result

Pelvic Organ

Prolapse

Quantifiation

(POP-Q) stage of I or 0 in the apical compartment seems to be acceptable and widely used as the optimum postoperative result.Slide73

Which surgery?

Tailored to the individual patient’s circumstances.

Both ASC and SSF are effective treatments for primary PHVP.

ASC is associated with

signifiantly

lower rates of recurrent vault

prolapse

,

dyspareunia

and postoperative stress urinary incontinence (SUI) when compared with SSF. Slide74

ASC Vs SSF

However, reoperation rates or higher patient satisfaction remain the same.

SSF is associated with earlier recovery compared with ASC.

SSF may not be appropriate in women with short vaginal length and should be carefully considered in women with pre-existing

dyspareunia

.Slide75

Lap Vs Abdominal

LSC can be equally effective as ASC in selected women with primary PHVP.

LSC can include mesh extension or be combined with other vaginal procedures to correct other compartment

prolapse

.

There is limited evidence on the effectiveness of RSC.Slide76

High uterosacral ligament suspension (HUSLS)

HUSLS - risk of

ureteric

injury, especially in the laparoscopic approach.Slide77

Transvaginal mesh (TVM) kits/grafts?

The limited evidence on TVM kits does not support their use as fist-line treatment of PHVP.Slide78

When should colpocleisis be used?

Colpocleisis

is a safe and effective procedure that can be considered for frail women and/or women who do not wish to retain sexual function.Slide79

Concomitant surgery for occult SUI?

Colposuspension

performed at the time of

sacrocolpopexy

is an effective measure to reduce postoperative symptomatic SUI in previously continent women.Slide80

Concomitant surgery for PHVP and overt SUI?

Colposuspension

at the time of ASC does not appear to be effective treatment for SUI.

Concomitant mid-urethral sling surgery may be considered when vaginal surgical approaches are used for the treatment of PHVP. Slide81

SacrocolpopexySlide82

Suspension of the vaginal vault to the sacrospinous

ligament.Slide83

Case 10

A 85 yr old C/o mass per vagina. K/C/o HTN, old IHD. ECHO – LVEF – 48%

O/E:

General

prolapse

with grade 3

cystocele

,

enterocele

, deficient perineum

Management –

If muscular support is good -

pessary

Pt not fit for hysterectomy – Le Fort’s repairSlide84

Partial

colpoclesisSlide85

Total colpoclesisSlide86

Partial

colpocleisis

/ Le Fort’s

Pt medically unfit/ sexually not active

Pap smear/ endometrial biopsy- must

Aggressive

perineorraphy

to narrow

introitus

Plication

of the bladder neck routinely done

Total

colpocleisis

/

Goodall’s

modification

Done in sexually active young menstruating women

Triangular flaps removed

Single vagina in lower 2/3 and double vagina in upper 1/3

- Channels on sides permit egress of menstrual bloodSlide87

LeFort’s

/ Partial

colpocleisis

:

Indications

Are very old or infirm women

Do not desire coital function

Have medical contra-indications for major procedures.

Post menopausal womenSlide88

Introital

tightening /

Dani’s

stitch :

Based on principle of

thiersch

stitch for rectal

prolapse

.

Alternative for

LeFort’s

Technique :

-

Cerclage

of the

introitusSlide89

KellySlide90

Fothegill

surgerySlide91

Wards modification (

cystocele

,

enterocele

repair):

Purse string suture is passed through UV fold of peritoneum, upper pedicle,

Mackenrodt’s

uterosacral

complex, & highest point on posterior peritoneum

United

uterosacral

and cardinal ligaments are tiedSlide92

Drawbacks

Broad ligaments are drawn into distorted position

Vagina is shortened

Due to interposition all sutures are under tension Slide93

Laparoscopy/Robotics

Better anatomical delineation – better repair

Subjective and objective cure?

Morbidity ?

Cost?

Further research neededSlide94

Case 8

A 24 yr old G3P2L2 with 12 wks gestation with mass per vagina

O/E: III uterine descent +

Treatment

Ring

pessary

, used until 16 weeks of gestation. Slide95

Treatment of edematous and congested prolapsed cervix with pregnancy

Foot end elevation

atleast

by 25cms

Cover the prolapsed cervix by soaked

guage

with

glycerine

MgSO4.

All these measures continued till 18 weeks of gestation.

Once replaced patient is allowed is ambulate.Slide96

Management of incarcerated pregnant uterus

Once it is diagnosed , pregnancy has to terminated, irrespective of period of gestation

During

labour

:

A close watch on cervical dilatation needed

Generally most of delivery go on spontaneously, if cervical dilatation fails then,

At <4cms

inspite

of good contraction

 Consider

Em

LSCSSlide97

At>7cm with good contraction 

DUHRSSEN INCISION

(2’0 and 10’0 clock)

↓

Delivery by vacuum and forceps.

Hyaluronidase

injected at multiple points on the cervical rim helps in cervical dilatation.Slide98

Case 9

Post Natal Day 3 . P2L2 had FTVD.

C/o mass per vagina

O/E- III uterine descent

Management

Consider physiotherapy

Use

pessaries

till corrective repair surgery done

Corrective repair surgery after 3 to 6 monthSlide99

Challenge

Challenges in the management of pelvic organ

prolapse

still remains……

High recurrence rates

Lack of randomized control trials

Poorly defined success and failure rates