Ventrisuspension

In this operation a patient's prolapsed uterus is sutured to her anterior abdominal wall. This relieves both her prolapse, and the rectocele or cystocele, which she will probably have also. If it does not, you can do a simple diamond-shaped excision of her anterior or posterior vaginal wall. Ventrisuspension alone does not interfere with her bladder, her urethra, her rectum, or her vagina. It is not difficult, and is a convenient operation if you are inexperienced, because you can do it through a large lower median incision; it does however sometimes fail. The approach is the same as that for a Caesarean section, which you will have to master anyway.

Aim to: (1) Make the anterior wall of her uterus, cervix, and bladder stick to her rectus muscles. (2) Make the peritoneum of her bladder, and the anterior wall of her cervix stick to the back of her pubis, so that there is no chance of an internal hernia occurring between them.

Opinions vary as to whether this operation is advisable in a premenopausal patient who may become pregnant. Pregnancy is possible, but it would seem wise to tie her tubes, if she will let you. You will occasionally find that, when you cut down on an old Caesarean section scar that was infected at the time of the original operation, you will go straight into the amniotic space. Such a patient has, in effect, had an unintentional ventrisuspension.

Fig. 20-10 VENTRISUSPENSION. A, the bare area you aim to create on the patient's uterus, with the sutures in place. B, her abdominal wall before starting the operation. C, her abdominal wall opened and her posterior rectus sheath reflected. D, the sutures in place, and the posterior sheath sewn to her uterus. E, and F, closing the sutures. G, a side view ]]of the completed operation, showing her uterus close up against her abdominal wall. H, the space through which gut can herniate that you are trying to avoid. Kindly contributed by Andrew Boddham-Whetham.

VENTRISUSPENSION INDICATIONS. (1) Any patient with a prolapse involving a considerable descent of her uterus. (2) Prolapse in old postmenopausal patients.

METHOD. Open the patient's abdomen through a midline incision, extending well down towards her symphysis pubis. The upper limit of the incision will depend on how far up you can pull up her uterus, when you have examined it.

Separate her uterus and adnexa from any adhesions, bring them into the wound, and examine them.

Identify the peritoneal reflexion of her bladder, so that you can avoid it. Separate her rectus abdominis muscles from their posterior sheath, along their whole length on each side of the wound.

Use a scalpel to vigorously excoriate the anterior surface of the body of her uterus, to within a centimetre of its upper and lateral borders (A, in Fig. 20-10). Don't excoriate her cervix. Instead, elevate and remove a strip of peritoneum about 2 cm wide off her cervix, her bladder, and her anterior abdominal wall, to join up with the skin incision.

Prepare three large curved cutting needles with strong monofilament. Decide how high up her uterus should come behind her abdominal wall.

Pass each needle through the outer surface of her rectus sheath on one side, through her rectus muscle, and then out of its bare posterior surface. Then pass it deeply in and out of the bare area of the anterior wall of her uterus, across into the bare area of her other rectus muscle, and out through her rectus sheath and anterior rectus muscle. As you do this, avoid her posterior rectus sheath, which will fold inwards (B, C, and D). Apply clamps to each suture, and leave them until later (E).

Now comes the tricky part. Using 2/0 monofilament on a round-bodied needle, and starting at the apex of her bladder (but without penetrating it), sew her peritoneum to itself along the line that you have previously excoriated. Leave no gap between her uterus and her anterior abdominal wall. When you have closed this gap, sew her peritoneum and her posterior rectus sheath (which are very thin) to the edges of the excoriated area on her uterus. Use a continuous suture, and make sure that it passes behind the three large sutures that emerge from the body of her uterus.

In this way, close her peritoneal cavity, still leaving most of her uterus and all her adnexae intraperitoneally, but with most of the excoriated area of her anterior uterine wall exposed in the bottom of the wound.

Now bring her rectus muscles lightly together with continuous monofilament sutures. Close her anterior rectus sheath with continuous monofilament, and tie the three large sutures which you previously passed through the anterior wall of her uterus. The main strength of the suspension is the adhesions that are formed, not these sutures.

If a ventrisuspension is not enough, you can do a simple diamond-shaped excision of her anterior or posterior vaginal wall, to tighten up her vagina without doing a full Manchester repair.