A patient's anterior vaginal wall, and with it her bladder, may bulge towards her introitus when she coughs or strains (cystocele). The same thing can happen to her rectum (rectocele). If her cervix descends more than a little at the same time, she needs a Manchester repair or a vaginal hysterectomy, or if you cannot do this or refer her for it, Le Fort's operation (20.11), or ventrisuspension (20.10). An anterior and particularly posterior repair are more difficult than these two procedures, but they are much more satisfactory, so learn to do them if you can.
An anterior colporrhaphy mobilizes her bladder, returns it to its normal place, and fixes it there. Cut through the tissues joining her cervix and her bladder, so as to expose the peritoneum of her uterovesical pouch, and then suture the fascia on either side, so as to make a supporting buttress from her urethra to her cervix.
A posterior colporrhaphy, reduces her gaping introitus, reconstitutes her perineal body, reinforces her pelvic diaphragm by approximating her levator ani muscles, corrects her rectocele and eliminates the hernia of her pouch of Douglas. You can feel the levator ani muscles of a normal nullip 5 cm from her introitus. The key sutures in this operation bring her levator ani muscles together in this position.
Fig. 20-12 COLPORRHAPHY[md]ONE. Anterior colporrhaphy: A, incise the patient's anterior vaginal wall. B, mobilize her cystocele. C, mobilize her cystocele from her cervix. D, insert the tightening suture as far laterally as you can. E, the obliteration of her cystocele is complete. F, remove her redundant vaginal wall.
Posterior colporrhaphy: G, excise an ellipse of skin at the junction of her vagina and perineum. H, mobilize her posterior vaginal wall. I, separate her rectocele from her posterior vaginal wall.
COLPORRHAPHY If possible, refer the patient for both these operations, otherwise proceed as follows. If she is postmenopausal, give her a course of oestradiol before starting.
ANTERIOR COLPORRHAPHY [s7](anterior repair) INDICATIONS. (1) Prolapse of her anterior vaginal wall which troubles her, especially if she has to push it back to micturate, provided there is little or no descent of her uterus. Preferably wait until childbearing is ended, because a prolapse may recur after pregnancy. She can be pre- or postmenopausal.
CONTRAINDICATIONS. (1) Ascites. (2) A severe chronic cough.
EXAMINATION. Lay her on her side in the left lateral position. Insert a Sims' speculum posteriorly and ask her to cough and strain downwards. Her cystocele will then show its full size and the degree of uterine descent. If her cervix comes down to her vulva, she is not suitable for an anterior repair alone. Refer her for a Manchester repair, or if this is impossible, consider doing le Fort's operation, or ventrisuspension. These are mainly for third degree prolapse (when the cervix is at the introitus or lower).
PREPARATION. Her tissues must be clean before you operate. Ask her to bath in a basin of salt solution (10 g/l). If she is already sufficiently clean, do this for 2 days prior to surgery.
ANAESTHESIA. (1) Subarachnoid anaesthesia (A 7.4). (2) Ketamine (A 8.1). (3) General anaesthesia (A 10.1).
METHOD. Put her into the lithotomy position and clean her vulva and vagina. Towel her and suture her labia minora to her skin with catgut about 4 cm from her vulva (optional, shown in I). Infiltrate her tissues, from her anterior urethral orifice to the anterior lip of her cervix, with 1/200 000 adrenalin in saline, or sterile water (A 5.4); you will probably need 20 or 30 ml.
Insert a Jacques (simple rubber) catheter to help identify her urethra. Put vulsellum forceps on her cervix and draw it down.
Incise her vaginal wall covering her cervix about 1.5 cm from her cervical os, and continue this laterally for about 2 cm on each side. Undermine the edge away from her cervix, and continue to within 1 cm of her urethral orifice, using the ''push and spread technique' with scissors (4-8).
CAUTION ! Keep close to her vaginal wall to avoid injuring her bladder. Distending her tissues with adrenalin solution makes this easier. The key to success is to work in the right layer.
Cut the wall of her vagina in the midline (A, Fig. 20-12). Dissect her vaginal wall away from the underlying tissues with a combination of blunt and sharp dissection, until you expose her bulging bladder fully on both sides. Where possible, use a gauze- wrapped finger (B). Take great care to separate her bladder from her vagina in the lateral part of the flap near her cervix. Dissection should be almost bloodless, until you reach the veins which lie well laterally.
Dissect her bladder away from her cervix (C).If necessary, draw up her bladder with dissecting forceps and cut it from her cervix with Mayo's scissors. Separate her bladder from her cervix with a retractor and expose the peritoneum of her uterovesical pouch, but don't open her peritoneal cavity. Using gauze dissection, separate the lateral extensions of her bladder from the lateral border of her uterus.
Feel for a stout pillar of fascia on each side of her uterus. The secret of success is wide and courageous dissection, the fascia you want is always there if you go far enough laterally. Use a series of interrupted simple, or, better, mattress sutures of chromic catgut or polyglycolic acid (''Dexon'), to pick up this fascia as far laterally as you can, starting anteriorly (D). If this fascia is difficult to identify, insert the sutures into the fascial envelope of her bladder. When you reach her cervix, take a bite of that. When you have tied the sutures, her bladder will be suspended (E).
Remove redundant vaginal wall (F); this usually needs to have a diamond-shape. If she has a large cystocele, you will have to remove much vaginal wall, but if you remove too much, her vagina will be too narrow. Close it with interrupted sutures. Insert a Foley catheter.
If she has a rectocele, usually accompanied by a deficient perineum, repair this at the same time.
POSTOPERATIVELY, drain her bladder into a bag or bottle. Spigot the catheter and remove it 2-hourly. Remove the catheter on the 5th day. About 6 hours later ask her to pass urine and then recatheterize her.
If her residual urine is [lt]100 ml, let her pass urine normally. Restart salt baths.
If her residual urine is [mt]100 ml, reinsert the catheter for another 2 days and repeat the process.
POSTERIOR COLPORRHAPHY [s7](posterior repair) INDICATIONS. A significant rectocele (bulging of her posterior vaginal wall), with little or no descent of her cervix. Usually her perineum is deficient also. Do the operation at the same time as an anterior repair (see above).
EXAMINATION. Lay her in the left lateral position, with the speculum placed anteriorly to push her anterior vaginal wall out of the way. Demonstrate her rectocele by asking her to cough and then strain.
PREPARATION. As for an anterior repair. Give her an enema preoperatively.
METHOD. Infiltrate her subepithelial tissues with adrenalin solution as above. On each side place Allis forceps about 2 cm apart over the posterior termination of her labium minus, just inside her fourchette at the level of her carunculae hymenales (the little skin tags remaining from the hymen), and retract them. If you place them lower than this, the repair produces a bridge of skin which, causes dyspareunia. Retract the forceps, and use scissors to remove a little ellipse of skin between them (G).
Hold her posterior vaginal wall with forceps. Use blunt dissection, and the ''push and spread technique' with scissors (H), to dissect to a point where her posterior vaginal wall bulges less. When you have established a plane of cleavage, you can use your index finger (I).
CAUTION ! Keep near her vaginal wall to avoid incising her rectum.
At this point you usually need to excise some posterior vaginal wall (J, and K). How much you remove will decide how tight you leave her vagina. If she does not want sex, remove a generous amount, if she does remove only a little (L, assumes that you have not removed any).
Use 1/0 chromic catgut or polyglycolic acid (''Dexon') sutures on a curved needle to pick up: (1) Her levator ani muscles high in the wound on each side. (2) The fascial layer, which is rather thin, and tie it on each side. This will support her rectal wall (L).
Pick up her transversus perinei muscles on each side to reconstitute her perineal body (M). Finally, close her posterior vaginal wall and skin longitudinally in the sagittal plane (N).
If you have done an anterior and a posterior repair together and she wants to have sex, her vagina should admit 2 fingers easily. If you can only insert one finger, she will have some dyspareunia. Remove the 2 sutures closing her vagina and skin, and reconstitute the margin (fourchette) transversely.
POSTOPERATIVELY, if you have done an anterior repair also, manage her for that. If you have done a posterior repair only, start salt baths on the second day, and give her a full diet on the third day. As soon as her bowels have opened and her wound is satisfactory, allow her home to continue salt baths there.
DIFFICULTIES [s7]WITH COLPORRHAPHY If THERE IS MUCH BLEEDING: (1) If it is venous, inject adrenalin solution and wait 3 minutes or better 5. If necessary, pack her vagina. Don't try to control venous bleeding with haemostats and ligatures. (2) Underpin a bleeding artery with a needle and catgut.
If you OPEN HER BLADDER BY MISTAKE, which is unusual if you operate carefully, repair it with a purse string suture and reinforce it with a second layer of Lembert sutures (9-5). Drain her bladder for 10 days.
If you OPENED HER RECTUM BY MISTAKE this is not a disaster. If it is a large wound, close it transversely; if it is a small one, longitudinal closure is adequate.
Fig. 20-13 COLPORRHAPHY[md]TWO. J, removing some skin from the posterior of the vagina. K, carrying the excision up to the apex of the freed vaginal skin. L, obliterate her rectocele by tightening the fascial layer. M, suture her perineal muscles together. N, both operations nearly complete. Fig. 20-16 AVOIDING THE URETER. A, notice how the ovarian vessels pass in front of the ureter. B, the ureter passes over the brim of the pelvis, just after the common iliac artery has divided into its internal and external iliac branches. C, the ureter passes close round the vault of the vagina under the uterine artery. D, the relation of the urethra, the trigone of the bladder, and the ureters when you retract the cervix. See also Fig. 3-7 which shows the relation of the ureter to the internal iliac artery when you come to tie it. Garry MG, ''Gynaecology Illustrated', pp. 308 and 309. Churchill Livingstone, with kind permission.