Gynsurgery

= Posterior and Anterior Colporraphy =

Indications:

 * 1) Anterior colporraphy
 * 2) pelvic pressure due to anterior  vaginal wall prolapse of midline defect into or out of vagina
 * 3) difficulty voiding urine due to urethral kinking (obstructed voiding, intermittent stream)
 * 4) frequent UTIs and irritative voiding symptoms due to balder being outside of vagina (Deg 3 or 4)
 * 5) ulceration of vaginal mucosa due to anterior wall prolapse and exposure
 * 6) Posterior colporraphy## pelvic pressure due to posterior vaginal wall prolapse into or out of vagina
 * 7) defecation difficulty usually requiring intravaginal digital assistance to defecate

Contraindications

 * 1)  anterior wall paravaginal defects (for cystocele repair)
 * 2)  undiagnosed rectal sphincter dysfunction (for rectocele repair)

Complications

 * 1) Dyspareunia
 * 2) Post operative persistent pain
 * 3) Bleeding /hematoma – Intraoperative, postoperative
 * 4) Bladder injury
 * 5) Cystotomy with urine leakage
 * 6) Fistula formation – vescovaginal,
 * 7) Suture in bladder
 * 8) Rectal/sigmoid injury
 * 9) Proctotomy
 * 10) Rectal vaginal fistula
 * 11) Vaginal granulation tissue
 * 12) Incision infection
 * 13) Incision dehissence/separation
 * 14) Post procedure recurrence of cystocoele or rectocoele or vaginal vault prolapse
 * 15) Low back pain

Complication Prevention

 * 1) Dyspareunia
 * 2) Avoid removing too much mucosa (too wide) and narrowing the vaginal aperature
 * 3) Avoid removing too much mucosa (too high toward cuff) and shortening the vagina
 * 4) Use rapidly absorbing suture material (chromic catgut, Monocryl) to prevent granulomas
 * 5) Avoid leaving knot(s) at hymeneal ring of introitus
 * 6) Post operative persistent pain
 * 7) Avoid placing sutures in levator ani muscles
 * 8) Bleeding /hematoma – Intraoperative, postoperative
 * 9) Discontinue ASA (5 days), Plavix (3 days) and other anti-clotting medications prior to surgery
 * 10) Inject under vaginal mucosa with a pitressin solution (10-20U/100ccNS)
 * 11) Bladder injury
 * 12) Cystotomy with urine leakage
 * 13) dissect with metzenbaum scissors curved away from bladder muscularis toward the vaginal muscularis
 * 14) Fistula formation – vescovaginal,
 * 15) Keep urine in bladder during procedure in order to recognize and repair any incidental cystotomy incision
 * 16) Suture in bladder
 * 17) Suture vaginal muscularis and mucosa together without including bladder muscularis
 * 18) Rectal/sigmoid injury
 * 19) Proctotomy
 * 20) dissect with metzenbaum scissors curved away from rectal muscularis toward the vaginal muscularis
 * 21) Rectal vaginal fistula
 * 22) avoid cautery use on rectal muscularis
 * 23) Vaginal granulation tissue
 * 24) Avoid using permanent or slowly absorbing suture materials
 * 25) Avoid using permanent mesh in repair if possible
 * 26) Incision infection
 * 27) Screen for bacterial vaginosis and treat patients if positive
 * 28) Recommend to clip perineal hair prior to surgery
 * 29) Order prophylactic antibiotics, at least 30-60 minutes before incision
 * 30) Avoid stool contamination of incision or needles
 * 31) Incision dehissence/separation
 * 32) Avoid excessive tension on vaginal suture lines with a vaginal pack if used
 * 33) Order mechanical bowel prep for the day before surgery
 * 34) Post procedure recurrence of cystocoele or rectocoele or vaginal vault prolapse
 * 35) If paravaginal defect is present it should be repaired
 * 36) Identify any vault descensus and if present, suspend it
 * 37) Excise vaginal mucosa/attenuated muscularis over rectocoele laterally to ruggated vaginal mucosa/muscularis
 * 38) Low back pain
 * 39) Use Allen stirrups for positioning rather than candy cane stirrups
 * 40) Avoid hyperelevation of legs