Vault prolapse: A case report

Thendral

Senior Consultant – Obstetrics and Gynecology, Kauvery Hospital, Radial Road, Chennai

Background

An Uncommon but challenging Post vaginal hysterectomy complication managed with laparoscopic pectopexy.

Case Presentation

A 65-year-old P6L5 previous normal delivery, vaginal hysterectomy undergone 10 years ago. Presented with mass descending PV for 1 year, difficulty in voiding for 1 year. Examination revealed a complete vault prolapse with large cystocele.

Diagnostic Tests

Speculum examination: Complete vault prolapse (POP Q STAGE III)

USG: No pelvic mass, adnexa normal

Routine blood investigations for surgical fitness.

Surgical Management and Outcome

Patient underwent laparoscopic pectopexy.

In lithotomy – hydro dissection done, incision made on cystocele, vaginal walls dissected and bladder reflected away, bladder buttressing done.

Laparoscopic Pectopexy proceeded, 10mm Supraumbilical optical port and 5mm secondary 3 ports made. Anterior and posterior vaginal peritoneum was dissected. Peritoneum opened along till the pelvic wall on both sides.

Vaginal vault manipulated from below using CCL vaginal ball retractor. Dissection begins at the right external iliac vein, blunt dissection done to expose 3-4 cm of segment of ileopectineal ligament, Same steps followed on left side.

Polypropylene Mesh attached to the cooper’s ligament by tacker and secured by suturing one end to the vault and other end to the opposite side cooper’s ligament. Anterior and posterior peritoneum closed for Peritonization of the mesh.

Postoperative Care and Outcome

Patient received DVT prophylaxis continuous bladder drainage for 48 hr, broad spectrum antibiotics 3 doses, analgesics.

Recovery was smooth, ambulated next day, optimal bowel bladder function restored and sent home on POD2 in stable condition.

Discussion

Vaginal vault prolapse is a common complication following vaginal hysterectomy with negative impact on women’s quality of life due to associated urinary, anorectal and Sexual dysfunction. A clear understanding of the supporting mechanism for the uterus and vagina is important in making the right choice of corrective procedure.

Management should be individualized, taking into consideration the surgeon’s experience, patients age, co-morbidities, previous surgery and sex life.

Nowadays, laparoscopic sacrocolpoplexy is the gold standard surgical method for the treatment of apical prolapse. However, defecation and urinary problems are often detected in patients who underwent it.

Laparoscopic pectopexy is a relatively newer procedure for apical prolapse correction that uses the iliopectineal ligaments as fixation point for the surgical mesh anchoring, thereby avoiding pre- sacral dissection and minimizing bowel adhesions and blood loss.

Studies show Laparoscopic Pectopexy was found to have shorter learning curve and operating times, better improvement in quality of life scores including sexual function and low complication rates.

Conclusion

On review patient assessed in OPD on POD 7 found to have good vault support, no descent, no SUI, Improved urinary function. Pain score – 0, no signs of infection, vaginal length and axis normal, high patient satisfaction.

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