Explain: Pelvic relaxation syndrome

Content: Manchester operation

Clinical Information:

The female patient had bearing down sensation, back soreness and lower abdominal pain for years. Palpable protruding prolapsed uterus was noted.

ICS staging {{I, II, III, IV}}.

Urodynamic study {normal finding, GSI, D.I., mixed incontinence, not done}} was noted.

Pad test : gm.

Menopause {{ +, -}}.

Hormone replacement therapy: {{yes, no}}

Urogynecologic ultrasonography {{ +, -}}.

Previous pelvic surgical history: [[no, Burch, Laparoscopic Burch, EBNS, Raz, Stamy, TVT, anterior colporraphy, posterior colporraphy, colposacropexy, S-S ligament suspension, others]]

Operative Procedures:

Type of operation: Manchester operation [[anterior colporraphy, posterior colporraphy, S-S ligament suspension, Raz]].

1.A Jacobs tenaculum is placed on the anterior lip of the cervix. Downward traction on the cervix exposes the junction of the vagina and cervix where a 360⁰ circumcision incision is made. The bladder is sharply and bluntly dissected off the lower uterine segment up to the vesicouterine fold.

2.A right angle retractor is placed under the bladder to expose the vesicouterine peritoneal fold. It is picked up and opened.

3.The anterior cul-de-sac is opened, a finger inserted, and the fundus and adnexa are explored.

4.A right angle Haney retractor is placed in the anterior cul-de sac allowing elevation of the bladder and ureter as desired. The cervix is rotated anteriorly exposing the posterior cul-de-sac. The peritoneum of the posterior cul-de-sac is picked up and opened.

5.The cul-de-sac is opened, a finger may be inserted into the cul-de-sac and the uterus and adnexa explored.

6.A right angle retractor is used to expose the lateral vaginal fornix. The cervix is retracted to the contralateral side exposing the uterosacral and cadinal ligament. The Haney clamp is placing, clamping and incising on the uetrosacral and cadinal ligaments. The pedicle is tied with 1-0 vicryl catgut.

7.The right angle lateral retractors moves to the left side of the vagina. The cervix is deviated to patient’s right and slightly anterior exposing the uterosacral ligament on the left. The uterosacral ligment is clamped, incised, and tied with 1-0 vicryl catgut.

8.Traction is made on the cervix and the amputation is made at the lower uterine segment.

9.The lower uterine segment is moved posteriorly. The cardinal and uterosacral ligaments are brought across the anterior surface of the cervix and sutured to the lower uterine segment.

10.Bilateral uterosacral and cardinal ligaments are sutured in place overlapping each other tin front of the lower uterine segment.

11.The closing of vaginal mucosa is extended across to the opposite side.

{{1,2,3,}}	{{1,2,3,}}	{{1,2,3,4,5,6,7,8,}}
{{2.5,3.5,4.5,}}	{{1,2,3,}}	{{1,2,3,4,5,6,7,8,}}
{{1,2,3,}}	{{1,2,3,}}	{{1,2,3,4,5,6,7,8,}}

Operative Findings:

Cystocele grade {{ I, II, III }}

Rectocele {{ I, II, III }}

Enterocele{{ +, -}}

ICS staging {{I, II, III, IV}}.

Vaginal cuff eversion: {{ I, II, III }}

Complication: [[massive bleeding, ureter injury, bladder injury, intestine injury, _______________]].

Dr:________________. Date: _______________.