Explain: Pelvic relaxation syndrome

Content: Vaginal total hysterectomy

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, VTH, colposacropexy, S-S ligament suspension, others]]

Operative Procedures:

Type of operation: Sacrospinous ligament suspension [[anterior colporraphy, posterior colporraphy, VTH, S-S ligament suspension]].

The cervix is exposed by placing a weighted posterior vaginal retractor into the vagina. A small right angle retractor is used to elevate the anterior vaginal wall, a second right angle retractor displaces one lateral vaginal wall exposing the cervix. Two Jacob’s tenacula are used to grasp the anterior and posterior lips of the cervix and pull the cervix out of the vaginal introitus. Using a 20ml syringe and {{epinephrine in saline 1: 200 000 dilution solution (1cc/10 iu of Pitressin are diluted with 20 ml of sterile saline), normal saline}} is injected in the submucosa areas around the cervix to aid in hemostasis. After the injection into the vaginal mucosa, the fornix-cervical junction mucosa is incised until a scalpel around the entire cervix. The incision stays above the pubo-cervical vesicle fascia anteriorly and the peri-rectal fascia posteriorly. A sponge-covered finger dissects the bladder all the way up to the peritoneal vesico-uterine fold. The peritoneal vesico-uterine fold is grasped with pickup forceps and incised with sharp curved Mayo scissors. Anterior to the cervix and the uterus but posterior to uterus but posterior to the bladder base , a Haney right angle retractor is placed into the peritoneal cavity . The Jacob’s tenacula are brought acutely upward toward the pubic symphysis, exposing the cul-de-sac. The peritoneum of the cul-de-sac is incised with curved Mayo scissors. A second right angle Haney retractor is placed into the posterior cul-de-sac after removeal of the weighted posterior vaginal retractor Using the two Haney retractors the broad ligament is exposed from the uterosacral ligament to the tubo-ovarian round ligament. Following revealing the uterosacral ligament by upward and lateral retraction via the Jacob’s tenacula , a curved Haney camp is placed into the posterior cul-de-sac until the uterosacral ligament is included in this clamp. A fixation suture of 1-0 chromic catgut is used to suture-ligate the uterosacral ligament. The cardinal ligament is suture- ligated with 1-0 vicryl catgut. When the uterosacral and cardinal ligaments have been clamped and incised, the remaining portion of the broad ligament attached to the lower uterine segment containing the uterine artery is sutured. Two Haney clamps are applied to the tubo-ovarian round ligament and it is incised close to the fundus. The tubo-ovarian round ligament is tied twice with 1-0 vicryl. At the same time, suture is placed between the second clamp. After the clamp at the pedicle is removed, the forward clamp is slightly opened and immediately closed to allow the suture to securely ligate all the structures in this pedicle. A second suture ligature is applied in a fixation stitch placing the suture in the mid-portion of its pedicle. The anterior and posterior Haney right angle retractors are removed and the weighted posterior vaginal retractor is replaced in the vagina. So, the uterus was removed.

The anterior vaginal wall is elevated with a short right angle retractor. This allows better vaginal cuff exposure. The entire broad ligament and its respective pedicles are exposed from the tubo-ovarian round ligament anteriorly to the uterosacral ligament posteriorly. A tree sponge is pushed into the peritoneal cavity to displace ovaries, tubes and bowels and give better exposure to the broad ligament structures in order to check for bleeding.. The vesicle peritoneal edge is identified by grasping the anterior vaginal cuff with tissue forceps. The reperitonealization of the pelvis, carried out with purse-string sutures using1-0 chromic catgut suture materials . The suture is started on the anterior peritoneal edge and brought through the stump of the tubo-ovarian round ligament. After the stump of the tubo-ovarian round ligament is sutured, the suture ligature held for retraction is cut. The purse-string is continued down through one or more of the pedicles and is finally brought through the uterosacral cardinal ligament pedicles and the vaginal mucosa. The suture is continued posteriorly across the peritoneum of the cul-de-sac with one or two stitches. A running locking 1-0 chromic catgut suture is started at the anterior vaginal cuff and is carried around the entire edge of the vagina until the cardinal and uterosacral ligaments are reached. The running locking suture is continued until the entire cuff has been sutured. The two retraction sutures held by Kelly clamps on the uterosacral ligaments are tied in the midline. This aids in obliterating the cul-de-sac and reduces the incidence of enterocele.

{{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: _______________.