pelvic organ prolapse gynaecology ppt
DESCRIPTION
genital prolapse uterine prolapse cystocele rectocele urethrocele anterior middle posterior compartments management sacroclopopexy ward mayos repair fothergills repair urogynaecology vaginal hysterectomy perineorrhaphy anterior colpopexy mesh repair khannas sling procedure pessariesTRANSCRIPT
![Page 1: Pelvic organ prolapse gynaecology ppt](https://reader035.vdocuments.mx/reader035/viewer/2022081415/55848508d8b42a9f028b4cab/html5/thumbnails/1.jpg)
Pelvic organ prolapse
![Page 2: Pelvic organ prolapse gynaecology ppt](https://reader035.vdocuments.mx/reader035/viewer/2022081415/55848508d8b42a9f028b4cab/html5/thumbnails/2.jpg)
GENITAL PROLAPSE
• Common complaint of elderly woman• Mostly in post menopausal and multiparous women• In prolapse straining causes protrusion of vaginal walls at vaginal
orifices• Extreme cases uterus may be protrude
![Page 3: Pelvic organ prolapse gynaecology ppt](https://reader035.vdocuments.mx/reader035/viewer/2022081415/55848508d8b42a9f028b4cab/html5/thumbnails/3.jpg)
Normal axis
Axis of the uterus and vagina: anteverted and anteflexed
![Page 4: Pelvic organ prolapse gynaecology ppt](https://reader035.vdocuments.mx/reader035/viewer/2022081415/55848508d8b42a9f028b4cab/html5/thumbnails/4.jpg)
![Page 5: Pelvic organ prolapse gynaecology ppt](https://reader035.vdocuments.mx/reader035/viewer/2022081415/55848508d8b42a9f028b4cab/html5/thumbnails/5.jpg)
PELVIC SUPPORTS
• PELVIC FLOOR • Comprises
Pelvic diaphragmEndopelvic fasciaPerineal membranePerineal body
![Page 6: Pelvic organ prolapse gynaecology ppt](https://reader035.vdocuments.mx/reader035/viewer/2022081415/55848508d8b42a9f028b4cab/html5/thumbnails/6.jpg)
PELVIC DIAPHRAGM
![Page 7: Pelvic organ prolapse gynaecology ppt](https://reader035.vdocuments.mx/reader035/viewer/2022081415/55848508d8b42a9f028b4cab/html5/thumbnails/7.jpg)
Pelvic diaphragm
![Page 8: Pelvic organ prolapse gynaecology ppt](https://reader035.vdocuments.mx/reader035/viewer/2022081415/55848508d8b42a9f028b4cab/html5/thumbnails/8.jpg)
![Page 9: Pelvic organ prolapse gynaecology ppt](https://reader035.vdocuments.mx/reader035/viewer/2022081415/55848508d8b42a9f028b4cab/html5/thumbnails/9.jpg)
Perineal membrane
![Page 10: Pelvic organ prolapse gynaecology ppt](https://reader035.vdocuments.mx/reader035/viewer/2022081415/55848508d8b42a9f028b4cab/html5/thumbnails/10.jpg)
Uterine ligaments
![Page 11: Pelvic organ prolapse gynaecology ppt](https://reader035.vdocuments.mx/reader035/viewer/2022081415/55848508d8b42a9f028b4cab/html5/thumbnails/11.jpg)
PERINEAL BODY
![Page 12: Pelvic organ prolapse gynaecology ppt](https://reader035.vdocuments.mx/reader035/viewer/2022081415/55848508d8b42a9f028b4cab/html5/thumbnails/12.jpg)
• The pelvic structures are divided into 3 compartments : • Anterior : urethra /bladder • Middle : uterus/vault • Posterior : rectum/anus
![Page 13: Pelvic organ prolapse gynaecology ppt](https://reader035.vdocuments.mx/reader035/viewer/2022081415/55848508d8b42a9f028b4cab/html5/thumbnails/13.jpg)
Levels of support of uterusDeLancey's three levels of support • 3 levels
![Page 14: Pelvic organ prolapse gynaecology ppt](https://reader035.vdocuments.mx/reader035/viewer/2022081415/55848508d8b42a9f028b4cab/html5/thumbnails/14.jpg)
![Page 15: Pelvic organ prolapse gynaecology ppt](https://reader035.vdocuments.mx/reader035/viewer/2022081415/55848508d8b42a9f028b4cab/html5/thumbnails/15.jpg)
Level 1 (suspensory axis)
• Level I- Uterosacral and cardinal ligaments • support the uterus and vaginal vault.
![Page 16: Pelvic organ prolapse gynaecology ppt](https://reader035.vdocuments.mx/reader035/viewer/2022081415/55848508d8b42a9f028b4cab/html5/thumbnails/16.jpg)
• Round ligament• (mackenrodts lig /
transverse/lateral cevical cervical ligament at the base of broad lig with uterine A & V
![Page 17: Pelvic organ prolapse gynaecology ppt](https://reader035.vdocuments.mx/reader035/viewer/2022081415/55848508d8b42a9f028b4cab/html5/thumbnails/17.jpg)
• Defects in level 1• Uterovaginal UV prolapse• Enterocele• Vault prolapse
![Page 18: Pelvic organ prolapse gynaecology ppt](https://reader035.vdocuments.mx/reader035/viewer/2022081415/55848508d8b42a9f028b4cab/html5/thumbnails/18.jpg)
Level 2 (attachment axis)
• Level II- Pelvic fascias and paracolpos • Fascial septae connects mid vagina to the pelvic sidewalls • Anteriorly
• Pubocervical • Posteriorly
• Rectovaginal facia• which connects the vagina to the white line on the lateral pelvic wall through
arcus tendinous
![Page 19: Pelvic organ prolapse gynaecology ppt](https://reader035.vdocuments.mx/reader035/viewer/2022081415/55848508d8b42a9f028b4cab/html5/thumbnails/19.jpg)
![Page 20: Pelvic organ prolapse gynaecology ppt](https://reader035.vdocuments.mx/reader035/viewer/2022081415/55848508d8b42a9f028b4cab/html5/thumbnails/20.jpg)
Level II and III detail. In level III, the vagina is fused to the medial surface of the levator ani muscles, urethra, and perineal body. The anterior surface of the vagina at its attachment to the arcus tendineus fascia pelvis forms the pubocervical fascia, while the posterior surface forms the rectovaginal fascia.
![Page 21: Pelvic organ prolapse gynaecology ppt](https://reader035.vdocuments.mx/reader035/viewer/2022081415/55848508d8b42a9f028b4cab/html5/thumbnails/21.jpg)
Defects in level2
• Paravaginal & para rectal defects
![Page 22: Pelvic organ prolapse gynaecology ppt](https://reader035.vdocuments.mx/reader035/viewer/2022081415/55848508d8b42a9f028b4cab/html5/thumbnails/22.jpg)
Level 3 (fusion axis )
• Level III-Levator ani muscle • supports the lower one-third of vagina.
• Anteriorly • Urethra• Urogenital diaphragm• Pubis
• laterally• Levator ani fascia
• Posteriorly• Perineal body
![Page 23: Pelvic organ prolapse gynaecology ppt](https://reader035.vdocuments.mx/reader035/viewer/2022081415/55848508d8b42a9f028b4cab/html5/thumbnails/23.jpg)
![Page 24: Pelvic organ prolapse gynaecology ppt](https://reader035.vdocuments.mx/reader035/viewer/2022081415/55848508d8b42a9f028b4cab/html5/thumbnails/24.jpg)
![Page 25: Pelvic organ prolapse gynaecology ppt](https://reader035.vdocuments.mx/reader035/viewer/2022081415/55848508d8b42a9f028b4cab/html5/thumbnails/25.jpg)
![Page 26: Pelvic organ prolapse gynaecology ppt](https://reader035.vdocuments.mx/reader035/viewer/2022081415/55848508d8b42a9f028b4cab/html5/thumbnails/26.jpg)
Etiology
• Menopause • birth injury • Prolonged bearing down in the second stage • Delivery of a big baby • Rapid succession of pregnancies • Lack of rest in peuperium • Peripheral nerve injury• raised intra-abdominal pressure • Surgeries • Congenital
![Page 27: Pelvic organ prolapse gynaecology ppt](https://reader035.vdocuments.mx/reader035/viewer/2022081415/55848508d8b42a9f028b4cab/html5/thumbnails/27.jpg)
Etiology
• Menopause • prolapse are of menopausal age when the pelvic floor muscles• d/t oestrogen deficiency and decreased collagen content in fascias atonicity
and asthenia that follow menopause
![Page 28: Pelvic organ prolapse gynaecology ppt](https://reader035.vdocuments.mx/reader035/viewer/2022081415/55848508d8b42a9f028b4cab/html5/thumbnails/28.jpg)
Causes related to child birth
• Birth injury
excessive stretching of the pelvic floor
muscles and ligaments
overstretching causes atonicity
Perineal tear is less harmful than
overstretching
whereas torn muscle could be
stitched or toned up
![Page 29: Pelvic organ prolapse gynaecology ppt](https://reader035.vdocuments.mx/reader035/viewer/2022081415/55848508d8b42a9f028b4cab/html5/thumbnails/29.jpg)
Causes related to child birth
• Peripheral nerve injury such as pudendal nerve during childbirth
• Delivery by untrained dais • This is because the patients are made to bear down before full dilatation of
the cervix and when the bladder is not empty
• Prolonged bearing down in the second stage
• Lacerations of the perineal body during childbirth, unless sutured immediately, will widen the hiatus urogenitalis
![Page 30: Pelvic organ prolapse gynaecology ppt](https://reader035.vdocuments.mx/reader035/viewer/2022081415/55848508d8b42a9f028b4cab/html5/thumbnails/30.jpg)
Causes related to child birth
• Delivery of a big baby• Lack of rest in peurperium• Lack of any pelvic exercises • Rapid succession of pregnancies
![Page 31: Pelvic organ prolapse gynaecology ppt](https://reader035.vdocuments.mx/reader035/viewer/2022081415/55848508d8b42a9f028b4cab/html5/thumbnails/31.jpg)
Raised intra abdominal pressure
• chronic bronchitis, • large abdominal tumours or • obesity • Smoking, • chronic cough and • constipation
![Page 32: Pelvic organ prolapse gynaecology ppt](https://reader035.vdocuments.mx/reader035/viewer/2022081415/55848508d8b42a9f028b4cab/html5/thumbnails/32.jpg)
Prolapse in unmarried or nulliparous women• spina bifida occulta and • split pelvis• Collagen vascular diseases
![Page 33: Pelvic organ prolapse gynaecology ppt](https://reader035.vdocuments.mx/reader035/viewer/2022081415/55848508d8b42a9f028b4cab/html5/thumbnails/33.jpg)
congenital weakness of the pelvic floor muscles• in unmarried or nulliparous women• h/o precipitate labour • Family h/o uterine prolapse
![Page 34: Pelvic organ prolapse gynaecology ppt](https://reader035.vdocuments.mx/reader035/viewer/2022081415/55848508d8b42a9f028b4cab/html5/thumbnails/34.jpg)
Surgeries
• Abdominoperineal excision of the rectum and • radical vulvectomy • Operations for stress incontinence such as Stamey and Pereyra
operations
![Page 35: Pelvic organ prolapse gynaecology ppt](https://reader035.vdocuments.mx/reader035/viewer/2022081415/55848508d8b42a9f028b4cab/html5/thumbnails/35.jpg)
Classification of prolapse
Upper two-third-Cystocele
Lower one-third-Urethrocele
Anterior vaginal
wall(anterior compartment)
Uterine descent
Middle compartment Upper one-third-
Enterocele (pouch of Douglas hernia)
Lower two-third-Rectocele
Posterior compartment
![Page 36: Pelvic organ prolapse gynaecology ppt](https://reader035.vdocuments.mx/reader035/viewer/2022081415/55848508d8b42a9f028b4cab/html5/thumbnails/36.jpg)
![Page 37: Pelvic organ prolapse gynaecology ppt](https://reader035.vdocuments.mx/reader035/viewer/2022081415/55848508d8b42a9f028b4cab/html5/thumbnails/37.jpg)
Cystocele the vesical and vaginal fasciae are thinned out and fail to support the bladder, so that the bladder prolapses with the anterior vaginal wall.
![Page 38: Pelvic organ prolapse gynaecology ppt](https://reader035.vdocuments.mx/reader035/viewer/2022081415/55848508d8b42a9f028b4cab/html5/thumbnails/38.jpg)
Urethrocele When the urethra along with the lower one-third of the anterior wall prolapses (failure of pubocervical ligament
Rare
stress incontinence
![Page 39: Pelvic organ prolapse gynaecology ppt](https://reader035.vdocuments.mx/reader035/viewer/2022081415/55848508d8b42a9f028b4cab/html5/thumbnails/39.jpg)
Uterine prolapse
![Page 40: Pelvic organ prolapse gynaecology ppt](https://reader035.vdocuments.mx/reader035/viewer/2022081415/55848508d8b42a9f028b4cab/html5/thumbnails/40.jpg)
![Page 41: Pelvic organ prolapse gynaecology ppt](https://reader035.vdocuments.mx/reader035/viewer/2022081415/55848508d8b42a9f028b4cab/html5/thumbnails/41.jpg)
Uterine descent
![Page 42: Pelvic organ prolapse gynaecology ppt](https://reader035.vdocuments.mx/reader035/viewer/2022081415/55848508d8b42a9f028b4cab/html5/thumbnails/42.jpg)
• Uterine descent • - Descent of the cervix into the vagina • - Descent of the cervix up to the introitus • - Descent of the cervix outside the introitus • -Procidentia-All of the uterus outside the introitus
![Page 43: Pelvic organ prolapse gynaecology ppt](https://reader035.vdocuments.mx/reader035/viewer/2022081415/55848508d8b42a9f028b4cab/html5/thumbnails/43.jpg)
![Page 44: Pelvic organ prolapse gynaecology ppt](https://reader035.vdocuments.mx/reader035/viewer/2022081415/55848508d8b42a9f028b4cab/html5/thumbnails/44.jpg)
Symptoms
• something protruding either at the vulva or externally• aggravated by straining and coughing, and by heavy work• reduces itself when she lies down
• large prolapse, the external swelling difficulty in walking or carrying out her everyday duties
![Page 45: Pelvic organ prolapse gynaecology ppt](https://reader035.vdocuments.mx/reader035/viewer/2022081415/55848508d8b42a9f028b4cab/html5/thumbnails/45.jpg)
Symptoms
• Backache • uterosacral strain
• Towards evening • relieved by rest
![Page 46: Pelvic organ prolapse gynaecology ppt](https://reader035.vdocuments.mx/reader035/viewer/2022081415/55848508d8b42a9f028b4cab/html5/thumbnails/46.jpg)
decubitus ulcer
• benign and is present on dependant part. • d/t venous stasis tissue anoxia.
• treated by • keeping the prolapse reduced, which will restore circulation and help in
healing. Prolapse can be kept in reduced position by packing.
![Page 47: Pelvic organ prolapse gynaecology ppt](https://reader035.vdocuments.mx/reader035/viewer/2022081415/55848508d8b42a9f028b4cab/html5/thumbnails/47.jpg)
micturition disturbances
• imperfect control of micturition• Frequency of micturition • (diurnal or nocturnal)• (d/t chronic cystitis & incomplete emptying
of the bladder)
• Manual reduction of the cystocele into the vagina with their fingers• Straining to pass urine
• Stress incontinence
![Page 48: Pelvic organ prolapse gynaecology ppt](https://reader035.vdocuments.mx/reader035/viewer/2022081415/55848508d8b42a9f028b4cab/html5/thumbnails/48.jpg)
• Ureteric obstruction and hydronephrosis } severe massive prolapse
![Page 49: Pelvic organ prolapse gynaecology ppt](https://reader035.vdocuments.mx/reader035/viewer/2022081415/55848508d8b42a9f028b4cab/html5/thumbnails/49.jpg)
Bowel symptoms
• Urgency • Straining • Feeling of incomplete emptying• Pressure on vagina or perineum to start or complete defaecation
![Page 50: Pelvic organ prolapse gynaecology ppt](https://reader035.vdocuments.mx/reader035/viewer/2022081415/55848508d8b42a9f028b4cab/html5/thumbnails/50.jpg)
Discharge per vaginum
• Mild vaginitis• Chronically inflamed lacerated cervix• Decubitus ulcer – discharge and bleeding
![Page 51: Pelvic organ prolapse gynaecology ppt](https://reader035.vdocuments.mx/reader035/viewer/2022081415/55848508d8b42a9f028b4cab/html5/thumbnails/51.jpg)
Coital difficulties
• With third degree uterine prolapse and procidentia prevents penetration and orgasm due to a lax outlet.
![Page 52: Pelvic organ prolapse gynaecology ppt](https://reader035.vdocuments.mx/reader035/viewer/2022081415/55848508d8b42a9f028b4cab/html5/thumbnails/52.jpg)
Signs
• Assessment of prolapse• In lithotomy position• Look for stress incontinence on a full bladder• patient is asked to strain / perform valsalva manoeuvre• Stress incontinence
• Vulva examined for perineal laceration • Three compartments evaluated separately;• decubitus ulcer
![Page 53: Pelvic organ prolapse gynaecology ppt](https://reader035.vdocuments.mx/reader035/viewer/2022081415/55848508d8b42a9f028b4cab/html5/thumbnails/53.jpg)
Per speculum examination
Anterior compartment
• Sim’s speculum retracting posterior vaginal wall
• Look for cystocele• Lateral cystocele or
paravaginal defect• Urethrocele } stress
incontinence
Middle compartment
• Degree of descent • Ulceration of cervix• Vagina may show
keratinisation• Vaginal examination –
length of cervix,position and mobility of uterus,any adnexal mass
• Cervical cytology
Posterior compartment
• Sim’s speculum retracting anterior vaginal wall
• Enterocele – bulge appears from above downwards
• Rectal examination – impulse on
• tip of finger- enterocele• pulp - rectocele• Bimanual examination-
r/o pelvic mass
![Page 54: Pelvic organ prolapse gynaecology ppt](https://reader035.vdocuments.mx/reader035/viewer/2022081415/55848508d8b42a9f028b4cab/html5/thumbnails/54.jpg)
Pelvic floor muscles
• Pubococcygeus part of levator ani assessed at 4 and 8o’clock position • Perineal body • Rectal examination – tone of anal sphincter
![Page 55: Pelvic organ prolapse gynaecology ppt](https://reader035.vdocuments.mx/reader035/viewer/2022081415/55848508d8b42a9f028b4cab/html5/thumbnails/55.jpg)
Lab investigations
• Hb • Urine examination,Urine culture,Xray,ECG• High vaginal swab in cases of vaginitis• RFT in long standing prolapse• Urodynamic investigations in case of incontinence• USG to r/o pelvic mass and hydronephrosis• IVP }massive prolapse• CT/MRI}
![Page 56: Pelvic organ prolapse gynaecology ppt](https://reader035.vdocuments.mx/reader035/viewer/2022081415/55848508d8b42a9f028b4cab/html5/thumbnails/56.jpg)
Differential diagnosis
• Vulval cyst or tumour• Cysts of anterior vaginal wall• Urethral diverticula• Congenital elongation of cervix• vaginal portion of the cervix is elongated and• no vaginal prolapse. • deep fornices
• Cervical fibroid polyp• Chronic inversion
![Page 57: Pelvic organ prolapse gynaecology ppt](https://reader035.vdocuments.mx/reader035/viewer/2022081415/55848508d8b42a9f028b4cab/html5/thumbnails/57.jpg)
COMPLICATIONS OF PROLAPSE
• Kinking of ureter with resulting renal damage • Surgical injury to ureter• Urinary tract infection (chronic) in large cystocele with residual urine
• decubitus ulcer and keratinisation pigmentation• if ring pessary is left in over a long period malignancy
![Page 58: Pelvic organ prolapse gynaecology ppt](https://reader035.vdocuments.mx/reader035/viewer/2022081415/55848508d8b42a9f028b4cab/html5/thumbnails/58.jpg)
ProphylaxisAntenatal physiotherapy ,relaxation exercises,due attention to
weight gain and anaemiaProper supervision and management of second stage of labourA generous episiotomyLow forceps delivery if there is delay in second stageSuture perineal tear Postnatal exercises and physiotherapyearly postnatal ambulationAdequate spacing of birthsAvoid multiparityProphylatic HRT in postmenopausal women
![Page 59: Pelvic organ prolapse gynaecology ppt](https://reader035.vdocuments.mx/reader035/viewer/2022081415/55848508d8b42a9f028b4cab/html5/thumbnails/59.jpg)
Treatment
• Surgical }• in women over 40• C/I in pregnancy
• Conservative management • mechanical devices and • pelvic floor muscle exercises ,abdominal massage,
• in mild degrees of prolapse,• surgery not desired by patient ,• in whom child bearing is not complete
• Should be advised 3 to 4 months following delivery• Surgery Pregnancy – contraindication for surgery
![Page 60: Pelvic organ prolapse gynaecology ppt](https://reader035.vdocuments.mx/reader035/viewer/2022081415/55848508d8b42a9f028b4cab/html5/thumbnails/60.jpg)
Pessaries
• Indications A young woman planning a pregnancyDuring early pregnancy (<18 weeks)PuerperiumTemporary use while clearing infection and decubitus ulcerA woman unfit for surgeryIn case a woman refuses for surgery
![Page 61: Pelvic organ prolapse gynaecology ppt](https://reader035.vdocuments.mx/reader035/viewer/2022081415/55848508d8b42a9f028b4cab/html5/thumbnails/61.jpg)
pess
arie
s
Support
Space filling
eg:ring pessarystage 1 and 2 prolapse
eg:gelhorn and cube pessaries for advanced stages
soft
pla
stic
poly
viny
l ch
lorid
e m
ater
ial
![Page 62: Pelvic organ prolapse gynaecology ppt](https://reader035.vdocuments.mx/reader035/viewer/2022081415/55848508d8b42a9f028b4cab/html5/thumbnails/62.jpg)
Limitations
• Never curative only palliative• Vaginitis• Needs to be changed every 3 months• Dyspareunia• Expulsion (if vaginal orifice is very patulous)• May cause ulcer,rarely Ca vagina and a vesico vaginal fistula• Does not cure urinary stress incontinence
![Page 63: Pelvic organ prolapse gynaecology ppt](https://reader035.vdocuments.mx/reader035/viewer/2022081415/55848508d8b42a9f028b4cab/html5/thumbnails/63.jpg)
SURGICAL APPROACHES• Ward-Mayo’s operation-vaginal hysterectomy with
pelvic floor repair with or without: sacrospinous colpopexy –vault suspended from
sacrospinous ligament• Fothergill’s or Manchester operation –uterus preserved
and part of cervix is cut• Shirodkar’s Extended Manchester operation-both
cervix and uterus preserved• Le Fort’s operation –obliterative procedure of anterior
and posterior walls of vagina
![Page 64: Pelvic organ prolapse gynaecology ppt](https://reader035.vdocuments.mx/reader035/viewer/2022081415/55848508d8b42a9f028b4cab/html5/thumbnails/64.jpg)
Anterior colporrhaphy
![Page 65: Pelvic organ prolapse gynaecology ppt](https://reader035.vdocuments.mx/reader035/viewer/2022081415/55848508d8b42a9f028b4cab/html5/thumbnails/65.jpg)
Anterior colporrhaphy
• performed to repair a cystocele and cystourethrocele
![Page 66: Pelvic organ prolapse gynaecology ppt](https://reader035.vdocuments.mx/reader035/viewer/2022081415/55848508d8b42a9f028b4cab/html5/thumbnails/66.jpg)
Anterior colporrhaphy
• TOC for anterior cystocele• Procedure
Lithotomy positionArea cleansed and drapedBladder emptiedSim’s speculum introducedAnterior lip of cervix pulled down using volsellum forceps
![Page 67: Pelvic organ prolapse gynaecology ppt](https://reader035.vdocuments.mx/reader035/viewer/2022081415/55848508d8b42a9f028b4cab/html5/thumbnails/67.jpg)
Inverted T-shaped incision on anterior vaginal wallVaginal flaps seperated from bladderVesicocervical ligament boldly cut,bladder pushed upBladder buttressing with delayed absorbable suturesIn large defects, plication in two layersExcess vaginal mucosa trimmed and closedBladder drained
![Page 68: Pelvic organ prolapse gynaecology ppt](https://reader035.vdocuments.mx/reader035/viewer/2022081415/55848508d8b42a9f028b4cab/html5/thumbnails/68.jpg)
• ComplicationsInfection, bleeding, injury, recurrence, failure
• AftercareAvoid lifting weights, coughing, sneezing, straining at
stools, sexual intercourse
![Page 69: Pelvic organ prolapse gynaecology ppt](https://reader035.vdocuments.mx/reader035/viewer/2022081415/55848508d8b42a9f028b4cab/html5/thumbnails/69.jpg)
![Page 70: Pelvic organ prolapse gynaecology ppt](https://reader035.vdocuments.mx/reader035/viewer/2022081415/55848508d8b42a9f028b4cab/html5/thumbnails/70.jpg)
![Page 71: Pelvic organ prolapse gynaecology ppt](https://reader035.vdocuments.mx/reader035/viewer/2022081415/55848508d8b42a9f028b4cab/html5/thumbnails/71.jpg)
• Sim's speculum is introduced, posterior lip of cervix is held by by multiple vulsellum and firmly brought down by assistant.
• Metal catheter is introduced to know the lower limit of bladder.• Inverted T incision made to anterior vaginal wall.
• Horizontal incision is made below the bladder and • vertical incision is made starting from midpoint of the transverse incision upto a point abount 1.5cm below
the external urethral meatus.
• The triangular vaginal flaps including fascia on either sides are separated from the endopelvic fascia covering the bladder by knife and gauze dissection.
• The bladder with the covering endopelvic fascia (pubocervical) is exposed as the edges of the vaginal wall are retracted laterally.
• The vesico cervical ligament is held up with Allis tissue forceps and divided. The bladder is then pushed up by gauze covered finger till the peritoneum of the uterovesical pouch is visible. The vesico-cervical space is now exposed.
![Page 72: Pelvic organ prolapse gynaecology ppt](https://reader035.vdocuments.mx/reader035/viewer/2022081415/55848508d8b42a9f028b4cab/html5/thumbnails/72.jpg)
![Page 73: Pelvic organ prolapse gynaecology ppt](https://reader035.vdocuments.mx/reader035/viewer/2022081415/55848508d8b42a9f028b4cab/html5/thumbnails/73.jpg)
• The pubocervical fascia is plicated by interupted sutures with No "O" chromic catgut using round body needle.The lower one or two stiches include a bite on the cervix thus closing the hiatus through which the bladder herniates. The redudndant portion of the vaginal mucosa is cut on either side.• The cut margins of the vagina are apposed by interrupted sutures with No 'O'
chromic catgut using cutting needle.• The catheter is reintroduced once more to be sure that the bladder is not
injured.• Toileting of the vagina is done.• Vagina is tight packed with roller gauze smeared with antiseptic cream.• A self retaining catheter is introduced
![Page 74: Pelvic organ prolapse gynaecology ppt](https://reader035.vdocuments.mx/reader035/viewer/2022081415/55848508d8b42a9f028b4cab/html5/thumbnails/74.jpg)
Paravaginal repair
• To correct lateral cystocele• Done abdominally, vaginally or laparoscopically• Repairing abdominallyInvolves entering retropubic space till arcus tendinous fascia pelvis
seen lateral vagina raised to arcus tendinous fasciaBoth are approximated with interrupted sutures
![Page 75: Pelvic organ prolapse gynaecology ppt](https://reader035.vdocuments.mx/reader035/viewer/2022081415/55848508d8b42a9f028b4cab/html5/thumbnails/75.jpg)
WARD-MAYO REPAIR
• Commonest operation in case of utero vaginal prolapse in cases where child bearing is complete• Indication• In an elderly women who has completed her family
![Page 76: Pelvic organ prolapse gynaecology ppt](https://reader035.vdocuments.mx/reader035/viewer/2022081415/55848508d8b42a9f028b4cab/html5/thumbnails/76.jpg)
WARD-MAYO REPAIR
• Vaginal hysterectomy + pelvic floor repair ± sacrospinous colpopexy
• Combined with cystocele,enterocele or rectocele repair Cystocele-ant.colporrhaphy(AC) Enterocele-Mc Call’s culdoplasty Rectocele-posterior colporrhaphy(PC)
![Page 77: Pelvic organ prolapse gynaecology ppt](https://reader035.vdocuments.mx/reader035/viewer/2022081415/55848508d8b42a9f028b4cab/html5/thumbnails/77.jpg)
WARD-MAYO REPAIR
VH
PFR
• anterior colporrhaphy and
• colpoperineorrhaphy
Sacrospinous colpopexy
• procidentia with complete vaginal eversion
• Vault prolapse.
![Page 78: Pelvic organ prolapse gynaecology ppt](https://reader035.vdocuments.mx/reader035/viewer/2022081415/55848508d8b42a9f028b4cab/html5/thumbnails/78.jpg)
Vaginal hysterectomy
A circular incision is made over the cervix below the bladder sulcus, and the vaginal mucosa dissected off the cervix all around.
![Page 79: Pelvic organ prolapse gynaecology ppt](https://reader035.vdocuments.mx/reader035/viewer/2022081415/55848508d8b42a9f028b4cab/html5/thumbnails/79.jpg)
![Page 80: Pelvic organ prolapse gynaecology ppt](https://reader035.vdocuments.mx/reader035/viewer/2022081415/55848508d8b42a9f028b4cab/html5/thumbnails/80.jpg)
![Page 81: Pelvic organ prolapse gynaecology ppt](https://reader035.vdocuments.mx/reader035/viewer/2022081415/55848508d8b42a9f028b4cab/html5/thumbnails/81.jpg)
![Page 82: Pelvic organ prolapse gynaecology ppt](https://reader035.vdocuments.mx/reader035/viewer/2022081415/55848508d8b42a9f028b4cab/html5/thumbnails/82.jpg)
![Page 83: Pelvic organ prolapse gynaecology ppt](https://reader035.vdocuments.mx/reader035/viewer/2022081415/55848508d8b42a9f028b4cab/html5/thumbnails/83.jpg)
![Page 84: Pelvic organ prolapse gynaecology ppt](https://reader035.vdocuments.mx/reader035/viewer/2022081415/55848508d8b42a9f028b4cab/html5/thumbnails/84.jpg)
![Page 85: Pelvic organ prolapse gynaecology ppt](https://reader035.vdocuments.mx/reader035/viewer/2022081415/55848508d8b42a9f028b4cab/html5/thumbnails/85.jpg)
![Page 86: Pelvic organ prolapse gynaecology ppt](https://reader035.vdocuments.mx/reader035/viewer/2022081415/55848508d8b42a9f028b4cab/html5/thumbnails/86.jpg)
![Page 87: Pelvic organ prolapse gynaecology ppt](https://reader035.vdocuments.mx/reader035/viewer/2022081415/55848508d8b42a9f028b4cab/html5/thumbnails/87.jpg)
![Page 88: Pelvic organ prolapse gynaecology ppt](https://reader035.vdocuments.mx/reader035/viewer/2022081415/55848508d8b42a9f028b4cab/html5/thumbnails/88.jpg)
![Page 89: Pelvic organ prolapse gynaecology ppt](https://reader035.vdocuments.mx/reader035/viewer/2022081415/55848508d8b42a9f028b4cab/html5/thumbnails/89.jpg)
![Page 90: Pelvic organ prolapse gynaecology ppt](https://reader035.vdocuments.mx/reader035/viewer/2022081415/55848508d8b42a9f028b4cab/html5/thumbnails/90.jpg)
![Page 91: Pelvic organ prolapse gynaecology ppt](https://reader035.vdocuments.mx/reader035/viewer/2022081415/55848508d8b42a9f028b4cab/html5/thumbnails/91.jpg)
![Page 92: Pelvic organ prolapse gynaecology ppt](https://reader035.vdocuments.mx/reader035/viewer/2022081415/55848508d8b42a9f028b4cab/html5/thumbnails/92.jpg)
To proceed as that of anterior colporraphy up to pushing up of
bladder
the UV fold of peritoneum incised
The cervical incision is extended posteriorly along the cervicovaginal junction and the pouch of douglas is
opened
Uterus is delivered anteriorly
First clamp on utero sacral and cardinal ligaments,tissues cut and ligated on
both sides
Second clamp involves uterinevessels which are cut and ligated
Third clamp on round ligament,fallopian tube and ovarian ligament which are cut and ligated
![Page 93: Pelvic organ prolapse gynaecology ppt](https://reader035.vdocuments.mx/reader035/viewer/2022081415/55848508d8b42a9f028b4cab/html5/thumbnails/93.jpg)
Uterus removed
Peritonium closed by purse string suture
enterocele correction done by McCall’s culdoplasty
Anterior colporrhaphy is completed
Posterior colpoperineorrhaphy performed if there is rectocele.
![Page 94: Pelvic organ prolapse gynaecology ppt](https://reader035.vdocuments.mx/reader035/viewer/2022081415/55848508d8b42a9f028b4cab/html5/thumbnails/94.jpg)
![Page 95: Pelvic organ prolapse gynaecology ppt](https://reader035.vdocuments.mx/reader035/viewer/2022081415/55848508d8b42a9f028b4cab/html5/thumbnails/95.jpg)
![Page 96: Pelvic organ prolapse gynaecology ppt](https://reader035.vdocuments.mx/reader035/viewer/2022081415/55848508d8b42a9f028b4cab/html5/thumbnails/96.jpg)
![Page 97: Pelvic organ prolapse gynaecology ppt](https://reader035.vdocuments.mx/reader035/viewer/2022081415/55848508d8b42a9f028b4cab/html5/thumbnails/97.jpg)
![Page 98: Pelvic organ prolapse gynaecology ppt](https://reader035.vdocuments.mx/reader035/viewer/2022081415/55848508d8b42a9f028b4cab/html5/thumbnails/98.jpg)
SACROSPINOUS COLPOPEXY
• Apical suspension procedure in procidentia with complete vaginal eversion Vault prolapse• Sacrospinous ligament is used to suspend the vault,by an approach
through rectovaginal space
![Page 99: Pelvic organ prolapse gynaecology ppt](https://reader035.vdocuments.mx/reader035/viewer/2022081415/55848508d8b42a9f028b4cab/html5/thumbnails/99.jpg)
Abdominal sacrocolpopexy
• Abdominal method of apical suspension • Used in Vault prolapse mainly • A mesh in the form of Y is used
![Page 100: Pelvic organ prolapse gynaecology ppt](https://reader035.vdocuments.mx/reader035/viewer/2022081415/55848508d8b42a9f028b4cab/html5/thumbnails/100.jpg)
• Long arm y anterior longitudinal ligament of sacrum @ sacral promontory
• Short arms anterior & posterior vagina
![Page 101: Pelvic organ prolapse gynaecology ppt](https://reader035.vdocuments.mx/reader035/viewer/2022081415/55848508d8b42a9f028b4cab/html5/thumbnails/101.jpg)
Manchester/Fothergill’s operation
• In a women who has completed her family• With lesser degrees of uterovaginal prolapse with supra vaginal
elongation of cervix• but wishes to retain the uterus and opts for a vaginal procedure • it can be combined with AC , PC or enterocele repair
![Page 102: Pelvic organ prolapse gynaecology ppt](https://reader035.vdocuments.mx/reader035/viewer/2022081415/55848508d8b42a9f028b4cab/html5/thumbnails/102.jpg)
Manchester/Fothergill’s operationDilatation of cervix
Anterior colporrhaphy
Isolation and ligation of cardinal ligaments
Amputation of cervix
Suturing the cardinal ligaments to the front of cervix
Reforming the lips of cervix using the vagina
![Page 103: Pelvic organ prolapse gynaecology ppt](https://reader035.vdocuments.mx/reader035/viewer/2022081415/55848508d8b42a9f028b4cab/html5/thumbnails/103.jpg)
The patient is placed in the dorsal lithotomy position. Thorough examination of the pelvis is performed. The bladder is not catheterized because it can be identified and dissected with greater safety when partially filled than when empty.
![Page 104: Pelvic organ prolapse gynaecology ppt](https://reader035.vdocuments.mx/reader035/viewer/2022081415/55848508d8b42a9f028b4cab/html5/thumbnails/104.jpg)
Dilation & cuerettage
![Page 105: Pelvic organ prolapse gynaecology ppt](https://reader035.vdocuments.mx/reader035/viewer/2022081415/55848508d8b42a9f028b4cab/html5/thumbnails/105.jpg)
The labia may be tacked to the perineum for retraction if they are redundant. 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 360° circumcision incision is made. The bladder is sharply and bluntly dissected off the lower uterine segment up to the vesicouterine fold
![Page 106: Pelvic organ prolapse gynaecology ppt](https://reader035.vdocuments.mx/reader035/viewer/2022081415/55848508d8b42a9f028b4cab/html5/thumbnails/106.jpg)
A right-angle retractor is placed under the bladder to expose the vesicouterine peritoneal fold. This is picked up and opened.
![Page 107: Pelvic organ prolapse gynaecology ppt](https://reader035.vdocuments.mx/reader035/viewer/2022081415/55848508d8b42a9f028b4cab/html5/thumbnails/107.jpg)
The anterior cul-de-sac is opened, a finger is inserted, and the fundus and adnexa are explored.
![Page 108: Pelvic organ prolapse gynaecology ppt](https://reader035.vdocuments.mx/reader035/viewer/2022081415/55848508d8b42a9f028b4cab/html5/thumbnails/108.jpg)
A right-angle Heaney retractor is placed in the anterior cul-de-sac, allowing elevation of the bladder and ureter. The cervix is rotated anteriorly, and the posterior cul-de-sac is exposed. The peritoneum of the posterior cul-de-sac is picked up and opened.
The posterior cul-de-sac is opened. A finger may be inserted into the cul-de-sac, and the uterus and adnexa explored.
![Page 109: Pelvic organ prolapse gynaecology ppt](https://reader035.vdocuments.mx/reader035/viewer/2022081415/55848508d8b42a9f028b4cab/html5/thumbnails/109.jpg)
![Page 110: Pelvic organ prolapse gynaecology ppt](https://reader035.vdocuments.mx/reader035/viewer/2022081415/55848508d8b42a9f028b4cab/html5/thumbnails/110.jpg)
![Page 111: Pelvic organ prolapse gynaecology ppt](https://reader035.vdocuments.mx/reader035/viewer/2022081415/55848508d8b42a9f028b4cab/html5/thumbnails/111.jpg)
![Page 112: Pelvic organ prolapse gynaecology ppt](https://reader035.vdocuments.mx/reader035/viewer/2022081415/55848508d8b42a9f028b4cab/html5/thumbnails/112.jpg)
the ligaments are fixed using Fothergill's stitch. Fothergill's stitch is used to make the uterus anteverted. The stitch passes through the following tissues in sequence. Vaginal skin at the level of Fothergill's lateral point->Mackenrodt's ligament->through the cervical tissue from outside inwards->cervical tissue from inside outwards->Mackenrodt's ligament of the other side -> vaginal skin(Fothergill's lateral point) of the other side.
![Page 113: Pelvic organ prolapse gynaecology ppt](https://reader035.vdocuments.mx/reader035/viewer/2022081415/55848508d8b42a9f028b4cab/html5/thumbnails/113.jpg)
![Page 114: Pelvic organ prolapse gynaecology ppt](https://reader035.vdocuments.mx/reader035/viewer/2022081415/55848508d8b42a9f028b4cab/html5/thumbnails/114.jpg)
![Page 115: Pelvic organ prolapse gynaecology ppt](https://reader035.vdocuments.mx/reader035/viewer/2022081415/55848508d8b42a9f028b4cab/html5/thumbnails/115.jpg)
![Page 116: Pelvic organ prolapse gynaecology ppt](https://reader035.vdocuments.mx/reader035/viewer/2022081415/55848508d8b42a9f028b4cab/html5/thumbnails/116.jpg)
Both Mackenrodt's ligaments have now been ligated and the cervix almost completely amputated. A vulsellum is attached to the anterior lip of the cervix above the amputation
![Page 117: Pelvic organ prolapse gynaecology ppt](https://reader035.vdocuments.mx/reader035/viewer/2022081415/55848508d8b42a9f028b4cab/html5/thumbnails/117.jpg)
A covering for the posterior lip of the cervix has been fashioned from the mobilized vaginal skin of the posterior fornix and this has been secured to the new cervix by deep sutures. Fothergill's stitch is illustrated and it should be noticed that it passes through vaginal skin in the region of Fothergill's lateral point, through Mackenrodt's ligament and through the anterior lip of the cervix into the cervical canal, and thence out to the other side and through Mackenrodt's ligament and vaginal sk
![Page 118: Pelvic organ prolapse gynaecology ppt](https://reader035.vdocuments.mx/reader035/viewer/2022081415/55848508d8b42a9f028b4cab/html5/thumbnails/118.jpg)
Shirodkar’s Extended Manchester operation
• Shirodkar’s Extended Manchester operation- in a women who wants to conceive
• Vaginal sling operation• Uterus and cervix are preserved• Strenghthening of uterosacral ligaments• Best for women with strong uterosacrals
![Page 119: Pelvic organ prolapse gynaecology ppt](https://reader035.vdocuments.mx/reader035/viewer/2022081415/55848508d8b42a9f028b4cab/html5/thumbnails/119.jpg)
STEPS..
AC done
Vaginal incision extended posteriorly around the cervix
The pouch oh Douglas is then opened
The uterosacral ligaments identified and divided close to cervix
They are isolated to form slings
They are crossed and stitched together infront of the cervix
![Page 120: Pelvic organ prolapse gynaecology ppt](https://reader035.vdocuments.mx/reader035/viewer/2022081415/55848508d8b42a9f028b4cab/html5/thumbnails/120.jpg)
Le Fort’s operation • Le Fort’s operation In very elderly women who is medically unfit for a
repair procedure and not desirous of vaginal intercourse.
• Colpocleisis• Obliterative procedure • Total colpocleisis-total obliteration of cavity• Partial colpocleisis-some part of vaginal epithelium is left unsutured
to provide drainage tract ,useful in women with uterus to drain cervical secretions
![Page 121: Pelvic organ prolapse gynaecology ppt](https://reader035.vdocuments.mx/reader035/viewer/2022081415/55848508d8b42a9f028b4cab/html5/thumbnails/121.jpg)
Le Fort’s operation
Vaginal epithelium is removed
Suturing of anterior and posterior wall of the denuded vagina
![Page 122: Pelvic organ prolapse gynaecology ppt](https://reader035.vdocuments.mx/reader035/viewer/2022081415/55848508d8b42a9f028b4cab/html5/thumbnails/122.jpg)
• Repairing vaginallyMore difficultMore risk of hemorrhageIf a paravaginal defect is present,retropubic space can be
reached readily vaginally4-6 permanent sutures between arcus tendineus and
lateral edge of fibromuscular layer
![Page 123: Pelvic organ prolapse gynaecology ppt](https://reader035.vdocuments.mx/reader035/viewer/2022081415/55848508d8b42a9f028b4cab/html5/thumbnails/123.jpg)
POSTERIOR COMPARTMENT
• Posterior colporrhaphy to correct rectocele
![Page 124: Pelvic organ prolapse gynaecology ppt](https://reader035.vdocuments.mx/reader035/viewer/2022081415/55848508d8b42a9f028b4cab/html5/thumbnails/124.jpg)
Posterior colporrhaphy
• ProcedurePair of Allis forceps at lower end of labium minus and a third one on
posterior vaginal wall above rectoceleIncision put joining first two forcepsVaginal mucosa dissected from prerectal fascia(Denonvillier’s fascia)
upto third forcepsVertical incision put from middle of this incision to the apex
![Page 125: Pelvic organ prolapse gynaecology ppt](https://reader035.vdocuments.mx/reader035/viewer/2022081415/55848508d8b42a9f028b4cab/html5/thumbnails/125.jpg)
Prerectal fascia approximated in the midline with delayed absorbable sutures
If defect identified, better to do a defect repairUsually anterior plication of pubococcygeus part of
levator ani also performed across the rectumThen vaginal mucosa trimmed and closedCombined with perineorrhaphy when defective
perineal body Superficial perineal muscles are plicated in the
midline and skin closed
![Page 126: Pelvic organ prolapse gynaecology ppt](https://reader035.vdocuments.mx/reader035/viewer/2022081415/55848508d8b42a9f028b4cab/html5/thumbnails/126.jpg)
Mesh repair
In repeat sxReplace patients own weak tissue • 4 types• Type 1 monofilament mesh preferred(pore size >75 micrometre)• Mesh of choice : Monofilament macroporous light weight
polypropylene mesh (eg : Gynemesh)• Main problem with use of mesh is mesh erosion
![Page 127: Pelvic organ prolapse gynaecology ppt](https://reader035.vdocuments.mx/reader035/viewer/2022081415/55848508d8b42a9f028b4cab/html5/thumbnails/127.jpg)
Postoperative care
• Parental fluids until bowel sounds return.• Early oral fluids are now advocated. • Antibiotics, sedatives, metronidazole for 24 hours IV. • Indwelling catheter for 48 hours. • Vaginal pack for 28 hours. • Early ambulation• DVT prophylaxis
![Page 128: Pelvic organ prolapse gynaecology ppt](https://reader035.vdocuments.mx/reader035/viewer/2022081415/55848508d8b42a9f028b4cab/html5/thumbnails/128.jpg)
Mc call culdoplasty for enterocele repair
![Page 129: Pelvic organ prolapse gynaecology ppt](https://reader035.vdocuments.mx/reader035/viewer/2022081415/55848508d8b42a9f028b4cab/html5/thumbnails/129.jpg)
![Page 130: Pelvic organ prolapse gynaecology ppt](https://reader035.vdocuments.mx/reader035/viewer/2022081415/55848508d8b42a9f028b4cab/html5/thumbnails/130.jpg)
VAULT PROLAPSE
Enterocele Secondary vault prolapse
![Page 131: Pelvic organ prolapse gynaecology ppt](https://reader035.vdocuments.mx/reader035/viewer/2022081415/55848508d8b42a9f028b4cab/html5/thumbnails/131.jpg)
ENTEROCELE• Herniation of upper third of posterior vaginal wall• Contain omentum or even loop of small bowel• Always look for and correct during prolapse repair• Prophylactic correction during vaginal or abdominal hyterectomy
![Page 132: Pelvic organ prolapse gynaecology ppt](https://reader035.vdocuments.mx/reader035/viewer/2022081415/55848508d8b42a9f028b4cab/html5/thumbnails/132.jpg)
MANAGEMENT• VAGINAL CORRECTION• STEPS
Inverted T shaped incisionDissect and expose sac Sac opened and contents pushed awayPeritoneum dissected and excisedPurse string suture – neck of the sacCervix pulled up ,interrupted suture around uterosaral ligaments
![Page 133: Pelvic organ prolapse gynaecology ppt](https://reader035.vdocuments.mx/reader035/viewer/2022081415/55848508d8b42a9f028b4cab/html5/thumbnails/133.jpg)
• VAGINAL CORRECTION OF POST HYSTERECTOMY ENTEROCELE• Uterus absent• internal Mc call suture
• ABDOMINAL CORRECTION• Vaginal vault – suspend to uterosacral ligament• Other procedure
HALBAN PROCEDURE MOSCOWITZ PROCEDURE
![Page 134: Pelvic organ prolapse gynaecology ppt](https://reader035.vdocuments.mx/reader035/viewer/2022081415/55848508d8b42a9f028b4cab/html5/thumbnails/134.jpg)
SECONDARY VAULT PROLAPSEProlapse of vaginal vault following
hysterectomyDue to failure to recognise and correct
– enterocele- during hyserectomyCan be
Vaginal eversion – vault suspensionCystocele Anterior and posterior Rectocele colporrhaphy
![Page 135: Pelvic organ prolapse gynaecology ppt](https://reader035.vdocuments.mx/reader035/viewer/2022081415/55848508d8b42a9f028b4cab/html5/thumbnails/135.jpg)
MANAGEMENTVaginal approach
Sacrospinous colpopexy + anterior and posterior colporrhaphyPreferred in old and less healthy women
• Abdominal approachSacrocolpopexy + Halban procedurePreffered in young women bcoz resultant vagina is longer
![Page 136: Pelvic organ prolapse gynaecology ppt](https://reader035.vdocuments.mx/reader035/viewer/2022081415/55848508d8b42a9f028b4cab/html5/thumbnails/136.jpg)
NULLIPAROUS PROLAPSE
• More likely to have spina bifida or connective tissue disorder• Uterine +vaginal prolapse , may include
complete vaginal inversion• Mesh required for repair• Following repair- aviod vaginal delivery –
perform elective caesarean section
![Page 137: Pelvic organ prolapse gynaecology ppt](https://reader035.vdocuments.mx/reader035/viewer/2022081415/55848508d8b42a9f028b4cab/html5/thumbnails/137.jpg)
MANAGEMENT
• Abdominal sacrohysteropexy• Teflon or mersilene mesh
• Purander’s sling operation or cervicopexy• Shirodkar’s sling operation• Khanna’s posterior sling
![Page 138: Pelvic organ prolapse gynaecology ppt](https://reader035.vdocuments.mx/reader035/viewer/2022081415/55848508d8b42a9f028b4cab/html5/thumbnails/138.jpg)
![Page 139: Pelvic organ prolapse gynaecology ppt](https://reader035.vdocuments.mx/reader035/viewer/2022081415/55848508d8b42a9f028b4cab/html5/thumbnails/139.jpg)
![Page 140: Pelvic organ prolapse gynaecology ppt](https://reader035.vdocuments.mx/reader035/viewer/2022081415/55848508d8b42a9f028b4cab/html5/thumbnails/140.jpg)
![Page 141: Pelvic organ prolapse gynaecology ppt](https://reader035.vdocuments.mx/reader035/viewer/2022081415/55848508d8b42a9f028b4cab/html5/thumbnails/141.jpg)
![Page 142: Pelvic organ prolapse gynaecology ppt](https://reader035.vdocuments.mx/reader035/viewer/2022081415/55848508d8b42a9f028b4cab/html5/thumbnails/142.jpg)
![Page 143: Pelvic organ prolapse gynaecology ppt](https://reader035.vdocuments.mx/reader035/viewer/2022081415/55848508d8b42a9f028b4cab/html5/thumbnails/143.jpg)
![Page 144: Pelvic organ prolapse gynaecology ppt](https://reader035.vdocuments.mx/reader035/viewer/2022081415/55848508d8b42a9f028b4cab/html5/thumbnails/144.jpg)
![Page 145: Pelvic organ prolapse gynaecology ppt](https://reader035.vdocuments.mx/reader035/viewer/2022081415/55848508d8b42a9f028b4cab/html5/thumbnails/145.jpg)
![Page 146: Pelvic organ prolapse gynaecology ppt](https://reader035.vdocuments.mx/reader035/viewer/2022081415/55848508d8b42a9f028b4cab/html5/thumbnails/146.jpg)