Home Page Home Article Read Close close

Figures in Letter to Editor by Professor PETER Petros MB BS (Syd) D Med Sc (Uppsala) DS (UWA) MD (Syd) FRCOG (Lond) FRANZCOG CU

Re
Posterior IVS for vault suspension: A re-evaluation.

Professor PETER Petros MB BS (Syd) D Med Sc (Uppsala) DS (UWA) MD (Syd) FRCOG (Lond) FRANZCOG CU

Reconstructive Pelvic Floor Surgeon and Certified Urogynaecologist - 14A Osborne Pde Claremont WA 6010 AUSTRALIA - Email kvinno @ highway1.com.au - Website www.integraltheory.org

 

(Fig. 1)

Xray of a nulliparous patient
Fig 1. – Xray of a nulliparous patient, resting sitting position. Note that the cervix I situated just below the level of the ischial spine. X marks the penetration point of the tunneller just medial and behind the ischial spine (IS). SSL=sacrospinous ligament; LP=levator plate; V=vagina; R=rectum; PB=perineal body; B=bladder. The tape and line of SSL have been superimposed on the original xray.


Close close

(Fig. 2 )

Xray of a nulliparous patient, straining

Fig. 2. – Xray of a nulliparous patient, straining. Same patient as figure 1. The tape and line of SSL have been superimposed on the original xray. Note the natural movement of the cervix and vagina activated by the posterior muscle forces. Whereas a tape allows such movements, fixation on SSL is far more rigid, and would inhibit them.



Close close



Response to the letter from Professor Petros

by Bruce Farnsworth

Centre for Pelvic Reconstructive Surgery - Sydney Adventist Hospital


(Fig. 1 )

uterosacral ligaments

Fig. 1. – The uterosacral ligaments (USL) extend from the coccyx to the cervix. The USL shares a common origin adjacent to the cervix with the sacrospinous ligament (SSL) which extends from the lower sacrum and coccyx to the ischial spine (IS). A suture bridge from position A to position B accurately recreates theUSL while a tape from position B to X or X1 does not. The traditional point of attachment of the Posterior IVS to the pelvic side wall is at position X below and medial to IS. Some surgeons advocate attachment of the Posterior IVS to the SSL itself at position X1. Position X1 is also the usual point of a attachment when performing a sacrospinous hitch procedure. A more physiological attachment of the vaginal apex can be achieved when the sacrospinous hitch is made to position A.


Close close

(Fig. 3 )

Lateral view of the position of a posterior IVS sling

Fig. 2. – Lateral view of the position of a posterior IVS sling which extends from the cervix (position 1) to the point of insertion through the levator muscle (position 2) and then down into the ischiorectal fossa (3) to exit the skin of the buttocks. This does not replicate the true attachment of the uterosacral ligaments at position 2a.




Close close

(Fig. 3 )

Demonstration of inappropriate trocar direction

Fig. 3. – Superior (“birds eye”) view of pelvic support ligaments. The Cervix (C) is the key support of the vaginal apex and uterus with ligamentous attachments to the pelvis (a: uterosacral ligaments, b: cardinal ligaments and c: arcus tendineous fascia pelvis. The uterosacral ligaments (USL) help support the rectum (R) which passes between them. The USL and SSL share a common insertion adjacent to the coccyx and lower sacrum at position A which is the best position for apical support. The Posterior IVS is attached to the levator plate at position B.


Close close