Chapter 23: Route of Pelvic Organ Surgery

INTRODUCTION

Gynecologists have been debating the optimal route for repair of pelvic organ prolapse throughout the last century. The minutes of a North of England Obstetrics & Gynaecological Society meeting in 1918 describe the debate over how an 18-year-old woman with procidentia should be treated. The treatment proposed was a vaginal repair and ventrofixation. William Blair Bell, professor of obstetrics and gynecology in Liverpool, founder of the RCOG, urged against ventrofixation. William Fletcher-Shaw, a leading gynecological surgeon, deprecated all abdominal operations for prolapse. William Fothergill, professor of obstetrics and gynecology in Manchester, who described the Manchester repair, was also not in favor of the abdominal approach to prolapse surgery. In 1921 he is quoted as saying “It is not to the credit of the profession that women should go home with their cervices still projecting at the vulval cleft after having undergone the risk, discomfort and expense of futile ventrofixations at the hands of those who have never attempted to learn vaginal surgery.”

Until 20 years ago, the additional morbidity of the abdominal approach to prolapse surgery through a laparotomy incision encouraged surgeons to employ a vaginal approach to prolapse repair whenever possible. The introduction of laparoscopic and robotic surgical techniques with decreased morbidity compared with open abdominal procedures has resulted in a lowered threshold for choice of the abdominal approach to repair of uterovaginal prolapse.

In this chapter we will discuss the factors that influence the approach a surgeon employs for the repair of pelvic organ prolapse. Little robust evidence for most practices exists and decisions regarding approach are mainly influenced by the opinion of leading surgeons of the era. In clinical practice the final decision on which approach is taken will often depend on a number of factors rather than a single one. Thus, the obese patient with a history of multiple complex abdominal surgeries and chronic obstructive airways disease is likely to be more suitable for the vaginal approach with regional analgesia, rather than an open or laparoscopic abdominal approach.

FACTORS THAT INFLUENCE THE SURGICAL APPROACH FOR PROLAPSE SURGERY

Type of Prolapse

Anterior or Posterior Vaginal Wall Prolapse

Prolapse of the anterior or posterior walls of the lower half of the vagina is clearly more easily approached surgically through the vaginal route. Prolapse of the anterior vaginal wall may be repaired by a paravaginal repair that can be performed vaginally or abdominally via an open or ...