Posterior Intravaginal Sling
(Infracoccygeal Sacropexy)
1. INTRODUCTION
The Posterior IVS procedure was first described by Petros in 1997. Dr Farnsworth adopted this procedure in 1998 and has now performed over 800 cases. He has also lectured and demonstrated the procedure in a number of universities and hospitals around the world. The Posterior IVS is a useful technique that now can be seen as part of a comprehensive repair technique.
The decision to undertake surgery is an important one. It must be realized and accepted that complications may occur. Although major complications are not common, they may be disabling and even life threatening, and may require further surgery to correct. This can lead to prolonged recovery time and even permanent disability.
The benefits of the operation must be weighed against the risks. A full consideration of alternative treatments should be made including the consequences of no treatment. It is your responsibility to make sure that you understand the proposed surgery and to ask any questions if you are unsure.
2. PROCEDURE
The Posterior IVS or Sacropexy is performed to correct an enterocoele, which forms after hysterectomy. The ligaments are weakened and a hernia forms at the site where the uterus was removed, pushed down by the bowel above and it protrudes through the vagina. To repair this defect, a tape is passed from near the coccyx bone, up past the rectum to the site of the enterocoele, and then passed down through the other side. This tape is attached to the remains of the weakened pelvic ligaments. A fibrous reaction occurs around the tape, to strengthen and replace the weakened ligament. Unlike other similar procedures, no vaginal pack or catheter is required.
3. ADMISSION TO HOSPITAL
This normally occurs the morning of the operation. You should have nothing to eat, drink or smoke from midnight the night before. If the operation is to be in the afternoon, you can have a light breakfast before 6.00am e.g. toast, tea or coffee. If you develop a cough, cold or fever before the operation it may need to be postponed.
The appropriate anaesthesia will be decided by the anaesthetist and should be discussed with him or her. The anaesthetist will arrange the appropriate premedication if required. If there are major medical problems, the operation can be performed under local anaesthesia.
If you are currently taking Aspirin, Indocid, Naprosyn or other anti-inflammatory drugs, these should be discontinued ten days before the operation. Please bring a packet of sanitary pads with you to the hospital with your own night attire and toiletries.
4. RECOVERY
You will wake in the post operative recovery room within the theatre complex. You may have an oxygen mask fitted comfortably over your mouth and nose. There may be an intravenous 'drip' (IV) needle in your arm. Analgesic medication will be prescribed to prevent any post-operative pain. The pain is usually minimal, as local anaesthetic is injected into the operative area.
There may be some nausea and vomiting, although medication to counteract this is routinely given during the operation. If you continue to feel nauseated, notify the nursing staff so that further medication may administered. The nursing staff will measure the volume of urine passes each time to make sure that there is no retention of urine. In this case, a small 'in-out' catheter will be passes to empty the bladder.
The amount of vaginal bleeding will be checked on a regular basis. Once fluids are tolerated, the intravenous 'drip' will be removed. You will normally be discharged home the afternoon of the operation or the next morning. A longer hospital stay can be arranged according to personal circumstances.
5. DISCHARGE HOME
The operation was designed for patients to return to work and normal activities as soon as possible i.e. in some cases drive your car, cook, shop, look after your children within a few days and return to some types of work within 2-4 weeks. However, in most patients, recovery will take longer depending on the amount of damage. In particular, when a sling is performed in combination with other procedures such as a mesh or fascial repair longer periods of recuperation will be necessary.
Please remember to be sensible. Most operations that fail do so because sutures tear out of the vagina due to excessive straining and lifting. Vaginal intercourse should be avoided for 6 weeks. Some sutures take 8 - 12 weeks to dissolve, and if necessary, can be removed earlier. Collagen cross bonding and strength is not achieved for at least 3 months and sometimes longer. Avoid tampons during this time and prevent constipation with orange juice, bran and other fibre products.
It is important to exercise extreme care when getting in or out of a car or getting up from a chair. In particular, the knees should be kept together as much as possible during activity, especially lifting and squatting.
6. FOLLOW-UP
An initial appointment can be made as early as one week after the operation if there is a problem. There is a routine follow-up at four to six weeks. There may be some vaginal bleeding for the first few days after the operation. This can last for a long time and is often associated with a discharge.
7. RESULTS OF THE OPERATION
The results of any operation cannot be guaranteed, and it is possible for the condition to recur at a later date. However, unlike other vaginal repair operations, there should be a cure of the prolapse without shortening the vagina or making it too tight and thus causing pain with intercourse. A subjective cure rate of 90% can be expected.
8. COMPLICATIONS
Complications are rare but it must be understood and accepted that these may occur.
The complications that can occur include, but are not limited to the following:
a) Infection - there may be a simple infection of the wound requiring antibiotics alone. However a pelvic abscess could develop, requiring drainage.
b) Haemorrhage - this is extremely rare. Most bleeding occurs 2-4 weeks after the operation when excessive movement can disrupt sutures.
c) Injury to Rectum - if the instrument inserting the tape passed through the rectum this could lead to infection, but as it is only a puncture wound, withdrawing the instrument should not cause any problems. With developments in surgical techniques over the last 2 years rectal perforation is extremely unlikely.
d) Deep Venous Thrombosis - a possible complication of any surgery, but much less likely with this type operation as you are mobilized almost immediately.
e) Rejection of the Tape - tape rejection is now extremely rare due to the new polypropylene tapes that are available. This is a tissue reaction, not an infection.
f) Injury to Bowel - if the bowel is well down in the enterocoele sac, there is a small risk that it could be caught in the sutures. This would require surgical repair and prolong your stay in hospital.
g) Tape Erosion - occurs in up to 3% of patients. Erosion means that a piece of tape becomes visible in the vagina. Treatment is simple and involves excision of the affected mesh then repair of the adjacent vagina.
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