VAGINAL RECONSTRUCTIVE SURGERY
1. INTRODUCTION
New techniques are now able to be utilised to restore function to the pelvis by replacing damaged tissues with prosthetic materials. Specialised procedures enable some reconstructive procedures to be performed as Day Surgery or overnight stay procedures. Other procedures utilising mesh and other implants facilitate major reconstruction with reduced morbidity and shorter hospital stays than would usually be associated with traditional procedures that aim to achieve the same result.
2. PROCEDURE
Repair surgery can involve tightening, strengthening and folding vaginal epithelium to reinforce ligaments.
The Posterior Intravaginal Sling is performed to correct an enterocoele, which forms after hysterectomy. The ligaments are weakened and a hernia forms at the site next to the uterus or 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 through the levator muscle to the site of the enterocoele, and then passed down through the other side. This tape is attached to the vaginal vault. A fibrous reaction occurs around the tape, to reattach the vaginal vault to the levator muscle and effectively replace the weakened ligament. Mesh or biological material can be used to replace the damaged walls of the vagina in a similar way. In vaginal suspension procedures permanent sutures are attached to the pelvic fascia or ligaments and the vagina or cervix is elevated to its original position. A hysterectomy is avoided if possible.
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. In more extensive operations a catheter may be left in place for up to two days. A pack will also be left in place if mesh is used. The amount of vaginal bleeding will be checked on a regular basis. Once fluids are tolerated, the intravenous 'drip' will be removed. If mesh or PELVICOL® is used as part of your repair procedure you will need a vaginal pack and urinary catheter for up to 48 hours and as a result your hospital stay will be at least 2-3 days.
5. DISCHARGE HOME
These operations are designed for patients to return to work and normal activities as soon as possible i.e. in the case of a simple anterior sling or repair you may be able to drive your car, cook, shop, or look after your children within 2-3 days and return to work within 14 days. However, in some patients, recovery will take longer. Patients with major prolapse need to be particularly careful for at least 3 months.
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 12 weeks. Some sutures take 8 - 12 months to dissolve, and if necessary, can be removed earlier. 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. Avoid bending and stretching.
6. FOLLOW-UP
An initial appointment should be made at any time after the operation if there is any problem. There is a routine follow-up at four to six weeks. There may be some vaginal bleeding after the operation.
7. RESULTS OF SURGERY
The results of any operation cannot be guaranteed, and it is possible for the condition to recur at a later date. However, unlike many 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.
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. A haematoma may need drainage or further surgery.
c) Injury to Rectum - if the instrument inserting the tape passed through the rectum this could lead to infection, but modern techniques make this complication 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. In more significant repair procedures special measures are instigated during and after surgery to minimise the risk of blood clots.
e) Rejection of Tape, Mesh or Implants - in tape or mesh rejection, which can occur even several months after the operation the implant may be expelled or cause a heavy discharge. This problem has been dramatically reduced by the use of polypropylene implants which evoke a minimal tissue reaction and the development of new surgical techniques.
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.
g) Nerve Damage - small nerves in the pelvis may become entrapped in sutures or damage by needles passed in suspension procedures. This problem is rare and usually temporary.
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