Repair of prolapse of the cervical stump by a polyethylene sling KEITH EDWARDS, CAPTAIN, MC, USA* IVAN H. BOX, CAPTAI.'l', MC, USAR** AMOS WAINER, M.D. Phoenixville, Pennsylvania
S E v E R A L different surgical techniques for repair of vaginal prolapse, with or without the cervical stump, have been described. When, because of the age of the patient, it is necessary to preserve the function of the vagina, a considerable amount of surgical ingenuity is required. No single operative procedure can be adequate in all cases. Ward1 described a suspensory operation using the fascia lata of the ox. Miller2 described an operation employing the technique of sacral fixation. Shaw 3 described a suspensory operation using strips of fascia from the sheath of the rectus in the midline. Williams and Richardson 4 described a suspensory operation using strips of fascia obtained from the aponeurosis of the external oblique muscle. We would now like to present another surgical technique using an operative procedure, modified according to the description of Shaw, and further employing the use of a length of size 15 polyethylene tubing.
previously, she had had an anterior and posterior colporrhaphy for repair of symptomatic cystocele and rectocele. She subsequently had one vaginal delivery. Twelve years ago, she had a subtotal hysterectomy for uterine prolapse with suspen· sion of the cervical stump. Approximately 9 months prior to this hospital admission, the patient had noted increasing pelvic and bladder pressure and more recently had been aware of "something falling out of the vagina." Physical examination on hospital admission, Sept. 18, 1958, revealed no gross abnormalities except in relationship to the female genital tract. Pelvic examination revealed complete prolapse of the vaginal cuff and ceiVix to the exterior with approximately 2 em. of vaginal cuff, including cervix, protruding beyond the introitus. The vagina with the ceiVix could be easily inverted. No uterosacral support was felt. No cystocele and no enterocele were present, but there was a second degree rectocele. The vaginal tissues were prepared with nightly applications of estrogen cream for approximately one week. On Sept. 25, 1958, an operation was performed. From the dorsal lithotomy position, a posterior colporrhaphy and perineorrhaphy were done. A Foley catheter was then inserted and a large vaginal pack placed in the vagina so as to push the cervix and vaginal cuff as high up into the abdominal cavity as possible. The patient was then placed in the dorsal supine position for abdominal laparotomy. A vertical midline incision was made at the site of a previous operation and the old scar was removed. The incision was carried down to the fascia of the rectus muscles, then the subcutaneous tissues and fat were dissected away from the fascia of the anterior abdominal wall out to the iliac crest on each side.
Case report The patient was a 45-year-old white woman, gravida iii, para iii, whose last delivery was 15 years prior to hospital admission. Nineteen years From the Valley Forge Army Hospital and jefferson Medical College. Presented at a meeting of the Obstetrical Society of Philadelphia, Oct. 1, 1959. *Present address: Trover Clinic, 55 E. North St., Madisonville, Kentucky. **Present address: Huntsville, Arkansas.
Edwards, Box, and Wainer
POLYETHYLEJI TUSING' •..
Match I. l'kic Oh>L & (;yn•·e.
~~r-~'"'"~'"' Hg. I. Diagram illustrating anatomical relations of the polyethylem· sling in place.
The fascia was opened vertically in the midline and the peritoneal cavity was entered. In a modification of the operation described by Shaw a 1 to 1.5 em. wide strip of fascia was cut away vertically from the aponeurosis of the external oblique muscles on each side. The lower end of this vertical strip of fascia was ldt attached at the level of the external inguinal ring. A single supporting suture was placed through the cervical stump for rl'traction and identification. The vaginal pack was removed from below and the bladder flap was dissected away from the cervical stump and anterior vaginal walL With the help of a Kelly damp, a tunnel was dissected down through the external inguinal ring, so as to extend between the leaves of the broad ligament and to arrive at the base of the cervical stump from each sid<: .. The strip;; of fascia previously dissected were tlwn pulled through these tunnels bilaterally and sutured in place to the cervical stump by means of interrupted sutures of 2-0 black silk. At this point, it was felt that support was not adequate and that the fascial strips were themselves attenuated, thin, and inherently weak. It was then elert~>d to reinforce this support of vaginal ruff and cervix hy the use of a sing!C', continuous pi<'rc of size 15 polyethylene tubing in the form of a sling. This continuous piece of tubing was inserted so as to extend from the levrl of the C'xtcrnal inguinal ring on ow· side down through the leaves of the broad ligament, across the base of the cervical stump, and back up through the leavPs of the broad ligament, thPn out the ext(•rnal inguinal ring on the othrr sidP. The tubing was sutured in place to the cNvical stump with 3 interrupted sutures of 2-0 hlack silk and anchored laterally on Pach side just above the external inguinal ring
with 3 similar interrupted, pt·rman<'nt sutures (Fig. 1). The bladder flap was then sutured over the cervical stump and the exposed polyethylene tubing. Tht> defect in the fascia of the external oblique muscles was closed with interrupted sutures of 2-0 black silk. It was noted rarcfnlly, prior to closure of the peritoneal cavity, that tlw sling, thus formed, gave adt·quate support, yet left no pockets for incarceration of loops of bowel. It was further nott'd that thP primary support of cervix and vagina was being borne hy the polyethylene tube and not by the fascial strips previously inserted. This patient had an unewnt ful postopt'rativt• rourse with a rapid and successful rrcovery. It is now approximately one year after the operation. The patient has bet·n question<'d and watched closely for any signs of irritation from the presence of the polyethyleiw tubin,g and any 'Yrnptoms of pain, either in the regions of th" inguinal rings or beneath the bladdt'r. Then• haw been no abnormal signs or symptoms. The n·rvical stump and vagina are still w<'ll-supportecl.
A case of prolapse of the cervix and following subtotal abdominal hys· tt'rectomy is presented. A new approach for support of the cervical stump and vagina. using polyethylene tubing, is described. va~ina
1. Ward, G. E.: Arch. Surg. 36: 163. 1938. :2. Miller, N. F.: Surg. Gym•c. & Obst. 44: 550, 1927. :l. Shaw, H. N.: West. J. Surg. 56: 127, !9+8. .J.. Williams. G. A., and Richardson, A. C.: AM. J. 0BsT. & Gnmc. 64: 552, 1952.