Laparoscopic Surgery for Uterovaginal and Vaginal Prolapse

The prolapse of uterus and vagina is one of the most frustrating and embarrassing disorders confronting the modern woman, who, with increased life expectancy, is interested in maintaining her femininity and capacity for sexual activity.

A prolapsed uterus or vagina is just a manifestation of the break down in the pelvic floor supporting system, and it is nearly coexists with other type of genital prolapse such as cystocele, rectocele, and enterocele. Therefore, the reconstructive surgery for uterovaginal or vaginal prolapse is just a part of the total repair of the pelvic floor, which is necessary for restoration of the normal anatomy and function. The length of the vagina in a normal adult female is approximately 10 - 12 cm.

In a standing female, her lower 1/3 of the vagina is pointing 90 degree to the floor and her upper 2/3 of vagina is in an angle almost parallel to the floor and directly toward her lower backbone. The vagina is basically supported on three different levels in the pelvis. The support of the upper 1/3 of vagina comes from the uterosacral ligaments, a pair of very strong fibromuscular structures that originate from lateral aspects of sacrum (the lowest part of our spine), going around the rectum and attaching to the cervix (the mouth of womb), and upper part of vagina.

These ligaments pull the top of vagina and cervix toward the sacrum and forms the normal axis of vagina. The middle third of the vagina is held in place by the lateral attachments of the fascia to the pelvic side wall. The lower third of vagina is blending into and merging with the fibromuscular tissue surrounding the opening of the vagina and anus.

It is of utmost importance for the readers to understand that the uterus, per se, has no bearing or effect on the vaginal support. In other words, a hysterectomy should not be considered as part of repair surgery for uterovaginal or vaginal prolapse unless there is distinct pathology of the uterus. In order to restore the vaginal depth and axis, all three levels of support must be attended at the time of surgery.