Laparoscopic Pelvic Surgery for Prolapse
A New Surgical Innovation - The Surgery of
the Future Today!
What is Prolapse?
Prolapse refers to the extrusion of a mass through the vagina. This creates
discomfort in walking, as well as, causing a feeling of pressure. On occasion, this
prolapsed mass can ulcerate and cause bleeding. The medical terms for prolapse include:
Cystocele, Rectocele, Enterocele, Procidentia and/or Uterine Prolapse. In the early stages
of prolapse, it is seen at the end of the day after exertion, but reduces itself in the
evening upon lying down. In the later stages, it remains out all the time. It also
interferes with the ability to completely empty the bladder, or have a bowel movement
without pushing the prolapse out of the way. Sometimes prolapse happens many years after
an abdominal or vaginal hysterectomy. In such cases the uterus has already been removed,
but insufficient support of the vagina causes eversion, very much like extruding one's
What is the Cause?
Prolapse is usually associated with weakening of the muscles during pushing at
childbirth. Around the time of menopause estrogen production by the body is reduced,
leading to further weakening of the vaginal muscles and prolapse is most commonly seen
around that time.
Associated Stress Incontinence
Prolapse may also be associated with urinary stress incontinence, where during
coughing or other physical activity urine leaks. The cause is similar due to weakening of
the urethral support.
What is Laparoscopy?
During laparoscopy, a laparoscope -- the surgical instrument -- is inserted
through the belly button. The laparoscope is a telescopic camera which provides
visualization of the abdomen. Surgery performed using a laparoscope usually requires three
to four small, quarter-inch incisions for insertion of additional surgical instruments.
Traditional surgery requires one large incision several inches in length.
Traditional Treatment - Non-Surgical
In the past, various forms of pessaries (a device worn in the vagina) were used
to prevent the extrusion of prolapse and these pessaries then had to be changed every
month. Today, this form of therapy is unacceptable to most women, except those who are
infirm and unable to ambulate. For the rest who lead active lives, surgery presents a much
Prolapse surgery has traditionally been performed by the vaginal route and has variously
been termed Anterior Repair, Posterior Repair, Repair of Enterocele, and/or Vaginal Vault
Suspension. However, when vaginal surgery results in recurrence of prolapse, an abdominal
operation has to be resorted to, where synthetic mesh is attached to the vagina and to the
sacral bone. This has traditionally been done through a large abdominal incision.
Laparoscopic Reconstructive Surgery
Today, in specialized centers, all forms of prolapse can be treated laparoscopically with
much better suspension of the vagina. This is because the suturing of the vagina can be
attached much higher up in the abdominal cavity, then is possible when working from below
in the vaginal area. Hysterectomy can also be performed laparoscopically, if needed, and
combined with the prolapse operation. The contemporary approach includes cystocele and
paravaginal repair performed laparoscopically; culdoplasty for enterocele with shortening
of the uterosacral ligaments; and in the case of post-hysterectomy prolapse, sacral
culpopexy is performed where a synthetic prolene mesh is sewn to the top of the vagina and
then sewed or tacked onto the sacral bone, pulling the vagina upwards and backwards in its
normal position. This results in repair of the prolapse with little risk of recurrence.
Recently, we have begun to employ this as a primary procedure after laparoscopic
hysterectomy, in women whose uteri have prolapsed out of the vagina. Pelvic reconstructive
surgery by laparoscopy is a new discipline and the doctors at the Milwaukee Institute of
Minimally Invasive Surgery (MIMIS) are involved in teaching the art to other doctors.
There are only about 10-15 centers nationwide where this is being practiced. Total
Laparoscopic HysterectomyIn this operation, removal of the uterus and closure of the
vagina is done laparoscopically. At the same time, other procedures may be performed to
support the vagina to the uterosacral ligament (High McCall) or sacral culpopexy in order
to prevent future chances of prolapse.