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Perioperative management - Supracervical hysterectomy, cervicosacropexy with gyno-mesh, bilateral adnexectomy, and anterior colporrhaphy, laparoscopic

gynecology
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Anatomy Perioperative management Technique Complications Evidence Total Video

  1. Medical History

    • Specific pelvic floor symptoms: Severity and impact on quality of life
    • Personal, family, obstetric, and social history: Pregnancy and birth course, genetic predisposition
    • Previous conservative and surgical therapy: Pelvic floor training, pessary therapy, previous surgeries
    • Sexual function and quality of life: Dyspareunia, limitations in intimacy
    • Social and occupational factors: Heavy physical labor as a risk factor
    • Comorbidities: Obesity, COPD, constipation, connective tissue disorders (e.g., Marfan syndrome), nicotine abuse
    • Medication history: Influence of medications on continence and defecatory functions (antidepressants, diuretics)

     

  2. Clinical Examination

    • Inspection of the external genitalia: Descent, fistulas, malformations, tumors
    • Speculum examination: Assessment of vaginal skin, degree of estrogenization, descent diagnostics
    • Palpation: Pelvic floor tone, levator avulsion, sphincter tone
    • Cough stress test: Detection of stress incontinence with and without repositioning of the prolapse
    • Urinalysis: Dipstick test, urine culture if infection is suspected
    • Residual urine determination: Sonographically or with a single-use catheter to assess bladder emptying

    Genital prolapse is classified into different grades that describe the extent of the prolapse. The common classifications are:

    ICS/IUGA Standardization (International Continence Society/International Urogynecological Association):

    • Stage 0: No descent visible or palpable.
    • Stage 1: The lowest point of the descent is more than 1 cm proximal (inside) to the hymenal ring.
    • Stage 2: The lowest point of the descent is between 1 cm proximal and 1 cm distal (outside) to the hymenal ring.
    • Stage 3: The lowest point of the descent is more than 1 cm distal to the hymenal ring, but not a complete prolapse.
    • Stage 4: Total prolapse of the uterus and/or vagina.

    Commonly used clinical grading:

    • Grade I: Descent within the vagina.
    • Grade II: Descent reaches the introitus vaginae (vaginal opening).
    • Grade III: Descent extends beyond the introitus vaginae.
    • Grade IV: Total prolapse of the uterus and/or vagina.

  3. Further preoperative diagnostics

    • Sonography: Pelvic floor, introitus, perineal, and vaginal sonography for the diagnosis of prolapse
    • Dynamic MRI: For complex findings for comprehensive assessment
    • Urodynamics: Differentiation between urge and stress incontinence
    • Cystourethroscopy: In cases of unclear hematuria or bladder complaints to clarify tumors or bladder stones

  4. Preoperative Information

    Clinical Picture: Explanation of the causes and symptoms of genital prolapse

    Treatment Options:

    • Conservative Therapies: Education on alternative treatment methods, pelvic floor training, pessaries
    • Surgical Procedures: Vaginal, abdominal, laparoscopic, robot-assisted methods, use of mesh or autologous tissue
    • Success Rates: Prognosis related to anatomical and functional outcomes
    • Need for Additional Interventions: Possibly accompanying incontinence surgery (masked stress incontinence)

    Possible Complications: 

    • Mesh complications
    • Impact on bladder and bowel function
    • Wound healing disorder
    • Infection, rarely intra-abdominal abscess requiring revision or percutaneous drainage
    • Postoperative ileus
    • Adhesions
    • Injuries to other organs, intestines, bladder, ureters 
    • Subcutaneous emphysema
    • Post-laparoscopic shoulder pain syndrome
    • General surgical risks (bleeding, rebleeding, thrombosis, embolism, HIT)
    • Possible conversion to open technique in case of complications
    • Continued need for preventive examinations
    • Urinary retention
    • Positioning injuries
    • Burns
    • Dissemination of benign as well as malignant cells, in rare cases worsening of prognosis in malignancy
    • Sexual function: Possible changes due to the surgery

    Possibility of a Second Opinion: Consultation through a specialized center

  5. Preoperative Preparation

    • no preoperative bowel evacuation
    • no shaving
    • antibiotic prophylaxis during induction of anesthesia (second-generation cephalosporins and metronidazole)

  6. Postoperative Phase

    Early Phase (0-7 Days)

    • Pain management: NSAIDs and opioids as needed
    • Thrombosis prophylaxis: Early mobilization, possibly anticoagulation
    • Urinary catheter: In the first days, until spontaneous bladder emptying is ensured
    • Wound control: Regular inspection for infections or hematomas
    • Bowel regulation: High-fiber diet, laxatives to prevent constipation
    • Avoidance of heavy physical exertion: No lifting of heavy loads, no straining

    Intermediate Phase (Week 2-6)

    • Gentle mobilization: Walks and light daily movement
    • No pelvic floor training: Only after complete wound healing, at the earliest after 6 weeks
    • Possibly estrogen therapy: In case of postoperative vaginal atrophy
    • Avoidance of sexual intercourse: Until complete healing (at least 6 weeks)

    Long-term Follow-up (from Week 6)

    • Regular follow-up examinations: Assessment of surgical success, prevention of recurrences
    • Pelvic floor training: Only after complete healing to support the musculature
    • Evaluation of postoperative complaints: Incontinence, recurrent prolapse, pain
    • Further therapies: If necessary, renewed conservative or surgical measures