IntroductionChapter 1

As with the usual old age menopausal prolapse, young nulliparous prolapse also have weakness of almost all the compartments of vagina, anterior, posterior, central or apical. All the defects should be evaluated properly in preoperative workup so that each one should be covered while 2doing conservative surgery. Leaving any compartmental defect while doing conservative surgery potentiates the chance of early recurrence. Not only this, one should try to find out the risk factor responsible for this problem so that it can also be modified if possible.

Among the conservative procedures we have suspension operations using different types of slings called as hysteropexy or cervicopexy. Dr VN Shirodkar is one of the pioneers in the field of conservative suspension surgery in cases of young prolapse. He used to use fascia lata femoris to strengthen the utero-sacral ligament and fixation is done with sacral promontory retro-peritoneally, forming the bilateral posterior slings.

Many suspension or sling operations have been designed for the young women suffering from second or third degree prolapse and who desire to retain their childbearing and menstrual functions. Such suspensions are called “hysteropexy” when uterine body is suspended with the ligamentous or bony supports and “cervicopexy” when the cervix is held up with the help of slings or tapes.

Suspensions or slings are further categorized as anterior, posterior or composite depending upon weather the uterus is held up to the structures of ventral aspect as abdominal wall or to the structures of dorsum as sacrum.

In posterior suspension operations, uterus or cervix is held up with the anterior sacral ligaments at the level of sacral promontary, while in anterior suspension operations they are held up to the aponeurosis of anterior abdominal wall or to the anterior superior iliac spine (ASIS). Both slings has their own pros and cons. However, posterior slings are superior choice because they provide more anatomical position to the genital structures. In posterior slings cervix and vagina along with, is pulled up posteriorly towards sacrum which is their normal anatomical direction and prevents the chances of enterocoele also.

Another way of classification of utero-cervical slings is according to the ultimate suspension point either ‘static’ or ‘dynamic’. Anterior abdominal wall slings where the uterus is suspended with rectus sheath or aponeurosis of external oblique are termed dynamic slings, while slings where the suspensory point is bony fixed is called static suspensions.

Dynamic slings where the suspension is made with abdominal wall fascial structures pulls the uterus further up in situations of raised abdominal pressure as coughing, sneezing, or squatting, etc. under the effect of contracting rectus abdominis muscle but they have higher chances of recurrence in long-term as with time fascial weakness supervenes. Static suspensions provide more strong bony point suspension with less chances of recurrence.

The objective of these uterine conservative suspension operations is to buttress the weakened supports like Mackenrodt and uterosacral ligaments by providing substitutes in the form of homologous or heterologous fascial slings. In the earlier (original) operations, the fascial strips from rectus sheath, aponeurosis of external oblique, fascia lata or other musculofascial slings were taken from the patients own tissues and 3were successfully used. Because tensile strength of these human body tissues is not consistent and decreases with the passage of time, toll of subsequent childbirth and age related weakenings. These tissue slings often get lengthened out with time, due to their inherent weakness, followed by uterine descent and prolapse used to recur after sometime.

Heterologous slings are the slings made up of either fascial tissues taken from the other species or animals as ox dura, or porcine dermis, etc. or synthetic materials like nylon, polypropylene, Mersilene mesh and the latest is Dacron tapes. Natural heterologous slings have the same problem as with homologous sling of getting weak and lengthened with time, along with high chances of tissue reactions and rejection therefore does not serve the purpose and are not used now a days.

To overcome this synthetic inorganic material slings has come up substituting the natural autologous and heterologous fascial slings because they are uniformly processed and are of consistent strength.

Problem with these synthetic materials as nylon, mersilene and teflon, etc. is that they produce the indissoluble fibrosis with the surrounding tissues, making the removal or any subsequent surgery difficult. The patient's healing tissue enters in between the mesh fibres and fibrosis develops which although reduces the chances of recurrence to a minimal, but a repeat operation as caesarian section or hysterectomy in future can be troublesome and complicated in such cases.

The latest silastic sling containing fine woven Dacron in the form of thin ‘tape’, which provokes only a fine sheath reaction, and surrounding tissue do not enter into any fibrosis, so the sling remains free and can be removed easily if required is said to be the best option at present.

Common conservative uterine or cervical sling operations in practice includes: