Course Philosophy

Surgical Philosophy Of This Skills Workshop

Genital prolapse and urinary incontinence are amongst the most prevalent problems in women’s health. Gynaecologic surgeons traditionally viewed prolapse in mechanically simplistic terms, as just a stretching of the endopelvic fascia. Hence, surgical strategies centred on techniques for plicating “thinned” vaginal walls or shortening “weakened” apical ligaments. The true defects causing prolapse went unnoticed and unrepaired. Although traditional colporrhaphy delivers reasonable symptom relief, the rates of recurrent prolapse and persistent incontinence are unacceptable. Moreover, “success” is sometimes achieved at a cost of compromised coital function. 

Recent anatomic research has shown that normal pelvic relationships depend upon several complementary mechanisms, which serve as a ‘fail-safe’ back up system. Primary support for the pelvic contents comes from the muscles of the pelvic diaphragm, which create a horizontal levator plate, a narrow urogenital hiatus, and sharp urethro-vesical / ano-rectal angles.  In this orientation, Valsalva pressure waves pin the bladder, vagina and rectum against a dynamic backstop created by the simultaneous contraction of the levator ani muscles.  Main supportive function of the endopelvic fascia is to anchor the viscera over the pelvic diaphragm. However, neuronal stretch injury during childbirth can transform the levator plate into a flaccid funnel.  Intra-abdominal forces then produce a shearing stress, which slowly propels the pelvic viscera towards a widened urogenital hiatus. The endopelvic fascial continuum can also be damaged by these powerful childbirth forces. Hypertrophy of the endopelvic connective tissue allows pelvic organ support to hold for a time; however, this connective tissues is not designed to resist chronic passive strain and will usually fail over time.