Supports of the Uterus & Uterine Prolapse

(As per Sheila Balakrishnan — Clinical Obstetrics & Gynaecology)

I. SUPPORTS OF THE UTERUS

A. Active Support (Most Important)

1. Pelvic Floor Muscles (Levator Ani)

• Pubococcygeus — the most important component; forms a sling around the vagina, urethra, and rectum
• Iliococcygeus
• Ischiococcygeus (Coccygeus)

Sheila emphasizes that levator ani is the most important support of the uterus. It maintains the pelvic floor by keeping the vaginal axis near-horizontal, so that increased intra-abdominal pressure compresses the vagina against the pelvic floor rather than pushing it through the introitus.

B. Passive Supports (Ligaments & Fascia)

1. Transverse Cervical (Cardinal) Ligament — Mackenrodt's Ligament

• Most important of the passive supports
• Condensation of endopelvic fascia extending from the cervix and upper vagina to the lateral pelvic walls
• Contains the uterine vessels
• Prevents lateral and downward displacement of the uterus

2. Uterosacral Ligaments

• Pass from the posterolateral aspect of the cervix to the sacrum (S2, S3, S4)
• Maintain the anteverted position of the uterus by pulling the cervix backwards and upwards
• With the cardinal ligaments, form the parametrium

3. Round Ligaments

• From the uterine cornu → pass through the inguinal canal → attach to the labium majus
• Maintain anteversion of the uterus
• Least important supports — they are not strong enough to prevent prolapse; they become elongated and hypertrophied in retroverted uteri

4. Broad Ligaments

• Double folds of peritoneum on either side of the uterus
• Provide minimal mechanical support; mainly carry blood vessels, lymphatics, and nerves
• Not true supports of the uterus

5. Pubocervical Fascia

• Endopelvic fascia between the bladder and the anterior vaginal wall
• Supports the bladder and anterior vaginal wall

6. Rectovaginal (Denonvilliers') Fascia

• Endopelvic fascia between the rectum and the posterior vaginal wall

Summary Table of Supports

II. UTERINE PROLAPSE

Definition

Aetiology (Sheila's Classification)

• Multiparity with difficult/prolonged labour → damage to levator ani and ligaments
• Chronically raised intra-abdominal pressure (chronic cough, constipation, heavy lifting)
• Oestrogen deficiency (post-menopausal atrophy of supporting tissues)
• Congenital weakness of supports
• Racial factors (more common in Asian and African women in some studies; Sheila notes it is common in Indian women)

Degrees of Uterine Prolapse

In procidentia, the bladder (forming a cystocele) and rectum (forming a rectocele) are also prolapsed along with the uterus. The cervix may show hypertrophy, elongation, ulceration (decubitus ulcer), or infection from exposure.

Associated Prolapse Conditions

Symptoms

• Dragging discomfort / heaviness in the pelvis ("something coming down")
• Backache — low sacral, relieved by lying down
• A lump at or outside the vaginal introitus
• Urinary symptoms — frequency, stress urinary incontinence, difficulty voiding
• Bowel symptoms (in rectocele) — constipation, need to digitally reduce the rectocele to defecate
• Coital difficulty
• Ulceration/bleeding — from exposed cervix in procidentia (decubitus ulcer)

Management (Sheila's Approach)

Conservative

• Pelvic floor exercises (Kegel's) — for mild cases and prevention
• Pessary (ring pessary) — for those unfit for surgery, during pregnancy, or awaiting surgery
  • Silicone ring inserted into vagina to mechanically support the prolapse
  • Needs to be changed every 4–6 months
  • Shelf pessary for procidentia

Surgical

Sheila particularly emphasizes the Manchester (Fothergill) operation as the classical operation for uterine prolapse when the uterus is to be conserved — consisting of: anterior colporrhaphy + amputation of the elongated cervix + suturing of Mackenrodt's ligaments in front of the stump + posterior colpoperineorrhaphy.

Key Points to Remember (Sheila)

1. Levator ani is the primary and most important support of the uterus
2. Mackenrodt's ligament is the most important ligamentous support
3. Round ligaments only maintain anteversion and are the least important
4. Procidentia = 3rd degree prolapse = complete uterine prolapse outside the introitus
5. A decubitus ulcer on the exposed cervix must be differentiated from cervical carcinoma by biopsy before surgery
6. Cystocele is the most common associated prolapse with uterine prolapse

Steps of Hysterectomy

(As per Sheila Balakrishnan — Clinical Obstetrics & Gynaecology)

Types of Hysterectomy

I. TOTAL ABDOMINAL HYSTERECTOMY (TAH)

Pre-operative Preparation

• Patient in supine position under general/spinal anaesthesia
• Catheterisation of the bladder
• Abdomen cleaned and draped
• Pfannenstiel or lower midline incision

Steps

Step 1 — Opening the Abdomen

• Pfannenstiel (transverse) incision is most common
• Lower midline incision for large uteri or malignancy
• Layers opened: skin → subcutaneous fat → rectus sheath → rectus muscles retracted → peritoneum opened

Step 2 — Exploration

• Assess the uterus, adnexa, bowel, and pelvic organs
• Pack bowel away with moist packs
• Place self-retaining retractor (e.g., Balfour)

Step 3 — Securing the Uterus

• Two strong Kocher clamps applied on either side of the uterus at the cornua (incorporating round ligament, fallopian tube, and ovarian ligament)
• These provide traction and haemostasis

Step 4 — Division of the Round Ligaments

• Round ligament on each side is clamped, cut, and ligated with No. 1 Vicryl
• This opens the broad ligament and provides access to the retroperitoneal space

Step 5 — Opening the Broad Ligament & Identifying the Ureter

• Anterior and posterior leaves of the broad ligament are opened
• The ureter is identified at the pelvic brim as it crosses the bifurcation of the common iliac artery — this is the most critical step to prevent ureteric injury

Step 6 — Dealing with the Adnexa

• The infundibulopelvic ligament is NOT cut
• The fallopian tube and ovarian ligament are clamped, cut, and ligated close to the uterus

• The infundibulopelvic (IP) ligament (containing ovarian vessels) is clamped, cut, and ligated
• Ureter must be clearly identified before clamping the IP ligament

Step 7 — Reflection of the Bladder

• The utero-vesical peritoneum (bladder peritoneum / bladder flap) is identified and incised transversely
• Bladder is gently pushed down off the lower uterine segment and cervix using a swab on a sponge-holding forceps
• This step protects the bladder during clamping of the uterine vessels

Step 8 — Clamping the Uterine Vessels (Most Important Step)

• The uterine artery and veins are clamped at the level of the internal os, perpendicular to the uterus
• Curved Heaney or Zeppelin clamps are used
• The pedicle is cut and ligated (suture ligation with Vicryl)
• The ureter passes 1.5 cm lateral to the cervix and below the uterine artery ("water under the bridge") — must be protected here

Step 9 — Clamping the Cardinal and Uterosacral Ligaments

• Mackenrodt's (cardinal) ligament is progressively clamped, cut, and ligated on each side
• Uterosacral ligaments are clamped, cut, and ligated
• These steps bring the surgeon down to the level of the vaginal vault

Step 10 — Opening the Vagina and Removing the Uterus

• The anterior vaginal wall is incised with scissors just below the cervix
• Curved clamps are placed on the vaginal angles on each side to prevent bleeding from descending cervical branch
• The cervix is circumcised from the vagina; the uterus is removed
• The vaginal cut edges are inspected

Step 11 — Closing the Vaginal Vault

• The vaginal vault is closed with interrupted or continuous Vicryl sutures
• The uterosacral and cardinal ligaments are incorporated into the angles of the vault for support (prevents vault prolapse)
• Some surgeons leave the vault open (open vault technique) for drainage

Step 12 — Reperitonealization and Closure

• The pelvic peritoneum may be closed (or left open — both acceptable)
• Check haemostasis thoroughly
• Bladder is checked — ensure it is intact
• Abdominal wall closed in layers
• Drain placed if needed

Anatomical Danger Points (Sheila emphasizes)

Sheila's mnemonic for the ureter: "Water under the bridge" — the uterine artery crosses OVER the ureter (artery is superior, ureter is inferior and lateral to the cervix).

II. VAGINAL HYSTERECTOMY (VH)

Steps

Step 1 — Position & Preparation

• Lithotomy position
• Catheterise the bladder
• Anterior and posterior vaginal walls retracted

Step 2 — Circumferential Incision around the Cervix

• A circular incision is made in the vaginal mucosa around the cervix at the cervicovaginal junction
• The bladder is pushed upwards anteriorly
• The posterior peritoneum (pouch of Douglas) is opened posteriorly first

Step 3 — Opening the Pouch of Douglas

• Pouch of Douglas (rectouterine pouch) entered posteriorly
• A retractor is placed into the peritoneal cavity to retract bowel

Step 4 — Opening the Utero-vesical Pouch

• The utero-vesical peritoneum is identified and opened anteriorly
• The bladder is mobilised upwards

Step 5 — Clamping the Uterosacral and Cardinal Ligaments

• Uterosacral ligaments — clamped, cut, and ligated on each side
• Cardinal (Mackenrodt's) ligaments — clamped, cut, and ligated

Step 6 — Clamping the Uterine Vessels

• Uterine arteries clamped, cut, and ligated bilaterally

Step 7 — Dealing with the Adnexa

• If ovaries conserved: fallopian tube + ovarian ligament clamped, cut, ligated
• If oophorectomy: IP ligament clamped, cut, ligated

Step 8 — Removal of Uterus

• Uterus delivered through the vagina (fundus last)
• If uterus is large — morcellation or bisection may be needed to deliver it

Step 9 — Vault Closure and Pelvic Floor Repair

• Vaginal vault is closed incorporating uterosacral ligaments for support
• Anterior colporrhaphy (for cystocele) and posterior colpoperineorrhaphy (for rectocele) are performed as needed
• This is the pelvic floor repair done simultaneously in prolapse cases

III. WERTHEIM'S RADICAL HYSTERECTOMY

1. All steps of TAH
2. Removal of parametrium (lateral to the cervix) widely
3. Upper 2–3 cm of vagina removed
4. Bilateral pelvic lymph node dissection (obturator, external iliac, internal iliac, common iliac nodes)
5. Ovaries may be conserved in young women

Key Points Summary (Sheila)