A Stepwise Approach to Lefort Colpocleisis

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Video Description

Objective: The objective of this educational video is to describe the technique and required equipment for performing a LeFort partial colpocleisis using surgical footage as well as a low cost surgical model.

Methods: Using surgical footage and low-cost surgical model, we demonstrate a LeFort partial colpocleisis in six steps.

  1. Proper patient positioning
  2. Mark rectangular resection area
  3. Dissect and resect vaginal epithelium
  4. Place red rubber catheter to allow for lateral channels
  5. Reduce prolapse using sequential pursestring sutures
  6. Perineorrhaphy

Conclusion: Pelvic organ prolapse affects the quality of life of many patients, and one in nine will require corrective surgery by the age of 80. LeFort partial colpocleisis is a highly successful, minimally invasive surgical approach that is indicated in patients with pelvic organ prolapse who are no longer having vaginal intercourse and/or have comorbidities that prohibit a more extensive procedure.

This video provides a stepwise approach to performing a LeFort partial colpocleisis.

Presented By

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Dr. Samantha Benlolo
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Dr. Elizabeth Miazga
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Dr. Annette Epp
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Dr. Alysha Nensi
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Dr. Dana Soroka

Affiliations

St. Michael’s Hospital, University of Toronto

See Also

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Video Transcript: A Stepwise Approach to Lefort Colpocleisis

We present a video on A Stepwise Approach to LeFort Colpocleisis. The objective of this educational video is to describe the technique and required equipment for performing a Lefort partial colpocleisis, using surgical footage as well as a low-cost surgical model. 

Pelvic organ prolapse is very common, with one in nine women requiring corrective surgery by the age of 80. The management approach depends on symptomology, age, medical comorbidities, recurrence risk and desire for sexual function or fertility. 

Conservative treatment includes lifestyle modification like weight loss and smoking cessation, pessaries and pelvic floor physio. Surgical treatment consists of reconstructive procedures as well as obliterative procedures like LeFort partial colpocleisis and complete colpocleisis. This video will focus on LeFort’s partial colpocleisis. 

LeFort is indicated in patients with prolapse who are no longer having vaginal intercourse and/or have comorbidities that prohibit a more extensive procedure. It’s associated with high success rates and low recurrence rates. 

Preoperatively, patients should undergo endometrial sampling as well as a pap test, if indicated, as the uterus will no longer be accessible following surgery. Assessment for latent stress urinary incontinence should also be performed. If stress incontinence is detected, an anti-incontinence procedure can be performed at the time of the surgery. 

Equipment needed includes a heavy weighted speculum, Deaver retractors, two double tooth tenacula, a number ten scalpel, a Foley catheter as well as a rubber catheter, four Allis clamps and three Kocher clamps, a sterile marking pen, and Metzenbaum scissors. 

The six surgical steps include number one, proper patient positioning. Number two, mark the resection area. Dissect and resect the vaginal epithelium. Then, placement of the red rubber catheter. Number five is to reduce their prolapse using sequential purse-strings and close the vaginal mucosa. Lastly, perineorrhaphy. 

We will now go into detail in all of these steps: 

Step One 

Patient positioning. The patient is placed in a high lithotomy position. A Foley catheter is inserted into the bladder and is kept there for the duration of the case. The anterior and posterior lips of the cervix are grasped with double tooth tenacula. 

Step Two

A sterile marking pen is used to draw a rectangle on both the anterior as well as the posterior surfaces of the vaginal mucosa 2 cm from the cervix. Care is taken to ensure enough mucosa is left to allow for the creation of lateral channels for future drainage of bladder discharge. 

Step Three

A number ten scalpel is used to dissect along the previously marked rectangular area. The mucosa is then grasped in the midline, and Metzenbaum scissors are used to undermine it in a distal to proximal fashion, with the tips of the scissors always facing upwards. 

The mucosa is then cut along the midline, dividing the rectangle into two halves to allow for easier dissection. Allis clamps are then placed along the cut edge to provide traction and aid with the dissection of the mucosa off the pubocervical fascia. Here, the principle of traction and counter traction is essential. Sharp dissection is then continued to the previously cut lateral margins of the rectangle. Once the lateral border is reached, the excess mucosa can then be trimmed off. 

The same step is then performed on the other half of the rectangle. This marks the lateral edge of the rectangle on the patient’s left side, and the excess mucosa can also be trimmed. The anterior rectangle has now been completely resected, and we are left with the exposed pubocervical fascia. The exact same procedure is then carried out along the posterior rectangle. 

Step Four

Securing the red rubber catheter. A red rubber catheter is placed at the level of the cervix and secured in place by suturing the distal cut edges of the anterior and the posterior rectangles to one another. This can be done with a delayed absorbable suture. 

When securing the midline, the red rubber catheter is fastened along the lateral edges in the same fashion. The sutures are placed in a distal to proximal direction along the length of the remaining vaginal mucosa. Prior to reducing the prolapse, care is taken to ensure that the red rubber catheter can continue to move freely. 

Step Five

Reducing the prolapse and closing the mucosa. The prolapse, including the cervix and the uterus, is then sequentially reduced using a series of purse-string sutures, spaced approximately 1 cm apart. This can be done with a delayed absorbable suture. Prior to tying the suture, a blunt forcep, such as Russians, are used to help further reduce the prolapse and keep it in place. 

Once the prolapse is completely reduced, the mucosal cut edges can then be reapproximated to one another using a delayed absorbable suture. This is done in a simple interrupted fashion along the length of the vaginal mucosa. 

Step Six 

Perineorrhaphy. Prior to performing a perineorrhaphy, we once again ensure that the red rubber catheter is freely mobile. Next, a perineorrhaphy is performed. Kocher clamps are placed at the lateral edges of the genital hiatus and a triangle is dissected along the perineal body with a ten blade scalpel. 

Mayo scissors are then used to access the bulbocavernosus muscle on both sides. The posterior vaginal mucosa, underlying connected tissue and muscle are reapproximated in the usual fashion. Finally, the red rubber catheter is tied and then trimmed and placed in the vagina. A digital rectal exam is performed at the end of the procedure. 

Postoperatively, the patient is admitted overnight. The urinary catheter is removed on postoperative day one, while the red rubber catheter is kept in situ to ensure patent lateral channels. It is removed in the clinic two weeks postoperatively. 

In summary, LeFort colpocleisis is a highly successful obliterative procedure for pelvic organ prolapse in select surgical candidates. Thanks for your attention.