Dr. Hall is one of the few pelvic surgeons in Southern California who is equally comfortable performing vaginal, laparoscopic, or open abdominal surgeries for female pelvic reconstruction. Route of surgery depends on multiple factors, such as the anatomy and complaints of that particular woman, the need for other procedures (such as hysterectomy with large fibroids), the woman’s age or functional status, the strength of the woman’s native tissues, and of course the patient’s wishes.
Midurethral slings. Often appropriate treatment for stress urinary incontinence, sling procedures (also called pubovaginal slings), are surgically placed to provide support to the bladder neck and urethra. Slings vary in size, material and durability. Slings have been used for 40 years for patients with severe and refractory stress urinary incontinence and 10 years ago were modified to provide a minimal invasive option for treatment. Midurethral slings can be placed vaginally in about 30 minutes. If done without additional procedures, the patient goes home the same day, has minimal post-operative pain, and can resume work within a few days. Slings can be combined with other reconstructive pelvic surgery according to the anatomy and symptoms of the patient.
Anterior and posterior repair with and without grafts. Anterior repair is a procedure that reduces vaginal bulge for the correction of cystocele (bladder prolapse). Posterior repair is used to treat rectocele (rectum or large bowel prolapse). Both procedures are performed vaginally. A traditional anterior or posterior repair utilizes the patient’s own tissues to reduce the prolapse. When the tissue is especially weak, grafts, both biologic and synthetic are sometimes used to supplement the patient’s tissues to improve outcomes, especially for recurrent prolapse.
Using grafts for vaginal repair. Mesh is used to support the front and/
or back walls of the vagina, especially if the patient’s own tissue is very weak. The use of mesh by general surgeons for hernia repair is the gold standard to improve outcomes. The mesh is non-reactive, non-absorbable and generally provides long lasting relief. Using synthetic grafts placed vaginally does result in higher rates of mesh erosion, in which case, it is required to perform a minor procedure to remove the portion of exposed mesh. There are other potential complications and your physician will discuss the various options with you to help make the best mutual decision for your care.
Perineorrhaphy. After childbearing, the entrance of the vagina (perineum) can be torn or weakened. This may result in a widening of the vagina, resulting in a higher risk of prolapse or sexual dysfunction. By reapproximating the lateral muscles, support is restored to this area.
Vaginal hysterectomy. A vaginal hysterectomy, when the uterus and cervix are removed through the vagina, is less invasive than an abdominal hysterectomy. It is critical that support is restored to the vaginal apex after performing hysterectomy to minimize the risk of future vaginal vault prolapse and enterocele.
Sacrospinous ligament suspension. For women with vaginal vault prolapse, sacrospinous ligament suspension may be an excellent option. The procedure consists of placing sutures vaginally to suspend the vaginal vault to a strong ligament in the pelvis. This can be done with or without using grafts.
High uterosacral suspension (McCall culdoplasty). If the native ligaments that usually support the uterus and cervix can be located and are adequate, a high uterosacral suspension can be performed. Care must be taken to not compromise the ureters (the tubes carrying urine from the kidneys to the bladder) during this surgery.
Vaginal paravaginal repair. In cases where the anterior vaginal wall and bladder are poorly supported, a paravaginal repair can be performed. This procedure involves suturing the anterior connective tissue or “fascia” to the pelvic sidewall, from which it has detached.
Colpocleisis. Colpocleisis is a procedure only used for women who are not sexually active. In effect, the vagina is closed by sewing the front and back walls together, eliminating most of the vaginal canal. Patients still void and defecate normally and look normal externally. This vaginal surgery has the lowest recurrence rates of all surgeries for prolapse.
Anal sphincterplasty. Anal sphincterplasty is done to corrrect fecal incontinence when the anal sphincter muscle is torn, usually after a difficult vaginal delivery or previous anal surgery. Dr. Hall works with Colorectal Surgeons when sphincterplasty is done in conjunction with other pelvic reconstructive procedures.
Transanal rectal prolapse repair is a minimally-invasive surgical option for rectal prolapse. Transanal rectal prolapse repairs may not have as good success rates as rectopexies in many patients.
ABDOMINAL OR LAPAROSCOPIC PROCEDURES
Many surgeries that have classically been performed abdominally through an incision, can be performed laparoscopically or robotically. Both techniques require greater skill of the surgeon but results in less pain, less scarring, and shorter recuperation time. In the past five years, Dr. Hall has performed more robotic and laparoscopic pelvic reconstructions than open surgeries with excellent success rates.
Laparoscopic hysterectomy or oophorectomy. An oophorectomy, the surgical removal of an ovary (ovaries), is performed in a small percentage of hysterectomies. Laparoscopic hysterectomy can be done in conjunction with laparoscopic sacrocolpopexies or rectopexies (see below) for faster recuperation.
Laparoscopy utilizes a camera and multiple small instruments to perform abdominal surgery with small incisions and SHORTER recuperation.
Abdomino-sacrocolpopexy and perineopexy. This procedure can be done open (usually through a bikini incision) or laparoscopically and repairs vaginal prolapse by anchoring the top of the vagina to the sacrum, the part of the spinal column that is directly connected with the pelvis. An inert mesh is used, similar to what is used for hernia repairs. Sacrocolpopexies have low rates of recurrence compared to some vaginal procedures but are longer surgeries and if done open, have longer recuperation times.
Burch colposuspension and paravaginal repair. Paravaginal repair can be done vaginally or open or laparoscopy by attaching the anterior wall to the pelvic sidewall to correct cystocele. Burch colposuspension corrects cystocele and stress urinary incontinence by restoring normal support to the urethra, bladder and bladder neck.
Rectopexy. This surgery is done for rectal prolapse, sometimes in conjunction with partial colon resection and/or sacrocolpopexy. Dr. Hall works closely with skilled Colorectal Surgeons that can do this procedure laparoscopically, with less pain and faster recuperation.
Periurethral injection of collagen, durasphere, or other materials is designed to partially close the urethra in patents with stress urinary incontinence. This can be done as an initial minimally-invasive option, or in patients who have recurrent urinary incontinence after previous surgeries.
BoTox—Botulism Toxin. Injection of BoTox into the detrusor muscle of the bladder essentially paralyzes part of the muscle and can be effective in cases of refractory overactive bladder.
Sacral nerve stimulation (SNS). Sacral nerve stimulation is a minimally invasive procedure where a wire lead adjacent to pelvic nerves is connected to a neurostimulator (think of it as a bladder pacemaker). The S3 nerve root controls the bladder and urethra, the lower rectum and anal sphincter, and the pelvic floor musculature. SNS can treat a wide range of pelvic floor disorders, such as overactive bladder, voiding dysfunction, and pelvic pain. Its primary indication in Europe is neurogenic fecal incontinence.