Ladies and gentlemen, I would like to introduce you to an interesting case which was resolved in our department. Pelvic organ prolapse is a very prevalent condition affecting up to half of women over the age of 50. By the age of 80, 11% of US women have undergone surgery for pelvic floor disorders. In 1877, Lefort described a technique of denuding segments of the anterior and posterior vaginal walls and then suturing them together, creating lateral channels. Obliterative surgery can be an option for women with larger prolapse who are not sexually active and don't plan to be so in the future. The patient was 61 years old. She had suffered from pelvic organ prolapse. The recommended solution was colporaphia anterior and colpoperineoplasty, which was performed in the year 1989. Two years later, the senses of the uterus was assessed. The laparoscopic hysterectomy was performed. In the year 2002, a recurrence of systocele and rectoenterocele was assessed and new re-operation was indicated. Polypathy anterior and colpoperineoplasty were performed. Four years later, in the year 2016, a recurrence of systocele and rectoenterocele were indication for new operations. The prolifed anterior and posterior were performed. Patient suffered from pelipathy after the operations. Considerable pain was associated with the prolifed posterior position and its arms. In April 2007, the next re-operation was the removal of the prolifed posterior. A year later, the senses of the vaginal apex was an indication for abdominal fixation of the vaginal apex to sacrouterine and ligamentum teres ligaments. In January 2009, spacing of the vaginal apex was an indication for its laparoscopic suture. In September 2016, the laparoscopic approach was used to treat vaginal hernia in the posterior vaginal wall. In March 2017, the recurrent anterocele was resolved by Lefort and Labhart colpoclases. After one year, the effect of the operation had failed and recurrent anterocele was assessed. The situation was an indication for recurrent Lefort with perineal skin flap and Labhart colpoclases. This picture depicts a modification of the Lefort procedure with perineal skin flap. The first step of this operation is transversal incision in the introitus. Skin incision is used to prepare a rectangular perineal skin flap. Subsequently, the skin between the skin flap and the incision in the introitus was separated from the surrounding tissue. The skin flap was removed through the tunnel in the vagina. The upper part of the skin flap was fixed to upper part of the vaginal mucosa. Next, resolvable vicryl stitches were used to suture the posterior vaginal wall with the lateral edges of the skin flap and anterior vaginal wall creating lateral channels. This video shows Lefort colpoclases with a skin flap. The first step of this modification of Lefort procedure with perineal skin flap is placement of 420 vicryl resolvable stitches into scar after laparoscopic assisted vaginal hysterectomy. Then transversal incision was performed in the introitus. A skin incision prepares a rectangular perineal skin flap 3.5 x 4 cm in size. Subsequently, skin was separated between the skin flap and the incision in the introitus and a tunnel was created. The skin flap was removed through the tunnel in the vagina. The upper part of the skin flap was fixed to the upper part of the vagina with previously positioned vicryl stitches. Next, vicryl stitches were used to fix the distal part of the skin flap to the distal part of posterior vaginal mucosa. Skin resolvable vicryl stitches were employed to suture the posterior vaginal wall with lateral edges of the skin flap and the anterior vaginal wall, creating lateral channels. A foley catheter was placed into urethra. The distal section of the posterior vaginal wall is sutured with the distal part of skin flap and anterior vaginal wall. Then a standard lab heart procedure was performed, a transverasal incision was made in the introitus and then the incision was sutured into sagittal plane. The last step of surgery was suture of subcutaneous tissue and skin with two zero-vicryl resolvable stitches, which closed the defect on the perineum. The postoperative course was uneventful. The foley catheter was removed three days after surgery. A follow-up visit after two months later revealed excellent healing. Ultrasound examination shows the position of the skin flap in the vagina during Valsalva maneuver, how this flap restrict descent of posterior vaginal wall. Ultrasound examination shows perfusion in the flap. Effect and healing of Lefort surgery with perineal skin flap after two months. Obliterative surgery can be an option for women with larger prolapse who are not sexually active and don't plan to be so in the future. The most frequent treatment of recurrent prolapse after Lefort colpoclases is total colpoclases. Treatment of Lefort with perineal skin flap and love heart colpoclases is one possible surgical technique which can treat recurrent pelvic organ prolapse in older patients where previous procedures failed and the mesh had to be removed. This method can be used when the problem is with ingrow of foreign implants to surrounding tissue or when the quality of vaginal tissue is too poor for the fixation of stitches.

treatment options

pelvic organ prolapse

Lefort procedure

perineal skin flap

recurrent prolapse