240. Nepal Day 7 part 2

Three cases today:
1. 60 year old with complete uterine prolapse (the ligaments that suspend the uterus are so stretched that the uterus has fallen first into and then outside the vagina. During surgery the small atrophic uterus is removed (my part) and then the gyn urologist does her part, elevating the vagina and tying it to a ligament near the spine .  A tedious procedure (because many sutures are required in hard-to-see spaces) for the the surgeon and for the assistant as well (that be me).

2. 38 year old with a weak rectal-vaginal septum (wall) that protrudes into the vagina and interferes with normal bowel function. Like a seamstress's dart, skin is brought together and redundant tissue removed.

3. 65 year old also with complete prolapse but in this non-sexually active (and never expecting to be) woman, removal of the uterus then closure of the vaginal opening is the safest route.  First the surface skin layer is removed from the vaginal ceiling and the vaginal floor. These exposed areas brought together with suture.  When healed they will form a strong wall that essentially closes the vaginal opening.

One would think that complete prolapse would make for easy hysterectomies since the primary target of the procedure--the uterus--is right there, easy to see and manipulate. But not so; the descent distorts normal anatomy (so blood vessels and other structures are not exactly where you think they should be). And the many year exposure to the outside environment toughens and thickens the vaginal skin.  Compare the peeling of a naval orange (normal anatomy) to a juice orange.