Ischemia buy levitra professional 20 mg with mastercard impotence 23 year old, however discount 20 mg levitra professional fast delivery ved erectile dysfunction treatment, produces complex time-dependent effects on the electrical properties of myocardial cells best purchase levitra professional impotence kegel exercises. Severe acute ischemia can reduce the resting membrane potential, shorten the duration of the action potential, and decrease the rate of rise and amplitude of phase 0 in the ischemic area (Fig. The key concept is that these perturbations cause a voltage gradient between normal and ischemic zones that leads to current flow between these regions. These electrophysiologic effects, singly or in combination, create a voltage gradient between ischemic and normal cells during different phases of the cardiac electrical cycle. The precise electrophysiologic mechanisms underlying injury currents and their directionality with ischemia and related conditions remains an area of active research and some controversy even after decades of study. Ischemic cells remain relatively depolarized, probably related importantly to potassium ion leakage, during phase 4 of the ventricular action potential (i. Therefore, during electrical diastole, current (the diastolic current of injury) will flow between the partly or completely depolarized ischemic myocardium and the neighboring, normally repolarized, uninjured myocardium. The injury current vector will be directed away from the more negative ischemic zone toward the more positive normal myocardium. In this scenario, the ischemic zone will be relatively positive during electrical systole because the cells are repolarized early, and the amplitude and upstroke velocity of their action potentials may be decreased. This subendocardial ischemia pattern is the typical finding during spontaneous episodes of angina pectoris or during symptomatic or asymptomatic (silent) ischemia induced by exercise or pharmacologic stress tests (see Chapter 13). This tracing also shows left axis deviation2 3 with small or absent inferior R waves, which raises the possibility of a previous inferior infarct. Necrosis of sufficient myocardial tissue can lead to decreased R wave amplitude or Q waves in the anterior, lateral, or inferior leads as a result of loss of electromotive forces in the infarcted area. Local conduction delays caused by acute ischemia also can contribute to Q wave pathogenesis in selected cases. However, careful experimental and correlative studies based on necropsy and imaging findings have convincingly indicated that transmural infarcts can occur without Q waves and that subendocardial or other nontransmural 2,42,46 infarcts can be associated with Q waves. Loss of depolarization forces in these regions can reciprocally increase R wave amplitude in lead V and1 sometimes V , rarely without causing diagnostic Q waves in any of the conventional leads. The2 differential diagnosis for major causes of prominent right precordial R waves is presented in Table 12. These are typically followed within hours to days by evolving T wave inversion and sometimes Q waves in the same lead distribution (see Fig. The T wave inversions can resolve after days or weeks or may persist indefinitely. In one series, T waves that were persistently negative (inverted) for more than 1 year in leads with Q waves were associated with transmural infarction; by contrast, T waves that were positive in leads with Q waves correlated with 52 nontransmural infarction, with viable myocardium within the wall. This development usually is associated with spontaneous recanalization or good collateral circulation and is a positive prognostic sign. Furthermore, T wave inversions of this type, especially in the setting of unstable angina, can correlate with segmental hypokinesis of the anterior wall and suggest a myocardial stunning syndrome. The natural history of this syndrome is unfavorable, with a high incidence of recurrent angina 42-44 and myocardial infarction. C, Following resolution of the chest pain, the T waves reverted to their baseline appearance. Of note is the finding that acute right ventricular infarction can project an injury current pattern in leads V through V or even V , thus simulating anterior infarction. For example, in some cases, ischemia can affect more than one region of the myocardium (e. Sometimes, however, partial normalization can result from cancellation of opposing vectorial forces. Infarction of the left ventricular free (or lateral) wall ordinarily results in abnormal Q waves in the midprecordial to lateral precordial leads and in selected limb leads. These initial Q waves probably reflect posterior and superior forces from4 6 the spared basal portion of the septum (Fig. Therefore, prominent Q waves may appear in leads V and V as a paradoxical marker of septal infarction. Secondary T wave inversions are characteristically seen in the lateral precordial leads. Further studies are needed to confirm this finding and test other proposed criteria. This mechanism of Q wave pathogenesis, however, is not specific for coronary artery disease with infarction. Any process, acute or chronic, that causes sufficient loss of regional electromotive potential can result in Q waves. For example, replacement of myocardial tissue by electrically inert material such as amyloid or tumor can cause noninfarction Q waves (see Chapters 77 and 95). A variety of dilated cardiomyopathies associated with extensive myocardial fibrosis can cause pseudoinfarction patterns. Prominent Q waves can be associated with a variety of positional factors that alter the orientation of the heart vis-à-vis a specific lead axis. With dextrocardia (see Chapter 75), in the absence of underlying structural abnormalities, normal R wave progression can be restored by recording leads V to V on the right side of the chest (with lead V placed in the V position). A rightward2 6 1 2 mediastinal shift with left pneumothorax can contribute to the apparent loss of left precordial R waves. Other positional factors associated with slow R wave progression include pectus excavatum and congenitally corrected transposition of the great vessels. An intrinsic change in the sequence of ventricular depolarization can lead to pathologic, noninfarct Q waves. Probably the most common findings are relatively prominent S waves in leads V and V. These small q1 3 waves can become more apparent if the leads are recorded one interspace above their usual position and disappear in leads that are one interspace below their usual position. Q waves caused by myocardial injury, whether ischemic or nonischemic in origin, can appear transiently and do not necessarily signify irreversible heart muscle damage. Severe ischemia can cause regional loss of electromotive potential without actual cell death (electrical stunning phenomenon). Transient conduction disturbances also can cause alterations in ventricular activation and result in noninfarctional Q waves. In some cases, transient Q waves may represent unmasking of a previous Q wave infarct. New but transient Q waves have been described in patients with severe hypotension from a variety of causes, as well as with tachyarrhythmias, myocarditis, Prinzmetal angina, protracted hypoglycemia, phosphorus poisoning, and hyperkalemia. Q waves in such settings can reflect a variety of mechanisms, including a change in the balance of early ventricular depolarization forces and altered cardiac geometry and position. A marked loss of R wave voltage, sometimes with frank Q waves from lead V to the lateral chest leads, can be seen with chronic obstructive pulmonary disease (1 see Fig. The presence of low limb voltage and signs of right atrial abnormality (P pulmonale) can serve as additional diagnostic clues. This loss of R wave progression in part may be related to right ventricular dilation and downward displacement of the heart in an emphysematous chest, as discussed earlier.
These symptoms may be present for pain present for 3 months and tenderness at 11 or more weeks before the spirochete spreads via blood and of 18 trigger points buy cheap levitra professional 20 mg on line erectile dysfunction rates. A chronic arthritis may appear months after Systemic Disorders the initial infection order levitra professional with a visa impotence at 35. The knee is a commonly Leukemia is the most common cancer in children order levitra professional visa erectile dysfunction statistics age, and affected joint. The patient has an antalgic limp with bone and joint pain is the most common presenting diffuse swelling and warmth of the knee joint anteri- complaint. The bone pain is diffuse and nonspecifc orly, as well as local synovial thickening. Radiographs of the limb at the distal end of the femur and the proximal end of the tibia show Neuroblastoma abnormal areas of radiolucency. Neuroblastoma is a malignant tumor that usually oc- curs in children under 5 years of age. It originates from Sickle Cell Disease cells in the sympathetic ganglia and adrenal medulla Sickle cell disease is a genetic disorder characterized by but can arise from any part of the sympathetic nervous production of hemoglobin S, an anemia secondary to system and metastasize to the bone. The presenting short erythrocyte survival, and sickle-shaped erythro- complaint may be varied, but bone pain, limp, pallor, cytes. In the urine, The child presents with painful or vaso-occlusive crises 3-methoxy-4-hydroxymandelic acid and homovanillic characterized by symmetrical, painful swelling of the acid levels are elevated. Older people report pain in long bones and joints, abdominal pain, decreased appetite, fever, Osteogenic Sarcoma and malaise. The laboratory fndings reveal a hemoglo- Osteogenic sarcoma occurs in people 10 to 25 years bin S genotype and anemia, but fndings can vary de- old, with the most common site being the distal femur pending on the hemoglobin genotype, age, gender, and or the proximal tibia. Sickle cell disease of local intermittent pain that quickly progresses to a is associated with osteonecrosis of the hip. Chapter 22 • Lower Extremity Limb Pain 271 Nerve Entrapment Syndromes Neuritis Peroneal Nerve Compression Vascular metabolism affected by systemic disorders, Peroneal nerve compression can be caused by a cast, such as diabetes mellitus, can cause a nerve to become sports injury, or trauma. Pain is felt across the head of ischemic, producing toxins that can directly damage the fbula and can result in footdrop. Soft tissue infammation contribut- Tarsal Tunnel Syndrome ing to neuropathy can be caused by collagen disorders Tarsal tunnel syndrome is occasionally associated (e. The Diabetes mellitus is commonly associated with posterior tibial nerve is involved, and the pain is felt sensory peripheral neuropathy and results in pain across the ankle and proximal foot. Patients may not and sensory loss that is more intense in the lower remember a specifc onset but report pain and weak- extremities. Tapping the posterior tibial Alcoholism is associated with distal, demyelinating nerve posterior and inferior to the medial malleolus neuropathy that may resolve with cessation of alcohol elicits pain. References and Readings Logan K: Stress fracture in the adolescent athlete, Pediatr Ann 36:738, 2007. It is helpful to distinguish between limb pain that affects the bones, muscles, and tendons. Key Questions Pain at the base of the thumb that occurs with grip or l Have you had a recent injury? If the injury does not warrant urgent attention, obtain l Were you able to use the limb after the injury? Constitutional Symptoms Strain The presence of generalized symptoms, such as fever, A strain is an injury to a muscle or tendon (fbrous weight loss, general malaise, or hot, swollen joints, cords that connect muscles to bone). Strains usually suggests the presence of a systemic disorder such as involve repetitive trauma. Treat- thritis include bacterial endocarditis, Lyme disease, ment usually consists of rest, splinting, ice, and nonste- syphilis, and such viruses as hepatitis B, rubella, cyto- roidal antiinfammatory medicines. Golfers will often megalovirus, human immunodefciency virus, Epstein- have wrist and elbow strain. Sprain Severity of Pain A sprain is a stretch or tear of a ligament (fbrous bands Unrelenting diffuse pain, often occurring at night, is an that connect bone to bone across a joint). Sprains of the indication of bone involvement, either through bone fngers are common. Humeral fracture is fairly common after a for the Type and Severity of Humeral blow to the arm. Obese children have an increased risk of sustaining mus- culoskeletal injuries compared with normal-weight peers If there is no history of trauma or a precipitating event, and are at greater risk of sustaining forearm fractures, what else is causing the pain? Activities A person may adapt to chronic musculoskeletal prob- Pain associated with fracture is often severe. Bursitis pain is duce symmetrical discomfort and pain with inactivity often associated with swelling and limited joint motion while noninfammatory conditions are often associated (see Chapter 22). In upper extremity (shoulder, wrist, elbow) joint pain with injury, what do I need to know about the specifc Key Questions l Is there any swelling? Generally, swelling secondary to trauma such as a l Did you engage in any activities that required over- strain develops immediately or within 2 hours after an use of one or more joints? Swelling 6 to 24 hours after an injury is usually of synovial origin, such as a subluxation, dislocation, Pain in the dominant hand may indicate repetitive mi- or ligamentous damage (sprain). Chapter 23 • Upper Extremity Limb Pain 277 Severe ligament sprain is manifested as an immedi- Night Pain ately disabling pain at the moment of the injury. Pain Rotator cuff tears can cause shoulder pain and upper experienced hours after an injury or physical activity is extremity numbness when sleeping on one’s affected usually caused by acute extensor injury or overuse. Patients may report noticing pain, weakness, or diff- culty in activities of daily living, such as using a hair Chronic diseases, such as sickle cell anemia, infam- dryer, opening jars, holding a pen, or handling eating matory bowel disease, Crohn disease, hypothyroidism utensils. Gonorrhea disseminates to the musculoskeletal system in 1% to 3% of infected individuals. Exposure to Key Questions other infectious agents, such as Chlamydia trachoma- l Have you had any joint stiffness? Stiffness is a common feature of any infammatory ar- Viral infections may cause diffuse myalgia. With most in- fammatory arthropathies, stiffness and pain are allevi- Figures 23-1 to 23-3 depict anatomic landmarks of the ated by activity; in contrast, mechanical problems are shoulder, elbow, hand, and wrist. Musculoskeletal tumors com- monly present with mild joint stiffness because of Observe Patient Walking, Removing Coat/Jacket muscle involvement but rarely demonstrate instability. People who have septic joints appear ill, and move- ment of the joint will increase pain. Shoulder pain from rotator cuff tendinitis is felt Medications over the lateral aspect of the deltoid. Transient arthralgia may occur 6 to 8 weeks after receiv- Swelling of the elbow may compress the ulnar ing immunizations. Recurrent or permanent arthritis may nerve, producing a tingling sensation in the fourth and follow rubella vaccination, especially in adult women. Inspect the Skin and Nails Osteoarthritis typically involves the distal interpha- Inspect the skin for redness and infammation. Joints are swollen with a fusiform- distends the joint in a smooth, symmetrical manner.
Fractures were Intuitively one does not expect recessed areas such as the most frequent severe injuries cheap 20mg levitra professional with amex erectile dysfunction drugs and nitroglycerin. One may one side of the body refects the orientation of the body observe hemorrhage within the “strap muscles” of the at the time of impact with the ground (Figure 11 buy cheap levitra professional 20 mg on-line erectile dysfunction treatments diabetes. In their study of 68 deaths from falls purchase levitra professional 20mg online erectile dysfunction treatment nyc, Turk evidence of the phenomenon in the English-speaking and Tsokos  described skeletal muscle hemorrhage forensic literature. In the absence of documented cases in the neck and fractures of the hyoid bone in 33% of it would seem a reasonable position to state that if bod- cases in falls greater than 10 m in height. One group of workers in Singapore fexion of the neck secondary to impact to the occiput attempted to relate the severity and pattern of injuries (Figure 11. What is somewhat surprising is that a number of Not surprisingly the severity of external and inter- papers in the literature have described unusual pat- nal injuries sustained depends upon whether the fall is terns of injury with respect to the distance fallen. Fractures are far less com- number of papers have described a bimodal distribu- mon when a fall is into water. A clear diference in the tion of skull fractures with respect to increasing height. Fourteen cases of suicidal jumps into water feature of falls below 7 m and above 30 m . Five of height of the fall in the latter study, with comminuted these cases were shown to have sufered relatively minor skull fractures associated with falls of greater than 7 injuries and subsequently died by drowning. Both authors raised the question as to whether the A study involving 100 consecutive cases where indi- reduction in head injury seen in cases of falls between viduals had jumped from the Golden Gate Bridge in the upper and lower heights could be explained by the San Francisco, California, was reported by Lukas and position of the falling body changing during the vari- colleagues in 1981 . Postmortem examination showed the presence of common injury sustained in the cases . In 52 of the hemothorax and hemoperitoneum in 82 and 84 cases, 80 cases, fractures of the skull were seen. Interestingly, pure basal erations, great vessel and cardiac lacerations, and liver skull fractures and ring fractures only occurred in four or splenic lacerations. Fractures of the In the series of cases the next most frequently fractured humerus were the most common injury (14 cases). Compression fractures to the spine were seen in later the man was discovered deceased on the ground at eight patients. An examination of the scene fractures and the probability of survival appeared to be indicated the deceased had struck an adjacent fence associated with the mode of entry into the water. A suicide note was located the water feet frst allows a longer time for deceleration in a backpack that was found on the ninth foor of the and thus decreased the deceleration forces applied to the parking lot. A single case of base of skull fracture and a second forehead with underlying palpable fractures. Case Study 1 ἀ e sagittal images of the body showed a fractured A 63-year-old man was witnessed driving his car to a sternum with wide separation of the fractured edges multilevel suburban parking lot, exiting his vehicle, then (Figure 11. He had previously stated to his wife he would kill ἀ e cause of death was issued as multiple injuries himself at that site. He then struck the ground face frst lower limbs showed fractures consistent with severe resulting in severe facial and skull fractures. It has been reported that fndings suggested the deceased had landed onto his legs those who jump from a high building tend to fall feet and subsequently onto the lef aspect of his back and to frst, whereas accidental falls result in a slightly higher the back of his head. An experiment that studied death and did not direct any further examination of the the alignment of a body during a fall was performed deceased’s body. It was suggested that by the author, although the fndings are interesting, one this information may shed light on whether a victim was cannot extrapolate this data directly to individual cases deceased before being thrown form a building or even due to the small number of the experiments, undoubted the mental state of a suicide victim. From each buildings as opposed to those who sufered a fall was inves- of the three starting positions the fnal impact was in a tigated in a recent clinical study . Signifcantly more cervical spine injuries were Injuries to the limbs mainly involved the metaphyseal seen in fallers as opposed to jumpers. Signifcantly of the calcaneus, ankles, and shafs of long bones were more jumpers had compression or burst thoracic vertebral all seen more frequently in those who had jumped from fractures as opposed to fallers. An interesting observation was that zygo- matic and nasal bone fractures rarely occurred in isola- Falls are a major cause of injury in the pediatric popula- tion. Babies may fall from the arms of parents and carers, or nose in such circumstances should raise the possibil- or from changing tables and beds. It is generally accepted that short dis- January 1, 1988, and June 30, 1999, was also reported, tance falls in the pediatric population do not result in a in part, to determine the potential lethality of a short life-threatening injury in the vast majority of cases. Sixty-three tance falls are relatively common events and the over- cases were identifed. Not surprisingly a signifcant correlation was A death from a short distance fall is a rare occurrence. A fracture requiring manipulation under anes- that providing the courts with estimates of the probabil- thesia or admission to the hospital occurred in falls over ity of death is injudicious. Seventy-two frequently as an explanation for serious nonaccidental cases were identifed. Two of the cases It is generally accepted that simple falls down stairs involved falls of just over 1 m and the third was from 80 rarely cause serious injury in children. A single base of skull study on 69 children with a median age of two years fracture resulted from a 3 m fall from a balcony. No ing to a pediatric emergency department showed that deaths were found among the cases. A wide range of book chapters, data- injury to the trunk was very uncommon and occurred in bases, peer-reviewed papers, and medical society papers only 2% of cases. Further important obser- tality rate for short falls afecting infants and young vations included the fact that children were no more likely children is <0. Baby Walker–Related Falls A review of the United States Consumer Product Baby walker–related falls are very common. It has been Safety Commission database for head injury between estimated that over 20,000 children are treated annually K13836. A particular issue in the pathogenesis were 17 parietal fractures, 8 frontal fractures, and 1 of the injury is whether the application of blunt force is occipital fracture. Two of these children “shaken impact syndrome” was coined to denote the had a second nondepressed fracture. Although an extra-axial collection or brain injury child with a fracture of the ulna and radius. As these scenarios may well be quite ogy and no objective evidence of a primary impact site. Of the fractures in children which may stimulate an early homicide investigation less than 12 years of age caused by abuse, 80% occur in (Figure 11. Less common causes of death include tion of the injury are very important in the correct reso- abdominal and chest injury. A parent or other carer who is present as smothering may leave no discernable injury, though a at the time of an assault that leads to a fracture or death close inspection of the mouth may reveal subtle injuries may either deny any knowledge of the event or attempt to the buccal mucosa . Not uncommonly the ἀ e mechanism of death in cases of head injury is reported circumstances of the incident contain some controversial. In 1962 Kempe and colleagues published element of truth though the severity of the incident is an article titled “ἀ e Battered-Child Syndrome” .
After the myoma is removed purchase levitra professional on line impotence help, the incision can be closed using laparoscopic suturing cheap levitra professional online master card male erectile dysfunction pills. Minilaparotomy or culdotomy facilitate removal but increase postop wound complication risks purchase levitra professional 20mg with amex erectile dysfunction diabetes reversible, such as infection or hernia formation. After myoma removal, the abdomen and pelvis are irrigated, the patient is taken out of the Trendelenburg position, and any fluid that might have tracked into the upper abdomen is suctioned. Robotic assistance: Robotic-assisted laparoscopic surgery is relatively new to the field of gynecologic surgery. The available evidence demonstrates the feasibility and safety of robotic-assisted laparoscopic surgery in benign gynecologic disease, but further study is needed to define the role of robotics in this field. With the advent of robotic-assisted surgery, the previously described procedures can be performed with three-dimensional visualization, improved magnification, and greater operative flexibility. The only major difference is location and sometimes size of the trocars used for the robotic arms as well as possible increased operative time. Nezhat C, Nezhat F, eds: Nazhat’s Video-Assisted and Robotic-Assisted Laparoscopy and Hysterectomy. Tinelli A, Malvasi A, Gustapane S, et al: Robotic assisted surgery in gynecology: current insights and future perspectives. The indications for hysterectomy ± salpingo- oophorectomy include leiomyomata (38%); malignancy (15%); ovarian tumors (10%); abnormal bleeding (13%); adenomyosis (9%); pelvic pain or adhesions (5%); endometriosis (3%); and uterine prolapse (1%). Other less common indications include parametrial disease, pelvic infection, and complications of pregnancy and delivery. Selection of surgical approach to hysterectomy requires consideration of the patient’s age, medical Hx, Hx of prior pelvic surgery, the presence or possibility of adhesions or endometriosis, uterine size, adnexal pathology, and the presence or amount of uterine prolapse. Laparoscopic hysterectomy offers the advantages of shorter recovery time, rapid return of bowel function, less pain, and a lower wound complication rate. Consultation with a urologist, bowel surgeon, and oncologist are sought as necessary. Diagnostic laparoscopy is performed, adhesions lysed, and any endometriosis treated. The course of the ureters is noted through the peritoneum until they are no longer visible at the level of the cardinal ligaments. When ureters cannot be identified clearly because of severe scarring or endometriosis, they are dissected retroperitoneally, and the dissection proceeds as for a radical hysterectomy. At the cardinal ligaments, the peritoneum is opened above or below the ureter, and hydrodissection is performed to lift the peritoneum off the ureter without damaging it. Routine hysterectomy using hydrodissection to identify tissue planes and limit blood loss can be performed following identification of the ureters. If the ovaries are to be spared, the uteroovarian ligament, proximal tube, and mesosalpinx are cauterized and cut progressively, and the posterior leaf of the broad ligament is opened with hydrodissection. Next, the uterine vessels are identified, noted to be free of ureter, desiccated, and cut. At the level of the cardinal ligaments, the ureters and descending branches of the uterine artery are close to one another and the cervix; therefore, cardinal ligament dissection and cautery must be precise to prevent bleeding and ureteral injury. In benign disease, a large uterus can be morcellated and then removed segmentally through the vagina. Pneumoperitoneum will be lost during this procedure, and care must be taken to keep instruments free of bowel or other abdominal structures as this occurs. If the procedure is to be completed entirely laparoscopically, pneumoperitoneum can be maintained by placing a glove containing two 4” × 4” sponges in the vagina. The vaginal wall is cut circumferentially, and the uterus is pulled to mid vagina, but not removed, to preserve the pneumoperitoneum. Alternatively, the uterus may be morcellated and removed through a 10-mm suprapubic port or placed in a laparoscopic specimen bag. The suprapubic incision also may be extended into a minilaparotomy incision for specimen removal. The vaginal cuff is closed transversely using laparoscopic sutures, and any coexisting cystocele or enterocele is repaired. After the uterus is removed and the vaginal cuff closed, the pelvic and abdominal cavities are reevaluated, irrigated, and cleared of blood and debris. Variant procedure: In patients with severe rectovaginal and vesical endometriosis, the retroperitoneal space is entered using hydrodissection, and the external iliac vessels, hypogastric artery, and ureters are identified. In cases where extensive dissection and resultant blood loss is anticipated, coagulation or ligation of the hypogastric artery with laparoscopic clips may be performed. Endometriosis of the rectum, rectovaginal septum, and uterosacral ligaments is treated by vaporization, excision, or a combination of both. Sigmoidoscopy with concurrent laparoscopic visualization of the pelvis may be necessary to r/o the presence of incidental enterotomy. The uterus is2 retracted medially and the ureter laterally as the cardinal and uterosacral ligaments are cauterized and cut with the ureter under direct visualization. After these vascular pedicles have been ligated and all endometriosis treated, the hysterectomy and specimen removal proceed as described earlier. Robotic Assistance: With the advent of robotic-assisted surgery all of the above procedures can be performed with three-dimensional visualization, improved magnification, and greater operative flexibility. With this setup, the surgeon sits at a console, and two or three assistants are at the side of the patient. The only major difference is location and size of trocars used for the robotic arms as well as possible increased operative time. After or at the time of closure of the vaginal cuff, some gynecologic surgeons perform a culdoplasty to close the posterior cul-de-sac. This is recommended to decrease the risk of enterocele formation and the potential development of vaginal vault prolapsed. The most common vaginal culdoplasty is the McCall culdoplasty where the uterosacral-cardinal complex is plicated and attached to the peritoneal surface of the posterior cul-de-sac to elevate the posterior vaginal cuff. After the uterus is removed, the patient is placed in dorsal lithotomy position to allow for vaginal access. Before closure of the cuff, an absorbable suture is placed through the full thickness of the posterior vaginal wall from outside to in, then passed through the left uterosacral ligament pedicle, the posterior peritoneum, the right uterosacral ligament pedicle, and back through the full thickness of the posterior vaginal cuff from inside out. The two ends of the suture are then tied, which brings the uterosacral ligaments together and this procedure is called Moskowitz culdoplasty. After the vaginal cuff is closed, a separate absorbable suture is closed the posterior cul-de-sac. Suture is passed through one of the uterosacral ligaments, through the posterior peritoneum, through the other uterosacral ligament, and then through another portion of the posterior peritoneum and tied to form a purse string. After the vaginal cuff is closed, interrupted suture are placed vertically across the posterior cul-de-sac starting with the posterior peritoneum over the rectum and taking small portions of the peritoneum up to and including the vaginal cuff apex. Because of the suturing of the uterosacral ligaments, which are very close to the ureters, the ureters are at risk for being obstructed by the culdoplasty stitch. Indigo carmine should be given intravenously prior to the procedure to help better identify the ureter. Cystoscopy should also be performed after the culdoplasty to ensure ureteral patency.
J. Nemrok. Lock Haven University. 2019.