Surgical Repair of Connective Tissue Structures

Reconstructive pelvic floor surgery according to the Integral Theory differs from conventional surgery in four ways:

1. It is minimally invasive (day-care).
2. It is based on specific surgical principles which minimize risk, pain and discomfort to the patient.
3. It takes an holistic approach to pelvic floor dysfunction by isolating the contribution(s) of each zone of the vagina to dysfunction.
4. It has a symptom-based emphasis (the Pictorial Diagnostic Algorithm) which expands the surgical indicators to include cases with major symptoms and only minimal prolapse.

In keeping with the overall framework of the Integral Theory, the surgical techniques are organised by zone. The zones consist of nine key structures which potentially need repair in pelvic reconstructive surgery (fig 1-10). Using a special delivery system, polypropylene tapes are inserted as an anterior sling at midurethra, a posterior sling in the position of the USLs, and other positions according to which structure in which zone has been damaged (fig 1-12).
The uterus needs to be conserved wherever possible. It is the central anchoring point for the posterior ligaments (USL), the rectovaginal fascia (RVF) and the pubocervical fascia (PCF). The descending branch of the uterine artery is a major blood supply for these structures, and should be conserved where possible even if subtotal hysterectomy is performed.

Fig. 1-10 The nine main connective tissue structures potentially needing surgical repair.