Added Steps to prevent recurrence in case of genital prolapse repair by vaginal route?

Following steps will help to prevent recurrence of prolapsed.  How many of us perform repair or corrective surgery in the form of as described below.

A) Plication of Pubo cervical ligaments (most cephalic part of ligament) which is quite thick and easily detectable & also rest of vesico urethral fascia.  Occasionally there is a threat of pricking some vessels in the root of P Cx lig if Assistant is distracted ( speaks to someone else at OT) or Needle holder is old or filled with serum or light & positioning  is poor. I have done it about 1 dozen time out of 5000 VH with repair since 1966 to  2015  , but it will be purudent not to control the bleeding by purse string suture because with rise of BP and tractions made by repair  may cause B lig Hematoma later.

B) To supplement &  repair of enterocele  either as therapeutic procedure (preoperatively demonstrable) or as prophylactic step by  identifying cephalic part of Utero Sacral  ligaments at vault and apply series of  —Purse string suture fixed with ant tinae of Pelvic colon,-à lat wall of pelvis-this time avoiding ureters on side walls –by dragging down I P lig stump . Four or 5 tiers of silk may be necessary depending upon preexisting degree of enterocele, Honestly speaking at this juncture one can repair the high rectocele component but being careful not to shorten the vagina in width or caliber . Usually most of us old persons(I am aged 76 yrs) are still  happy, comfortable with  00-Anacap silk –thereby obliterating POD altogether resulting into finally achieving  adequate length  of post  vagina(point D as it called in POP-Q classification –Quantification) . I have performed 4 times hematoma on ant wall  of P colon –which however was quickly repaired and dealt with & about 7 times slipping of omentum adherent with uterus out of PID or MTP perforations which was also dealt with by purse sting by putting a moist  roller gauze inside the abd cavity and gently drawing it out. By doing so the offending omentum will peep and large torn distal end of omentum which slipped become visible,

Q. 3. The next step will be to oppose Mc Ligament medial parts as a support of vault and thereby assuring near 100% prevention of vault prolapsed at a later date. I must again confess that I have injured about 7 times some veins in the upper part of ureteric tunnel (roof of ureter as it enters into MC ligament) but easily repaired. For beginner  I like to convey that that  ureters can be traced vaginally too by making a gentle nick  on lat wall of pelvis and identified by rolling it like spermatic cord or thick thread . Then only one can pass stitch to tie the offending vessels. But this bleeding from ureteric roof occur only cases of gross PID or say endometriosis if it is really from ureteric roof which has to be dissected & clamped in Wertheim’s opn. It will be safer to have a look in the bladder cavity so that urinary spurts are visible on either side → liberal availability of Cystoscope one can do always Cystoscopic before closure if in doubt.

Q.4. how many members feel narrowing of total length of vagina can be prevented by TR closure of vagina? Members practice pattern Pl.

These steps, I feel are essential for Indian Rural women who have to work hard say lifting bucket full of water or carrying heavy household material from market or roof house and sometimes assisting her family members in agricultural works. Member’s opinion please on this prophylactic or therapeutic approach along with vaginal hysterectomy.