CHAPTER 34 Anterior vaginal wall prolapse may be the result of detachment of the vagina from its normal lateral attachment. The object of the paravaginal defect repair is to reattach bilaterally the anterior lateral vaginal sulcus with its overlying fascia to the lateral sidewall at the level of the arcus tendineus fasciae pelvis, which is its normal attachment. The retropubic space is entered, and the bladder and vagina are depressed and retracted medially to allow visualization of the lateral retropubic space and the lateral pelvic sidewall, including the obturator internus muscle and the fossa containing the obturator neurovascular bundle (Figs. 34–1 through 34–3; also see Chapter 31 on Retropubic Anatomy). Blunt dissection can be carried dorsally from this point until the ischial spine is palpated. The arcus tendineus fasciae pelvis, or white line, is often visualized as a white band of tissue running from the back of the symphysis pubis to the ischial spine (see Figs. 34–2 and 34–3). It is the anatomic separation between the lower edge of the obturator internus muscle and the beginning of the iliococcygeal portion of the levator ani muscle. A paravaginal defect represents avulsion of the vagina with its muscular layer or pubocervical fascia off the arcus tendineus fasciae pelvis or possibly an avulsion of the arcus as well as the fascia off the obturator internus muscle (see Figs. 34–1 through 34–3). Figure 34–1C depicts various anatomic defects that can be encountered when a paravaginal defect is present. It should be noted that at times the white line can be so attenuated that it may not be anatomically identifiable.
Retropubic Paravaginal Repair
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