Principles of surgery according to the Integral Theory Paradigm (ITP)

Abstract

A core concept of the Integral Theory System is that "ligaments are for structure; vagina is for function". The vagina and uterus should be conserved. Because the vagina is an organ, its collagen and elastin, which are so necessary for its function, cannot regenerate once they are removed. Removing the uterus involves severing the descending uterine artery, which is the principal blood supply of the proximal part of the uterosacral ligaments (USLs), and so may cause atrophy, which can cause future incontinence problems because of collagen loss after menopause. The diagnostic algorithm guides which of the five pelvic ligaments need repair. Native ligament plication can be adequate for prolapse/symptom cure, but only in premenopausal women. Postmenopausal women are usually collagen deficient and require collagen-creating tapes or wide-bore polyester sutures to restore structural collagen in the ligaments. Of extreme importance, vaginal tissue excision should be avoided, as consequent scarring may cause "tethered vagina syndrome" (TVS). TVS can cause massive uncontrolled urine loss because the scar tissue in the bladder neck area of the vagina can link the more powerful posterior muscles to the anterior, so the posterior urethra wall is forcibly pulled open, when given the signal to close. Instead of vaginal excision, a "concertina" suture technique re-assigns and shrinks excess vaginal tissue to normal anatomy by 6 weeks. In conclusion, the five key surgical principles of the Integral Theory System are: ligaments are for structure, vagina is for function; structure (prolapse) and function (symptoms) are related; repair the structure and you will restore the function; avoid vaginal excision and hysterectomy; create new collagen to reinforce the damaged ligaments.

Keywords: Surgery principles; collagen; ligaments; polyester sutures; vagina.

Figure 1

The suspension bridge analogy for pelvic organ support. (A) The vagina is suspended by ligaments like a suspension bridge. Both walls of the vagina, PCF anteriorly, and RVF posteriorly, are suspended like the traffic part of a suspension bridge, by suspensory ligaments, PUL, CL, USL, ATFP laterally and PB inferiorly. The opposite muscle forces “M” (PCM, LP, and conjoint LMA), lie below the ligaments, and impart strength to the vaginal membrane by stretching it in opposite directions like a trampoline. (B) The suspension bridge analogy. Ligaments suspend the vagina from above and the pelvic muscles support it from below. The opposite muscle forces (arrows) stretch the vagina in opposite directions to tension it. Both images reused from Petros P. The female pelvic floor function, dysfunction and management according to the Integral Theory. 3^rd ed. Heidelberg: Springer Berlin; 2010. With permission from Peter Petros; retains ownership of the copyright. PS, pubic symphysis; PUL, pubourethral ligament; PCM, pubococcygeus muscle; PB, perineal body; ATFP, arcus tendineus fascia pelvis; R, rectum; U, urethra; N, bladder base stretch receptors; PCF, pubocervical fascia; CX, cervix; RVF, rectovaginal fascia; PRM, puborectalis muscle; EAS, external anal sphincter; S, sacrum; IS, ischial spine; CL, cardinal ligament; USL, uterosacral ligament; LP, levator plate; LMA, longitudinal muscle of the anus; PS, pubic symphysis; M, muscle; F, fascia.

Figure 2

Formation of artificial collagenous neoligaments. Specimen of vagina (V), vulva bladder (B) dissected from a dog, 2 weeks after the implanted tape had been removed. Note the significant artificial collagenous neoligament created by tissue reaction against the tape (white arrows). Reused from Petros P. The female pelvic floor function, dysfunction and management according to the Integral Theory. 3^rd ed. Heidelberg: Springer Berlin; 2010. With permission from Peter Petros; retains ownership of the copyright.

Figure 3

Diagnostic algorithm. A “short-hand” diagnostic method where symptoms indicate which ligaments are causing which prolapse and which symptoms. The connective tissue structures fall naturally into three zones of causation. Symptoms, even if occurring “sometimes”, are ticked in each box where they occur. The ticked boxes also serve as a guide to surgery. For example, nocturia and pelvic pain are almost exclusively caused by the “USL” laxity; stress incontinence, by pubourethral laxity “PUL”. Reused from Petros P. The female pelvic floor function, dysfunction and management according to the Integral Theory. 3^rd ed. Heidelberg: Springer Berlin; 2010. With permission from Peter Petros; retains ownership of the copyright. PS, pubic symphysis; PUL, pubourethral ligament; PCM, pubococcygeus muscle; V, vagina; PB, perineal body; ATFP, arcus tendineus fascia pelvis; R, rectum; U, urethra; PCF, pubocervical fascia; CX, cervix; RVF, rectovaginal fascia; PRM, puborectalis muscle; EAS, external anal sphincter; S, sacrum; IS, ischial spine; CL, cardinal ligament; USL, uterosacral ligament; LP, levator plate; LMA, longitudinal muscle of the anus; EUL, external urethral ligament.

Figure 4

The concertina method. The “concertina” method of re-attaching ballooned vaginal epithelium to the underlying fascial layer. Using a continuous (or interrupted) 00 vicryl suture, a suture “e” is placed 2 mm from the vaginal edge and sutured deep into the fascia “f”. The 1^st and 2^nd fingers are placed around the suture to push the epithelium down onto the fascia “f” after each suture. Then the suture is placed through the contralateral fascia, then into the vaginal edge “e”. The vaginal edge “e” is pushed down onto “f” as before, and the suture is continued. (A) The concertina method. Published with permission from Peter Petros: Personal Collection. (B) The concertina method. Reused from Petros P. The female pelvic floor function, dysfunction and management according to the Integral Theory. 3^rd ed. Heidelberg: Springer Berlin; 2010. With permission from Peter Petros; retains ownership of the copyright.

Figure 5

Precisely placed tapes create new collagen to repair five damaged ligaments and restore muscle function. Reused from Petros P. The female pelvic floor function, dysfunction and management according to the Integral Theory. 3^rd ed. Heidelberg: Springer Berlin; 2010. With permission from Peter Petros; retains ownership of the copyright. PUL, pubourethral ligament; PCM, pubococcygeus muscle; ATFP, arcus tendineus fascia pelvis; PB, perineal body; T, tape; CL, cardinal ligament; USL, uterosacral ligament; LP, levator plate; LMA, longitudinal muscle of the anus.

Video S1

Video abstract.

Video S2

Demonstrates the principle of compressing thin vaginal epithelium to the underlying fascia, in order to avoid excision of vaginal tissue. By permission Professor Peter Petros.