deprest – iuga 2015 - colpopexy2015.iuga.org/wp-content/uploads/workshops/ws13_deprest.pdf ·...
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Deprest – IUGA 2015 - Colpopexy
technique
laparoscopic sacrocolpopexyJ Deprest MD PhD FRCOG
Pelvic Floor Unit, University Hospitals Leuven, KU Leuven
Leuven,Belgium
Disclosure: Our lab receives funding from Bard, Ethicon, Cook, AMS, FEG for independent research.
Vault prolapse
documented with permission of patient
• Preoperative– consent
– Crossmatch blood – 2 units “stand bye”
– Antibiotic prophylaxis (with uscefazolin + metronidazol)
– bowel preparation
• Installation: – frog position– catheter > 18 Ch, Y‐tubing so
bladder can be filled
– Pusher and digital access tovagina and rectum
– Mesh of your choice
– large bore catheter IV
Technique (laparoscopy)
• Umbilical port: open laparoscopy
• Ancillary trocars– Two 5 mm– one for suturing (12 mm)– additional for dissection deep,
posterior aspect
• Instruments and consumables(our preference):– dissecting scissors– monopolar (& bipolar) coagulation– needle holder and assistant needle
holder– we use PDS 120 cm sutures– (stapler)
Deprest – IUGA 2015 - Colpopexy
Overview
First restore anatomyConfirmation of length and mobility of vagina
Entry point
Vessels
Frontal view Posterior view
Deprest – IUGA 2015 - Colpopexy
Technique: entry point
Sacral hollow more difficult to access; promontory is fixation point
Technique: entry point
Promontory
Deprest – IUGA 2015 - Colpopexy
Dissection
Liberal use of monopolar surgery
Technique: extent dissection & suspension
Posterior and distal dissection
• Sigmoidal fixation (Wattiez 2001, Kaouk 2008, Agarwala 2007)
• Rectal (Antiphon 2004, Ross 2005, Gadonneix 2005)
Gaston & Ramsden BJU 2011
Deprest – IUGA 2015 - Colpopexy
Dissection completed
Landmarks after dissection
PPA confirms position rectumAssess depth of dissection
(other patient than previous)
vagina
Testing bladder integrity
Deprest – IUGA 2015 - Colpopexy
Preparation of the mesh
Until 2011, out of one flat mesh
two parts were cut to cover
posterior and anterior aspect of the vagina
15 cm
10 cm 7.5 cm 2.5 cm
15 cm
Y - meshes
Y-mesh: prefabricated Y-mesh is available
5 cm
From: Timmons et al.
Vault coverage and fixation
We use a lot of sutures
PDS 0 120 cm Extracorporealtechnique
Deprest – IUGA 2015 - Colpopexy
Mesh insertion
Posterior Amid type I (macroporous) mesh is deployed
The blue stripes will facilitate orientation
Extracorporeal technique
Suture low in the pelvis
through the right levator
Extra-corporeal technique
extra‐corporeal knot tying
with monofilamentary PDS
fast process
Cutting the suture
Deprest – IUGA 2015 - Colpopexy
Posterior aspect
at the level of the perineum
over the entire posterior aspect
four sutures (arrows) fix the mesh
rectum
Same view behind the mesh
Posterior aspect
at the level of the perineum
over the entire posterior aspect
four sutures fix the mesh
Higher up
Along the enterire
posterior aspect
several rows of sutures
fix the mesh
Posterior aspect
view on the posterior mesh
at the level of the vault
being fixed to the vagina
Stripes facilitate position suture
Higher up
Along the enterire
posterior aspect
several rows of sutures
fix the mesh
vault
Deprest – IUGA 2015 - Colpopexy
anterior aspect
anterior aspect
mesh deployed
anterior aspect
anterior aspect
mesh deployed
overview of the anterior
aspect of the vagina
after suturing the mesh
• Suture fixation (Wattiez 01, Cosson 00, Gaston 07)
• Staples/tackers (Higgs 05, Paraiso 05, Ross 09, Claerhout 09)
Gaston & Ramsden BJU 2011
Fixation at the promontory
Deprest – IUGA 2015 - Colpopexy
Sacral fixation
tension free fixation to promontorywith 3 staples
Peritonealisation
Nygaard, et al. – Obstet Gynecol 2004:most authors recommend burying graft underperitoneum to minimize risk bowel obstruction (1.1 % (range 0.6‐8.6%))
use rest of staples and purse string rest
with monofilament PDS
Postoperative
• Medication:– Pain relief: on demand– prophylactic antibiotics: limited to 24 hrs
• Catheter and pack: 48 hrs• Ambulation, feeding, discharge : on demand• On discharge:
– No heavy weight lifting for 6 wks (5kg) and another 6 wks(10kg)
– Stool softeners– Sexual activity: ad libitum– LMW heparin for ? 6 wks
• Scheduled visit after 6 wks
Deprest – IUGA 2015 - Colpopexy
Misassessment …
In the vast majority of patients, the bifurcation is above the promontory
Thank you