Because surgery can be easier than you think

In this interesting video, some small sequences of Professor Wattiez’s sacrocolpopexy technique that may have gone unnoticed but which may make your surgery easier are presented. Some questions will be answered, like when use a straight or a curved needle in bowel suspension to gain exposure, or how to remove them safely. A nice way to easily find the right plane of bladder dissection will be explained. Some tips about mesh fixation in puborectalis muscle, vagina or promontory will be given too. And last but not least, some tricks on peritonization will be demonstrated, as this is a very important step in this surgery.

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Because surgery can be easier than you think

Authors

A Wattiez, S Maia, A Vázquez Rodriguez, P Trompoukis

Abstract

In this interesting video, some small sequences of Professor Wattiez’s sacrocolpopexy technique that may have gone unnoticed but which may make your surgery easier are presented. Some questions will be answered, like when use a straight or a curved needle in bowel suspension to gain exposure, or how to remove them safely. A nice way to easily find the right plane of bladder dissection will be explained. Some tips about mesh fixation in puborectalis muscle, vagina or promontory will be given too. And last but not least, some tricks on peritonization will be demonstrated, as this is a very important step in this surgery.

Classification

tips and tricks

Keywords

Sacrocolpopexy, bowel exposure, straight needle, curved needle, mesh fixation, bladder dissection, peritonization

Media type

Surgical video

Duration

09'23''

Publication

2011-03

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E-publication

WeBSurg.com, Mar 2011;11(03).
URL: http://www.websurg.com/doi-vd01en3187.htm

Because surgery can be easier than you think

1. Transparietal suspension of the large bowel 00'23''

This video outlines the importance of exposure in sacrocolpopexy. Bowel suspension is a critical step that gives freedom to the hand of the assistant and enables an easy fixation of the mesh in the promontory. A transparietal suspension of the large bowel is made by passing a straight needle armed with a monofilament suture through some of the epiploic appendices of the middle sigmoid. Once the needle has been passed through the epiploic appendices, the assistant has to follow the movements of the surgeon accompanying the bowel towards the abdominal wall in order to decrease tension and facilitate the suspension.

2. Transparietal suspension of the small bowel 01'19''

In obese patients, the suspension of the small bowel may be also required. For this purpose, it is preferable to use a curved needle that allows to perform a running suture on the mesenteric fat as close as possible to the bowel. Next, the needle is cut and threads are passed through the abdominal wall using a Berci needle.

3. Removal of bowel suspension 02'04''

Removal of bowel suspension must be always accomplished under vision to rule out any complications.

4. Bladder dissection 02'16''

The assistant plays here a very important role by lifting up the bladder, exposing and applying the necessary traction to make dissection possible. This schematic representation shows what happens when you grasp only the overlying peritoneal fold: dissection is carried out towards the bladder. The critical point here is to grasp the whole bladder and not only the overlying peritoneal fold. This allows for an optimal dissection of the vesico-vaginal plane and reduces the risks of bladder damage.

5. Transparietal suspension of the cervical suture 03'15''

Mesh fixation at the puborectalis muscle is a delicate step with challenging exposure. A transvaginal uterine manipulator may be used to achieve good exposure in cases in which no hysterectomy is performed. If a subtotal hysterectomy is carried out, a transparietal suspension of the cervical suture will be used.

6. Mesh fixation at the puborectalis muscle 03'49''

It is important to take a big bite of puborectalis muscle to have a correct posterior fixation of the mesh, taking care not to strangulate it with a tight suture.

7. Anterior fixation of the mesh 04'42''

Conversely, on the anterior aspect, the mesh has to be fixed with only a small bite of vaginal wall to avoid mesh erosion.

8. Fixation of the mesh to the promontory 05'08''

To reduce the risk of migration at the promontory fixation point, suggestion is made to pass the thread through and then to tie a loop around the extremity of the mesh.

9. Peritonization 05'49''

Peritonization or mesh burial is a very important step of sacrocolpopexy.

10. Low peritonization 05'58''

While doing posterior mesh burial, it is important to keep the arm of the mesh under tension and well stretched to avoid folds.

11. Final peritonization 06'37''

The right ureter must be clearly identified, since the majority of ureteral complications in open sacrocolpopexy occur during peritonization. A two-passage continuous running suture is achieved. A monofilament suture is preferable here because it glides better through the tissues. It is important to avoid getting the mesh into the suture, because, as you can see, it can break and you will waste your time doing another suture. Remember, the best way to save time in laparoscopic surgery is to avoid unnecessary maneuvers.