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Vidéos chirurgicales sur WeBSurg
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English - 08'00''
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The video focuses on vaginal vault prolapse, cyctocele and rectocele in a patient after hysterectomy. The video describes principles and laparoscopic technique and explains the advantage of the laparoscopic approach.
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| 00'18'' | Case presentation
The advent of laparoscopic surgery has allowed urologists to perform operations via minimally invasive approaches. These new techniques are used for treatment of genitourinary prolapse. The rule for this treatment is based on the double promontory fixation of cystoceles and rectoceles by synthetic tissues. At the same time, a Burch colposuspension is proposed to cure or prevent stress urinary incontinence. Four ports are placed. The first one is in the umbilicus, the 3 others are placed in the right lower quadrant and left lower quadrant in the midline. In the frequent case of a hysterectomized woman, treatment always begins with the treatment of the rectocele. The peritoneal incision is made in the anterior wall of Douglas’s pouch along the posterior vaginal wall. Laparoscopic approach gives an excellent view of the dissection planes, which is often not possible in conventional approach. Dissection is extended to the anal margin. The synthetic prosthesis is then fixed on the posterior vaginal wall with a suture on each side. The treatment of cystocele also begins with the peritoneal incision and the dissection of the plane between the vagina and the bladder. This is also facilitated by the quality of the laparoscopic visualization. The same prosthesis is fixed on the anterior vaginal wall with 2 sutures. Traction on the 2 prosthetic wings allows good prolapse reduction. A low anterior approach is never a problem even with fat patients or patients who have had a prior surgical procedure. The peritoneal incision goes on along the right side of the pelvis in order to prepare the subperitoneal bed, which will receive the prosthesis -- passage of the stitch in the pre-vertebral disc with the suture, which will fix the 2 prostheses without any traction. The suture of the peritoneal edges allows perfect extraperitoneal protection of the prosthesis. A Burch procedure must then be performed in order to cure associated stress incontinence or to prevent risk of future incontinence. Dissection of the space of Retzius’s becomes easily performed here. The dissection is then extended to the endopelvic fascia. We have here a very good approach to the cervicourethral area. Under digital control, sutures are passed through the vagina and next through Cooper’s ligament. An extracorporeal knot allows adjustment of tension. The same procedure is repeated on the opposite side with 2 stitches on each side. The tension on the bladder neck can then be visualized. This operation can also be performed in the same way with an existing uterus in the case of a woman who has not had a hysterectomy. The anterior prosthesis is then passed through on the right as seen here. Nowadays, development of laparoscopic procedures allows an exact transposition of conventional surgical techniques to minimally invasive. |
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Laparoscopic treatment of genitourinary prolapse and stress incontinence
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