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Gynecology

Find all the surgical interventions, lectures, experts opinions, debates, webinars and operative techniques per specialty.
Laparoscopic dissection of sacral promontory for sacrocolpopexy
Objective: To describe the laparoscopic dissection of the sacral promontory during a laparoscopic sacrocolpopexy, with a special focus on anatomical landmarks and surgical traps.
Setting: Department of Gynecology, CMCO, Strasbourg University Hospital, France.
Patients: Women with invalidating genital prolapse
Interventions: Laparoscopic sacrocolpopexy is performed using three operative ports (one midline, suprapubic port and two lateral ports) and a 0-degree umbilical Karl Storz optical port. In order to suture a polypropylene mesh to the anterior vertebral ligament, the promontory area must be dissected. To improve sacral promontory exposure, the rectum is usually suspended to the left anterior abdominal wall by means of T’Lift™ tissue retraction systems. By palpating the area under the aortic bifurcation and the confluence of iliac veins, the sacral promontory is identified. The right ureter is also identified. Using two duck jaw fenestrated forceps, the peritoneum is lifted --retroperitoneal vessels are fixed to the vertebral elements, and widely opened. The promontory is carefully dissected until the anterior vertebral ligament becomes visible. As the presacral space is rich in blood vessels and nerve elements, surgeons are advised to preserve it.
However, the surgical approach to the vertebral ligament is sometimes difficult in obese women, when patients present anatomical variations such as a low iliac venous circulation confluence, a duplicity of middle sacral vessels, periosteal perforators, a winding right common iliac artery, or in the presence of lymph nodes.
Discussion: Laparoscopic sacrocolpopexy complications rates such as bleeding originating from the promontory varying from 0 to 4.7%, which sometimes require conversion to open abdominal sacrocolpopexy. Described by radiologists at almost 3cm from the sacral promontory, the right ureter can also be injured during reperitonization.
Conclusion: Laparoscopic dissection of the promontory requires specific and careful attention to be paid to non-infrequent anatomical variations.
V Gabriele, AJ Carin, K Afors, O Garbin
Surgical intervention
4 years ago
5238 views
227 likes
0 comments
07:24
Laparoscopic dissection of sacral promontory for sacrocolpopexy
Objective: To describe the laparoscopic dissection of the sacral promontory during a laparoscopic sacrocolpopexy, with a special focus on anatomical landmarks and surgical traps.
Setting: Department of Gynecology, CMCO, Strasbourg University Hospital, France.
Patients: Women with invalidating genital prolapse
Interventions: Laparoscopic sacrocolpopexy is performed using three operative ports (one midline, suprapubic port and two lateral ports) and a 0-degree umbilical Karl Storz optical port. In order to suture a polypropylene mesh to the anterior vertebral ligament, the promontory area must be dissected. To improve sacral promontory exposure, the rectum is usually suspended to the left anterior abdominal wall by means of T’Lift™ tissue retraction systems. By palpating the area under the aortic bifurcation and the confluence of iliac veins, the sacral promontory is identified. The right ureter is also identified. Using two duck jaw fenestrated forceps, the peritoneum is lifted --retroperitoneal vessels are fixed to the vertebral elements, and widely opened. The promontory is carefully dissected until the anterior vertebral ligament becomes visible. As the presacral space is rich in blood vessels and nerve elements, surgeons are advised to preserve it.
However, the surgical approach to the vertebral ligament is sometimes difficult in obese women, when patients present anatomical variations such as a low iliac venous circulation confluence, a duplicity of middle sacral vessels, periosteal perforators, a winding right common iliac artery, or in the presence of lymph nodes.
Discussion: Laparoscopic sacrocolpopexy complications rates such as bleeding originating from the promontory varying from 0 to 4.7%, which sometimes require conversion to open abdominal sacrocolpopexy. Described by radiologists at almost 3cm from the sacral promontory, the right ureter can also be injured during reperitonization.
Conclusion: Laparoscopic dissection of the promontory requires specific and careful attention to be paid to non-infrequent anatomical variations.
Bowel obstruction: a late complication after laparoscopic colposacropexy
This video illustrates the case of a patient with bowel adherent to an exposed portion of mesh used for treatment of a previous apical prolapse. The patient presents with abdominal symptoms following a laparoscopic sacrocolpopexy.
In this video, Professor Wattiez performs an extensive pelvic adhesiolysis, detaching the bowel from the mesh, and identifying adequate correction of vaginal prolapse, without any sign of infection. Reperitonization of the vaginal vault and the long arm (sacrum arm) of the mesh was also performed.
This unique case highlights the importance of peritonization when using mesh. Complications such as mesh exposure may occur, however this can be appropriately managed laparoscopically.
A Wattiez, J Castellano, R Fernandes, G Centini, C Meza Paul, K Afors
Surgical intervention
5 years ago
1820 views
37 likes
0 comments
23:25
Bowel obstruction: a late complication after laparoscopic colposacropexy
This video illustrates the case of a patient with bowel adherent to an exposed portion of mesh used for treatment of a previous apical prolapse. The patient presents with abdominal symptoms following a laparoscopic sacrocolpopexy.
In this video, Professor Wattiez performs an extensive pelvic adhesiolysis, detaching the bowel from the mesh, and identifying adequate correction of vaginal prolapse, without any sign of infection. Reperitonization of the vaginal vault and the long arm (sacrum arm) of the mesh was also performed.
This unique case highlights the importance of peritonization when using mesh. Complications such as mesh exposure may occur, however this can be appropriately managed laparoscopically.
Laparoscopic colposacropexy for the treatment of an apical defect in a patient with previous total hysterectomy
We present the case of a 69-year-old patient who suffered from an elytrocele. Previously, she had undergone a total hysterectomy with anterior and posterior colpoperineoplasty due to the presence of a grade 2 cystocele, without urinary incontinence. The management of genital prolapse requires a thorough knowledge of the anatomy and physiology of the female pelvic floor. This video outlines the main steps to follow for the repair of an apical defect with no true rectocele or cystocele. It also offers a very good insight of the specific issues to be considered when performing dissection and mesh fixation in specific situations, such as distortion of the normal anatomy due to the scarring process from a previous surgery and obesity. This surgery was performed and streamed live.
A Wattiez, C Redondo Guisasola, M Puga, F Asencio
Surgical intervention
5 years ago
4434 views
77 likes
0 comments
18:00
Laparoscopic colposacropexy for the treatment of an apical defect in a patient with previous total hysterectomy
We present the case of a 69-year-old patient who suffered from an elytrocele. Previously, she had undergone a total hysterectomy with anterior and posterior colpoperineoplasty due to the presence of a grade 2 cystocele, without urinary incontinence. The management of genital prolapse requires a thorough knowledge of the anatomy and physiology of the female pelvic floor. This video outlines the main steps to follow for the repair of an apical defect with no true rectocele or cystocele. It also offers a very good insight of the specific issues to be considered when performing dissection and mesh fixation in specific situations, such as distortion of the normal anatomy due to the scarring process from a previous surgery and obesity. This surgery was performed and streamed live.
Laparoscopic sacrocolpopexy with subtotal hysterectomy: the six points technique
Standardization means: implementing guidelines or measurements in order to obtain solutions to a disorganized system. Laparoscopic sacrocolpopexy is a long and complete surgical procedure that requires good knowledge of the anatomy and of the surgical technique, as well as advanced suturing skills. Laparoscopic sacrocolpopexy is also the gold standard procedure for POP repair, and its standardization is justified by its difficulty.
This video demonstrates the standard technique for laparoscopic sacrocolpopexy with sub-total hysterectomy. It is called “the six-point technique” due to the six stitches used to fix the meshes.
A Wattiez, E Baulon, J Nassif, S Maia, P Trompoukis, J Alcocer, A Vázquez Rodriguez
Surgical intervention
8 years ago
8211 views
99 likes
0 comments
28:50
Laparoscopic sacrocolpopexy with subtotal hysterectomy: the six points technique
Standardization means: implementing guidelines or measurements in order to obtain solutions to a disorganized system. Laparoscopic sacrocolpopexy is a long and complete surgical procedure that requires good knowledge of the anatomy and of the surgical technique, as well as advanced suturing skills. Laparoscopic sacrocolpopexy is also the gold standard procedure for POP repair, and its standardization is justified by its difficulty.
This video demonstrates the standard technique for laparoscopic sacrocolpopexy with sub-total hysterectomy. It is called “the six-point technique” due to the six stitches used to fix the meshes.
Surgical tutorial: laparoscopic prolapse repair
In this lecture, Dr. Ted Lee, MD, director of the department of minimally invasive gynecologic surgery in Pittsburgh, Pennsylvania, USA, focuses on the sacrocolpopexy procedure in relation to his experience in the treatment of genital organ prolapse. He highlights some important key steps of the procedure, together with some tips and tricks on optimizing exposure, facilitating dissection, suturing of the mesh and how to minimize complications.
The first step of the procedure is an adequate exposure with bowel retraction in order to have sufficient space to work in the sacral promontory area.
The next step is the rectovaginal dissection, with caution to keep the dissection close to the vagina, leave enough adipose tissue to the rectum, and dissect the pararectal spaces until the levator ani muscles. Dr. Lee stresses the fact that the depth of the dissection depends on the posterior wall defect. So in patients with a posterior defect not protruding outside the hymen, the dissection should stop at the level of the midvagina. This is in order to avoid future constipation with deep dissection. Only in patients with large posterior wall defects, the dissection should be performed at the level of the levator ani. Dr. Lee indicates some surgical instruments, such as the rectal probes and retractors, that are useful for the dissection of the rectovaginal space.
Next step is the vesicovaginal dissection, which can be very challenging, especially in patients with previous hysterectomy. Some tips and tricks such as the use of a Foley catheter or the use of a large probe to distend the vagina in order to facilitate dissection are demonstrated.
Next is the presacral dissection with skeletonization of the fibrofatty tissue, dissection from right to left to preserve the hypogastric nerve, and identification of a good plane of dissection to avoid bleeding, especially from the left common iliac vein, but also from sacral vessels, which can be dissected.
The last step is the suturing of the mesh. He explains that there is no longer the need to use non-absorbable sutures together with the use of tackers in order to secure the mesh to the sacrum without complications. A nice technique of suturing and knotting is demonstrated during mesh peritonization.
Finally, in patients where the uterus needs to be preserved for fertility purposes (sacrohysteropexy), Dr. Lee explains an alternative method to place the mesh medial to the uterine vessels in order to perform, if need be, a hysterectomy more easily later on. He also demonstrates a nice uterosacral suspension technique used in patients who do not wish to be treated with a mesh for their prolapse.
T Lee
Lecture
8 years ago
2634 views
65 likes
0 comments
25:34
Surgical tutorial: laparoscopic prolapse repair
In this lecture, Dr. Ted Lee, MD, director of the department of minimally invasive gynecologic surgery in Pittsburgh, Pennsylvania, USA, focuses on the sacrocolpopexy procedure in relation to his experience in the treatment of genital organ prolapse. He highlights some important key steps of the procedure, together with some tips and tricks on optimizing exposure, facilitating dissection, suturing of the mesh and how to minimize complications.
The first step of the procedure is an adequate exposure with bowel retraction in order to have sufficient space to work in the sacral promontory area.
The next step is the rectovaginal dissection, with caution to keep the dissection close to the vagina, leave enough adipose tissue to the rectum, and dissect the pararectal spaces until the levator ani muscles. Dr. Lee stresses the fact that the depth of the dissection depends on the posterior wall defect. So in patients with a posterior defect not protruding outside the hymen, the dissection should stop at the level of the midvagina. This is in order to avoid future constipation with deep dissection. Only in patients with large posterior wall defects, the dissection should be performed at the level of the levator ani. Dr. Lee indicates some surgical instruments, such as the rectal probes and retractors, that are useful for the dissection of the rectovaginal space.
Next step is the vesicovaginal dissection, which can be very challenging, especially in patients with previous hysterectomy. Some tips and tricks such as the use of a Foley catheter or the use of a large probe to distend the vagina in order to facilitate dissection are demonstrated.
Next is the presacral dissection with skeletonization of the fibrofatty tissue, dissection from right to left to preserve the hypogastric nerve, and identification of a good plane of dissection to avoid bleeding, especially from the left common iliac vein, but also from sacral vessels, which can be dissected.
The last step is the suturing of the mesh. He explains that there is no longer the need to use non-absorbable sutures together with the use of tackers in order to secure the mesh to the sacrum without complications. A nice technique of suturing and knotting is demonstrated during mesh peritonization.
Finally, in patients where the uterus needs to be preserved for fertility purposes (sacrohysteropexy), Dr. Lee explains an alternative method to place the mesh medial to the uterine vessels in order to perform, if need be, a hysterectomy more easily later on. He also demonstrates a nice uterosacral suspension technique used in patients who do not wish to be treated with a mesh for their prolapse.
Laparoscopic treatment of a chronic mesh infection 4 years after sacral colpopexy
In this video, we present the case of a late infectious complication after abdominal hysterectomy and sacral colpopexy using mesh interposition. We demonstrate the complete laparoscopic removal of the infected mesh, including excision of all the affected surrounding tissue. This is the case of a 57-year-old patient who had a total hysterectomy with bilateral adnexectomy and sacrocolpopexy in 2005. In 2009, she started to complain of an abundant, continuous and smelly vaginal discharge. The microbiological exam revealed a vaginal infection by Proteus mirabilis and the gynecologic examination showed a painful vaginal tumor with a drainage hole.
A Wattiez, S Barata, B Gabriel, J Nassif
Surgical intervention
8 years ago
3961 views
25 likes
0 comments
09:55
Laparoscopic treatment of a chronic mesh infection 4 years after sacral colpopexy
In this video, we present the case of a late infectious complication after abdominal hysterectomy and sacral colpopexy using mesh interposition. We demonstrate the complete laparoscopic removal of the infected mesh, including excision of all the affected surrounding tissue. This is the case of a 57-year-old patient who had a total hysterectomy with bilateral adnexectomy and sacrocolpopexy in 2005. In 2009, she started to complain of an abundant, continuous and smelly vaginal discharge. The microbiological exam revealed a vaginal infection by Proteus mirabilis and the gynecologic examination showed a painful vaginal tumor with a drainage hole.
Richter's sacrospinous ligament fixation of the prolapsed vaginal vault
The description of the Richter's sacrospinous ligament fixation of the prolapsed vaginal vault covers all aspects of the surgical procedure used for the management of vaginal vault prolapse following hysterectomy.
Operating room set up, position of patient and equipment, instruments used are thoroughly described. The technical key steps of the surgical procedure are presented in a step by step way: posterior colpotomy, opening of fossae, exposure, sutures, checking the hemostasis, myorrhaphy, suspension of vaginal floor, end of procedure, complications.
Consequently, this operating technique is well standardized for the management of this condition.
M Cosson, B Occelli, D Querleu
Operative technique
17 years ago
3070 views
110 likes
0 comments
Richter's sacrospinous ligament fixation of the prolapsed vaginal vault
The description of the Richter's sacrospinous ligament fixation of the prolapsed vaginal vault covers all aspects of the surgical procedure used for the management of vaginal vault prolapse following hysterectomy.
Operating room set up, position of patient and equipment, instruments used are thoroughly described. The technical key steps of the surgical procedure are presented in a step by step way: posterior colpotomy, opening of fossae, exposure, sutures, checking the hemostasis, myorrhaphy, suspension of vaginal floor, end of procedure, complications.
Consequently, this operating technique is well standardized for the management of this condition.