LSH and LIH tissue conserving solutions for hysterectomy
Epublication WebSurg.com, Feb 2012;12(02). URL: http://websurg.com/doi/lt03enlyons001
The objectives of pelvic floor reconstructive surgery are to restore anatomy, optimize function, and reduce morbidity. The anatomic fundamentals comprise normal vaginal axis, fascial attachments, fascial breaks, vascularity and neuromuscular considerations. Operative alternatives depending on the pelvic floor compartment: Posterior wall: Enterocele: Enterocele repair performed vaginally, which is a minimally invasive approach; Mc Call’s culdoplasty; sacrospinous fixation; sacral culpopexy and mesh kits. Rectocele: posterior colporrhaphy; fascial reconstruction; Zacharin grafting and mesh kits. Abdominal alternatives include enterocele repair, high McCall’s suspension, sacral culdopexy and sacrospinous vault suspension. All of these can be carried out laparoscopically. Anterior wall: Abdominal approach: open or laparoscopic Burch, paravaginal repair and sling. Vaginal alternative: anterior culdorrhaphy, traditional sling, TVT, TOT, RF sling, etc. Recommendations: the defects should be assessed preoperatively, and at the time of surgery, the objective is to evaluate the pelvis, to isolate the defects, and to repair each defect. The site-specific repair technique includes standard modified lithotomy position, trocar placement to facilitate suturing, repair of posterior defects first; anterior defect repair with paravaginal defects repaired first, followed by Burch sutures, and permanent sutures for all structural repairs. Failure or complications include poor vaginal axis, recurrent enterocele, graft problems, Urinary Stress Incontinence (USI) and sacral radiculopathy. Conclusions: The objectives of pelvic surgery can be accomplished via laparoscopy. In virtually all studies evaluating the morbidity of laparoscopy versus laparotomy, morbidity was less in the laparoscopic group.