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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
5 years ago
5718 views
234 likes
1 comment
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
6 years ago
1883 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.
Colonic stomal prolapse and parastomal incisional hernia: laparoscopic Sugarbaker repair procedure
The objective of this film is to demonstrate stoma prolapse and parastomal incisional hernia repair according to the technique described by Sugarbaker in open surgery, reproduced here with a laparoscopic approach.
Mesh placement into the abdominal cavity presents a risk that seems minimized by the development of dual-sided composite meshes, with one collagen coating that will be in contact with the digestive tract, hence limiting the risk of adhesions.
The principle of the Sugarbaker technique is to create a colonic zigzag route and to fix it on the non-absorbable side of the mesh, thereby preventing colonic prolapse. The mesh is also used as an obstacle to the passage of small bowel loops into the parastomal defect.
Here, the difficulty lies in the combined presence of an incisional hernia and prolapse on a diverting transverse colostomy. The risk of vascular injury is all the more important. Here, authors highlight pitfalls as well as tips and tricks to overcome them.
J Leroy, J Marescaux
Surgical intervention
6 years ago
4281 views
109 likes
0 comments
11:09
Colonic stomal prolapse and parastomal incisional hernia: laparoscopic Sugarbaker repair procedure
The objective of this film is to demonstrate stoma prolapse and parastomal incisional hernia repair according to the technique described by Sugarbaker in open surgery, reproduced here with a laparoscopic approach.
Mesh placement into the abdominal cavity presents a risk that seems minimized by the development of dual-sided composite meshes, with one collagen coating that will be in contact with the digestive tract, hence limiting the risk of adhesions.
The principle of the Sugarbaker technique is to create a colonic zigzag route and to fix it on the non-absorbable side of the mesh, thereby preventing colonic prolapse. The mesh is also used as an obstacle to the passage of small bowel loops into the parastomal defect.
Here, the difficulty lies in the combined presence of an incisional hernia and prolapse on a diverting transverse colostomy. The risk of vascular injury is all the more important. Here, authors highlight pitfalls as well as tips and tricks to overcome them.
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
6 years ago
4685 views
79 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.