Tips and tricks improving surgical efficiency at time of laparoscopic native tissue repair for pelvic organ prolapse and stress urinary incontinence
IUGA Academy. Gangal M. Jun 30, 2018; 213278; 148 Topic: Pelvic Organ Prolapse
Mihnea Gangal
Mihnea Gangal

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148

Tips and tricks improving surgical efficiency at time of laparoscopic native tissue repair for pelvic organ prolapse and stress urinary incontinence

Lachance, C1;Gangal, M1; Walter, JE1

1: McGill University Hospital Center (MUHC)

Introduction: Pelvic organ prolapse (POP) and stress urinary incontinence (SUI) coexist in up to 80% of women with pelvic floor dysfunction. While commonly in use, surgical meshes for the treatment of POP and SUI can lead to complications not necessarily encountered in native tissue repair. Furthermore, many patients hear of litigious claims against mesh products and are afraid to undergo surgery using these products. Therefore, more patients are asking to use their own tissues to correct their symptoms. In our institution, we offer these young patients a laparoscopic uterosacral suspension, a paravaginal defect repair, and a Burch colpourethropexy. Evidence suggests that laparoscopic uterosacral ligament hysteropexy is safe and effective, but different techniques are accepted among experts. The Burch colpourethropexy is a well studied procedure to correct SUI and the laparoscopic approach has shown equivalent efficacy in medium follow-up randomized trials compared to its open counterpart. While being minimally invasive, these can prove to be time-consuming surgeries.

Objective: The purpose of this video is to present tips and surgical techniques that improve efficiency and ergonomics in the context of laparoscopic uterosacral ligament hysteropexy, paravaginal defect repair, and Burch colpourethropexy.

Methods: This is a video of a fellowship-trained urogynecologist and fellows in Female Pelvic Medicine and Reconstructive Surgery performing native tissue laparoscopic surgery. The presented surgery is a laparoscopic approach to an uterosacral ligament hysteropexy, a bilateral paravaginal defect repair and a Burch colpourethropexy. The patient received antibioprophylaxis, thrombophylaxis and a general anesthesia. Four trocars were used (10 mm umbilical with 0-degree laparoscope, two 5 mm on the left side, and a 12 mm in right lower quadrant).

Results: We propose four techniques to improve the efficiency of the surgery:

1) A continuous suture is used to repeatedly plicate each uterosacral ligament and fixate it to its cervical insertion point (instead of interrupted sutures).

2) The repair of the paravaginal defect is performed using a running barbed suture (instead of interrupted sutures).

3) The sutures for the Burch colpourethropexy are passed through contralateral separate trocars (improves ergonomics and decreases tangling).

4) A running suture and intracorporeal knot tying are used for closing the peritoneal incision (avoiding the use of barbed suture on peritoneum and time consuming interrupted sutures).

Combination of these surgical techniques decreases operative time and increase efficiency, likely without compromising surgical outcomes.

Conclusions: Laparoscopic uterosacral hysteropexy, bilateral paravaginal defect repair, and Burch colpourethropexy are minimally invasive surgical techniques that can be used to correct POP and SUI on patients who desire hysteropreservation but refuse use of any mesh material. We expect that that the surgical time will be reduced compared to traditional methods, without compromising surgical outcomes. Further studies with a comparison group will be needed to confirm this.

Disclosure:

Work supported by industry: no.

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