work shop cape town tips and tricks …2016.iuga.org/wp-content/uploads/workshops/ws3_bdeval.pdfcape...
TRANSCRIPT
WORK SHOP CAPE TOWN ndash TIPS AND TRICKS
CONVENTIONAL LAPAROSCOPIC SACRO-
COLPOPEXY AND HYSTEROPEXY
Pr Bruno DEVAL MD
Geoffroy Saint-Hilaire ndashPrivate Hospital
Hotel ndashDieu de Paris
Paris V University
HISTORY OF HSYERO-SACRO - COLPOPEXY
58 years old OPSC 21 years old LSC
11 years old RSC
bull Arthure H et al
ndash Uterine prolapse and prolapse of the vaginal vault treated by sacral hysteropexy
bull BJOG an international journal of obstetrics and gynaecology 1957
bull Huguier et al
ndash Posterior suspension of the genital axis on the lumbosacral disk in the treatment
of uterine prolapse
bull Presse Med 1958
bull Nezhat C et al
ndash Laparoscopic sacral colpopexy for vaginal vault prolapse
bull Obstetrics and gynecology 1994
bull Eliott D et al
ndash Gynecologic use of robotically assisted laparoscopy Sacrocolpopexy for the
treatment of high-grade vaginal vault prolapse
bull Am J Surg 2004
Age overweight or obesity
Prior abdominal or pelvic surgery Uterine Pathology
LIMITS
5 STEPS OF THE PROCEDURE
Technical GUIDE LINES
A Prepare carefully sacral promontory and avoid excessivedissection All the anatomic landmark should be recognized(Vessels +++)
B Wide preparation of the vaginal walls
C Prefer polypropylene meshes vs Polyesther meshD Use re-absorbable suture on the vaginaE Avoid folding and wrinkling the mesh must be well stretchedF Fix the mesh on the posterior vaginal wall and not on the
elevator ani muscleG Use non-absorbable suture to fix the meshes on the sacrumH Avoid excessive tension on the meshesI Close the retroperitoneumJ Do not perform contemporary Burch procedure or tape
CONVENTIONAL LAPAROSCOPIC SACROCOLPOPEXY FOR FEMALE GENITAL PROLAPSE A CMPREHENSIVE REVIEW
Bruno DEVALa Denise Hatsumi de Freitas Yanasse ORTEGAb Hisham AMajeed FAHIMb Jorge Milhem HADDADd
bull A PubMed online search performed from 01 January 1991to 31 December 2014 using laparoscopy laparoscopicsacrocolpopexy sacral and colpopexy pelvic organprolapse
bull 180 manuscripts were initially identified
bull Only English-language studies with over 40 patients wereincluded resulted in choice of 28 papers
ANATOMICAL RESULTS
LAPAROSCOPIC SACROCOLPOPEXY FOR FEMALE GENITAL PROLAPSE A COMPREHENSIVE REVIEW
Bruno DEVALa Denise Hatsumi de Freitas Yanasse ORTEGAb Hisham AMajeed FAHIMb Jorge Milhem HADDADd
(Submited)
N NFU
Mean FU(Month)
OBJ CURE SUBJ CURE
3142 2721(868)
233 23962676895
20492286896
FONTIONNAL RESULTS
LAPAROSCOPIC SACROCOLPOPEXY FOR FEMALE GENITAL PROLAPSE A COMPREHENSIVE REVIEWBruno DEVALa Denise Hatsumi de Freitas Yanasse ORTEGAb Hisham AMajeed FAHIMb Jorge Milhem HADDADd
(Submited)
DenovoSUI
De NovoDyspareunia
DenovoDyschesia
2002180(91)
1041200(86)
1811720(105)
PER ndash OP MORBIDITY
LAPAROSCOPIC SACROCOLPOPEXY FOR FEMALE GENITAL PROLAPSE A COMPREHENSIVE REVIEW
Bruno DEVALa Denise Hatsumi de Freitas Yanasse ORTEGAb Hisham AMajeed FAHIMb Jorge Milhem HADDADd
(Submited)
N Conversion to Laparotomy
Bladderinjury
Rectal Bowellinjury
Vaginal Injury
3030 583030
(19)
513030
(17)
223030
(07)
93030
(03)
Post ndash OP MORBIDITY
LAPAROSCOPIC SACROCOLPOPEXY FOR FEMALE GENITAL PROLAPSE A COMPREHENSIVE REVIEW
Bruno DEVALa and al
(Submitted)
Complication TOTAL
Urinary infection 69 (25)
Voiding dysfunctionᵜ 1772721 (65)
Related to trocar site 82721 (03)
Wound infection 9 (033)
Mechanical ileus 9 (033)
Septical peritonitis 1 (003)
Bleeding 132721 (047)
Recurrent acute cystitis 1 (003)
Low back pain or sciatica 192721 (069)
Nerve lesion 3 (01)
Pain related to mesh 552721(22)
Detachment of mesh 32721(01)
Vault infection 2(0073)
Mesh infection 6(022)
Lombosacral spondylodiscitis 72721(025)
Suture erosion 5(018)
Mesh erosion 652721(24)
Rectovaginal fistula 1(003)
Vesicovaginal fistula 32721(01)
anal pain 5(018)
phlebitis 22721(0073)
fever 10(036)
stool incontinence 1(003)
LEARNING CURVE AND EVIDENCE
0
1000
2000
3000
4000
5000
6000
surgery laparoscopy robotic vaginal colorectal SCP
Prospectiv Study n= 206 patients
175 mn after 90 cases
ANALYSIS OF THE LEARNING PROCESS FOR LAPAROSCOPIC SACROCOLPOPEXY
IDENTIFICATION OF CHALLENGING STEPS
Claerhout et al Int j Urogynecol J ndash 2014 25
bull Prospectiv Study POP stade II
ndash Fellow n = 60 cases vs senior-teacher n= 30 cases
bull Fellow senior + Pelvitrainer
bull 5 Steps
bull 30 cases step 1-2
bull 30 to 50 cases steps 3-4
bull Last 10 cases full procedure
bull Comparativ itmes ndash Time
ndash Score
ndash morbidity
ndash Result
LAPAROSCOPIC SURGICAL BOX MODEL TRAINING FOR SURGICAL TRAINEES
WITH NO PRIOR LAPAROSCOPIC EXPERIENCE
Myura Nagendran et al
bull Authors included randomised clinical trials comparing
boxmodel trainers versus no training in surgical trainees
with no prior laparoscopic experience
bull 16 trials (464 participants) provided data for meta-analysis
of box training (248 participants) versus no supplementary
training (216 participants)
bull All the 16 trials in this comparison used video trainers
bull The meta-analysis showed that the time taken for task
completion was significantly shorter in the box trainer
group than the control group
bull Compared with the control group the box trainer group
also had lower error score better accuracy score and
better composite performance scores
bull Laparoscopic box model training appears to improve
technical skills compared with no training in trainees
with no previous laparoscopic experience
Laparoscopic surgical box model training for surgical trainees
with no prior laparoscopic experience
Myura Nagendran et al
Power Point slide deck adapted from
Canadian Agency for Drugs and Technologies in Health
Robot-Assisted Surgery Compared with Open Surgery and Laparoscopic Surgery Clinical Effectiveness and Economic Analyses
Chuong Ho MDEva Tsakonas BA MSc
Khai Tran MSc PhDKaren Cimon
Melissa Severn MIStMonika Mierzwinski-Urban BA MLIS
Jacques Corcos MDStephen Pautler MD FRCSC
September 2014
Adapted by Michael Fung-Kee-Fung MBBS FRCSC MBA
Nancy Jaworski BComm MHA
Walter Gotlieb MD PhD
Adapted from CADTH Technology Report on Robot-Assisted Surgery 2011
Indications for Robot Use ndash Disease Prevalence
bull 24700 new cases of prostate cancer diagnosed in Canada in 2008
bull 219 of patients lt60 years old will choose prostatectomy as initial treatmentUrology
bull 36000 hysterectomies performed in Canada in 200708
bull Hysterectomy is performed for several indications Gynecology
bull 5 year prevalence (2005) 482100000 male amp 318100000 female
bull Surgery is the primary treatment for localized renal cell carcinomaNephrology
bull An estimated 20000 coronary artery bypass graft (CABG) surgeries were performed in Canada in 200001
Cardiac Surgery
Adapted from CADTH Technology Report on Robot-Assisted Surgery 2011
Economic Analysis
bull Robot-Assisted vs Laparoscopic
Economic Model Base Case (Robot not donated)
Hospital Budget Impact
Hospital Budget Impact
ANATOMY OF THE PRESACRAL SPACE
STRUCTURES TO BE
RESPECTED
FOR A SAFE FIXATION
OF THE MESH
RATE OF
BLOOD TRANSFUSION
02
ANATOMICAL VARIATIONS
OF THE LEFT COMMON ILIAC VEIN MIDDLE PART PROMONTORY
bull Distances between the left common iliac vein and the midsacral promontory
bull Dissection of 52 cadavers
bull Mean of d1 = 27 mm (9 - 52)
bull Mean of d2 = 22 mm (9 - 35)
Wieslander CK et al Vascular anatomy of the presacral space in unembalmedfemale cadaversAmerican journal of obstetrics and gynecology 2006 195 1736
d1
RATE OF
BLOOD TRANSFUSION
02
ANATOMICAL VARIATIONS OF PRESACRAL VESSELS
MIDDLE PART PROMONTORY
bull Presacral vesselsndash Middle sacral vein
Oslash= 2mm (1- 4)
double (80)
left to P= 33
right to P= 52
crossing P= 5
mean of d3 = 7 mm (0-17)
P
d3
Wieslander CK et al Vascular anatomy of the presacral space in unembalmed female cadavers American journal of obstetrics and gynecology 2006 195 1736
ANATOMICAL VARIATIONS OF PRESACRAL VESSELS
MIDDLE PART PROMONTORY
bull Presacral vesselsndash Middle sacral artery
Oslash= 2mm (1- 4)
Left to P= 62
Right to P= 30
Crossing P= 8
Mean of d4 = 4 mm (0-15)
Pd4
Wieslander CK et al Vascular anatomy of the presacral space in unembalmed female cadavers American journal of obstetrics and gynecology 2006 195 1736
ANATOMICAL VARIATIONS OF PRESACRAL VESSELS
MIDDLE PART PROMONTORY
bull Presacral space avascular areas
bull Overlay of vascular structures
bull (10 cadavers)
Flynn MK et al Vascular anatomy of the presacral space a freshtissue cadaver dissectionAmerican journal of obstetrics and gynecology2005 192 1501
rarr Dissection right to the medline = safer
ANATOMICAL VARIATIONS OF THE RIGHT URETER
MIDDLE PART PROMONTORY
Flynn MK et al Vascular anatomy of the presacral space a fresh tissue cadaver dissectionAmerican journal of obstetrics and gynecology 2005 192 1501
bull Distances between the right ureter and the midsacral promontory
bull Dissection of 10 cadavers
ANATOMICAL VARIATIONS
OF THE
SUPERIOR HYPOGASTRIC PLEXUS
bull SHP sympathetic plexus connected to IHP
Shiozawa T et al Nerve-preserving sacrocolpopexy anatomical study and surgical approachEuropean journal of obstetrics and gynecology and reproductive biology2010 152 103
ANATOMICAL VARIATIONS OF SUPERIOR HYPOGASTRIC PLEXUS
bull Right hypogastric nerve
Wieslander CK et al Vascular anatomy of the presacral space in unembalmed female cadaversAmerican journal of obstetrics and gynecology 2006 195 1736
d6bull Mean of d6 = 7 mm (0 - 17)
Nerve-preserving sacrocolpopexy anatomical study and surgical approach
Shiozawa T1 et al
By protecting the superiorhypogastric plexus and the part of thepresacral area below the promontorywe can preserve the hypogastricnerves the sacral and pelvicsplanchnic nerves and thus theautonomic innervation of the pelvicorgans
ANATOMICAL VARIATIONS OF LVCA
bull Fixation into the anterior longitudinal
ligament
ANATOMICAL VARIATIONS OF LVCA
Boukkerou M et alPromontofixation procedures use of non-absorbable sutures or tackers Journal de gyneacutecologie obsteacutetrique et biologie de la reproduction2003 32 54
bull Fixation into the anterior longitudinal ligament
and NOT into the disc
ANATOMICAL VARIATIONS OF LVCA
bull Tackers go deep into the bone
Boukkerou M et alPromontofixation procedures use of non-absorbable sutures or tackers Journal de gyneacutecologie obsteacutetrique et biologie de la reproduction2003 32 54
Spondilithis03
ndash Preacutevention bull Asepsie and per-op antibioprophylaxy
ndash Diagnosis ndash Lombalgia fever tence neurologic diseases
ndash Inflammatory Syndrome (CRP)
ndash Radiologic signs (IRM)
bull Immobilisation
bull Antibiotheacuterapie prolongeacutee +- ponction discale
bull Ablation des prothegraveses
bull +- Arthrodegravese laminectomie
Posterior Dissection ndash DENONVILLIERS FASCIA
Since Charles-PierreDenonvilliers first discoveredthe firm membranousstructure between the rectumand prostate or bladder in1836 now calledldquoDenonvilliersrsquo fasciardquo (DF)the origin of DF has remainedcontroversial
Posterior Dissection ndash DENONVILLIERS FASCIA
Based on the evidencesurgeons should be awareof variations and search forthem to create a suitabledissection plane to avoidiatrogenic positive marginsand rectal injury
Rectal Injury04
ndash Sub-peacuteritoneacuteal rectum
bull There is a recto-vaginal space
bull Horizontal Position ++
bull Close to the post face of the vagina on the distal points
bull Danger on the proximal part of the Recto-Vaginal Septum
ndash Preacutevention
bull Follow the post-face of the vagina
bull Systeacutematic pre-operativ preparation
ndash NORMACOL reg
bull Maleable Retractor
ndash Treatment
bull Immeacutediat Suture
bull Mesh contra-Indication
Vaginal Injury04
ndash Preacuteventionbull Ant Vaginal Length - 6 cm ( 4 ndash 75) Jayle et al Masson 1918
bull Post Vaginal Lenght- 9cm (65 ndash 115) Jayle et al Masson 1918
bull There is no difference between the anterior and posteriorvagina thickness
bull If the vagina is too thin ndash Plicature of the vagina
ndash Treatmentbull If Vagina Injury Suture of the vagina
bull There is no contra indication to fix the meshes
RISK OF URETERAL
INJURY lt 11000
ndash Preacutevention
bull Parietal Uretera
ndash Cross between right extern iliac artery and uterine artery
bull Visceral Uretera
ndash Behind the ligaments
ndash Under the bladder
ndash In contact with the bladder
ndash Treatment
bull Per-op
ndash Per-op Bleu carmin en IV
ndash Ureteacuteral Catheter
bull Post-op
ndash Uro-scanner
ndash JJ Ureteral
Bladder
Collection
Sagittal T2
Vagina
Uterus
Ureter ariving in urinoma
Axial T2
Coronale T2
Bladder Injury2
ndash Sub-peacuteritoneacuteal Bladder
bull Vertical Position ++
bull Close to the ant face of the vagina
bull There is NO space
ndash Preacutevention
bull Following the Ant- Face of the vagina
bull Maleable Retractor
ndash Treatment
bull Immeacutediat Suture
bull Mesh Indication
bull Bladder Catheterisation 5 days
Small and Large Bowel Injury
bull Occur when adhesiolysis has to be undertaken
bull Avoid distended bowel at surgery by 48 hours pre op bowel prep
bull Avoid nitrous oxide during surgery as it causes bowel distension
bull If small bowel injured
ndash Repair laparoscopically
ndash Mesh can still be placed
bull Antibiotic cover for 7 days post op
CONCLUSION 1
1 To open the peritoneum tigh-it
2 Dissection on the right side of the mid-sacral ligament
3 Repair carefuly the vessels and the Right ureter
4 Try to preserve the right hypogatsric nerve
5 Fix your needle 1 cm below the promontory
MESH SELECTIONPERTINENT MESH SCIENCEWHY USE A CERTAIN MESH
Pr Bruno DEVAL MD Geoffroy Saint-Hilaire ndash Clinic
Hotel ndashDieu de Paris
Paris V University
MESH STIFFNESS
bullIncreased fibrosis and deposits of unorganized collagen create an increased stiffness
bull (Klinge 1999)
bullStiffness has been linked to clinical complications-heavier stiffer meshes having higher complications
bull (Dietz 2003)
bullStiffer meshes showed decreases in smooth muscle collagen and structural proteins following implantation
bull (Moalli P AUGS 2011)
bullHeavier stiffer meshes showed a greater propensity for stress shielding which in turn could cause reoccurrences of prolapse
bull (Moalli P AUGS 2011)
IMPACT OF VAGINAL SYNTHETIC PROLAPSE MESHES ON THE MECHANICS
OF THE HOST TISSUE RESPONSE
Feola Andrew J 02 February 2012 Doctoral Dissertation University of Pittsburgh
ldquoImplantation of the stiffest mesh in the non human primate
resulted in an exhibition of a stress-shielding response
manifested by inferior biomechanical properties of the
abdominal and vaginal tissues
Less stiff meshes resulted in preservation of tissue
propertiesrdquo
Wolffrsquos Law ndash remodeling of bone in response to stress
MESH CHARACTERISTICS
Density - Filament size ndash Elasticity - Pore size
Surface area ndash Overall ldquomesh loadrdquo
Biomechanical engineers working with type-1
polypropylene have focused on reducing overall
ldquomesh loadrdquo while maintaining durability
bullOptimal tissue incorporation and collagen growthbullNo erosionbullNo palpable mesh to patient and her partnerbullVaginal elasticity
TO OBTAIN
So lighter is better
WHAT KIND OF MESH
bull To date polypropylene meshes are the best type on the market
bull Absorbable meshes do not work
bull There is an evidence to use Polypropylene vs polyesther
bull PTFE and NW meshes are contra ndash indicated in the POP Repair
ULTRA- LIGHT POLYPROPYLENE
bull Physiologically compatible 19 gsm1
bull Ultra lightweightbull Lowest weight available for pelvic restoration
bull 18 millimeter macropores1
ndash Consistent size throughout the mesh
bull 100 micron interstitial Smartporestrade 1ndash Simultaneously encourages both collagen growth and
bacteria fighting propertiesbull Fibroblasts will enter holes that are 50 to 200 microns in size23
bull Macrophages and neutrophils will enter holes that are 50 to 120 microns in size23
bull Reduce inflammation1 Data on file2 Greca FH et at (2007) The influence of porosity on integration histology of two polypropylene meshes for the treatment of abdominal wall
defects in dogs Hernia (12) 45-493 Marois Y et all (2000) Biostability inflammatory response and healing characteristics flourpassivated polyester-knit mesh in the repair of
experimental abdominal hernias Artif Organs 24533-543
ULTRA ndash LIGHT CLINICAL EVIDENCE
SUMMARY
bull Rates of Erosion and Exposurebull Less than 1 erosion rate1
bull Anterior exposure rate 172
bull Posterior exposure rate 052
bull Greater tissue strength 3 months post-op ndash 71 more collagen growth3
bull Mature vaginal elastin decrease was not observed with Smartmesh4
bull Smartmesh did not induce a negative change in collagen metabolism5
bull Smartmesh had similar innervation density as sham 6
bull Low incidence of de novo dyspareunia71 Alinsod R et al (2008) Long term outcomes of vaginal pelvic floor repair using an ultra lightweight mesh AAGL (2008)2 Alinsod R Et al (2012) Durability and Complications of an Ultra Lightweight Transvaginal Mesh in the Treatment of Pelvic Organ Prolapse Presented at the 37th Annual Meeting of IUGA3 Greca FH et al (2007) The influence of porosity on the integration histology of two polypropylene meshes for the treatment of abdominal wall defects in dogs Hernia (12) 45-494 Moalli et al (2012) Mesh implantation negatively impacts vagina elastin metabolism Female Pelvic Medicine amp Reconstructive Surgery Vol 18 (Suppl 2)S258-9 SeptOct paper 235 Moalli et al (2012) Increasing mesh stiffness negatively impacts vaginal collagen metabolism Female Pelvic Medicine amp Reconstructive Surgery Vol 18 (Suppl 2)S258-9 SeptOct paper 246 Moalli et al (2012) The impact of mesh implantation on vaginal smooth muscle innervation Female Pelvic Medicine amp Reconstructive Surgery Vol 18 (Suppl 2)S258-9 SeptOct paper 257 Hawthorn R et al (2007) Use of ultra lightweight mesh in vaginal vault repairs to minimize complications A two centre observation study British International Congress of Obstetrics amp Gynaecology
PRE FORMED Y-MESH VS CUTTING MESH AND MAKING IT TO FIT PATIENTS
Pr Bruno DEVAL MD Geoffroy Saint-Hilaire ndash Clinic
Hotel ndashDieu de Paris
Paris V University
Mesh and operative handling
The shape and weight of the mesh can help us during
laparoscopic procedure
A large Y mesh is a good choice for vaginal vault shape
Better intra-operative manipulation and suturing
Lower mesh mass accommodates easy passage through narrow
laparoscopic ports
Use re-absorbable sutures on the vagina
bull Stitch erosions are reported
bull Folding and wrinkling can cause
erosions and dyspaurenia
Avoid folding and wrinkling the
mesh must be well stretched
DO WE NEED TO DISSECT POSTERIOR DOWN TO PERINEUM OR
IN WHICH PATIENTS THIS IS INDICATED
Pr Bruno DEVAL MD Geoffroy Saint-Hilaire ndash Clinic
Hotel ndashDieu de Paris
Paris V University
Fix the mesh on the posterior
vaginal wall and not on the
elevator ani muscle
bull To avoid dyschezia and chronic
pelvic pain
bull Sacrocolpopexy should only be performed by board certified eligible surgeons (ObGyn or Urology)
bull Knowledge surgical skills and experience in reconstructive pelvic surgery
FPMRS fellowship
CME documentation
Proctoring on 10 cases
gt 50 practice in reconstructive surgery
bull Outcomes and complications of should be monitored by annual internal audit
bull Informed consent should highlight
Alternatives to ASC including pessary
Complications of ASC
Complications of mesh
AUGS Guidelines on Sacrocolpopexy Privileges(March 2013)
Source wwwaugsorg
Conclusion
bull The technique and expertise are
fundamental
bull Laparoscopic colposacropexy can safely
be offered to women with symptomatic
POP
bull Conventional LSCP = Open Way =
robotic way
bull Conventional LSCP gt Vaginal Way
HISTORY OF HSYERO-SACRO - COLPOPEXY
58 years old OPSC 21 years old LSC
11 years old RSC
bull Arthure H et al
ndash Uterine prolapse and prolapse of the vaginal vault treated by sacral hysteropexy
bull BJOG an international journal of obstetrics and gynaecology 1957
bull Huguier et al
ndash Posterior suspension of the genital axis on the lumbosacral disk in the treatment
of uterine prolapse
bull Presse Med 1958
bull Nezhat C et al
ndash Laparoscopic sacral colpopexy for vaginal vault prolapse
bull Obstetrics and gynecology 1994
bull Eliott D et al
ndash Gynecologic use of robotically assisted laparoscopy Sacrocolpopexy for the
treatment of high-grade vaginal vault prolapse
bull Am J Surg 2004
Age overweight or obesity
Prior abdominal or pelvic surgery Uterine Pathology
LIMITS
5 STEPS OF THE PROCEDURE
Technical GUIDE LINES
A Prepare carefully sacral promontory and avoid excessivedissection All the anatomic landmark should be recognized(Vessels +++)
B Wide preparation of the vaginal walls
C Prefer polypropylene meshes vs Polyesther meshD Use re-absorbable suture on the vaginaE Avoid folding and wrinkling the mesh must be well stretchedF Fix the mesh on the posterior vaginal wall and not on the
elevator ani muscleG Use non-absorbable suture to fix the meshes on the sacrumH Avoid excessive tension on the meshesI Close the retroperitoneumJ Do not perform contemporary Burch procedure or tape
CONVENTIONAL LAPAROSCOPIC SACROCOLPOPEXY FOR FEMALE GENITAL PROLAPSE A CMPREHENSIVE REVIEW
Bruno DEVALa Denise Hatsumi de Freitas Yanasse ORTEGAb Hisham AMajeed FAHIMb Jorge Milhem HADDADd
bull A PubMed online search performed from 01 January 1991to 31 December 2014 using laparoscopy laparoscopicsacrocolpopexy sacral and colpopexy pelvic organprolapse
bull 180 manuscripts were initially identified
bull Only English-language studies with over 40 patients wereincluded resulted in choice of 28 papers
ANATOMICAL RESULTS
LAPAROSCOPIC SACROCOLPOPEXY FOR FEMALE GENITAL PROLAPSE A COMPREHENSIVE REVIEW
Bruno DEVALa Denise Hatsumi de Freitas Yanasse ORTEGAb Hisham AMajeed FAHIMb Jorge Milhem HADDADd
(Submited)
N NFU
Mean FU(Month)
OBJ CURE SUBJ CURE
3142 2721(868)
233 23962676895
20492286896
FONTIONNAL RESULTS
LAPAROSCOPIC SACROCOLPOPEXY FOR FEMALE GENITAL PROLAPSE A COMPREHENSIVE REVIEWBruno DEVALa Denise Hatsumi de Freitas Yanasse ORTEGAb Hisham AMajeed FAHIMb Jorge Milhem HADDADd
(Submited)
DenovoSUI
De NovoDyspareunia
DenovoDyschesia
2002180(91)
1041200(86)
1811720(105)
PER ndash OP MORBIDITY
LAPAROSCOPIC SACROCOLPOPEXY FOR FEMALE GENITAL PROLAPSE A COMPREHENSIVE REVIEW
Bruno DEVALa Denise Hatsumi de Freitas Yanasse ORTEGAb Hisham AMajeed FAHIMb Jorge Milhem HADDADd
(Submited)
N Conversion to Laparotomy
Bladderinjury
Rectal Bowellinjury
Vaginal Injury
3030 583030
(19)
513030
(17)
223030
(07)
93030
(03)
Post ndash OP MORBIDITY
LAPAROSCOPIC SACROCOLPOPEXY FOR FEMALE GENITAL PROLAPSE A COMPREHENSIVE REVIEW
Bruno DEVALa and al
(Submitted)
Complication TOTAL
Urinary infection 69 (25)
Voiding dysfunctionᵜ 1772721 (65)
Related to trocar site 82721 (03)
Wound infection 9 (033)
Mechanical ileus 9 (033)
Septical peritonitis 1 (003)
Bleeding 132721 (047)
Recurrent acute cystitis 1 (003)
Low back pain or sciatica 192721 (069)
Nerve lesion 3 (01)
Pain related to mesh 552721(22)
Detachment of mesh 32721(01)
Vault infection 2(0073)
Mesh infection 6(022)
Lombosacral spondylodiscitis 72721(025)
Suture erosion 5(018)
Mesh erosion 652721(24)
Rectovaginal fistula 1(003)
Vesicovaginal fistula 32721(01)
anal pain 5(018)
phlebitis 22721(0073)
fever 10(036)
stool incontinence 1(003)
LEARNING CURVE AND EVIDENCE
0
1000
2000
3000
4000
5000
6000
surgery laparoscopy robotic vaginal colorectal SCP
Prospectiv Study n= 206 patients
175 mn after 90 cases
ANALYSIS OF THE LEARNING PROCESS FOR LAPAROSCOPIC SACROCOLPOPEXY
IDENTIFICATION OF CHALLENGING STEPS
Claerhout et al Int j Urogynecol J ndash 2014 25
bull Prospectiv Study POP stade II
ndash Fellow n = 60 cases vs senior-teacher n= 30 cases
bull Fellow senior + Pelvitrainer
bull 5 Steps
bull 30 cases step 1-2
bull 30 to 50 cases steps 3-4
bull Last 10 cases full procedure
bull Comparativ itmes ndash Time
ndash Score
ndash morbidity
ndash Result
LAPAROSCOPIC SURGICAL BOX MODEL TRAINING FOR SURGICAL TRAINEES
WITH NO PRIOR LAPAROSCOPIC EXPERIENCE
Myura Nagendran et al
bull Authors included randomised clinical trials comparing
boxmodel trainers versus no training in surgical trainees
with no prior laparoscopic experience
bull 16 trials (464 participants) provided data for meta-analysis
of box training (248 participants) versus no supplementary
training (216 participants)
bull All the 16 trials in this comparison used video trainers
bull The meta-analysis showed that the time taken for task
completion was significantly shorter in the box trainer
group than the control group
bull Compared with the control group the box trainer group
also had lower error score better accuracy score and
better composite performance scores
bull Laparoscopic box model training appears to improve
technical skills compared with no training in trainees
with no previous laparoscopic experience
Laparoscopic surgical box model training for surgical trainees
with no prior laparoscopic experience
Myura Nagendran et al
Power Point slide deck adapted from
Canadian Agency for Drugs and Technologies in Health
Robot-Assisted Surgery Compared with Open Surgery and Laparoscopic Surgery Clinical Effectiveness and Economic Analyses
Chuong Ho MDEva Tsakonas BA MSc
Khai Tran MSc PhDKaren Cimon
Melissa Severn MIStMonika Mierzwinski-Urban BA MLIS
Jacques Corcos MDStephen Pautler MD FRCSC
September 2014
Adapted by Michael Fung-Kee-Fung MBBS FRCSC MBA
Nancy Jaworski BComm MHA
Walter Gotlieb MD PhD
Adapted from CADTH Technology Report on Robot-Assisted Surgery 2011
Indications for Robot Use ndash Disease Prevalence
bull 24700 new cases of prostate cancer diagnosed in Canada in 2008
bull 219 of patients lt60 years old will choose prostatectomy as initial treatmentUrology
bull 36000 hysterectomies performed in Canada in 200708
bull Hysterectomy is performed for several indications Gynecology
bull 5 year prevalence (2005) 482100000 male amp 318100000 female
bull Surgery is the primary treatment for localized renal cell carcinomaNephrology
bull An estimated 20000 coronary artery bypass graft (CABG) surgeries were performed in Canada in 200001
Cardiac Surgery
Adapted from CADTH Technology Report on Robot-Assisted Surgery 2011
Economic Analysis
bull Robot-Assisted vs Laparoscopic
Economic Model Base Case (Robot not donated)
Hospital Budget Impact
Hospital Budget Impact
ANATOMY OF THE PRESACRAL SPACE
STRUCTURES TO BE
RESPECTED
FOR A SAFE FIXATION
OF THE MESH
RATE OF
BLOOD TRANSFUSION
02
ANATOMICAL VARIATIONS
OF THE LEFT COMMON ILIAC VEIN MIDDLE PART PROMONTORY
bull Distances between the left common iliac vein and the midsacral promontory
bull Dissection of 52 cadavers
bull Mean of d1 = 27 mm (9 - 52)
bull Mean of d2 = 22 mm (9 - 35)
Wieslander CK et al Vascular anatomy of the presacral space in unembalmedfemale cadaversAmerican journal of obstetrics and gynecology 2006 195 1736
d1
RATE OF
BLOOD TRANSFUSION
02
ANATOMICAL VARIATIONS OF PRESACRAL VESSELS
MIDDLE PART PROMONTORY
bull Presacral vesselsndash Middle sacral vein
Oslash= 2mm (1- 4)
double (80)
left to P= 33
right to P= 52
crossing P= 5
mean of d3 = 7 mm (0-17)
P
d3
Wieslander CK et al Vascular anatomy of the presacral space in unembalmed female cadavers American journal of obstetrics and gynecology 2006 195 1736
ANATOMICAL VARIATIONS OF PRESACRAL VESSELS
MIDDLE PART PROMONTORY
bull Presacral vesselsndash Middle sacral artery
Oslash= 2mm (1- 4)
Left to P= 62
Right to P= 30
Crossing P= 8
Mean of d4 = 4 mm (0-15)
Pd4
Wieslander CK et al Vascular anatomy of the presacral space in unembalmed female cadavers American journal of obstetrics and gynecology 2006 195 1736
ANATOMICAL VARIATIONS OF PRESACRAL VESSELS
MIDDLE PART PROMONTORY
bull Presacral space avascular areas
bull Overlay of vascular structures
bull (10 cadavers)
Flynn MK et al Vascular anatomy of the presacral space a freshtissue cadaver dissectionAmerican journal of obstetrics and gynecology2005 192 1501
rarr Dissection right to the medline = safer
ANATOMICAL VARIATIONS OF THE RIGHT URETER
MIDDLE PART PROMONTORY
Flynn MK et al Vascular anatomy of the presacral space a fresh tissue cadaver dissectionAmerican journal of obstetrics and gynecology 2005 192 1501
bull Distances between the right ureter and the midsacral promontory
bull Dissection of 10 cadavers
ANATOMICAL VARIATIONS
OF THE
SUPERIOR HYPOGASTRIC PLEXUS
bull SHP sympathetic plexus connected to IHP
Shiozawa T et al Nerve-preserving sacrocolpopexy anatomical study and surgical approachEuropean journal of obstetrics and gynecology and reproductive biology2010 152 103
ANATOMICAL VARIATIONS OF SUPERIOR HYPOGASTRIC PLEXUS
bull Right hypogastric nerve
Wieslander CK et al Vascular anatomy of the presacral space in unembalmed female cadaversAmerican journal of obstetrics and gynecology 2006 195 1736
d6bull Mean of d6 = 7 mm (0 - 17)
Nerve-preserving sacrocolpopexy anatomical study and surgical approach
Shiozawa T1 et al
By protecting the superiorhypogastric plexus and the part of thepresacral area below the promontorywe can preserve the hypogastricnerves the sacral and pelvicsplanchnic nerves and thus theautonomic innervation of the pelvicorgans
ANATOMICAL VARIATIONS OF LVCA
bull Fixation into the anterior longitudinal
ligament
ANATOMICAL VARIATIONS OF LVCA
Boukkerou M et alPromontofixation procedures use of non-absorbable sutures or tackers Journal de gyneacutecologie obsteacutetrique et biologie de la reproduction2003 32 54
bull Fixation into the anterior longitudinal ligament
and NOT into the disc
ANATOMICAL VARIATIONS OF LVCA
bull Tackers go deep into the bone
Boukkerou M et alPromontofixation procedures use of non-absorbable sutures or tackers Journal de gyneacutecologie obsteacutetrique et biologie de la reproduction2003 32 54
Spondilithis03
ndash Preacutevention bull Asepsie and per-op antibioprophylaxy
ndash Diagnosis ndash Lombalgia fever tence neurologic diseases
ndash Inflammatory Syndrome (CRP)
ndash Radiologic signs (IRM)
bull Immobilisation
bull Antibiotheacuterapie prolongeacutee +- ponction discale
bull Ablation des prothegraveses
bull +- Arthrodegravese laminectomie
Posterior Dissection ndash DENONVILLIERS FASCIA
Since Charles-PierreDenonvilliers first discoveredthe firm membranousstructure between the rectumand prostate or bladder in1836 now calledldquoDenonvilliersrsquo fasciardquo (DF)the origin of DF has remainedcontroversial
Posterior Dissection ndash DENONVILLIERS FASCIA
Based on the evidencesurgeons should be awareof variations and search forthem to create a suitabledissection plane to avoidiatrogenic positive marginsand rectal injury
Rectal Injury04
ndash Sub-peacuteritoneacuteal rectum
bull There is a recto-vaginal space
bull Horizontal Position ++
bull Close to the post face of the vagina on the distal points
bull Danger on the proximal part of the Recto-Vaginal Septum
ndash Preacutevention
bull Follow the post-face of the vagina
bull Systeacutematic pre-operativ preparation
ndash NORMACOL reg
bull Maleable Retractor
ndash Treatment
bull Immeacutediat Suture
bull Mesh contra-Indication
Vaginal Injury04
ndash Preacuteventionbull Ant Vaginal Length - 6 cm ( 4 ndash 75) Jayle et al Masson 1918
bull Post Vaginal Lenght- 9cm (65 ndash 115) Jayle et al Masson 1918
bull There is no difference between the anterior and posteriorvagina thickness
bull If the vagina is too thin ndash Plicature of the vagina
ndash Treatmentbull If Vagina Injury Suture of the vagina
bull There is no contra indication to fix the meshes
RISK OF URETERAL
INJURY lt 11000
ndash Preacutevention
bull Parietal Uretera
ndash Cross between right extern iliac artery and uterine artery
bull Visceral Uretera
ndash Behind the ligaments
ndash Under the bladder
ndash In contact with the bladder
ndash Treatment
bull Per-op
ndash Per-op Bleu carmin en IV
ndash Ureteacuteral Catheter
bull Post-op
ndash Uro-scanner
ndash JJ Ureteral
Bladder
Collection
Sagittal T2
Vagina
Uterus
Ureter ariving in urinoma
Axial T2
Coronale T2
Bladder Injury2
ndash Sub-peacuteritoneacuteal Bladder
bull Vertical Position ++
bull Close to the ant face of the vagina
bull There is NO space
ndash Preacutevention
bull Following the Ant- Face of the vagina
bull Maleable Retractor
ndash Treatment
bull Immeacutediat Suture
bull Mesh Indication
bull Bladder Catheterisation 5 days
Small and Large Bowel Injury
bull Occur when adhesiolysis has to be undertaken
bull Avoid distended bowel at surgery by 48 hours pre op bowel prep
bull Avoid nitrous oxide during surgery as it causes bowel distension
bull If small bowel injured
ndash Repair laparoscopically
ndash Mesh can still be placed
bull Antibiotic cover for 7 days post op
CONCLUSION 1
1 To open the peritoneum tigh-it
2 Dissection on the right side of the mid-sacral ligament
3 Repair carefuly the vessels and the Right ureter
4 Try to preserve the right hypogatsric nerve
5 Fix your needle 1 cm below the promontory
MESH SELECTIONPERTINENT MESH SCIENCEWHY USE A CERTAIN MESH
Pr Bruno DEVAL MD Geoffroy Saint-Hilaire ndash Clinic
Hotel ndashDieu de Paris
Paris V University
MESH STIFFNESS
bullIncreased fibrosis and deposits of unorganized collagen create an increased stiffness
bull (Klinge 1999)
bullStiffness has been linked to clinical complications-heavier stiffer meshes having higher complications
bull (Dietz 2003)
bullStiffer meshes showed decreases in smooth muscle collagen and structural proteins following implantation
bull (Moalli P AUGS 2011)
bullHeavier stiffer meshes showed a greater propensity for stress shielding which in turn could cause reoccurrences of prolapse
bull (Moalli P AUGS 2011)
IMPACT OF VAGINAL SYNTHETIC PROLAPSE MESHES ON THE MECHANICS
OF THE HOST TISSUE RESPONSE
Feola Andrew J 02 February 2012 Doctoral Dissertation University of Pittsburgh
ldquoImplantation of the stiffest mesh in the non human primate
resulted in an exhibition of a stress-shielding response
manifested by inferior biomechanical properties of the
abdominal and vaginal tissues
Less stiff meshes resulted in preservation of tissue
propertiesrdquo
Wolffrsquos Law ndash remodeling of bone in response to stress
MESH CHARACTERISTICS
Density - Filament size ndash Elasticity - Pore size
Surface area ndash Overall ldquomesh loadrdquo
Biomechanical engineers working with type-1
polypropylene have focused on reducing overall
ldquomesh loadrdquo while maintaining durability
bullOptimal tissue incorporation and collagen growthbullNo erosionbullNo palpable mesh to patient and her partnerbullVaginal elasticity
TO OBTAIN
So lighter is better
WHAT KIND OF MESH
bull To date polypropylene meshes are the best type on the market
bull Absorbable meshes do not work
bull There is an evidence to use Polypropylene vs polyesther
bull PTFE and NW meshes are contra ndash indicated in the POP Repair
ULTRA- LIGHT POLYPROPYLENE
bull Physiologically compatible 19 gsm1
bull Ultra lightweightbull Lowest weight available for pelvic restoration
bull 18 millimeter macropores1
ndash Consistent size throughout the mesh
bull 100 micron interstitial Smartporestrade 1ndash Simultaneously encourages both collagen growth and
bacteria fighting propertiesbull Fibroblasts will enter holes that are 50 to 200 microns in size23
bull Macrophages and neutrophils will enter holes that are 50 to 120 microns in size23
bull Reduce inflammation1 Data on file2 Greca FH et at (2007) The influence of porosity on integration histology of two polypropylene meshes for the treatment of abdominal wall
defects in dogs Hernia (12) 45-493 Marois Y et all (2000) Biostability inflammatory response and healing characteristics flourpassivated polyester-knit mesh in the repair of
experimental abdominal hernias Artif Organs 24533-543
ULTRA ndash LIGHT CLINICAL EVIDENCE
SUMMARY
bull Rates of Erosion and Exposurebull Less than 1 erosion rate1
bull Anterior exposure rate 172
bull Posterior exposure rate 052
bull Greater tissue strength 3 months post-op ndash 71 more collagen growth3
bull Mature vaginal elastin decrease was not observed with Smartmesh4
bull Smartmesh did not induce a negative change in collagen metabolism5
bull Smartmesh had similar innervation density as sham 6
bull Low incidence of de novo dyspareunia71 Alinsod R et al (2008) Long term outcomes of vaginal pelvic floor repair using an ultra lightweight mesh AAGL (2008)2 Alinsod R Et al (2012) Durability and Complications of an Ultra Lightweight Transvaginal Mesh in the Treatment of Pelvic Organ Prolapse Presented at the 37th Annual Meeting of IUGA3 Greca FH et al (2007) The influence of porosity on the integration histology of two polypropylene meshes for the treatment of abdominal wall defects in dogs Hernia (12) 45-494 Moalli et al (2012) Mesh implantation negatively impacts vagina elastin metabolism Female Pelvic Medicine amp Reconstructive Surgery Vol 18 (Suppl 2)S258-9 SeptOct paper 235 Moalli et al (2012) Increasing mesh stiffness negatively impacts vaginal collagen metabolism Female Pelvic Medicine amp Reconstructive Surgery Vol 18 (Suppl 2)S258-9 SeptOct paper 246 Moalli et al (2012) The impact of mesh implantation on vaginal smooth muscle innervation Female Pelvic Medicine amp Reconstructive Surgery Vol 18 (Suppl 2)S258-9 SeptOct paper 257 Hawthorn R et al (2007) Use of ultra lightweight mesh in vaginal vault repairs to minimize complications A two centre observation study British International Congress of Obstetrics amp Gynaecology
PRE FORMED Y-MESH VS CUTTING MESH AND MAKING IT TO FIT PATIENTS
Pr Bruno DEVAL MD Geoffroy Saint-Hilaire ndash Clinic
Hotel ndashDieu de Paris
Paris V University
Mesh and operative handling
The shape and weight of the mesh can help us during
laparoscopic procedure
A large Y mesh is a good choice for vaginal vault shape
Better intra-operative manipulation and suturing
Lower mesh mass accommodates easy passage through narrow
laparoscopic ports
Use re-absorbable sutures on the vagina
bull Stitch erosions are reported
bull Folding and wrinkling can cause
erosions and dyspaurenia
Avoid folding and wrinkling the
mesh must be well stretched
DO WE NEED TO DISSECT POSTERIOR DOWN TO PERINEUM OR
IN WHICH PATIENTS THIS IS INDICATED
Pr Bruno DEVAL MD Geoffroy Saint-Hilaire ndash Clinic
Hotel ndashDieu de Paris
Paris V University
Fix the mesh on the posterior
vaginal wall and not on the
elevator ani muscle
bull To avoid dyschezia and chronic
pelvic pain
bull Sacrocolpopexy should only be performed by board certified eligible surgeons (ObGyn or Urology)
bull Knowledge surgical skills and experience in reconstructive pelvic surgery
FPMRS fellowship
CME documentation
Proctoring on 10 cases
gt 50 practice in reconstructive surgery
bull Outcomes and complications of should be monitored by annual internal audit
bull Informed consent should highlight
Alternatives to ASC including pessary
Complications of ASC
Complications of mesh
AUGS Guidelines on Sacrocolpopexy Privileges(March 2013)
Source wwwaugsorg
Conclusion
bull The technique and expertise are
fundamental
bull Laparoscopic colposacropexy can safely
be offered to women with symptomatic
POP
bull Conventional LSCP = Open Way =
robotic way
bull Conventional LSCP gt Vaginal Way
Age overweight or obesity
Prior abdominal or pelvic surgery Uterine Pathology
LIMITS
5 STEPS OF THE PROCEDURE
Technical GUIDE LINES
A Prepare carefully sacral promontory and avoid excessivedissection All the anatomic landmark should be recognized(Vessels +++)
B Wide preparation of the vaginal walls
C Prefer polypropylene meshes vs Polyesther meshD Use re-absorbable suture on the vaginaE Avoid folding and wrinkling the mesh must be well stretchedF Fix the mesh on the posterior vaginal wall and not on the
elevator ani muscleG Use non-absorbable suture to fix the meshes on the sacrumH Avoid excessive tension on the meshesI Close the retroperitoneumJ Do not perform contemporary Burch procedure or tape
CONVENTIONAL LAPAROSCOPIC SACROCOLPOPEXY FOR FEMALE GENITAL PROLAPSE A CMPREHENSIVE REVIEW
Bruno DEVALa Denise Hatsumi de Freitas Yanasse ORTEGAb Hisham AMajeed FAHIMb Jorge Milhem HADDADd
bull A PubMed online search performed from 01 January 1991to 31 December 2014 using laparoscopy laparoscopicsacrocolpopexy sacral and colpopexy pelvic organprolapse
bull 180 manuscripts were initially identified
bull Only English-language studies with over 40 patients wereincluded resulted in choice of 28 papers
ANATOMICAL RESULTS
LAPAROSCOPIC SACROCOLPOPEXY FOR FEMALE GENITAL PROLAPSE A COMPREHENSIVE REVIEW
Bruno DEVALa Denise Hatsumi de Freitas Yanasse ORTEGAb Hisham AMajeed FAHIMb Jorge Milhem HADDADd
(Submited)
N NFU
Mean FU(Month)
OBJ CURE SUBJ CURE
3142 2721(868)
233 23962676895
20492286896
FONTIONNAL RESULTS
LAPAROSCOPIC SACROCOLPOPEXY FOR FEMALE GENITAL PROLAPSE A COMPREHENSIVE REVIEWBruno DEVALa Denise Hatsumi de Freitas Yanasse ORTEGAb Hisham AMajeed FAHIMb Jorge Milhem HADDADd
(Submited)
DenovoSUI
De NovoDyspareunia
DenovoDyschesia
2002180(91)
1041200(86)
1811720(105)
PER ndash OP MORBIDITY
LAPAROSCOPIC SACROCOLPOPEXY FOR FEMALE GENITAL PROLAPSE A COMPREHENSIVE REVIEW
Bruno DEVALa Denise Hatsumi de Freitas Yanasse ORTEGAb Hisham AMajeed FAHIMb Jorge Milhem HADDADd
(Submited)
N Conversion to Laparotomy
Bladderinjury
Rectal Bowellinjury
Vaginal Injury
3030 583030
(19)
513030
(17)
223030
(07)
93030
(03)
Post ndash OP MORBIDITY
LAPAROSCOPIC SACROCOLPOPEXY FOR FEMALE GENITAL PROLAPSE A COMPREHENSIVE REVIEW
Bruno DEVALa and al
(Submitted)
Complication TOTAL
Urinary infection 69 (25)
Voiding dysfunctionᵜ 1772721 (65)
Related to trocar site 82721 (03)
Wound infection 9 (033)
Mechanical ileus 9 (033)
Septical peritonitis 1 (003)
Bleeding 132721 (047)
Recurrent acute cystitis 1 (003)
Low back pain or sciatica 192721 (069)
Nerve lesion 3 (01)
Pain related to mesh 552721(22)
Detachment of mesh 32721(01)
Vault infection 2(0073)
Mesh infection 6(022)
Lombosacral spondylodiscitis 72721(025)
Suture erosion 5(018)
Mesh erosion 652721(24)
Rectovaginal fistula 1(003)
Vesicovaginal fistula 32721(01)
anal pain 5(018)
phlebitis 22721(0073)
fever 10(036)
stool incontinence 1(003)
LEARNING CURVE AND EVIDENCE
0
1000
2000
3000
4000
5000
6000
surgery laparoscopy robotic vaginal colorectal SCP
Prospectiv Study n= 206 patients
175 mn after 90 cases
ANALYSIS OF THE LEARNING PROCESS FOR LAPAROSCOPIC SACROCOLPOPEXY
IDENTIFICATION OF CHALLENGING STEPS
Claerhout et al Int j Urogynecol J ndash 2014 25
bull Prospectiv Study POP stade II
ndash Fellow n = 60 cases vs senior-teacher n= 30 cases
bull Fellow senior + Pelvitrainer
bull 5 Steps
bull 30 cases step 1-2
bull 30 to 50 cases steps 3-4
bull Last 10 cases full procedure
bull Comparativ itmes ndash Time
ndash Score
ndash morbidity
ndash Result
LAPAROSCOPIC SURGICAL BOX MODEL TRAINING FOR SURGICAL TRAINEES
WITH NO PRIOR LAPAROSCOPIC EXPERIENCE
Myura Nagendran et al
bull Authors included randomised clinical trials comparing
boxmodel trainers versus no training in surgical trainees
with no prior laparoscopic experience
bull 16 trials (464 participants) provided data for meta-analysis
of box training (248 participants) versus no supplementary
training (216 participants)
bull All the 16 trials in this comparison used video trainers
bull The meta-analysis showed that the time taken for task
completion was significantly shorter in the box trainer
group than the control group
bull Compared with the control group the box trainer group
also had lower error score better accuracy score and
better composite performance scores
bull Laparoscopic box model training appears to improve
technical skills compared with no training in trainees
with no previous laparoscopic experience
Laparoscopic surgical box model training for surgical trainees
with no prior laparoscopic experience
Myura Nagendran et al
Power Point slide deck adapted from
Canadian Agency for Drugs and Technologies in Health
Robot-Assisted Surgery Compared with Open Surgery and Laparoscopic Surgery Clinical Effectiveness and Economic Analyses
Chuong Ho MDEva Tsakonas BA MSc
Khai Tran MSc PhDKaren Cimon
Melissa Severn MIStMonika Mierzwinski-Urban BA MLIS
Jacques Corcos MDStephen Pautler MD FRCSC
September 2014
Adapted by Michael Fung-Kee-Fung MBBS FRCSC MBA
Nancy Jaworski BComm MHA
Walter Gotlieb MD PhD
Adapted from CADTH Technology Report on Robot-Assisted Surgery 2011
Indications for Robot Use ndash Disease Prevalence
bull 24700 new cases of prostate cancer diagnosed in Canada in 2008
bull 219 of patients lt60 years old will choose prostatectomy as initial treatmentUrology
bull 36000 hysterectomies performed in Canada in 200708
bull Hysterectomy is performed for several indications Gynecology
bull 5 year prevalence (2005) 482100000 male amp 318100000 female
bull Surgery is the primary treatment for localized renal cell carcinomaNephrology
bull An estimated 20000 coronary artery bypass graft (CABG) surgeries were performed in Canada in 200001
Cardiac Surgery
Adapted from CADTH Technology Report on Robot-Assisted Surgery 2011
Economic Analysis
bull Robot-Assisted vs Laparoscopic
Economic Model Base Case (Robot not donated)
Hospital Budget Impact
Hospital Budget Impact
ANATOMY OF THE PRESACRAL SPACE
STRUCTURES TO BE
RESPECTED
FOR A SAFE FIXATION
OF THE MESH
RATE OF
BLOOD TRANSFUSION
02
ANATOMICAL VARIATIONS
OF THE LEFT COMMON ILIAC VEIN MIDDLE PART PROMONTORY
bull Distances between the left common iliac vein and the midsacral promontory
bull Dissection of 52 cadavers
bull Mean of d1 = 27 mm (9 - 52)
bull Mean of d2 = 22 mm (9 - 35)
Wieslander CK et al Vascular anatomy of the presacral space in unembalmedfemale cadaversAmerican journal of obstetrics and gynecology 2006 195 1736
d1
RATE OF
BLOOD TRANSFUSION
02
ANATOMICAL VARIATIONS OF PRESACRAL VESSELS
MIDDLE PART PROMONTORY
bull Presacral vesselsndash Middle sacral vein
Oslash= 2mm (1- 4)
double (80)
left to P= 33
right to P= 52
crossing P= 5
mean of d3 = 7 mm (0-17)
P
d3
Wieslander CK et al Vascular anatomy of the presacral space in unembalmed female cadavers American journal of obstetrics and gynecology 2006 195 1736
ANATOMICAL VARIATIONS OF PRESACRAL VESSELS
MIDDLE PART PROMONTORY
bull Presacral vesselsndash Middle sacral artery
Oslash= 2mm (1- 4)
Left to P= 62
Right to P= 30
Crossing P= 8
Mean of d4 = 4 mm (0-15)
Pd4
Wieslander CK et al Vascular anatomy of the presacral space in unembalmed female cadavers American journal of obstetrics and gynecology 2006 195 1736
ANATOMICAL VARIATIONS OF PRESACRAL VESSELS
MIDDLE PART PROMONTORY
bull Presacral space avascular areas
bull Overlay of vascular structures
bull (10 cadavers)
Flynn MK et al Vascular anatomy of the presacral space a freshtissue cadaver dissectionAmerican journal of obstetrics and gynecology2005 192 1501
rarr Dissection right to the medline = safer
ANATOMICAL VARIATIONS OF THE RIGHT URETER
MIDDLE PART PROMONTORY
Flynn MK et al Vascular anatomy of the presacral space a fresh tissue cadaver dissectionAmerican journal of obstetrics and gynecology 2005 192 1501
bull Distances between the right ureter and the midsacral promontory
bull Dissection of 10 cadavers
ANATOMICAL VARIATIONS
OF THE
SUPERIOR HYPOGASTRIC PLEXUS
bull SHP sympathetic plexus connected to IHP
Shiozawa T et al Nerve-preserving sacrocolpopexy anatomical study and surgical approachEuropean journal of obstetrics and gynecology and reproductive biology2010 152 103
ANATOMICAL VARIATIONS OF SUPERIOR HYPOGASTRIC PLEXUS
bull Right hypogastric nerve
Wieslander CK et al Vascular anatomy of the presacral space in unembalmed female cadaversAmerican journal of obstetrics and gynecology 2006 195 1736
d6bull Mean of d6 = 7 mm (0 - 17)
Nerve-preserving sacrocolpopexy anatomical study and surgical approach
Shiozawa T1 et al
By protecting the superiorhypogastric plexus and the part of thepresacral area below the promontorywe can preserve the hypogastricnerves the sacral and pelvicsplanchnic nerves and thus theautonomic innervation of the pelvicorgans
ANATOMICAL VARIATIONS OF LVCA
bull Fixation into the anterior longitudinal
ligament
ANATOMICAL VARIATIONS OF LVCA
Boukkerou M et alPromontofixation procedures use of non-absorbable sutures or tackers Journal de gyneacutecologie obsteacutetrique et biologie de la reproduction2003 32 54
bull Fixation into the anterior longitudinal ligament
and NOT into the disc
ANATOMICAL VARIATIONS OF LVCA
bull Tackers go deep into the bone
Boukkerou M et alPromontofixation procedures use of non-absorbable sutures or tackers Journal de gyneacutecologie obsteacutetrique et biologie de la reproduction2003 32 54
Spondilithis03
ndash Preacutevention bull Asepsie and per-op antibioprophylaxy
ndash Diagnosis ndash Lombalgia fever tence neurologic diseases
ndash Inflammatory Syndrome (CRP)
ndash Radiologic signs (IRM)
bull Immobilisation
bull Antibiotheacuterapie prolongeacutee +- ponction discale
bull Ablation des prothegraveses
bull +- Arthrodegravese laminectomie
Posterior Dissection ndash DENONVILLIERS FASCIA
Since Charles-PierreDenonvilliers first discoveredthe firm membranousstructure between the rectumand prostate or bladder in1836 now calledldquoDenonvilliersrsquo fasciardquo (DF)the origin of DF has remainedcontroversial
Posterior Dissection ndash DENONVILLIERS FASCIA
Based on the evidencesurgeons should be awareof variations and search forthem to create a suitabledissection plane to avoidiatrogenic positive marginsand rectal injury
Rectal Injury04
ndash Sub-peacuteritoneacuteal rectum
bull There is a recto-vaginal space
bull Horizontal Position ++
bull Close to the post face of the vagina on the distal points
bull Danger on the proximal part of the Recto-Vaginal Septum
ndash Preacutevention
bull Follow the post-face of the vagina
bull Systeacutematic pre-operativ preparation
ndash NORMACOL reg
bull Maleable Retractor
ndash Treatment
bull Immeacutediat Suture
bull Mesh contra-Indication
Vaginal Injury04
ndash Preacuteventionbull Ant Vaginal Length - 6 cm ( 4 ndash 75) Jayle et al Masson 1918
bull Post Vaginal Lenght- 9cm (65 ndash 115) Jayle et al Masson 1918
bull There is no difference between the anterior and posteriorvagina thickness
bull If the vagina is too thin ndash Plicature of the vagina
ndash Treatmentbull If Vagina Injury Suture of the vagina
bull There is no contra indication to fix the meshes
RISK OF URETERAL
INJURY lt 11000
ndash Preacutevention
bull Parietal Uretera
ndash Cross between right extern iliac artery and uterine artery
bull Visceral Uretera
ndash Behind the ligaments
ndash Under the bladder
ndash In contact with the bladder
ndash Treatment
bull Per-op
ndash Per-op Bleu carmin en IV
ndash Ureteacuteral Catheter
bull Post-op
ndash Uro-scanner
ndash JJ Ureteral
Bladder
Collection
Sagittal T2
Vagina
Uterus
Ureter ariving in urinoma
Axial T2
Coronale T2
Bladder Injury2
ndash Sub-peacuteritoneacuteal Bladder
bull Vertical Position ++
bull Close to the ant face of the vagina
bull There is NO space
ndash Preacutevention
bull Following the Ant- Face of the vagina
bull Maleable Retractor
ndash Treatment
bull Immeacutediat Suture
bull Mesh Indication
bull Bladder Catheterisation 5 days
Small and Large Bowel Injury
bull Occur when adhesiolysis has to be undertaken
bull Avoid distended bowel at surgery by 48 hours pre op bowel prep
bull Avoid nitrous oxide during surgery as it causes bowel distension
bull If small bowel injured
ndash Repair laparoscopically
ndash Mesh can still be placed
bull Antibiotic cover for 7 days post op
CONCLUSION 1
1 To open the peritoneum tigh-it
2 Dissection on the right side of the mid-sacral ligament
3 Repair carefuly the vessels and the Right ureter
4 Try to preserve the right hypogatsric nerve
5 Fix your needle 1 cm below the promontory
MESH SELECTIONPERTINENT MESH SCIENCEWHY USE A CERTAIN MESH
Pr Bruno DEVAL MD Geoffroy Saint-Hilaire ndash Clinic
Hotel ndashDieu de Paris
Paris V University
MESH STIFFNESS
bullIncreased fibrosis and deposits of unorganized collagen create an increased stiffness
bull (Klinge 1999)
bullStiffness has been linked to clinical complications-heavier stiffer meshes having higher complications
bull (Dietz 2003)
bullStiffer meshes showed decreases in smooth muscle collagen and structural proteins following implantation
bull (Moalli P AUGS 2011)
bullHeavier stiffer meshes showed a greater propensity for stress shielding which in turn could cause reoccurrences of prolapse
bull (Moalli P AUGS 2011)
IMPACT OF VAGINAL SYNTHETIC PROLAPSE MESHES ON THE MECHANICS
OF THE HOST TISSUE RESPONSE
Feola Andrew J 02 February 2012 Doctoral Dissertation University of Pittsburgh
ldquoImplantation of the stiffest mesh in the non human primate
resulted in an exhibition of a stress-shielding response
manifested by inferior biomechanical properties of the
abdominal and vaginal tissues
Less stiff meshes resulted in preservation of tissue
propertiesrdquo
Wolffrsquos Law ndash remodeling of bone in response to stress
MESH CHARACTERISTICS
Density - Filament size ndash Elasticity - Pore size
Surface area ndash Overall ldquomesh loadrdquo
Biomechanical engineers working with type-1
polypropylene have focused on reducing overall
ldquomesh loadrdquo while maintaining durability
bullOptimal tissue incorporation and collagen growthbullNo erosionbullNo palpable mesh to patient and her partnerbullVaginal elasticity
TO OBTAIN
So lighter is better
WHAT KIND OF MESH
bull To date polypropylene meshes are the best type on the market
bull Absorbable meshes do not work
bull There is an evidence to use Polypropylene vs polyesther
bull PTFE and NW meshes are contra ndash indicated in the POP Repair
ULTRA- LIGHT POLYPROPYLENE
bull Physiologically compatible 19 gsm1
bull Ultra lightweightbull Lowest weight available for pelvic restoration
bull 18 millimeter macropores1
ndash Consistent size throughout the mesh
bull 100 micron interstitial Smartporestrade 1ndash Simultaneously encourages both collagen growth and
bacteria fighting propertiesbull Fibroblasts will enter holes that are 50 to 200 microns in size23
bull Macrophages and neutrophils will enter holes that are 50 to 120 microns in size23
bull Reduce inflammation1 Data on file2 Greca FH et at (2007) The influence of porosity on integration histology of two polypropylene meshes for the treatment of abdominal wall
defects in dogs Hernia (12) 45-493 Marois Y et all (2000) Biostability inflammatory response and healing characteristics flourpassivated polyester-knit mesh in the repair of
experimental abdominal hernias Artif Organs 24533-543
ULTRA ndash LIGHT CLINICAL EVIDENCE
SUMMARY
bull Rates of Erosion and Exposurebull Less than 1 erosion rate1
bull Anterior exposure rate 172
bull Posterior exposure rate 052
bull Greater tissue strength 3 months post-op ndash 71 more collagen growth3
bull Mature vaginal elastin decrease was not observed with Smartmesh4
bull Smartmesh did not induce a negative change in collagen metabolism5
bull Smartmesh had similar innervation density as sham 6
bull Low incidence of de novo dyspareunia71 Alinsod R et al (2008) Long term outcomes of vaginal pelvic floor repair using an ultra lightweight mesh AAGL (2008)2 Alinsod R Et al (2012) Durability and Complications of an Ultra Lightweight Transvaginal Mesh in the Treatment of Pelvic Organ Prolapse Presented at the 37th Annual Meeting of IUGA3 Greca FH et al (2007) The influence of porosity on the integration histology of two polypropylene meshes for the treatment of abdominal wall defects in dogs Hernia (12) 45-494 Moalli et al (2012) Mesh implantation negatively impacts vagina elastin metabolism Female Pelvic Medicine amp Reconstructive Surgery Vol 18 (Suppl 2)S258-9 SeptOct paper 235 Moalli et al (2012) Increasing mesh stiffness negatively impacts vaginal collagen metabolism Female Pelvic Medicine amp Reconstructive Surgery Vol 18 (Suppl 2)S258-9 SeptOct paper 246 Moalli et al (2012) The impact of mesh implantation on vaginal smooth muscle innervation Female Pelvic Medicine amp Reconstructive Surgery Vol 18 (Suppl 2)S258-9 SeptOct paper 257 Hawthorn R et al (2007) Use of ultra lightweight mesh in vaginal vault repairs to minimize complications A two centre observation study British International Congress of Obstetrics amp Gynaecology
PRE FORMED Y-MESH VS CUTTING MESH AND MAKING IT TO FIT PATIENTS
Pr Bruno DEVAL MD Geoffroy Saint-Hilaire ndash Clinic
Hotel ndashDieu de Paris
Paris V University
Mesh and operative handling
The shape and weight of the mesh can help us during
laparoscopic procedure
A large Y mesh is a good choice for vaginal vault shape
Better intra-operative manipulation and suturing
Lower mesh mass accommodates easy passage through narrow
laparoscopic ports
Use re-absorbable sutures on the vagina
bull Stitch erosions are reported
bull Folding and wrinkling can cause
erosions and dyspaurenia
Avoid folding and wrinkling the
mesh must be well stretched
DO WE NEED TO DISSECT POSTERIOR DOWN TO PERINEUM OR
IN WHICH PATIENTS THIS IS INDICATED
Pr Bruno DEVAL MD Geoffroy Saint-Hilaire ndash Clinic
Hotel ndashDieu de Paris
Paris V University
Fix the mesh on the posterior
vaginal wall and not on the
elevator ani muscle
bull To avoid dyschezia and chronic
pelvic pain
bull Sacrocolpopexy should only be performed by board certified eligible surgeons (ObGyn or Urology)
bull Knowledge surgical skills and experience in reconstructive pelvic surgery
FPMRS fellowship
CME documentation
Proctoring on 10 cases
gt 50 practice in reconstructive surgery
bull Outcomes and complications of should be monitored by annual internal audit
bull Informed consent should highlight
Alternatives to ASC including pessary
Complications of ASC
Complications of mesh
AUGS Guidelines on Sacrocolpopexy Privileges(March 2013)
Source wwwaugsorg
Conclusion
bull The technique and expertise are
fundamental
bull Laparoscopic colposacropexy can safely
be offered to women with symptomatic
POP
bull Conventional LSCP = Open Way =
robotic way
bull Conventional LSCP gt Vaginal Way
5 STEPS OF THE PROCEDURE
Technical GUIDE LINES
A Prepare carefully sacral promontory and avoid excessivedissection All the anatomic landmark should be recognized(Vessels +++)
B Wide preparation of the vaginal walls
C Prefer polypropylene meshes vs Polyesther meshD Use re-absorbable suture on the vaginaE Avoid folding and wrinkling the mesh must be well stretchedF Fix the mesh on the posterior vaginal wall and not on the
elevator ani muscleG Use non-absorbable suture to fix the meshes on the sacrumH Avoid excessive tension on the meshesI Close the retroperitoneumJ Do not perform contemporary Burch procedure or tape
CONVENTIONAL LAPAROSCOPIC SACROCOLPOPEXY FOR FEMALE GENITAL PROLAPSE A CMPREHENSIVE REVIEW
Bruno DEVALa Denise Hatsumi de Freitas Yanasse ORTEGAb Hisham AMajeed FAHIMb Jorge Milhem HADDADd
bull A PubMed online search performed from 01 January 1991to 31 December 2014 using laparoscopy laparoscopicsacrocolpopexy sacral and colpopexy pelvic organprolapse
bull 180 manuscripts were initially identified
bull Only English-language studies with over 40 patients wereincluded resulted in choice of 28 papers
ANATOMICAL RESULTS
LAPAROSCOPIC SACROCOLPOPEXY FOR FEMALE GENITAL PROLAPSE A COMPREHENSIVE REVIEW
Bruno DEVALa Denise Hatsumi de Freitas Yanasse ORTEGAb Hisham AMajeed FAHIMb Jorge Milhem HADDADd
(Submited)
N NFU
Mean FU(Month)
OBJ CURE SUBJ CURE
3142 2721(868)
233 23962676895
20492286896
FONTIONNAL RESULTS
LAPAROSCOPIC SACROCOLPOPEXY FOR FEMALE GENITAL PROLAPSE A COMPREHENSIVE REVIEWBruno DEVALa Denise Hatsumi de Freitas Yanasse ORTEGAb Hisham AMajeed FAHIMb Jorge Milhem HADDADd
(Submited)
DenovoSUI
De NovoDyspareunia
DenovoDyschesia
2002180(91)
1041200(86)
1811720(105)
PER ndash OP MORBIDITY
LAPAROSCOPIC SACROCOLPOPEXY FOR FEMALE GENITAL PROLAPSE A COMPREHENSIVE REVIEW
Bruno DEVALa Denise Hatsumi de Freitas Yanasse ORTEGAb Hisham AMajeed FAHIMb Jorge Milhem HADDADd
(Submited)
N Conversion to Laparotomy
Bladderinjury
Rectal Bowellinjury
Vaginal Injury
3030 583030
(19)
513030
(17)
223030
(07)
93030
(03)
Post ndash OP MORBIDITY
LAPAROSCOPIC SACROCOLPOPEXY FOR FEMALE GENITAL PROLAPSE A COMPREHENSIVE REVIEW
Bruno DEVALa and al
(Submitted)
Complication TOTAL
Urinary infection 69 (25)
Voiding dysfunctionᵜ 1772721 (65)
Related to trocar site 82721 (03)
Wound infection 9 (033)
Mechanical ileus 9 (033)
Septical peritonitis 1 (003)
Bleeding 132721 (047)
Recurrent acute cystitis 1 (003)
Low back pain or sciatica 192721 (069)
Nerve lesion 3 (01)
Pain related to mesh 552721(22)
Detachment of mesh 32721(01)
Vault infection 2(0073)
Mesh infection 6(022)
Lombosacral spondylodiscitis 72721(025)
Suture erosion 5(018)
Mesh erosion 652721(24)
Rectovaginal fistula 1(003)
Vesicovaginal fistula 32721(01)
anal pain 5(018)
phlebitis 22721(0073)
fever 10(036)
stool incontinence 1(003)
LEARNING CURVE AND EVIDENCE
0
1000
2000
3000
4000
5000
6000
surgery laparoscopy robotic vaginal colorectal SCP
Prospectiv Study n= 206 patients
175 mn after 90 cases
ANALYSIS OF THE LEARNING PROCESS FOR LAPAROSCOPIC SACROCOLPOPEXY
IDENTIFICATION OF CHALLENGING STEPS
Claerhout et al Int j Urogynecol J ndash 2014 25
bull Prospectiv Study POP stade II
ndash Fellow n = 60 cases vs senior-teacher n= 30 cases
bull Fellow senior + Pelvitrainer
bull 5 Steps
bull 30 cases step 1-2
bull 30 to 50 cases steps 3-4
bull Last 10 cases full procedure
bull Comparativ itmes ndash Time
ndash Score
ndash morbidity
ndash Result
LAPAROSCOPIC SURGICAL BOX MODEL TRAINING FOR SURGICAL TRAINEES
WITH NO PRIOR LAPAROSCOPIC EXPERIENCE
Myura Nagendran et al
bull Authors included randomised clinical trials comparing
boxmodel trainers versus no training in surgical trainees
with no prior laparoscopic experience
bull 16 trials (464 participants) provided data for meta-analysis
of box training (248 participants) versus no supplementary
training (216 participants)
bull All the 16 trials in this comparison used video trainers
bull The meta-analysis showed that the time taken for task
completion was significantly shorter in the box trainer
group than the control group
bull Compared with the control group the box trainer group
also had lower error score better accuracy score and
better composite performance scores
bull Laparoscopic box model training appears to improve
technical skills compared with no training in trainees
with no previous laparoscopic experience
Laparoscopic surgical box model training for surgical trainees
with no prior laparoscopic experience
Myura Nagendran et al
Power Point slide deck adapted from
Canadian Agency for Drugs and Technologies in Health
Robot-Assisted Surgery Compared with Open Surgery and Laparoscopic Surgery Clinical Effectiveness and Economic Analyses
Chuong Ho MDEva Tsakonas BA MSc
Khai Tran MSc PhDKaren Cimon
Melissa Severn MIStMonika Mierzwinski-Urban BA MLIS
Jacques Corcos MDStephen Pautler MD FRCSC
September 2014
Adapted by Michael Fung-Kee-Fung MBBS FRCSC MBA
Nancy Jaworski BComm MHA
Walter Gotlieb MD PhD
Adapted from CADTH Technology Report on Robot-Assisted Surgery 2011
Indications for Robot Use ndash Disease Prevalence
bull 24700 new cases of prostate cancer diagnosed in Canada in 2008
bull 219 of patients lt60 years old will choose prostatectomy as initial treatmentUrology
bull 36000 hysterectomies performed in Canada in 200708
bull Hysterectomy is performed for several indications Gynecology
bull 5 year prevalence (2005) 482100000 male amp 318100000 female
bull Surgery is the primary treatment for localized renal cell carcinomaNephrology
bull An estimated 20000 coronary artery bypass graft (CABG) surgeries were performed in Canada in 200001
Cardiac Surgery
Adapted from CADTH Technology Report on Robot-Assisted Surgery 2011
Economic Analysis
bull Robot-Assisted vs Laparoscopic
Economic Model Base Case (Robot not donated)
Hospital Budget Impact
Hospital Budget Impact
ANATOMY OF THE PRESACRAL SPACE
STRUCTURES TO BE
RESPECTED
FOR A SAFE FIXATION
OF THE MESH
RATE OF
BLOOD TRANSFUSION
02
ANATOMICAL VARIATIONS
OF THE LEFT COMMON ILIAC VEIN MIDDLE PART PROMONTORY
bull Distances between the left common iliac vein and the midsacral promontory
bull Dissection of 52 cadavers
bull Mean of d1 = 27 mm (9 - 52)
bull Mean of d2 = 22 mm (9 - 35)
Wieslander CK et al Vascular anatomy of the presacral space in unembalmedfemale cadaversAmerican journal of obstetrics and gynecology 2006 195 1736
d1
RATE OF
BLOOD TRANSFUSION
02
ANATOMICAL VARIATIONS OF PRESACRAL VESSELS
MIDDLE PART PROMONTORY
bull Presacral vesselsndash Middle sacral vein
Oslash= 2mm (1- 4)
double (80)
left to P= 33
right to P= 52
crossing P= 5
mean of d3 = 7 mm (0-17)
P
d3
Wieslander CK et al Vascular anatomy of the presacral space in unembalmed female cadavers American journal of obstetrics and gynecology 2006 195 1736
ANATOMICAL VARIATIONS OF PRESACRAL VESSELS
MIDDLE PART PROMONTORY
bull Presacral vesselsndash Middle sacral artery
Oslash= 2mm (1- 4)
Left to P= 62
Right to P= 30
Crossing P= 8
Mean of d4 = 4 mm (0-15)
Pd4
Wieslander CK et al Vascular anatomy of the presacral space in unembalmed female cadavers American journal of obstetrics and gynecology 2006 195 1736
ANATOMICAL VARIATIONS OF PRESACRAL VESSELS
MIDDLE PART PROMONTORY
bull Presacral space avascular areas
bull Overlay of vascular structures
bull (10 cadavers)
Flynn MK et al Vascular anatomy of the presacral space a freshtissue cadaver dissectionAmerican journal of obstetrics and gynecology2005 192 1501
rarr Dissection right to the medline = safer
ANATOMICAL VARIATIONS OF THE RIGHT URETER
MIDDLE PART PROMONTORY
Flynn MK et al Vascular anatomy of the presacral space a fresh tissue cadaver dissectionAmerican journal of obstetrics and gynecology 2005 192 1501
bull Distances between the right ureter and the midsacral promontory
bull Dissection of 10 cadavers
ANATOMICAL VARIATIONS
OF THE
SUPERIOR HYPOGASTRIC PLEXUS
bull SHP sympathetic plexus connected to IHP
Shiozawa T et al Nerve-preserving sacrocolpopexy anatomical study and surgical approachEuropean journal of obstetrics and gynecology and reproductive biology2010 152 103
ANATOMICAL VARIATIONS OF SUPERIOR HYPOGASTRIC PLEXUS
bull Right hypogastric nerve
Wieslander CK et al Vascular anatomy of the presacral space in unembalmed female cadaversAmerican journal of obstetrics and gynecology 2006 195 1736
d6bull Mean of d6 = 7 mm (0 - 17)
Nerve-preserving sacrocolpopexy anatomical study and surgical approach
Shiozawa T1 et al
By protecting the superiorhypogastric plexus and the part of thepresacral area below the promontorywe can preserve the hypogastricnerves the sacral and pelvicsplanchnic nerves and thus theautonomic innervation of the pelvicorgans
ANATOMICAL VARIATIONS OF LVCA
bull Fixation into the anterior longitudinal
ligament
ANATOMICAL VARIATIONS OF LVCA
Boukkerou M et alPromontofixation procedures use of non-absorbable sutures or tackers Journal de gyneacutecologie obsteacutetrique et biologie de la reproduction2003 32 54
bull Fixation into the anterior longitudinal ligament
and NOT into the disc
ANATOMICAL VARIATIONS OF LVCA
bull Tackers go deep into the bone
Boukkerou M et alPromontofixation procedures use of non-absorbable sutures or tackers Journal de gyneacutecologie obsteacutetrique et biologie de la reproduction2003 32 54
Spondilithis03
ndash Preacutevention bull Asepsie and per-op antibioprophylaxy
ndash Diagnosis ndash Lombalgia fever tence neurologic diseases
ndash Inflammatory Syndrome (CRP)
ndash Radiologic signs (IRM)
bull Immobilisation
bull Antibiotheacuterapie prolongeacutee +- ponction discale
bull Ablation des prothegraveses
bull +- Arthrodegravese laminectomie
Posterior Dissection ndash DENONVILLIERS FASCIA
Since Charles-PierreDenonvilliers first discoveredthe firm membranousstructure between the rectumand prostate or bladder in1836 now calledldquoDenonvilliersrsquo fasciardquo (DF)the origin of DF has remainedcontroversial
Posterior Dissection ndash DENONVILLIERS FASCIA
Based on the evidencesurgeons should be awareof variations and search forthem to create a suitabledissection plane to avoidiatrogenic positive marginsand rectal injury
Rectal Injury04
ndash Sub-peacuteritoneacuteal rectum
bull There is a recto-vaginal space
bull Horizontal Position ++
bull Close to the post face of the vagina on the distal points
bull Danger on the proximal part of the Recto-Vaginal Septum
ndash Preacutevention
bull Follow the post-face of the vagina
bull Systeacutematic pre-operativ preparation
ndash NORMACOL reg
bull Maleable Retractor
ndash Treatment
bull Immeacutediat Suture
bull Mesh contra-Indication
Vaginal Injury04
ndash Preacuteventionbull Ant Vaginal Length - 6 cm ( 4 ndash 75) Jayle et al Masson 1918
bull Post Vaginal Lenght- 9cm (65 ndash 115) Jayle et al Masson 1918
bull There is no difference between the anterior and posteriorvagina thickness
bull If the vagina is too thin ndash Plicature of the vagina
ndash Treatmentbull If Vagina Injury Suture of the vagina
bull There is no contra indication to fix the meshes
RISK OF URETERAL
INJURY lt 11000
ndash Preacutevention
bull Parietal Uretera
ndash Cross between right extern iliac artery and uterine artery
bull Visceral Uretera
ndash Behind the ligaments
ndash Under the bladder
ndash In contact with the bladder
ndash Treatment
bull Per-op
ndash Per-op Bleu carmin en IV
ndash Ureteacuteral Catheter
bull Post-op
ndash Uro-scanner
ndash JJ Ureteral
Bladder
Collection
Sagittal T2
Vagina
Uterus
Ureter ariving in urinoma
Axial T2
Coronale T2
Bladder Injury2
ndash Sub-peacuteritoneacuteal Bladder
bull Vertical Position ++
bull Close to the ant face of the vagina
bull There is NO space
ndash Preacutevention
bull Following the Ant- Face of the vagina
bull Maleable Retractor
ndash Treatment
bull Immeacutediat Suture
bull Mesh Indication
bull Bladder Catheterisation 5 days
Small and Large Bowel Injury
bull Occur when adhesiolysis has to be undertaken
bull Avoid distended bowel at surgery by 48 hours pre op bowel prep
bull Avoid nitrous oxide during surgery as it causes bowel distension
bull If small bowel injured
ndash Repair laparoscopically
ndash Mesh can still be placed
bull Antibiotic cover for 7 days post op
CONCLUSION 1
1 To open the peritoneum tigh-it
2 Dissection on the right side of the mid-sacral ligament
3 Repair carefuly the vessels and the Right ureter
4 Try to preserve the right hypogatsric nerve
5 Fix your needle 1 cm below the promontory
MESH SELECTIONPERTINENT MESH SCIENCEWHY USE A CERTAIN MESH
Pr Bruno DEVAL MD Geoffroy Saint-Hilaire ndash Clinic
Hotel ndashDieu de Paris
Paris V University
MESH STIFFNESS
bullIncreased fibrosis and deposits of unorganized collagen create an increased stiffness
bull (Klinge 1999)
bullStiffness has been linked to clinical complications-heavier stiffer meshes having higher complications
bull (Dietz 2003)
bullStiffer meshes showed decreases in smooth muscle collagen and structural proteins following implantation
bull (Moalli P AUGS 2011)
bullHeavier stiffer meshes showed a greater propensity for stress shielding which in turn could cause reoccurrences of prolapse
bull (Moalli P AUGS 2011)
IMPACT OF VAGINAL SYNTHETIC PROLAPSE MESHES ON THE MECHANICS
OF THE HOST TISSUE RESPONSE
Feola Andrew J 02 February 2012 Doctoral Dissertation University of Pittsburgh
ldquoImplantation of the stiffest mesh in the non human primate
resulted in an exhibition of a stress-shielding response
manifested by inferior biomechanical properties of the
abdominal and vaginal tissues
Less stiff meshes resulted in preservation of tissue
propertiesrdquo
Wolffrsquos Law ndash remodeling of bone in response to stress
MESH CHARACTERISTICS
Density - Filament size ndash Elasticity - Pore size
Surface area ndash Overall ldquomesh loadrdquo
Biomechanical engineers working with type-1
polypropylene have focused on reducing overall
ldquomesh loadrdquo while maintaining durability
bullOptimal tissue incorporation and collagen growthbullNo erosionbullNo palpable mesh to patient and her partnerbullVaginal elasticity
TO OBTAIN
So lighter is better
WHAT KIND OF MESH
bull To date polypropylene meshes are the best type on the market
bull Absorbable meshes do not work
bull There is an evidence to use Polypropylene vs polyesther
bull PTFE and NW meshes are contra ndash indicated in the POP Repair
ULTRA- LIGHT POLYPROPYLENE
bull Physiologically compatible 19 gsm1
bull Ultra lightweightbull Lowest weight available for pelvic restoration
bull 18 millimeter macropores1
ndash Consistent size throughout the mesh
bull 100 micron interstitial Smartporestrade 1ndash Simultaneously encourages both collagen growth and
bacteria fighting propertiesbull Fibroblasts will enter holes that are 50 to 200 microns in size23
bull Macrophages and neutrophils will enter holes that are 50 to 120 microns in size23
bull Reduce inflammation1 Data on file2 Greca FH et at (2007) The influence of porosity on integration histology of two polypropylene meshes for the treatment of abdominal wall
defects in dogs Hernia (12) 45-493 Marois Y et all (2000) Biostability inflammatory response and healing characteristics flourpassivated polyester-knit mesh in the repair of
experimental abdominal hernias Artif Organs 24533-543
ULTRA ndash LIGHT CLINICAL EVIDENCE
SUMMARY
bull Rates of Erosion and Exposurebull Less than 1 erosion rate1
bull Anterior exposure rate 172
bull Posterior exposure rate 052
bull Greater tissue strength 3 months post-op ndash 71 more collagen growth3
bull Mature vaginal elastin decrease was not observed with Smartmesh4
bull Smartmesh did not induce a negative change in collagen metabolism5
bull Smartmesh had similar innervation density as sham 6
bull Low incidence of de novo dyspareunia71 Alinsod R et al (2008) Long term outcomes of vaginal pelvic floor repair using an ultra lightweight mesh AAGL (2008)2 Alinsod R Et al (2012) Durability and Complications of an Ultra Lightweight Transvaginal Mesh in the Treatment of Pelvic Organ Prolapse Presented at the 37th Annual Meeting of IUGA3 Greca FH et al (2007) The influence of porosity on the integration histology of two polypropylene meshes for the treatment of abdominal wall defects in dogs Hernia (12) 45-494 Moalli et al (2012) Mesh implantation negatively impacts vagina elastin metabolism Female Pelvic Medicine amp Reconstructive Surgery Vol 18 (Suppl 2)S258-9 SeptOct paper 235 Moalli et al (2012) Increasing mesh stiffness negatively impacts vaginal collagen metabolism Female Pelvic Medicine amp Reconstructive Surgery Vol 18 (Suppl 2)S258-9 SeptOct paper 246 Moalli et al (2012) The impact of mesh implantation on vaginal smooth muscle innervation Female Pelvic Medicine amp Reconstructive Surgery Vol 18 (Suppl 2)S258-9 SeptOct paper 257 Hawthorn R et al (2007) Use of ultra lightweight mesh in vaginal vault repairs to minimize complications A two centre observation study British International Congress of Obstetrics amp Gynaecology
PRE FORMED Y-MESH VS CUTTING MESH AND MAKING IT TO FIT PATIENTS
Pr Bruno DEVAL MD Geoffroy Saint-Hilaire ndash Clinic
Hotel ndashDieu de Paris
Paris V University
Mesh and operative handling
The shape and weight of the mesh can help us during
laparoscopic procedure
A large Y mesh is a good choice for vaginal vault shape
Better intra-operative manipulation and suturing
Lower mesh mass accommodates easy passage through narrow
laparoscopic ports
Use re-absorbable sutures on the vagina
bull Stitch erosions are reported
bull Folding and wrinkling can cause
erosions and dyspaurenia
Avoid folding and wrinkling the
mesh must be well stretched
DO WE NEED TO DISSECT POSTERIOR DOWN TO PERINEUM OR
IN WHICH PATIENTS THIS IS INDICATED
Pr Bruno DEVAL MD Geoffroy Saint-Hilaire ndash Clinic
Hotel ndashDieu de Paris
Paris V University
Fix the mesh on the posterior
vaginal wall and not on the
elevator ani muscle
bull To avoid dyschezia and chronic
pelvic pain
bull Sacrocolpopexy should only be performed by board certified eligible surgeons (ObGyn or Urology)
bull Knowledge surgical skills and experience in reconstructive pelvic surgery
FPMRS fellowship
CME documentation
Proctoring on 10 cases
gt 50 practice in reconstructive surgery
bull Outcomes and complications of should be monitored by annual internal audit
bull Informed consent should highlight
Alternatives to ASC including pessary
Complications of ASC
Complications of mesh
AUGS Guidelines on Sacrocolpopexy Privileges(March 2013)
Source wwwaugsorg
Conclusion
bull The technique and expertise are
fundamental
bull Laparoscopic colposacropexy can safely
be offered to women with symptomatic
POP
bull Conventional LSCP = Open Way =
robotic way
bull Conventional LSCP gt Vaginal Way
Technical GUIDE LINES
A Prepare carefully sacral promontory and avoid excessivedissection All the anatomic landmark should be recognized(Vessels +++)
B Wide preparation of the vaginal walls
C Prefer polypropylene meshes vs Polyesther meshD Use re-absorbable suture on the vaginaE Avoid folding and wrinkling the mesh must be well stretchedF Fix the mesh on the posterior vaginal wall and not on the
elevator ani muscleG Use non-absorbable suture to fix the meshes on the sacrumH Avoid excessive tension on the meshesI Close the retroperitoneumJ Do not perform contemporary Burch procedure or tape
CONVENTIONAL LAPAROSCOPIC SACROCOLPOPEXY FOR FEMALE GENITAL PROLAPSE A CMPREHENSIVE REVIEW
Bruno DEVALa Denise Hatsumi de Freitas Yanasse ORTEGAb Hisham AMajeed FAHIMb Jorge Milhem HADDADd
bull A PubMed online search performed from 01 January 1991to 31 December 2014 using laparoscopy laparoscopicsacrocolpopexy sacral and colpopexy pelvic organprolapse
bull 180 manuscripts were initially identified
bull Only English-language studies with over 40 patients wereincluded resulted in choice of 28 papers
ANATOMICAL RESULTS
LAPAROSCOPIC SACROCOLPOPEXY FOR FEMALE GENITAL PROLAPSE A COMPREHENSIVE REVIEW
Bruno DEVALa Denise Hatsumi de Freitas Yanasse ORTEGAb Hisham AMajeed FAHIMb Jorge Milhem HADDADd
(Submited)
N NFU
Mean FU(Month)
OBJ CURE SUBJ CURE
3142 2721(868)
233 23962676895
20492286896
FONTIONNAL RESULTS
LAPAROSCOPIC SACROCOLPOPEXY FOR FEMALE GENITAL PROLAPSE A COMPREHENSIVE REVIEWBruno DEVALa Denise Hatsumi de Freitas Yanasse ORTEGAb Hisham AMajeed FAHIMb Jorge Milhem HADDADd
(Submited)
DenovoSUI
De NovoDyspareunia
DenovoDyschesia
2002180(91)
1041200(86)
1811720(105)
PER ndash OP MORBIDITY
LAPAROSCOPIC SACROCOLPOPEXY FOR FEMALE GENITAL PROLAPSE A COMPREHENSIVE REVIEW
Bruno DEVALa Denise Hatsumi de Freitas Yanasse ORTEGAb Hisham AMajeed FAHIMb Jorge Milhem HADDADd
(Submited)
N Conversion to Laparotomy
Bladderinjury
Rectal Bowellinjury
Vaginal Injury
3030 583030
(19)
513030
(17)
223030
(07)
93030
(03)
Post ndash OP MORBIDITY
LAPAROSCOPIC SACROCOLPOPEXY FOR FEMALE GENITAL PROLAPSE A COMPREHENSIVE REVIEW
Bruno DEVALa and al
(Submitted)
Complication TOTAL
Urinary infection 69 (25)
Voiding dysfunctionᵜ 1772721 (65)
Related to trocar site 82721 (03)
Wound infection 9 (033)
Mechanical ileus 9 (033)
Septical peritonitis 1 (003)
Bleeding 132721 (047)
Recurrent acute cystitis 1 (003)
Low back pain or sciatica 192721 (069)
Nerve lesion 3 (01)
Pain related to mesh 552721(22)
Detachment of mesh 32721(01)
Vault infection 2(0073)
Mesh infection 6(022)
Lombosacral spondylodiscitis 72721(025)
Suture erosion 5(018)
Mesh erosion 652721(24)
Rectovaginal fistula 1(003)
Vesicovaginal fistula 32721(01)
anal pain 5(018)
phlebitis 22721(0073)
fever 10(036)
stool incontinence 1(003)
LEARNING CURVE AND EVIDENCE
0
1000
2000
3000
4000
5000
6000
surgery laparoscopy robotic vaginal colorectal SCP
Prospectiv Study n= 206 patients
175 mn after 90 cases
ANALYSIS OF THE LEARNING PROCESS FOR LAPAROSCOPIC SACROCOLPOPEXY
IDENTIFICATION OF CHALLENGING STEPS
Claerhout et al Int j Urogynecol J ndash 2014 25
bull Prospectiv Study POP stade II
ndash Fellow n = 60 cases vs senior-teacher n= 30 cases
bull Fellow senior + Pelvitrainer
bull 5 Steps
bull 30 cases step 1-2
bull 30 to 50 cases steps 3-4
bull Last 10 cases full procedure
bull Comparativ itmes ndash Time
ndash Score
ndash morbidity
ndash Result
LAPAROSCOPIC SURGICAL BOX MODEL TRAINING FOR SURGICAL TRAINEES
WITH NO PRIOR LAPAROSCOPIC EXPERIENCE
Myura Nagendran et al
bull Authors included randomised clinical trials comparing
boxmodel trainers versus no training in surgical trainees
with no prior laparoscopic experience
bull 16 trials (464 participants) provided data for meta-analysis
of box training (248 participants) versus no supplementary
training (216 participants)
bull All the 16 trials in this comparison used video trainers
bull The meta-analysis showed that the time taken for task
completion was significantly shorter in the box trainer
group than the control group
bull Compared with the control group the box trainer group
also had lower error score better accuracy score and
better composite performance scores
bull Laparoscopic box model training appears to improve
technical skills compared with no training in trainees
with no previous laparoscopic experience
Laparoscopic surgical box model training for surgical trainees
with no prior laparoscopic experience
Myura Nagendran et al
Power Point slide deck adapted from
Canadian Agency for Drugs and Technologies in Health
Robot-Assisted Surgery Compared with Open Surgery and Laparoscopic Surgery Clinical Effectiveness and Economic Analyses
Chuong Ho MDEva Tsakonas BA MSc
Khai Tran MSc PhDKaren Cimon
Melissa Severn MIStMonika Mierzwinski-Urban BA MLIS
Jacques Corcos MDStephen Pautler MD FRCSC
September 2014
Adapted by Michael Fung-Kee-Fung MBBS FRCSC MBA
Nancy Jaworski BComm MHA
Walter Gotlieb MD PhD
Adapted from CADTH Technology Report on Robot-Assisted Surgery 2011
Indications for Robot Use ndash Disease Prevalence
bull 24700 new cases of prostate cancer diagnosed in Canada in 2008
bull 219 of patients lt60 years old will choose prostatectomy as initial treatmentUrology
bull 36000 hysterectomies performed in Canada in 200708
bull Hysterectomy is performed for several indications Gynecology
bull 5 year prevalence (2005) 482100000 male amp 318100000 female
bull Surgery is the primary treatment for localized renal cell carcinomaNephrology
bull An estimated 20000 coronary artery bypass graft (CABG) surgeries were performed in Canada in 200001
Cardiac Surgery
Adapted from CADTH Technology Report on Robot-Assisted Surgery 2011
Economic Analysis
bull Robot-Assisted vs Laparoscopic
Economic Model Base Case (Robot not donated)
Hospital Budget Impact
Hospital Budget Impact
ANATOMY OF THE PRESACRAL SPACE
STRUCTURES TO BE
RESPECTED
FOR A SAFE FIXATION
OF THE MESH
RATE OF
BLOOD TRANSFUSION
02
ANATOMICAL VARIATIONS
OF THE LEFT COMMON ILIAC VEIN MIDDLE PART PROMONTORY
bull Distances between the left common iliac vein and the midsacral promontory
bull Dissection of 52 cadavers
bull Mean of d1 = 27 mm (9 - 52)
bull Mean of d2 = 22 mm (9 - 35)
Wieslander CK et al Vascular anatomy of the presacral space in unembalmedfemale cadaversAmerican journal of obstetrics and gynecology 2006 195 1736
d1
RATE OF
BLOOD TRANSFUSION
02
ANATOMICAL VARIATIONS OF PRESACRAL VESSELS
MIDDLE PART PROMONTORY
bull Presacral vesselsndash Middle sacral vein
Oslash= 2mm (1- 4)
double (80)
left to P= 33
right to P= 52
crossing P= 5
mean of d3 = 7 mm (0-17)
P
d3
Wieslander CK et al Vascular anatomy of the presacral space in unembalmed female cadavers American journal of obstetrics and gynecology 2006 195 1736
ANATOMICAL VARIATIONS OF PRESACRAL VESSELS
MIDDLE PART PROMONTORY
bull Presacral vesselsndash Middle sacral artery
Oslash= 2mm (1- 4)
Left to P= 62
Right to P= 30
Crossing P= 8
Mean of d4 = 4 mm (0-15)
Pd4
Wieslander CK et al Vascular anatomy of the presacral space in unembalmed female cadavers American journal of obstetrics and gynecology 2006 195 1736
ANATOMICAL VARIATIONS OF PRESACRAL VESSELS
MIDDLE PART PROMONTORY
bull Presacral space avascular areas
bull Overlay of vascular structures
bull (10 cadavers)
Flynn MK et al Vascular anatomy of the presacral space a freshtissue cadaver dissectionAmerican journal of obstetrics and gynecology2005 192 1501
rarr Dissection right to the medline = safer
ANATOMICAL VARIATIONS OF THE RIGHT URETER
MIDDLE PART PROMONTORY
Flynn MK et al Vascular anatomy of the presacral space a fresh tissue cadaver dissectionAmerican journal of obstetrics and gynecology 2005 192 1501
bull Distances between the right ureter and the midsacral promontory
bull Dissection of 10 cadavers
ANATOMICAL VARIATIONS
OF THE
SUPERIOR HYPOGASTRIC PLEXUS
bull SHP sympathetic plexus connected to IHP
Shiozawa T et al Nerve-preserving sacrocolpopexy anatomical study and surgical approachEuropean journal of obstetrics and gynecology and reproductive biology2010 152 103
ANATOMICAL VARIATIONS OF SUPERIOR HYPOGASTRIC PLEXUS
bull Right hypogastric nerve
Wieslander CK et al Vascular anatomy of the presacral space in unembalmed female cadaversAmerican journal of obstetrics and gynecology 2006 195 1736
d6bull Mean of d6 = 7 mm (0 - 17)
Nerve-preserving sacrocolpopexy anatomical study and surgical approach
Shiozawa T1 et al
By protecting the superiorhypogastric plexus and the part of thepresacral area below the promontorywe can preserve the hypogastricnerves the sacral and pelvicsplanchnic nerves and thus theautonomic innervation of the pelvicorgans
ANATOMICAL VARIATIONS OF LVCA
bull Fixation into the anterior longitudinal
ligament
ANATOMICAL VARIATIONS OF LVCA
Boukkerou M et alPromontofixation procedures use of non-absorbable sutures or tackers Journal de gyneacutecologie obsteacutetrique et biologie de la reproduction2003 32 54
bull Fixation into the anterior longitudinal ligament
and NOT into the disc
ANATOMICAL VARIATIONS OF LVCA
bull Tackers go deep into the bone
Boukkerou M et alPromontofixation procedures use of non-absorbable sutures or tackers Journal de gyneacutecologie obsteacutetrique et biologie de la reproduction2003 32 54
Spondilithis03
ndash Preacutevention bull Asepsie and per-op antibioprophylaxy
ndash Diagnosis ndash Lombalgia fever tence neurologic diseases
ndash Inflammatory Syndrome (CRP)
ndash Radiologic signs (IRM)
bull Immobilisation
bull Antibiotheacuterapie prolongeacutee +- ponction discale
bull Ablation des prothegraveses
bull +- Arthrodegravese laminectomie
Posterior Dissection ndash DENONVILLIERS FASCIA
Since Charles-PierreDenonvilliers first discoveredthe firm membranousstructure between the rectumand prostate or bladder in1836 now calledldquoDenonvilliersrsquo fasciardquo (DF)the origin of DF has remainedcontroversial
Posterior Dissection ndash DENONVILLIERS FASCIA
Based on the evidencesurgeons should be awareof variations and search forthem to create a suitabledissection plane to avoidiatrogenic positive marginsand rectal injury
Rectal Injury04
ndash Sub-peacuteritoneacuteal rectum
bull There is a recto-vaginal space
bull Horizontal Position ++
bull Close to the post face of the vagina on the distal points
bull Danger on the proximal part of the Recto-Vaginal Septum
ndash Preacutevention
bull Follow the post-face of the vagina
bull Systeacutematic pre-operativ preparation
ndash NORMACOL reg
bull Maleable Retractor
ndash Treatment
bull Immeacutediat Suture
bull Mesh contra-Indication
Vaginal Injury04
ndash Preacuteventionbull Ant Vaginal Length - 6 cm ( 4 ndash 75) Jayle et al Masson 1918
bull Post Vaginal Lenght- 9cm (65 ndash 115) Jayle et al Masson 1918
bull There is no difference between the anterior and posteriorvagina thickness
bull If the vagina is too thin ndash Plicature of the vagina
ndash Treatmentbull If Vagina Injury Suture of the vagina
bull There is no contra indication to fix the meshes
RISK OF URETERAL
INJURY lt 11000
ndash Preacutevention
bull Parietal Uretera
ndash Cross between right extern iliac artery and uterine artery
bull Visceral Uretera
ndash Behind the ligaments
ndash Under the bladder
ndash In contact with the bladder
ndash Treatment
bull Per-op
ndash Per-op Bleu carmin en IV
ndash Ureteacuteral Catheter
bull Post-op
ndash Uro-scanner
ndash JJ Ureteral
Bladder
Collection
Sagittal T2
Vagina
Uterus
Ureter ariving in urinoma
Axial T2
Coronale T2
Bladder Injury2
ndash Sub-peacuteritoneacuteal Bladder
bull Vertical Position ++
bull Close to the ant face of the vagina
bull There is NO space
ndash Preacutevention
bull Following the Ant- Face of the vagina
bull Maleable Retractor
ndash Treatment
bull Immeacutediat Suture
bull Mesh Indication
bull Bladder Catheterisation 5 days
Small and Large Bowel Injury
bull Occur when adhesiolysis has to be undertaken
bull Avoid distended bowel at surgery by 48 hours pre op bowel prep
bull Avoid nitrous oxide during surgery as it causes bowel distension
bull If small bowel injured
ndash Repair laparoscopically
ndash Mesh can still be placed
bull Antibiotic cover for 7 days post op
CONCLUSION 1
1 To open the peritoneum tigh-it
2 Dissection on the right side of the mid-sacral ligament
3 Repair carefuly the vessels and the Right ureter
4 Try to preserve the right hypogatsric nerve
5 Fix your needle 1 cm below the promontory
MESH SELECTIONPERTINENT MESH SCIENCEWHY USE A CERTAIN MESH
Pr Bruno DEVAL MD Geoffroy Saint-Hilaire ndash Clinic
Hotel ndashDieu de Paris
Paris V University
MESH STIFFNESS
bullIncreased fibrosis and deposits of unorganized collagen create an increased stiffness
bull (Klinge 1999)
bullStiffness has been linked to clinical complications-heavier stiffer meshes having higher complications
bull (Dietz 2003)
bullStiffer meshes showed decreases in smooth muscle collagen and structural proteins following implantation
bull (Moalli P AUGS 2011)
bullHeavier stiffer meshes showed a greater propensity for stress shielding which in turn could cause reoccurrences of prolapse
bull (Moalli P AUGS 2011)
IMPACT OF VAGINAL SYNTHETIC PROLAPSE MESHES ON THE MECHANICS
OF THE HOST TISSUE RESPONSE
Feola Andrew J 02 February 2012 Doctoral Dissertation University of Pittsburgh
ldquoImplantation of the stiffest mesh in the non human primate
resulted in an exhibition of a stress-shielding response
manifested by inferior biomechanical properties of the
abdominal and vaginal tissues
Less stiff meshes resulted in preservation of tissue
propertiesrdquo
Wolffrsquos Law ndash remodeling of bone in response to stress
MESH CHARACTERISTICS
Density - Filament size ndash Elasticity - Pore size
Surface area ndash Overall ldquomesh loadrdquo
Biomechanical engineers working with type-1
polypropylene have focused on reducing overall
ldquomesh loadrdquo while maintaining durability
bullOptimal tissue incorporation and collagen growthbullNo erosionbullNo palpable mesh to patient and her partnerbullVaginal elasticity
TO OBTAIN
So lighter is better
WHAT KIND OF MESH
bull To date polypropylene meshes are the best type on the market
bull Absorbable meshes do not work
bull There is an evidence to use Polypropylene vs polyesther
bull PTFE and NW meshes are contra ndash indicated in the POP Repair
ULTRA- LIGHT POLYPROPYLENE
bull Physiologically compatible 19 gsm1
bull Ultra lightweightbull Lowest weight available for pelvic restoration
bull 18 millimeter macropores1
ndash Consistent size throughout the mesh
bull 100 micron interstitial Smartporestrade 1ndash Simultaneously encourages both collagen growth and
bacteria fighting propertiesbull Fibroblasts will enter holes that are 50 to 200 microns in size23
bull Macrophages and neutrophils will enter holes that are 50 to 120 microns in size23
bull Reduce inflammation1 Data on file2 Greca FH et at (2007) The influence of porosity on integration histology of two polypropylene meshes for the treatment of abdominal wall
defects in dogs Hernia (12) 45-493 Marois Y et all (2000) Biostability inflammatory response and healing characteristics flourpassivated polyester-knit mesh in the repair of
experimental abdominal hernias Artif Organs 24533-543
ULTRA ndash LIGHT CLINICAL EVIDENCE
SUMMARY
bull Rates of Erosion and Exposurebull Less than 1 erosion rate1
bull Anterior exposure rate 172
bull Posterior exposure rate 052
bull Greater tissue strength 3 months post-op ndash 71 more collagen growth3
bull Mature vaginal elastin decrease was not observed with Smartmesh4
bull Smartmesh did not induce a negative change in collagen metabolism5
bull Smartmesh had similar innervation density as sham 6
bull Low incidence of de novo dyspareunia71 Alinsod R et al (2008) Long term outcomes of vaginal pelvic floor repair using an ultra lightweight mesh AAGL (2008)2 Alinsod R Et al (2012) Durability and Complications of an Ultra Lightweight Transvaginal Mesh in the Treatment of Pelvic Organ Prolapse Presented at the 37th Annual Meeting of IUGA3 Greca FH et al (2007) The influence of porosity on the integration histology of two polypropylene meshes for the treatment of abdominal wall defects in dogs Hernia (12) 45-494 Moalli et al (2012) Mesh implantation negatively impacts vagina elastin metabolism Female Pelvic Medicine amp Reconstructive Surgery Vol 18 (Suppl 2)S258-9 SeptOct paper 235 Moalli et al (2012) Increasing mesh stiffness negatively impacts vaginal collagen metabolism Female Pelvic Medicine amp Reconstructive Surgery Vol 18 (Suppl 2)S258-9 SeptOct paper 246 Moalli et al (2012) The impact of mesh implantation on vaginal smooth muscle innervation Female Pelvic Medicine amp Reconstructive Surgery Vol 18 (Suppl 2)S258-9 SeptOct paper 257 Hawthorn R et al (2007) Use of ultra lightweight mesh in vaginal vault repairs to minimize complications A two centre observation study British International Congress of Obstetrics amp Gynaecology
PRE FORMED Y-MESH VS CUTTING MESH AND MAKING IT TO FIT PATIENTS
Pr Bruno DEVAL MD Geoffroy Saint-Hilaire ndash Clinic
Hotel ndashDieu de Paris
Paris V University
Mesh and operative handling
The shape and weight of the mesh can help us during
laparoscopic procedure
A large Y mesh is a good choice for vaginal vault shape
Better intra-operative manipulation and suturing
Lower mesh mass accommodates easy passage through narrow
laparoscopic ports
Use re-absorbable sutures on the vagina
bull Stitch erosions are reported
bull Folding and wrinkling can cause
erosions and dyspaurenia
Avoid folding and wrinkling the
mesh must be well stretched
DO WE NEED TO DISSECT POSTERIOR DOWN TO PERINEUM OR
IN WHICH PATIENTS THIS IS INDICATED
Pr Bruno DEVAL MD Geoffroy Saint-Hilaire ndash Clinic
Hotel ndashDieu de Paris
Paris V University
Fix the mesh on the posterior
vaginal wall and not on the
elevator ani muscle
bull To avoid dyschezia and chronic
pelvic pain
bull Sacrocolpopexy should only be performed by board certified eligible surgeons (ObGyn or Urology)
bull Knowledge surgical skills and experience in reconstructive pelvic surgery
FPMRS fellowship
CME documentation
Proctoring on 10 cases
gt 50 practice in reconstructive surgery
bull Outcomes and complications of should be monitored by annual internal audit
bull Informed consent should highlight
Alternatives to ASC including pessary
Complications of ASC
Complications of mesh
AUGS Guidelines on Sacrocolpopexy Privileges(March 2013)
Source wwwaugsorg
Conclusion
bull The technique and expertise are
fundamental
bull Laparoscopic colposacropexy can safely
be offered to women with symptomatic
POP
bull Conventional LSCP = Open Way =
robotic way
bull Conventional LSCP gt Vaginal Way
CONVENTIONAL LAPAROSCOPIC SACROCOLPOPEXY FOR FEMALE GENITAL PROLAPSE A CMPREHENSIVE REVIEW
Bruno DEVALa Denise Hatsumi de Freitas Yanasse ORTEGAb Hisham AMajeed FAHIMb Jorge Milhem HADDADd
bull A PubMed online search performed from 01 January 1991to 31 December 2014 using laparoscopy laparoscopicsacrocolpopexy sacral and colpopexy pelvic organprolapse
bull 180 manuscripts were initially identified
bull Only English-language studies with over 40 patients wereincluded resulted in choice of 28 papers
ANATOMICAL RESULTS
LAPAROSCOPIC SACROCOLPOPEXY FOR FEMALE GENITAL PROLAPSE A COMPREHENSIVE REVIEW
Bruno DEVALa Denise Hatsumi de Freitas Yanasse ORTEGAb Hisham AMajeed FAHIMb Jorge Milhem HADDADd
(Submited)
N NFU
Mean FU(Month)
OBJ CURE SUBJ CURE
3142 2721(868)
233 23962676895
20492286896
FONTIONNAL RESULTS
LAPAROSCOPIC SACROCOLPOPEXY FOR FEMALE GENITAL PROLAPSE A COMPREHENSIVE REVIEWBruno DEVALa Denise Hatsumi de Freitas Yanasse ORTEGAb Hisham AMajeed FAHIMb Jorge Milhem HADDADd
(Submited)
DenovoSUI
De NovoDyspareunia
DenovoDyschesia
2002180(91)
1041200(86)
1811720(105)
PER ndash OP MORBIDITY
LAPAROSCOPIC SACROCOLPOPEXY FOR FEMALE GENITAL PROLAPSE A COMPREHENSIVE REVIEW
Bruno DEVALa Denise Hatsumi de Freitas Yanasse ORTEGAb Hisham AMajeed FAHIMb Jorge Milhem HADDADd
(Submited)
N Conversion to Laparotomy
Bladderinjury
Rectal Bowellinjury
Vaginal Injury
3030 583030
(19)
513030
(17)
223030
(07)
93030
(03)
Post ndash OP MORBIDITY
LAPAROSCOPIC SACROCOLPOPEXY FOR FEMALE GENITAL PROLAPSE A COMPREHENSIVE REVIEW
Bruno DEVALa and al
(Submitted)
Complication TOTAL
Urinary infection 69 (25)
Voiding dysfunctionᵜ 1772721 (65)
Related to trocar site 82721 (03)
Wound infection 9 (033)
Mechanical ileus 9 (033)
Septical peritonitis 1 (003)
Bleeding 132721 (047)
Recurrent acute cystitis 1 (003)
Low back pain or sciatica 192721 (069)
Nerve lesion 3 (01)
Pain related to mesh 552721(22)
Detachment of mesh 32721(01)
Vault infection 2(0073)
Mesh infection 6(022)
Lombosacral spondylodiscitis 72721(025)
Suture erosion 5(018)
Mesh erosion 652721(24)
Rectovaginal fistula 1(003)
Vesicovaginal fistula 32721(01)
anal pain 5(018)
phlebitis 22721(0073)
fever 10(036)
stool incontinence 1(003)
LEARNING CURVE AND EVIDENCE
0
1000
2000
3000
4000
5000
6000
surgery laparoscopy robotic vaginal colorectal SCP
Prospectiv Study n= 206 patients
175 mn after 90 cases
ANALYSIS OF THE LEARNING PROCESS FOR LAPAROSCOPIC SACROCOLPOPEXY
IDENTIFICATION OF CHALLENGING STEPS
Claerhout et al Int j Urogynecol J ndash 2014 25
bull Prospectiv Study POP stade II
ndash Fellow n = 60 cases vs senior-teacher n= 30 cases
bull Fellow senior + Pelvitrainer
bull 5 Steps
bull 30 cases step 1-2
bull 30 to 50 cases steps 3-4
bull Last 10 cases full procedure
bull Comparativ itmes ndash Time
ndash Score
ndash morbidity
ndash Result
LAPAROSCOPIC SURGICAL BOX MODEL TRAINING FOR SURGICAL TRAINEES
WITH NO PRIOR LAPAROSCOPIC EXPERIENCE
Myura Nagendran et al
bull Authors included randomised clinical trials comparing
boxmodel trainers versus no training in surgical trainees
with no prior laparoscopic experience
bull 16 trials (464 participants) provided data for meta-analysis
of box training (248 participants) versus no supplementary
training (216 participants)
bull All the 16 trials in this comparison used video trainers
bull The meta-analysis showed that the time taken for task
completion was significantly shorter in the box trainer
group than the control group
bull Compared with the control group the box trainer group
also had lower error score better accuracy score and
better composite performance scores
bull Laparoscopic box model training appears to improve
technical skills compared with no training in trainees
with no previous laparoscopic experience
Laparoscopic surgical box model training for surgical trainees
with no prior laparoscopic experience
Myura Nagendran et al
Power Point slide deck adapted from
Canadian Agency for Drugs and Technologies in Health
Robot-Assisted Surgery Compared with Open Surgery and Laparoscopic Surgery Clinical Effectiveness and Economic Analyses
Chuong Ho MDEva Tsakonas BA MSc
Khai Tran MSc PhDKaren Cimon
Melissa Severn MIStMonika Mierzwinski-Urban BA MLIS
Jacques Corcos MDStephen Pautler MD FRCSC
September 2014
Adapted by Michael Fung-Kee-Fung MBBS FRCSC MBA
Nancy Jaworski BComm MHA
Walter Gotlieb MD PhD
Adapted from CADTH Technology Report on Robot-Assisted Surgery 2011
Indications for Robot Use ndash Disease Prevalence
bull 24700 new cases of prostate cancer diagnosed in Canada in 2008
bull 219 of patients lt60 years old will choose prostatectomy as initial treatmentUrology
bull 36000 hysterectomies performed in Canada in 200708
bull Hysterectomy is performed for several indications Gynecology
bull 5 year prevalence (2005) 482100000 male amp 318100000 female
bull Surgery is the primary treatment for localized renal cell carcinomaNephrology
bull An estimated 20000 coronary artery bypass graft (CABG) surgeries were performed in Canada in 200001
Cardiac Surgery
Adapted from CADTH Technology Report on Robot-Assisted Surgery 2011
Economic Analysis
bull Robot-Assisted vs Laparoscopic
Economic Model Base Case (Robot not donated)
Hospital Budget Impact
Hospital Budget Impact
ANATOMY OF THE PRESACRAL SPACE
STRUCTURES TO BE
RESPECTED
FOR A SAFE FIXATION
OF THE MESH
RATE OF
BLOOD TRANSFUSION
02
ANATOMICAL VARIATIONS
OF THE LEFT COMMON ILIAC VEIN MIDDLE PART PROMONTORY
bull Distances between the left common iliac vein and the midsacral promontory
bull Dissection of 52 cadavers
bull Mean of d1 = 27 mm (9 - 52)
bull Mean of d2 = 22 mm (9 - 35)
Wieslander CK et al Vascular anatomy of the presacral space in unembalmedfemale cadaversAmerican journal of obstetrics and gynecology 2006 195 1736
d1
RATE OF
BLOOD TRANSFUSION
02
ANATOMICAL VARIATIONS OF PRESACRAL VESSELS
MIDDLE PART PROMONTORY
bull Presacral vesselsndash Middle sacral vein
Oslash= 2mm (1- 4)
double (80)
left to P= 33
right to P= 52
crossing P= 5
mean of d3 = 7 mm (0-17)
P
d3
Wieslander CK et al Vascular anatomy of the presacral space in unembalmed female cadavers American journal of obstetrics and gynecology 2006 195 1736
ANATOMICAL VARIATIONS OF PRESACRAL VESSELS
MIDDLE PART PROMONTORY
bull Presacral vesselsndash Middle sacral artery
Oslash= 2mm (1- 4)
Left to P= 62
Right to P= 30
Crossing P= 8
Mean of d4 = 4 mm (0-15)
Pd4
Wieslander CK et al Vascular anatomy of the presacral space in unembalmed female cadavers American journal of obstetrics and gynecology 2006 195 1736
ANATOMICAL VARIATIONS OF PRESACRAL VESSELS
MIDDLE PART PROMONTORY
bull Presacral space avascular areas
bull Overlay of vascular structures
bull (10 cadavers)
Flynn MK et al Vascular anatomy of the presacral space a freshtissue cadaver dissectionAmerican journal of obstetrics and gynecology2005 192 1501
rarr Dissection right to the medline = safer
ANATOMICAL VARIATIONS OF THE RIGHT URETER
MIDDLE PART PROMONTORY
Flynn MK et al Vascular anatomy of the presacral space a fresh tissue cadaver dissectionAmerican journal of obstetrics and gynecology 2005 192 1501
bull Distances between the right ureter and the midsacral promontory
bull Dissection of 10 cadavers
ANATOMICAL VARIATIONS
OF THE
SUPERIOR HYPOGASTRIC PLEXUS
bull SHP sympathetic plexus connected to IHP
Shiozawa T et al Nerve-preserving sacrocolpopexy anatomical study and surgical approachEuropean journal of obstetrics and gynecology and reproductive biology2010 152 103
ANATOMICAL VARIATIONS OF SUPERIOR HYPOGASTRIC PLEXUS
bull Right hypogastric nerve
Wieslander CK et al Vascular anatomy of the presacral space in unembalmed female cadaversAmerican journal of obstetrics and gynecology 2006 195 1736
d6bull Mean of d6 = 7 mm (0 - 17)
Nerve-preserving sacrocolpopexy anatomical study and surgical approach
Shiozawa T1 et al
By protecting the superiorhypogastric plexus and the part of thepresacral area below the promontorywe can preserve the hypogastricnerves the sacral and pelvicsplanchnic nerves and thus theautonomic innervation of the pelvicorgans
ANATOMICAL VARIATIONS OF LVCA
bull Fixation into the anterior longitudinal
ligament
ANATOMICAL VARIATIONS OF LVCA
Boukkerou M et alPromontofixation procedures use of non-absorbable sutures or tackers Journal de gyneacutecologie obsteacutetrique et biologie de la reproduction2003 32 54
bull Fixation into the anterior longitudinal ligament
and NOT into the disc
ANATOMICAL VARIATIONS OF LVCA
bull Tackers go deep into the bone
Boukkerou M et alPromontofixation procedures use of non-absorbable sutures or tackers Journal de gyneacutecologie obsteacutetrique et biologie de la reproduction2003 32 54
Spondilithis03
ndash Preacutevention bull Asepsie and per-op antibioprophylaxy
ndash Diagnosis ndash Lombalgia fever tence neurologic diseases
ndash Inflammatory Syndrome (CRP)
ndash Radiologic signs (IRM)
bull Immobilisation
bull Antibiotheacuterapie prolongeacutee +- ponction discale
bull Ablation des prothegraveses
bull +- Arthrodegravese laminectomie
Posterior Dissection ndash DENONVILLIERS FASCIA
Since Charles-PierreDenonvilliers first discoveredthe firm membranousstructure between the rectumand prostate or bladder in1836 now calledldquoDenonvilliersrsquo fasciardquo (DF)the origin of DF has remainedcontroversial
Posterior Dissection ndash DENONVILLIERS FASCIA
Based on the evidencesurgeons should be awareof variations and search forthem to create a suitabledissection plane to avoidiatrogenic positive marginsand rectal injury
Rectal Injury04
ndash Sub-peacuteritoneacuteal rectum
bull There is a recto-vaginal space
bull Horizontal Position ++
bull Close to the post face of the vagina on the distal points
bull Danger on the proximal part of the Recto-Vaginal Septum
ndash Preacutevention
bull Follow the post-face of the vagina
bull Systeacutematic pre-operativ preparation
ndash NORMACOL reg
bull Maleable Retractor
ndash Treatment
bull Immeacutediat Suture
bull Mesh contra-Indication
Vaginal Injury04
ndash Preacuteventionbull Ant Vaginal Length - 6 cm ( 4 ndash 75) Jayle et al Masson 1918
bull Post Vaginal Lenght- 9cm (65 ndash 115) Jayle et al Masson 1918
bull There is no difference between the anterior and posteriorvagina thickness
bull If the vagina is too thin ndash Plicature of the vagina
ndash Treatmentbull If Vagina Injury Suture of the vagina
bull There is no contra indication to fix the meshes
RISK OF URETERAL
INJURY lt 11000
ndash Preacutevention
bull Parietal Uretera
ndash Cross between right extern iliac artery and uterine artery
bull Visceral Uretera
ndash Behind the ligaments
ndash Under the bladder
ndash In contact with the bladder
ndash Treatment
bull Per-op
ndash Per-op Bleu carmin en IV
ndash Ureteacuteral Catheter
bull Post-op
ndash Uro-scanner
ndash JJ Ureteral
Bladder
Collection
Sagittal T2
Vagina
Uterus
Ureter ariving in urinoma
Axial T2
Coronale T2
Bladder Injury2
ndash Sub-peacuteritoneacuteal Bladder
bull Vertical Position ++
bull Close to the ant face of the vagina
bull There is NO space
ndash Preacutevention
bull Following the Ant- Face of the vagina
bull Maleable Retractor
ndash Treatment
bull Immeacutediat Suture
bull Mesh Indication
bull Bladder Catheterisation 5 days
Small and Large Bowel Injury
bull Occur when adhesiolysis has to be undertaken
bull Avoid distended bowel at surgery by 48 hours pre op bowel prep
bull Avoid nitrous oxide during surgery as it causes bowel distension
bull If small bowel injured
ndash Repair laparoscopically
ndash Mesh can still be placed
bull Antibiotic cover for 7 days post op
CONCLUSION 1
1 To open the peritoneum tigh-it
2 Dissection on the right side of the mid-sacral ligament
3 Repair carefuly the vessels and the Right ureter
4 Try to preserve the right hypogatsric nerve
5 Fix your needle 1 cm below the promontory
MESH SELECTIONPERTINENT MESH SCIENCEWHY USE A CERTAIN MESH
Pr Bruno DEVAL MD Geoffroy Saint-Hilaire ndash Clinic
Hotel ndashDieu de Paris
Paris V University
MESH STIFFNESS
bullIncreased fibrosis and deposits of unorganized collagen create an increased stiffness
bull (Klinge 1999)
bullStiffness has been linked to clinical complications-heavier stiffer meshes having higher complications
bull (Dietz 2003)
bullStiffer meshes showed decreases in smooth muscle collagen and structural proteins following implantation
bull (Moalli P AUGS 2011)
bullHeavier stiffer meshes showed a greater propensity for stress shielding which in turn could cause reoccurrences of prolapse
bull (Moalli P AUGS 2011)
IMPACT OF VAGINAL SYNTHETIC PROLAPSE MESHES ON THE MECHANICS
OF THE HOST TISSUE RESPONSE
Feola Andrew J 02 February 2012 Doctoral Dissertation University of Pittsburgh
ldquoImplantation of the stiffest mesh in the non human primate
resulted in an exhibition of a stress-shielding response
manifested by inferior biomechanical properties of the
abdominal and vaginal tissues
Less stiff meshes resulted in preservation of tissue
propertiesrdquo
Wolffrsquos Law ndash remodeling of bone in response to stress
MESH CHARACTERISTICS
Density - Filament size ndash Elasticity - Pore size
Surface area ndash Overall ldquomesh loadrdquo
Biomechanical engineers working with type-1
polypropylene have focused on reducing overall
ldquomesh loadrdquo while maintaining durability
bullOptimal tissue incorporation and collagen growthbullNo erosionbullNo palpable mesh to patient and her partnerbullVaginal elasticity
TO OBTAIN
So lighter is better
WHAT KIND OF MESH
bull To date polypropylene meshes are the best type on the market
bull Absorbable meshes do not work
bull There is an evidence to use Polypropylene vs polyesther
bull PTFE and NW meshes are contra ndash indicated in the POP Repair
ULTRA- LIGHT POLYPROPYLENE
bull Physiologically compatible 19 gsm1
bull Ultra lightweightbull Lowest weight available for pelvic restoration
bull 18 millimeter macropores1
ndash Consistent size throughout the mesh
bull 100 micron interstitial Smartporestrade 1ndash Simultaneously encourages both collagen growth and
bacteria fighting propertiesbull Fibroblasts will enter holes that are 50 to 200 microns in size23
bull Macrophages and neutrophils will enter holes that are 50 to 120 microns in size23
bull Reduce inflammation1 Data on file2 Greca FH et at (2007) The influence of porosity on integration histology of two polypropylene meshes for the treatment of abdominal wall
defects in dogs Hernia (12) 45-493 Marois Y et all (2000) Biostability inflammatory response and healing characteristics flourpassivated polyester-knit mesh in the repair of
experimental abdominal hernias Artif Organs 24533-543
ULTRA ndash LIGHT CLINICAL EVIDENCE
SUMMARY
bull Rates of Erosion and Exposurebull Less than 1 erosion rate1
bull Anterior exposure rate 172
bull Posterior exposure rate 052
bull Greater tissue strength 3 months post-op ndash 71 more collagen growth3
bull Mature vaginal elastin decrease was not observed with Smartmesh4
bull Smartmesh did not induce a negative change in collagen metabolism5
bull Smartmesh had similar innervation density as sham 6
bull Low incidence of de novo dyspareunia71 Alinsod R et al (2008) Long term outcomes of vaginal pelvic floor repair using an ultra lightweight mesh AAGL (2008)2 Alinsod R Et al (2012) Durability and Complications of an Ultra Lightweight Transvaginal Mesh in the Treatment of Pelvic Organ Prolapse Presented at the 37th Annual Meeting of IUGA3 Greca FH et al (2007) The influence of porosity on the integration histology of two polypropylene meshes for the treatment of abdominal wall defects in dogs Hernia (12) 45-494 Moalli et al (2012) Mesh implantation negatively impacts vagina elastin metabolism Female Pelvic Medicine amp Reconstructive Surgery Vol 18 (Suppl 2)S258-9 SeptOct paper 235 Moalli et al (2012) Increasing mesh stiffness negatively impacts vaginal collagen metabolism Female Pelvic Medicine amp Reconstructive Surgery Vol 18 (Suppl 2)S258-9 SeptOct paper 246 Moalli et al (2012) The impact of mesh implantation on vaginal smooth muscle innervation Female Pelvic Medicine amp Reconstructive Surgery Vol 18 (Suppl 2)S258-9 SeptOct paper 257 Hawthorn R et al (2007) Use of ultra lightweight mesh in vaginal vault repairs to minimize complications A two centre observation study British International Congress of Obstetrics amp Gynaecology
PRE FORMED Y-MESH VS CUTTING MESH AND MAKING IT TO FIT PATIENTS
Pr Bruno DEVAL MD Geoffroy Saint-Hilaire ndash Clinic
Hotel ndashDieu de Paris
Paris V University
Mesh and operative handling
The shape and weight of the mesh can help us during
laparoscopic procedure
A large Y mesh is a good choice for vaginal vault shape
Better intra-operative manipulation and suturing
Lower mesh mass accommodates easy passage through narrow
laparoscopic ports
Use re-absorbable sutures on the vagina
bull Stitch erosions are reported
bull Folding and wrinkling can cause
erosions and dyspaurenia
Avoid folding and wrinkling the
mesh must be well stretched
DO WE NEED TO DISSECT POSTERIOR DOWN TO PERINEUM OR
IN WHICH PATIENTS THIS IS INDICATED
Pr Bruno DEVAL MD Geoffroy Saint-Hilaire ndash Clinic
Hotel ndashDieu de Paris
Paris V University
Fix the mesh on the posterior
vaginal wall and not on the
elevator ani muscle
bull To avoid dyschezia and chronic
pelvic pain
bull Sacrocolpopexy should only be performed by board certified eligible surgeons (ObGyn or Urology)
bull Knowledge surgical skills and experience in reconstructive pelvic surgery
FPMRS fellowship
CME documentation
Proctoring on 10 cases
gt 50 practice in reconstructive surgery
bull Outcomes and complications of should be monitored by annual internal audit
bull Informed consent should highlight
Alternatives to ASC including pessary
Complications of ASC
Complications of mesh
AUGS Guidelines on Sacrocolpopexy Privileges(March 2013)
Source wwwaugsorg
Conclusion
bull The technique and expertise are
fundamental
bull Laparoscopic colposacropexy can safely
be offered to women with symptomatic
POP
bull Conventional LSCP = Open Way =
robotic way
bull Conventional LSCP gt Vaginal Way
ANATOMICAL RESULTS
LAPAROSCOPIC SACROCOLPOPEXY FOR FEMALE GENITAL PROLAPSE A COMPREHENSIVE REVIEW
Bruno DEVALa Denise Hatsumi de Freitas Yanasse ORTEGAb Hisham AMajeed FAHIMb Jorge Milhem HADDADd
(Submited)
N NFU
Mean FU(Month)
OBJ CURE SUBJ CURE
3142 2721(868)
233 23962676895
20492286896
FONTIONNAL RESULTS
LAPAROSCOPIC SACROCOLPOPEXY FOR FEMALE GENITAL PROLAPSE A COMPREHENSIVE REVIEWBruno DEVALa Denise Hatsumi de Freitas Yanasse ORTEGAb Hisham AMajeed FAHIMb Jorge Milhem HADDADd
(Submited)
DenovoSUI
De NovoDyspareunia
DenovoDyschesia
2002180(91)
1041200(86)
1811720(105)
PER ndash OP MORBIDITY
LAPAROSCOPIC SACROCOLPOPEXY FOR FEMALE GENITAL PROLAPSE A COMPREHENSIVE REVIEW
Bruno DEVALa Denise Hatsumi de Freitas Yanasse ORTEGAb Hisham AMajeed FAHIMb Jorge Milhem HADDADd
(Submited)
N Conversion to Laparotomy
Bladderinjury
Rectal Bowellinjury
Vaginal Injury
3030 583030
(19)
513030
(17)
223030
(07)
93030
(03)
Post ndash OP MORBIDITY
LAPAROSCOPIC SACROCOLPOPEXY FOR FEMALE GENITAL PROLAPSE A COMPREHENSIVE REVIEW
Bruno DEVALa and al
(Submitted)
Complication TOTAL
Urinary infection 69 (25)
Voiding dysfunctionᵜ 1772721 (65)
Related to trocar site 82721 (03)
Wound infection 9 (033)
Mechanical ileus 9 (033)
Septical peritonitis 1 (003)
Bleeding 132721 (047)
Recurrent acute cystitis 1 (003)
Low back pain or sciatica 192721 (069)
Nerve lesion 3 (01)
Pain related to mesh 552721(22)
Detachment of mesh 32721(01)
Vault infection 2(0073)
Mesh infection 6(022)
Lombosacral spondylodiscitis 72721(025)
Suture erosion 5(018)
Mesh erosion 652721(24)
Rectovaginal fistula 1(003)
Vesicovaginal fistula 32721(01)
anal pain 5(018)
phlebitis 22721(0073)
fever 10(036)
stool incontinence 1(003)
LEARNING CURVE AND EVIDENCE
0
1000
2000
3000
4000
5000
6000
surgery laparoscopy robotic vaginal colorectal SCP
Prospectiv Study n= 206 patients
175 mn after 90 cases
ANALYSIS OF THE LEARNING PROCESS FOR LAPAROSCOPIC SACROCOLPOPEXY
IDENTIFICATION OF CHALLENGING STEPS
Claerhout et al Int j Urogynecol J ndash 2014 25
bull Prospectiv Study POP stade II
ndash Fellow n = 60 cases vs senior-teacher n= 30 cases
bull Fellow senior + Pelvitrainer
bull 5 Steps
bull 30 cases step 1-2
bull 30 to 50 cases steps 3-4
bull Last 10 cases full procedure
bull Comparativ itmes ndash Time
ndash Score
ndash morbidity
ndash Result
LAPAROSCOPIC SURGICAL BOX MODEL TRAINING FOR SURGICAL TRAINEES
WITH NO PRIOR LAPAROSCOPIC EXPERIENCE
Myura Nagendran et al
bull Authors included randomised clinical trials comparing
boxmodel trainers versus no training in surgical trainees
with no prior laparoscopic experience
bull 16 trials (464 participants) provided data for meta-analysis
of box training (248 participants) versus no supplementary
training (216 participants)
bull All the 16 trials in this comparison used video trainers
bull The meta-analysis showed that the time taken for task
completion was significantly shorter in the box trainer
group than the control group
bull Compared with the control group the box trainer group
also had lower error score better accuracy score and
better composite performance scores
bull Laparoscopic box model training appears to improve
technical skills compared with no training in trainees
with no previous laparoscopic experience
Laparoscopic surgical box model training for surgical trainees
with no prior laparoscopic experience
Myura Nagendran et al
Power Point slide deck adapted from
Canadian Agency for Drugs and Technologies in Health
Robot-Assisted Surgery Compared with Open Surgery and Laparoscopic Surgery Clinical Effectiveness and Economic Analyses
Chuong Ho MDEva Tsakonas BA MSc
Khai Tran MSc PhDKaren Cimon
Melissa Severn MIStMonika Mierzwinski-Urban BA MLIS
Jacques Corcos MDStephen Pautler MD FRCSC
September 2014
Adapted by Michael Fung-Kee-Fung MBBS FRCSC MBA
Nancy Jaworski BComm MHA
Walter Gotlieb MD PhD
Adapted from CADTH Technology Report on Robot-Assisted Surgery 2011
Indications for Robot Use ndash Disease Prevalence
bull 24700 new cases of prostate cancer diagnosed in Canada in 2008
bull 219 of patients lt60 years old will choose prostatectomy as initial treatmentUrology
bull 36000 hysterectomies performed in Canada in 200708
bull Hysterectomy is performed for several indications Gynecology
bull 5 year prevalence (2005) 482100000 male amp 318100000 female
bull Surgery is the primary treatment for localized renal cell carcinomaNephrology
bull An estimated 20000 coronary artery bypass graft (CABG) surgeries were performed in Canada in 200001
Cardiac Surgery
Adapted from CADTH Technology Report on Robot-Assisted Surgery 2011
Economic Analysis
bull Robot-Assisted vs Laparoscopic
Economic Model Base Case (Robot not donated)
Hospital Budget Impact
Hospital Budget Impact
ANATOMY OF THE PRESACRAL SPACE
STRUCTURES TO BE
RESPECTED
FOR A SAFE FIXATION
OF THE MESH
RATE OF
BLOOD TRANSFUSION
02
ANATOMICAL VARIATIONS
OF THE LEFT COMMON ILIAC VEIN MIDDLE PART PROMONTORY
bull Distances between the left common iliac vein and the midsacral promontory
bull Dissection of 52 cadavers
bull Mean of d1 = 27 mm (9 - 52)
bull Mean of d2 = 22 mm (9 - 35)
Wieslander CK et al Vascular anatomy of the presacral space in unembalmedfemale cadaversAmerican journal of obstetrics and gynecology 2006 195 1736
d1
RATE OF
BLOOD TRANSFUSION
02
ANATOMICAL VARIATIONS OF PRESACRAL VESSELS
MIDDLE PART PROMONTORY
bull Presacral vesselsndash Middle sacral vein
Oslash= 2mm (1- 4)
double (80)
left to P= 33
right to P= 52
crossing P= 5
mean of d3 = 7 mm (0-17)
P
d3
Wieslander CK et al Vascular anatomy of the presacral space in unembalmed female cadavers American journal of obstetrics and gynecology 2006 195 1736
ANATOMICAL VARIATIONS OF PRESACRAL VESSELS
MIDDLE PART PROMONTORY
bull Presacral vesselsndash Middle sacral artery
Oslash= 2mm (1- 4)
Left to P= 62
Right to P= 30
Crossing P= 8
Mean of d4 = 4 mm (0-15)
Pd4
Wieslander CK et al Vascular anatomy of the presacral space in unembalmed female cadavers American journal of obstetrics and gynecology 2006 195 1736
ANATOMICAL VARIATIONS OF PRESACRAL VESSELS
MIDDLE PART PROMONTORY
bull Presacral space avascular areas
bull Overlay of vascular structures
bull (10 cadavers)
Flynn MK et al Vascular anatomy of the presacral space a freshtissue cadaver dissectionAmerican journal of obstetrics and gynecology2005 192 1501
rarr Dissection right to the medline = safer
ANATOMICAL VARIATIONS OF THE RIGHT URETER
MIDDLE PART PROMONTORY
Flynn MK et al Vascular anatomy of the presacral space a fresh tissue cadaver dissectionAmerican journal of obstetrics and gynecology 2005 192 1501
bull Distances between the right ureter and the midsacral promontory
bull Dissection of 10 cadavers
ANATOMICAL VARIATIONS
OF THE
SUPERIOR HYPOGASTRIC PLEXUS
bull SHP sympathetic plexus connected to IHP
Shiozawa T et al Nerve-preserving sacrocolpopexy anatomical study and surgical approachEuropean journal of obstetrics and gynecology and reproductive biology2010 152 103
ANATOMICAL VARIATIONS OF SUPERIOR HYPOGASTRIC PLEXUS
bull Right hypogastric nerve
Wieslander CK et al Vascular anatomy of the presacral space in unembalmed female cadaversAmerican journal of obstetrics and gynecology 2006 195 1736
d6bull Mean of d6 = 7 mm (0 - 17)
Nerve-preserving sacrocolpopexy anatomical study and surgical approach
Shiozawa T1 et al
By protecting the superiorhypogastric plexus and the part of thepresacral area below the promontorywe can preserve the hypogastricnerves the sacral and pelvicsplanchnic nerves and thus theautonomic innervation of the pelvicorgans
ANATOMICAL VARIATIONS OF LVCA
bull Fixation into the anterior longitudinal
ligament
ANATOMICAL VARIATIONS OF LVCA
Boukkerou M et alPromontofixation procedures use of non-absorbable sutures or tackers Journal de gyneacutecologie obsteacutetrique et biologie de la reproduction2003 32 54
bull Fixation into the anterior longitudinal ligament
and NOT into the disc
ANATOMICAL VARIATIONS OF LVCA
bull Tackers go deep into the bone
Boukkerou M et alPromontofixation procedures use of non-absorbable sutures or tackers Journal de gyneacutecologie obsteacutetrique et biologie de la reproduction2003 32 54
Spondilithis03
ndash Preacutevention bull Asepsie and per-op antibioprophylaxy
ndash Diagnosis ndash Lombalgia fever tence neurologic diseases
ndash Inflammatory Syndrome (CRP)
ndash Radiologic signs (IRM)
bull Immobilisation
bull Antibiotheacuterapie prolongeacutee +- ponction discale
bull Ablation des prothegraveses
bull +- Arthrodegravese laminectomie
Posterior Dissection ndash DENONVILLIERS FASCIA
Since Charles-PierreDenonvilliers first discoveredthe firm membranousstructure between the rectumand prostate or bladder in1836 now calledldquoDenonvilliersrsquo fasciardquo (DF)the origin of DF has remainedcontroversial
Posterior Dissection ndash DENONVILLIERS FASCIA
Based on the evidencesurgeons should be awareof variations and search forthem to create a suitabledissection plane to avoidiatrogenic positive marginsand rectal injury
Rectal Injury04
ndash Sub-peacuteritoneacuteal rectum
bull There is a recto-vaginal space
bull Horizontal Position ++
bull Close to the post face of the vagina on the distal points
bull Danger on the proximal part of the Recto-Vaginal Septum
ndash Preacutevention
bull Follow the post-face of the vagina
bull Systeacutematic pre-operativ preparation
ndash NORMACOL reg
bull Maleable Retractor
ndash Treatment
bull Immeacutediat Suture
bull Mesh contra-Indication
Vaginal Injury04
ndash Preacuteventionbull Ant Vaginal Length - 6 cm ( 4 ndash 75) Jayle et al Masson 1918
bull Post Vaginal Lenght- 9cm (65 ndash 115) Jayle et al Masson 1918
bull There is no difference between the anterior and posteriorvagina thickness
bull If the vagina is too thin ndash Plicature of the vagina
ndash Treatmentbull If Vagina Injury Suture of the vagina
bull There is no contra indication to fix the meshes
RISK OF URETERAL
INJURY lt 11000
ndash Preacutevention
bull Parietal Uretera
ndash Cross between right extern iliac artery and uterine artery
bull Visceral Uretera
ndash Behind the ligaments
ndash Under the bladder
ndash In contact with the bladder
ndash Treatment
bull Per-op
ndash Per-op Bleu carmin en IV
ndash Ureteacuteral Catheter
bull Post-op
ndash Uro-scanner
ndash JJ Ureteral
Bladder
Collection
Sagittal T2
Vagina
Uterus
Ureter ariving in urinoma
Axial T2
Coronale T2
Bladder Injury2
ndash Sub-peacuteritoneacuteal Bladder
bull Vertical Position ++
bull Close to the ant face of the vagina
bull There is NO space
ndash Preacutevention
bull Following the Ant- Face of the vagina
bull Maleable Retractor
ndash Treatment
bull Immeacutediat Suture
bull Mesh Indication
bull Bladder Catheterisation 5 days
Small and Large Bowel Injury
bull Occur when adhesiolysis has to be undertaken
bull Avoid distended bowel at surgery by 48 hours pre op bowel prep
bull Avoid nitrous oxide during surgery as it causes bowel distension
bull If small bowel injured
ndash Repair laparoscopically
ndash Mesh can still be placed
bull Antibiotic cover for 7 days post op
CONCLUSION 1
1 To open the peritoneum tigh-it
2 Dissection on the right side of the mid-sacral ligament
3 Repair carefuly the vessels and the Right ureter
4 Try to preserve the right hypogatsric nerve
5 Fix your needle 1 cm below the promontory
MESH SELECTIONPERTINENT MESH SCIENCEWHY USE A CERTAIN MESH
Pr Bruno DEVAL MD Geoffroy Saint-Hilaire ndash Clinic
Hotel ndashDieu de Paris
Paris V University
MESH STIFFNESS
bullIncreased fibrosis and deposits of unorganized collagen create an increased stiffness
bull (Klinge 1999)
bullStiffness has been linked to clinical complications-heavier stiffer meshes having higher complications
bull (Dietz 2003)
bullStiffer meshes showed decreases in smooth muscle collagen and structural proteins following implantation
bull (Moalli P AUGS 2011)
bullHeavier stiffer meshes showed a greater propensity for stress shielding which in turn could cause reoccurrences of prolapse
bull (Moalli P AUGS 2011)
IMPACT OF VAGINAL SYNTHETIC PROLAPSE MESHES ON THE MECHANICS
OF THE HOST TISSUE RESPONSE
Feola Andrew J 02 February 2012 Doctoral Dissertation University of Pittsburgh
ldquoImplantation of the stiffest mesh in the non human primate
resulted in an exhibition of a stress-shielding response
manifested by inferior biomechanical properties of the
abdominal and vaginal tissues
Less stiff meshes resulted in preservation of tissue
propertiesrdquo
Wolffrsquos Law ndash remodeling of bone in response to stress
MESH CHARACTERISTICS
Density - Filament size ndash Elasticity - Pore size
Surface area ndash Overall ldquomesh loadrdquo
Biomechanical engineers working with type-1
polypropylene have focused on reducing overall
ldquomesh loadrdquo while maintaining durability
bullOptimal tissue incorporation and collagen growthbullNo erosionbullNo palpable mesh to patient and her partnerbullVaginal elasticity
TO OBTAIN
So lighter is better
WHAT KIND OF MESH
bull To date polypropylene meshes are the best type on the market
bull Absorbable meshes do not work
bull There is an evidence to use Polypropylene vs polyesther
bull PTFE and NW meshes are contra ndash indicated in the POP Repair
ULTRA- LIGHT POLYPROPYLENE
bull Physiologically compatible 19 gsm1
bull Ultra lightweightbull Lowest weight available for pelvic restoration
bull 18 millimeter macropores1
ndash Consistent size throughout the mesh
bull 100 micron interstitial Smartporestrade 1ndash Simultaneously encourages both collagen growth and
bacteria fighting propertiesbull Fibroblasts will enter holes that are 50 to 200 microns in size23
bull Macrophages and neutrophils will enter holes that are 50 to 120 microns in size23
bull Reduce inflammation1 Data on file2 Greca FH et at (2007) The influence of porosity on integration histology of two polypropylene meshes for the treatment of abdominal wall
defects in dogs Hernia (12) 45-493 Marois Y et all (2000) Biostability inflammatory response and healing characteristics flourpassivated polyester-knit mesh in the repair of
experimental abdominal hernias Artif Organs 24533-543
ULTRA ndash LIGHT CLINICAL EVIDENCE
SUMMARY
bull Rates of Erosion and Exposurebull Less than 1 erosion rate1
bull Anterior exposure rate 172
bull Posterior exposure rate 052
bull Greater tissue strength 3 months post-op ndash 71 more collagen growth3
bull Mature vaginal elastin decrease was not observed with Smartmesh4
bull Smartmesh did not induce a negative change in collagen metabolism5
bull Smartmesh had similar innervation density as sham 6
bull Low incidence of de novo dyspareunia71 Alinsod R et al (2008) Long term outcomes of vaginal pelvic floor repair using an ultra lightweight mesh AAGL (2008)2 Alinsod R Et al (2012) Durability and Complications of an Ultra Lightweight Transvaginal Mesh in the Treatment of Pelvic Organ Prolapse Presented at the 37th Annual Meeting of IUGA3 Greca FH et al (2007) The influence of porosity on the integration histology of two polypropylene meshes for the treatment of abdominal wall defects in dogs Hernia (12) 45-494 Moalli et al (2012) Mesh implantation negatively impacts vagina elastin metabolism Female Pelvic Medicine amp Reconstructive Surgery Vol 18 (Suppl 2)S258-9 SeptOct paper 235 Moalli et al (2012) Increasing mesh stiffness negatively impacts vaginal collagen metabolism Female Pelvic Medicine amp Reconstructive Surgery Vol 18 (Suppl 2)S258-9 SeptOct paper 246 Moalli et al (2012) The impact of mesh implantation on vaginal smooth muscle innervation Female Pelvic Medicine amp Reconstructive Surgery Vol 18 (Suppl 2)S258-9 SeptOct paper 257 Hawthorn R et al (2007) Use of ultra lightweight mesh in vaginal vault repairs to minimize complications A two centre observation study British International Congress of Obstetrics amp Gynaecology
PRE FORMED Y-MESH VS CUTTING MESH AND MAKING IT TO FIT PATIENTS
Pr Bruno DEVAL MD Geoffroy Saint-Hilaire ndash Clinic
Hotel ndashDieu de Paris
Paris V University
Mesh and operative handling
The shape and weight of the mesh can help us during
laparoscopic procedure
A large Y mesh is a good choice for vaginal vault shape
Better intra-operative manipulation and suturing
Lower mesh mass accommodates easy passage through narrow
laparoscopic ports
Use re-absorbable sutures on the vagina
bull Stitch erosions are reported
bull Folding and wrinkling can cause
erosions and dyspaurenia
Avoid folding and wrinkling the
mesh must be well stretched
DO WE NEED TO DISSECT POSTERIOR DOWN TO PERINEUM OR
IN WHICH PATIENTS THIS IS INDICATED
Pr Bruno DEVAL MD Geoffroy Saint-Hilaire ndash Clinic
Hotel ndashDieu de Paris
Paris V University
Fix the mesh on the posterior
vaginal wall and not on the
elevator ani muscle
bull To avoid dyschezia and chronic
pelvic pain
bull Sacrocolpopexy should only be performed by board certified eligible surgeons (ObGyn or Urology)
bull Knowledge surgical skills and experience in reconstructive pelvic surgery
FPMRS fellowship
CME documentation
Proctoring on 10 cases
gt 50 practice in reconstructive surgery
bull Outcomes and complications of should be monitored by annual internal audit
bull Informed consent should highlight
Alternatives to ASC including pessary
Complications of ASC
Complications of mesh
AUGS Guidelines on Sacrocolpopexy Privileges(March 2013)
Source wwwaugsorg
Conclusion
bull The technique and expertise are
fundamental
bull Laparoscopic colposacropexy can safely
be offered to women with symptomatic
POP
bull Conventional LSCP = Open Way =
robotic way
bull Conventional LSCP gt Vaginal Way
FONTIONNAL RESULTS
LAPAROSCOPIC SACROCOLPOPEXY FOR FEMALE GENITAL PROLAPSE A COMPREHENSIVE REVIEWBruno DEVALa Denise Hatsumi de Freitas Yanasse ORTEGAb Hisham AMajeed FAHIMb Jorge Milhem HADDADd
(Submited)
DenovoSUI
De NovoDyspareunia
DenovoDyschesia
2002180(91)
1041200(86)
1811720(105)
PER ndash OP MORBIDITY
LAPAROSCOPIC SACROCOLPOPEXY FOR FEMALE GENITAL PROLAPSE A COMPREHENSIVE REVIEW
Bruno DEVALa Denise Hatsumi de Freitas Yanasse ORTEGAb Hisham AMajeed FAHIMb Jorge Milhem HADDADd
(Submited)
N Conversion to Laparotomy
Bladderinjury
Rectal Bowellinjury
Vaginal Injury
3030 583030
(19)
513030
(17)
223030
(07)
93030
(03)
Post ndash OP MORBIDITY
LAPAROSCOPIC SACROCOLPOPEXY FOR FEMALE GENITAL PROLAPSE A COMPREHENSIVE REVIEW
Bruno DEVALa and al
(Submitted)
Complication TOTAL
Urinary infection 69 (25)
Voiding dysfunctionᵜ 1772721 (65)
Related to trocar site 82721 (03)
Wound infection 9 (033)
Mechanical ileus 9 (033)
Septical peritonitis 1 (003)
Bleeding 132721 (047)
Recurrent acute cystitis 1 (003)
Low back pain or sciatica 192721 (069)
Nerve lesion 3 (01)
Pain related to mesh 552721(22)
Detachment of mesh 32721(01)
Vault infection 2(0073)
Mesh infection 6(022)
Lombosacral spondylodiscitis 72721(025)
Suture erosion 5(018)
Mesh erosion 652721(24)
Rectovaginal fistula 1(003)
Vesicovaginal fistula 32721(01)
anal pain 5(018)
phlebitis 22721(0073)
fever 10(036)
stool incontinence 1(003)
LEARNING CURVE AND EVIDENCE
0
1000
2000
3000
4000
5000
6000
surgery laparoscopy robotic vaginal colorectal SCP
Prospectiv Study n= 206 patients
175 mn after 90 cases
ANALYSIS OF THE LEARNING PROCESS FOR LAPAROSCOPIC SACROCOLPOPEXY
IDENTIFICATION OF CHALLENGING STEPS
Claerhout et al Int j Urogynecol J ndash 2014 25
bull Prospectiv Study POP stade II
ndash Fellow n = 60 cases vs senior-teacher n= 30 cases
bull Fellow senior + Pelvitrainer
bull 5 Steps
bull 30 cases step 1-2
bull 30 to 50 cases steps 3-4
bull Last 10 cases full procedure
bull Comparativ itmes ndash Time
ndash Score
ndash morbidity
ndash Result
LAPAROSCOPIC SURGICAL BOX MODEL TRAINING FOR SURGICAL TRAINEES
WITH NO PRIOR LAPAROSCOPIC EXPERIENCE
Myura Nagendran et al
bull Authors included randomised clinical trials comparing
boxmodel trainers versus no training in surgical trainees
with no prior laparoscopic experience
bull 16 trials (464 participants) provided data for meta-analysis
of box training (248 participants) versus no supplementary
training (216 participants)
bull All the 16 trials in this comparison used video trainers
bull The meta-analysis showed that the time taken for task
completion was significantly shorter in the box trainer
group than the control group
bull Compared with the control group the box trainer group
also had lower error score better accuracy score and
better composite performance scores
bull Laparoscopic box model training appears to improve
technical skills compared with no training in trainees
with no previous laparoscopic experience
Laparoscopic surgical box model training for surgical trainees
with no prior laparoscopic experience
Myura Nagendran et al
Power Point slide deck adapted from
Canadian Agency for Drugs and Technologies in Health
Robot-Assisted Surgery Compared with Open Surgery and Laparoscopic Surgery Clinical Effectiveness and Economic Analyses
Chuong Ho MDEva Tsakonas BA MSc
Khai Tran MSc PhDKaren Cimon
Melissa Severn MIStMonika Mierzwinski-Urban BA MLIS
Jacques Corcos MDStephen Pautler MD FRCSC
September 2014
Adapted by Michael Fung-Kee-Fung MBBS FRCSC MBA
Nancy Jaworski BComm MHA
Walter Gotlieb MD PhD
Adapted from CADTH Technology Report on Robot-Assisted Surgery 2011
Indications for Robot Use ndash Disease Prevalence
bull 24700 new cases of prostate cancer diagnosed in Canada in 2008
bull 219 of patients lt60 years old will choose prostatectomy as initial treatmentUrology
bull 36000 hysterectomies performed in Canada in 200708
bull Hysterectomy is performed for several indications Gynecology
bull 5 year prevalence (2005) 482100000 male amp 318100000 female
bull Surgery is the primary treatment for localized renal cell carcinomaNephrology
bull An estimated 20000 coronary artery bypass graft (CABG) surgeries were performed in Canada in 200001
Cardiac Surgery
Adapted from CADTH Technology Report on Robot-Assisted Surgery 2011
Economic Analysis
bull Robot-Assisted vs Laparoscopic
Economic Model Base Case (Robot not donated)
Hospital Budget Impact
Hospital Budget Impact
ANATOMY OF THE PRESACRAL SPACE
STRUCTURES TO BE
RESPECTED
FOR A SAFE FIXATION
OF THE MESH
RATE OF
BLOOD TRANSFUSION
02
ANATOMICAL VARIATIONS
OF THE LEFT COMMON ILIAC VEIN MIDDLE PART PROMONTORY
bull Distances between the left common iliac vein and the midsacral promontory
bull Dissection of 52 cadavers
bull Mean of d1 = 27 mm (9 - 52)
bull Mean of d2 = 22 mm (9 - 35)
Wieslander CK et al Vascular anatomy of the presacral space in unembalmedfemale cadaversAmerican journal of obstetrics and gynecology 2006 195 1736
d1
RATE OF
BLOOD TRANSFUSION
02
ANATOMICAL VARIATIONS OF PRESACRAL VESSELS
MIDDLE PART PROMONTORY
bull Presacral vesselsndash Middle sacral vein
Oslash= 2mm (1- 4)
double (80)
left to P= 33
right to P= 52
crossing P= 5
mean of d3 = 7 mm (0-17)
P
d3
Wieslander CK et al Vascular anatomy of the presacral space in unembalmed female cadavers American journal of obstetrics and gynecology 2006 195 1736
ANATOMICAL VARIATIONS OF PRESACRAL VESSELS
MIDDLE PART PROMONTORY
bull Presacral vesselsndash Middle sacral artery
Oslash= 2mm (1- 4)
Left to P= 62
Right to P= 30
Crossing P= 8
Mean of d4 = 4 mm (0-15)
Pd4
Wieslander CK et al Vascular anatomy of the presacral space in unembalmed female cadavers American journal of obstetrics and gynecology 2006 195 1736
ANATOMICAL VARIATIONS OF PRESACRAL VESSELS
MIDDLE PART PROMONTORY
bull Presacral space avascular areas
bull Overlay of vascular structures
bull (10 cadavers)
Flynn MK et al Vascular anatomy of the presacral space a freshtissue cadaver dissectionAmerican journal of obstetrics and gynecology2005 192 1501
rarr Dissection right to the medline = safer
ANATOMICAL VARIATIONS OF THE RIGHT URETER
MIDDLE PART PROMONTORY
Flynn MK et al Vascular anatomy of the presacral space a fresh tissue cadaver dissectionAmerican journal of obstetrics and gynecology 2005 192 1501
bull Distances between the right ureter and the midsacral promontory
bull Dissection of 10 cadavers
ANATOMICAL VARIATIONS
OF THE
SUPERIOR HYPOGASTRIC PLEXUS
bull SHP sympathetic plexus connected to IHP
Shiozawa T et al Nerve-preserving sacrocolpopexy anatomical study and surgical approachEuropean journal of obstetrics and gynecology and reproductive biology2010 152 103
ANATOMICAL VARIATIONS OF SUPERIOR HYPOGASTRIC PLEXUS
bull Right hypogastric nerve
Wieslander CK et al Vascular anatomy of the presacral space in unembalmed female cadaversAmerican journal of obstetrics and gynecology 2006 195 1736
d6bull Mean of d6 = 7 mm (0 - 17)
Nerve-preserving sacrocolpopexy anatomical study and surgical approach
Shiozawa T1 et al
By protecting the superiorhypogastric plexus and the part of thepresacral area below the promontorywe can preserve the hypogastricnerves the sacral and pelvicsplanchnic nerves and thus theautonomic innervation of the pelvicorgans
ANATOMICAL VARIATIONS OF LVCA
bull Fixation into the anterior longitudinal
ligament
ANATOMICAL VARIATIONS OF LVCA
Boukkerou M et alPromontofixation procedures use of non-absorbable sutures or tackers Journal de gyneacutecologie obsteacutetrique et biologie de la reproduction2003 32 54
bull Fixation into the anterior longitudinal ligament
and NOT into the disc
ANATOMICAL VARIATIONS OF LVCA
bull Tackers go deep into the bone
Boukkerou M et alPromontofixation procedures use of non-absorbable sutures or tackers Journal de gyneacutecologie obsteacutetrique et biologie de la reproduction2003 32 54
Spondilithis03
ndash Preacutevention bull Asepsie and per-op antibioprophylaxy
ndash Diagnosis ndash Lombalgia fever tence neurologic diseases
ndash Inflammatory Syndrome (CRP)
ndash Radiologic signs (IRM)
bull Immobilisation
bull Antibiotheacuterapie prolongeacutee +- ponction discale
bull Ablation des prothegraveses
bull +- Arthrodegravese laminectomie
Posterior Dissection ndash DENONVILLIERS FASCIA
Since Charles-PierreDenonvilliers first discoveredthe firm membranousstructure between the rectumand prostate or bladder in1836 now calledldquoDenonvilliersrsquo fasciardquo (DF)the origin of DF has remainedcontroversial
Posterior Dissection ndash DENONVILLIERS FASCIA
Based on the evidencesurgeons should be awareof variations and search forthem to create a suitabledissection plane to avoidiatrogenic positive marginsand rectal injury
Rectal Injury04
ndash Sub-peacuteritoneacuteal rectum
bull There is a recto-vaginal space
bull Horizontal Position ++
bull Close to the post face of the vagina on the distal points
bull Danger on the proximal part of the Recto-Vaginal Septum
ndash Preacutevention
bull Follow the post-face of the vagina
bull Systeacutematic pre-operativ preparation
ndash NORMACOL reg
bull Maleable Retractor
ndash Treatment
bull Immeacutediat Suture
bull Mesh contra-Indication
Vaginal Injury04
ndash Preacuteventionbull Ant Vaginal Length - 6 cm ( 4 ndash 75) Jayle et al Masson 1918
bull Post Vaginal Lenght- 9cm (65 ndash 115) Jayle et al Masson 1918
bull There is no difference between the anterior and posteriorvagina thickness
bull If the vagina is too thin ndash Plicature of the vagina
ndash Treatmentbull If Vagina Injury Suture of the vagina
bull There is no contra indication to fix the meshes
RISK OF URETERAL
INJURY lt 11000
ndash Preacutevention
bull Parietal Uretera
ndash Cross between right extern iliac artery and uterine artery
bull Visceral Uretera
ndash Behind the ligaments
ndash Under the bladder
ndash In contact with the bladder
ndash Treatment
bull Per-op
ndash Per-op Bleu carmin en IV
ndash Ureteacuteral Catheter
bull Post-op
ndash Uro-scanner
ndash JJ Ureteral
Bladder
Collection
Sagittal T2
Vagina
Uterus
Ureter ariving in urinoma
Axial T2
Coronale T2
Bladder Injury2
ndash Sub-peacuteritoneacuteal Bladder
bull Vertical Position ++
bull Close to the ant face of the vagina
bull There is NO space
ndash Preacutevention
bull Following the Ant- Face of the vagina
bull Maleable Retractor
ndash Treatment
bull Immeacutediat Suture
bull Mesh Indication
bull Bladder Catheterisation 5 days
Small and Large Bowel Injury
bull Occur when adhesiolysis has to be undertaken
bull Avoid distended bowel at surgery by 48 hours pre op bowel prep
bull Avoid nitrous oxide during surgery as it causes bowel distension
bull If small bowel injured
ndash Repair laparoscopically
ndash Mesh can still be placed
bull Antibiotic cover for 7 days post op
CONCLUSION 1
1 To open the peritoneum tigh-it
2 Dissection on the right side of the mid-sacral ligament
3 Repair carefuly the vessels and the Right ureter
4 Try to preserve the right hypogatsric nerve
5 Fix your needle 1 cm below the promontory
MESH SELECTIONPERTINENT MESH SCIENCEWHY USE A CERTAIN MESH
Pr Bruno DEVAL MD Geoffroy Saint-Hilaire ndash Clinic
Hotel ndashDieu de Paris
Paris V University
MESH STIFFNESS
bullIncreased fibrosis and deposits of unorganized collagen create an increased stiffness
bull (Klinge 1999)
bullStiffness has been linked to clinical complications-heavier stiffer meshes having higher complications
bull (Dietz 2003)
bullStiffer meshes showed decreases in smooth muscle collagen and structural proteins following implantation
bull (Moalli P AUGS 2011)
bullHeavier stiffer meshes showed a greater propensity for stress shielding which in turn could cause reoccurrences of prolapse
bull (Moalli P AUGS 2011)
IMPACT OF VAGINAL SYNTHETIC PROLAPSE MESHES ON THE MECHANICS
OF THE HOST TISSUE RESPONSE
Feola Andrew J 02 February 2012 Doctoral Dissertation University of Pittsburgh
ldquoImplantation of the stiffest mesh in the non human primate
resulted in an exhibition of a stress-shielding response
manifested by inferior biomechanical properties of the
abdominal and vaginal tissues
Less stiff meshes resulted in preservation of tissue
propertiesrdquo
Wolffrsquos Law ndash remodeling of bone in response to stress
MESH CHARACTERISTICS
Density - Filament size ndash Elasticity - Pore size
Surface area ndash Overall ldquomesh loadrdquo
Biomechanical engineers working with type-1
polypropylene have focused on reducing overall
ldquomesh loadrdquo while maintaining durability
bullOptimal tissue incorporation and collagen growthbullNo erosionbullNo palpable mesh to patient and her partnerbullVaginal elasticity
TO OBTAIN
So lighter is better
WHAT KIND OF MESH
bull To date polypropylene meshes are the best type on the market
bull Absorbable meshes do not work
bull There is an evidence to use Polypropylene vs polyesther
bull PTFE and NW meshes are contra ndash indicated in the POP Repair
ULTRA- LIGHT POLYPROPYLENE
bull Physiologically compatible 19 gsm1
bull Ultra lightweightbull Lowest weight available for pelvic restoration
bull 18 millimeter macropores1
ndash Consistent size throughout the mesh
bull 100 micron interstitial Smartporestrade 1ndash Simultaneously encourages both collagen growth and
bacteria fighting propertiesbull Fibroblasts will enter holes that are 50 to 200 microns in size23
bull Macrophages and neutrophils will enter holes that are 50 to 120 microns in size23
bull Reduce inflammation1 Data on file2 Greca FH et at (2007) The influence of porosity on integration histology of two polypropylene meshes for the treatment of abdominal wall
defects in dogs Hernia (12) 45-493 Marois Y et all (2000) Biostability inflammatory response and healing characteristics flourpassivated polyester-knit mesh in the repair of
experimental abdominal hernias Artif Organs 24533-543
ULTRA ndash LIGHT CLINICAL EVIDENCE
SUMMARY
bull Rates of Erosion and Exposurebull Less than 1 erosion rate1
bull Anterior exposure rate 172
bull Posterior exposure rate 052
bull Greater tissue strength 3 months post-op ndash 71 more collagen growth3
bull Mature vaginal elastin decrease was not observed with Smartmesh4
bull Smartmesh did not induce a negative change in collagen metabolism5
bull Smartmesh had similar innervation density as sham 6
bull Low incidence of de novo dyspareunia71 Alinsod R et al (2008) Long term outcomes of vaginal pelvic floor repair using an ultra lightweight mesh AAGL (2008)2 Alinsod R Et al (2012) Durability and Complications of an Ultra Lightweight Transvaginal Mesh in the Treatment of Pelvic Organ Prolapse Presented at the 37th Annual Meeting of IUGA3 Greca FH et al (2007) The influence of porosity on the integration histology of two polypropylene meshes for the treatment of abdominal wall defects in dogs Hernia (12) 45-494 Moalli et al (2012) Mesh implantation negatively impacts vagina elastin metabolism Female Pelvic Medicine amp Reconstructive Surgery Vol 18 (Suppl 2)S258-9 SeptOct paper 235 Moalli et al (2012) Increasing mesh stiffness negatively impacts vaginal collagen metabolism Female Pelvic Medicine amp Reconstructive Surgery Vol 18 (Suppl 2)S258-9 SeptOct paper 246 Moalli et al (2012) The impact of mesh implantation on vaginal smooth muscle innervation Female Pelvic Medicine amp Reconstructive Surgery Vol 18 (Suppl 2)S258-9 SeptOct paper 257 Hawthorn R et al (2007) Use of ultra lightweight mesh in vaginal vault repairs to minimize complications A two centre observation study British International Congress of Obstetrics amp Gynaecology
PRE FORMED Y-MESH VS CUTTING MESH AND MAKING IT TO FIT PATIENTS
Pr Bruno DEVAL MD Geoffroy Saint-Hilaire ndash Clinic
Hotel ndashDieu de Paris
Paris V University
Mesh and operative handling
The shape and weight of the mesh can help us during
laparoscopic procedure
A large Y mesh is a good choice for vaginal vault shape
Better intra-operative manipulation and suturing
Lower mesh mass accommodates easy passage through narrow
laparoscopic ports
Use re-absorbable sutures on the vagina
bull Stitch erosions are reported
bull Folding and wrinkling can cause
erosions and dyspaurenia
Avoid folding and wrinkling the
mesh must be well stretched
DO WE NEED TO DISSECT POSTERIOR DOWN TO PERINEUM OR
IN WHICH PATIENTS THIS IS INDICATED
Pr Bruno DEVAL MD Geoffroy Saint-Hilaire ndash Clinic
Hotel ndashDieu de Paris
Paris V University
Fix the mesh on the posterior
vaginal wall and not on the
elevator ani muscle
bull To avoid dyschezia and chronic
pelvic pain
bull Sacrocolpopexy should only be performed by board certified eligible surgeons (ObGyn or Urology)
bull Knowledge surgical skills and experience in reconstructive pelvic surgery
FPMRS fellowship
CME documentation
Proctoring on 10 cases
gt 50 practice in reconstructive surgery
bull Outcomes and complications of should be monitored by annual internal audit
bull Informed consent should highlight
Alternatives to ASC including pessary
Complications of ASC
Complications of mesh
AUGS Guidelines on Sacrocolpopexy Privileges(March 2013)
Source wwwaugsorg
Conclusion
bull The technique and expertise are
fundamental
bull Laparoscopic colposacropexy can safely
be offered to women with symptomatic
POP
bull Conventional LSCP = Open Way =
robotic way
bull Conventional LSCP gt Vaginal Way
PER ndash OP MORBIDITY
LAPAROSCOPIC SACROCOLPOPEXY FOR FEMALE GENITAL PROLAPSE A COMPREHENSIVE REVIEW
Bruno DEVALa Denise Hatsumi de Freitas Yanasse ORTEGAb Hisham AMajeed FAHIMb Jorge Milhem HADDADd
(Submited)
N Conversion to Laparotomy
Bladderinjury
Rectal Bowellinjury
Vaginal Injury
3030 583030
(19)
513030
(17)
223030
(07)
93030
(03)
Post ndash OP MORBIDITY
LAPAROSCOPIC SACROCOLPOPEXY FOR FEMALE GENITAL PROLAPSE A COMPREHENSIVE REVIEW
Bruno DEVALa and al
(Submitted)
Complication TOTAL
Urinary infection 69 (25)
Voiding dysfunctionᵜ 1772721 (65)
Related to trocar site 82721 (03)
Wound infection 9 (033)
Mechanical ileus 9 (033)
Septical peritonitis 1 (003)
Bleeding 132721 (047)
Recurrent acute cystitis 1 (003)
Low back pain or sciatica 192721 (069)
Nerve lesion 3 (01)
Pain related to mesh 552721(22)
Detachment of mesh 32721(01)
Vault infection 2(0073)
Mesh infection 6(022)
Lombosacral spondylodiscitis 72721(025)
Suture erosion 5(018)
Mesh erosion 652721(24)
Rectovaginal fistula 1(003)
Vesicovaginal fistula 32721(01)
anal pain 5(018)
phlebitis 22721(0073)
fever 10(036)
stool incontinence 1(003)
LEARNING CURVE AND EVIDENCE
0
1000
2000
3000
4000
5000
6000
surgery laparoscopy robotic vaginal colorectal SCP
Prospectiv Study n= 206 patients
175 mn after 90 cases
ANALYSIS OF THE LEARNING PROCESS FOR LAPAROSCOPIC SACROCOLPOPEXY
IDENTIFICATION OF CHALLENGING STEPS
Claerhout et al Int j Urogynecol J ndash 2014 25
bull Prospectiv Study POP stade II
ndash Fellow n = 60 cases vs senior-teacher n= 30 cases
bull Fellow senior + Pelvitrainer
bull 5 Steps
bull 30 cases step 1-2
bull 30 to 50 cases steps 3-4
bull Last 10 cases full procedure
bull Comparativ itmes ndash Time
ndash Score
ndash morbidity
ndash Result
LAPAROSCOPIC SURGICAL BOX MODEL TRAINING FOR SURGICAL TRAINEES
WITH NO PRIOR LAPAROSCOPIC EXPERIENCE
Myura Nagendran et al
bull Authors included randomised clinical trials comparing
boxmodel trainers versus no training in surgical trainees
with no prior laparoscopic experience
bull 16 trials (464 participants) provided data for meta-analysis
of box training (248 participants) versus no supplementary
training (216 participants)
bull All the 16 trials in this comparison used video trainers
bull The meta-analysis showed that the time taken for task
completion was significantly shorter in the box trainer
group than the control group
bull Compared with the control group the box trainer group
also had lower error score better accuracy score and
better composite performance scores
bull Laparoscopic box model training appears to improve
technical skills compared with no training in trainees
with no previous laparoscopic experience
Laparoscopic surgical box model training for surgical trainees
with no prior laparoscopic experience
Myura Nagendran et al
Power Point slide deck adapted from
Canadian Agency for Drugs and Technologies in Health
Robot-Assisted Surgery Compared with Open Surgery and Laparoscopic Surgery Clinical Effectiveness and Economic Analyses
Chuong Ho MDEva Tsakonas BA MSc
Khai Tran MSc PhDKaren Cimon
Melissa Severn MIStMonika Mierzwinski-Urban BA MLIS
Jacques Corcos MDStephen Pautler MD FRCSC
September 2014
Adapted by Michael Fung-Kee-Fung MBBS FRCSC MBA
Nancy Jaworski BComm MHA
Walter Gotlieb MD PhD
Adapted from CADTH Technology Report on Robot-Assisted Surgery 2011
Indications for Robot Use ndash Disease Prevalence
bull 24700 new cases of prostate cancer diagnosed in Canada in 2008
bull 219 of patients lt60 years old will choose prostatectomy as initial treatmentUrology
bull 36000 hysterectomies performed in Canada in 200708
bull Hysterectomy is performed for several indications Gynecology
bull 5 year prevalence (2005) 482100000 male amp 318100000 female
bull Surgery is the primary treatment for localized renal cell carcinomaNephrology
bull An estimated 20000 coronary artery bypass graft (CABG) surgeries were performed in Canada in 200001
Cardiac Surgery
Adapted from CADTH Technology Report on Robot-Assisted Surgery 2011
Economic Analysis
bull Robot-Assisted vs Laparoscopic
Economic Model Base Case (Robot not donated)
Hospital Budget Impact
Hospital Budget Impact
ANATOMY OF THE PRESACRAL SPACE
STRUCTURES TO BE
RESPECTED
FOR A SAFE FIXATION
OF THE MESH
RATE OF
BLOOD TRANSFUSION
02
ANATOMICAL VARIATIONS
OF THE LEFT COMMON ILIAC VEIN MIDDLE PART PROMONTORY
bull Distances between the left common iliac vein and the midsacral promontory
bull Dissection of 52 cadavers
bull Mean of d1 = 27 mm (9 - 52)
bull Mean of d2 = 22 mm (9 - 35)
Wieslander CK et al Vascular anatomy of the presacral space in unembalmedfemale cadaversAmerican journal of obstetrics and gynecology 2006 195 1736
d1
RATE OF
BLOOD TRANSFUSION
02
ANATOMICAL VARIATIONS OF PRESACRAL VESSELS
MIDDLE PART PROMONTORY
bull Presacral vesselsndash Middle sacral vein
Oslash= 2mm (1- 4)
double (80)
left to P= 33
right to P= 52
crossing P= 5
mean of d3 = 7 mm (0-17)
P
d3
Wieslander CK et al Vascular anatomy of the presacral space in unembalmed female cadavers American journal of obstetrics and gynecology 2006 195 1736
ANATOMICAL VARIATIONS OF PRESACRAL VESSELS
MIDDLE PART PROMONTORY
bull Presacral vesselsndash Middle sacral artery
Oslash= 2mm (1- 4)
Left to P= 62
Right to P= 30
Crossing P= 8
Mean of d4 = 4 mm (0-15)
Pd4
Wieslander CK et al Vascular anatomy of the presacral space in unembalmed female cadavers American journal of obstetrics and gynecology 2006 195 1736
ANATOMICAL VARIATIONS OF PRESACRAL VESSELS
MIDDLE PART PROMONTORY
bull Presacral space avascular areas
bull Overlay of vascular structures
bull (10 cadavers)
Flynn MK et al Vascular anatomy of the presacral space a freshtissue cadaver dissectionAmerican journal of obstetrics and gynecology2005 192 1501
rarr Dissection right to the medline = safer
ANATOMICAL VARIATIONS OF THE RIGHT URETER
MIDDLE PART PROMONTORY
Flynn MK et al Vascular anatomy of the presacral space a fresh tissue cadaver dissectionAmerican journal of obstetrics and gynecology 2005 192 1501
bull Distances between the right ureter and the midsacral promontory
bull Dissection of 10 cadavers
ANATOMICAL VARIATIONS
OF THE
SUPERIOR HYPOGASTRIC PLEXUS
bull SHP sympathetic plexus connected to IHP
Shiozawa T et al Nerve-preserving sacrocolpopexy anatomical study and surgical approachEuropean journal of obstetrics and gynecology and reproductive biology2010 152 103
ANATOMICAL VARIATIONS OF SUPERIOR HYPOGASTRIC PLEXUS
bull Right hypogastric nerve
Wieslander CK et al Vascular anatomy of the presacral space in unembalmed female cadaversAmerican journal of obstetrics and gynecology 2006 195 1736
d6bull Mean of d6 = 7 mm (0 - 17)
Nerve-preserving sacrocolpopexy anatomical study and surgical approach
Shiozawa T1 et al
By protecting the superiorhypogastric plexus and the part of thepresacral area below the promontorywe can preserve the hypogastricnerves the sacral and pelvicsplanchnic nerves and thus theautonomic innervation of the pelvicorgans
ANATOMICAL VARIATIONS OF LVCA
bull Fixation into the anterior longitudinal
ligament
ANATOMICAL VARIATIONS OF LVCA
Boukkerou M et alPromontofixation procedures use of non-absorbable sutures or tackers Journal de gyneacutecologie obsteacutetrique et biologie de la reproduction2003 32 54
bull Fixation into the anterior longitudinal ligament
and NOT into the disc
ANATOMICAL VARIATIONS OF LVCA
bull Tackers go deep into the bone
Boukkerou M et alPromontofixation procedures use of non-absorbable sutures or tackers Journal de gyneacutecologie obsteacutetrique et biologie de la reproduction2003 32 54
Spondilithis03
ndash Preacutevention bull Asepsie and per-op antibioprophylaxy
ndash Diagnosis ndash Lombalgia fever tence neurologic diseases
ndash Inflammatory Syndrome (CRP)
ndash Radiologic signs (IRM)
bull Immobilisation
bull Antibiotheacuterapie prolongeacutee +- ponction discale
bull Ablation des prothegraveses
bull +- Arthrodegravese laminectomie
Posterior Dissection ndash DENONVILLIERS FASCIA
Since Charles-PierreDenonvilliers first discoveredthe firm membranousstructure between the rectumand prostate or bladder in1836 now calledldquoDenonvilliersrsquo fasciardquo (DF)the origin of DF has remainedcontroversial
Posterior Dissection ndash DENONVILLIERS FASCIA
Based on the evidencesurgeons should be awareof variations and search forthem to create a suitabledissection plane to avoidiatrogenic positive marginsand rectal injury
Rectal Injury04
ndash Sub-peacuteritoneacuteal rectum
bull There is a recto-vaginal space
bull Horizontal Position ++
bull Close to the post face of the vagina on the distal points
bull Danger on the proximal part of the Recto-Vaginal Septum
ndash Preacutevention
bull Follow the post-face of the vagina
bull Systeacutematic pre-operativ preparation
ndash NORMACOL reg
bull Maleable Retractor
ndash Treatment
bull Immeacutediat Suture
bull Mesh contra-Indication
Vaginal Injury04
ndash Preacuteventionbull Ant Vaginal Length - 6 cm ( 4 ndash 75) Jayle et al Masson 1918
bull Post Vaginal Lenght- 9cm (65 ndash 115) Jayle et al Masson 1918
bull There is no difference between the anterior and posteriorvagina thickness
bull If the vagina is too thin ndash Plicature of the vagina
ndash Treatmentbull If Vagina Injury Suture of the vagina
bull There is no contra indication to fix the meshes
RISK OF URETERAL
INJURY lt 11000
ndash Preacutevention
bull Parietal Uretera
ndash Cross between right extern iliac artery and uterine artery
bull Visceral Uretera
ndash Behind the ligaments
ndash Under the bladder
ndash In contact with the bladder
ndash Treatment
bull Per-op
ndash Per-op Bleu carmin en IV
ndash Ureteacuteral Catheter
bull Post-op
ndash Uro-scanner
ndash JJ Ureteral
Bladder
Collection
Sagittal T2
Vagina
Uterus
Ureter ariving in urinoma
Axial T2
Coronale T2
Bladder Injury2
ndash Sub-peacuteritoneacuteal Bladder
bull Vertical Position ++
bull Close to the ant face of the vagina
bull There is NO space
ndash Preacutevention
bull Following the Ant- Face of the vagina
bull Maleable Retractor
ndash Treatment
bull Immeacutediat Suture
bull Mesh Indication
bull Bladder Catheterisation 5 days
Small and Large Bowel Injury
bull Occur when adhesiolysis has to be undertaken
bull Avoid distended bowel at surgery by 48 hours pre op bowel prep
bull Avoid nitrous oxide during surgery as it causes bowel distension
bull If small bowel injured
ndash Repair laparoscopically
ndash Mesh can still be placed
bull Antibiotic cover for 7 days post op
CONCLUSION 1
1 To open the peritoneum tigh-it
2 Dissection on the right side of the mid-sacral ligament
3 Repair carefuly the vessels and the Right ureter
4 Try to preserve the right hypogatsric nerve
5 Fix your needle 1 cm below the promontory
MESH SELECTIONPERTINENT MESH SCIENCEWHY USE A CERTAIN MESH
Pr Bruno DEVAL MD Geoffroy Saint-Hilaire ndash Clinic
Hotel ndashDieu de Paris
Paris V University
MESH STIFFNESS
bullIncreased fibrosis and deposits of unorganized collagen create an increased stiffness
bull (Klinge 1999)
bullStiffness has been linked to clinical complications-heavier stiffer meshes having higher complications
bull (Dietz 2003)
bullStiffer meshes showed decreases in smooth muscle collagen and structural proteins following implantation
bull (Moalli P AUGS 2011)
bullHeavier stiffer meshes showed a greater propensity for stress shielding which in turn could cause reoccurrences of prolapse
bull (Moalli P AUGS 2011)
IMPACT OF VAGINAL SYNTHETIC PROLAPSE MESHES ON THE MECHANICS
OF THE HOST TISSUE RESPONSE
Feola Andrew J 02 February 2012 Doctoral Dissertation University of Pittsburgh
ldquoImplantation of the stiffest mesh in the non human primate
resulted in an exhibition of a stress-shielding response
manifested by inferior biomechanical properties of the
abdominal and vaginal tissues
Less stiff meshes resulted in preservation of tissue
propertiesrdquo
Wolffrsquos Law ndash remodeling of bone in response to stress
MESH CHARACTERISTICS
Density - Filament size ndash Elasticity - Pore size
Surface area ndash Overall ldquomesh loadrdquo
Biomechanical engineers working with type-1
polypropylene have focused on reducing overall
ldquomesh loadrdquo while maintaining durability
bullOptimal tissue incorporation and collagen growthbullNo erosionbullNo palpable mesh to patient and her partnerbullVaginal elasticity
TO OBTAIN
So lighter is better
WHAT KIND OF MESH
bull To date polypropylene meshes are the best type on the market
bull Absorbable meshes do not work
bull There is an evidence to use Polypropylene vs polyesther
bull PTFE and NW meshes are contra ndash indicated in the POP Repair
ULTRA- LIGHT POLYPROPYLENE
bull Physiologically compatible 19 gsm1
bull Ultra lightweightbull Lowest weight available for pelvic restoration
bull 18 millimeter macropores1
ndash Consistent size throughout the mesh
bull 100 micron interstitial Smartporestrade 1ndash Simultaneously encourages both collagen growth and
bacteria fighting propertiesbull Fibroblasts will enter holes that are 50 to 200 microns in size23
bull Macrophages and neutrophils will enter holes that are 50 to 120 microns in size23
bull Reduce inflammation1 Data on file2 Greca FH et at (2007) The influence of porosity on integration histology of two polypropylene meshes for the treatment of abdominal wall
defects in dogs Hernia (12) 45-493 Marois Y et all (2000) Biostability inflammatory response and healing characteristics flourpassivated polyester-knit mesh in the repair of
experimental abdominal hernias Artif Organs 24533-543
ULTRA ndash LIGHT CLINICAL EVIDENCE
SUMMARY
bull Rates of Erosion and Exposurebull Less than 1 erosion rate1
bull Anterior exposure rate 172
bull Posterior exposure rate 052
bull Greater tissue strength 3 months post-op ndash 71 more collagen growth3
bull Mature vaginal elastin decrease was not observed with Smartmesh4
bull Smartmesh did not induce a negative change in collagen metabolism5
bull Smartmesh had similar innervation density as sham 6
bull Low incidence of de novo dyspareunia71 Alinsod R et al (2008) Long term outcomes of vaginal pelvic floor repair using an ultra lightweight mesh AAGL (2008)2 Alinsod R Et al (2012) Durability and Complications of an Ultra Lightweight Transvaginal Mesh in the Treatment of Pelvic Organ Prolapse Presented at the 37th Annual Meeting of IUGA3 Greca FH et al (2007) The influence of porosity on the integration histology of two polypropylene meshes for the treatment of abdominal wall defects in dogs Hernia (12) 45-494 Moalli et al (2012) Mesh implantation negatively impacts vagina elastin metabolism Female Pelvic Medicine amp Reconstructive Surgery Vol 18 (Suppl 2)S258-9 SeptOct paper 235 Moalli et al (2012) Increasing mesh stiffness negatively impacts vaginal collagen metabolism Female Pelvic Medicine amp Reconstructive Surgery Vol 18 (Suppl 2)S258-9 SeptOct paper 246 Moalli et al (2012) The impact of mesh implantation on vaginal smooth muscle innervation Female Pelvic Medicine amp Reconstructive Surgery Vol 18 (Suppl 2)S258-9 SeptOct paper 257 Hawthorn R et al (2007) Use of ultra lightweight mesh in vaginal vault repairs to minimize complications A two centre observation study British International Congress of Obstetrics amp Gynaecology
PRE FORMED Y-MESH VS CUTTING MESH AND MAKING IT TO FIT PATIENTS
Pr Bruno DEVAL MD Geoffroy Saint-Hilaire ndash Clinic
Hotel ndashDieu de Paris
Paris V University
Mesh and operative handling
The shape and weight of the mesh can help us during
laparoscopic procedure
A large Y mesh is a good choice for vaginal vault shape
Better intra-operative manipulation and suturing
Lower mesh mass accommodates easy passage through narrow
laparoscopic ports
Use re-absorbable sutures on the vagina
bull Stitch erosions are reported
bull Folding and wrinkling can cause
erosions and dyspaurenia
Avoid folding and wrinkling the
mesh must be well stretched
DO WE NEED TO DISSECT POSTERIOR DOWN TO PERINEUM OR
IN WHICH PATIENTS THIS IS INDICATED
Pr Bruno DEVAL MD Geoffroy Saint-Hilaire ndash Clinic
Hotel ndashDieu de Paris
Paris V University
Fix the mesh on the posterior
vaginal wall and not on the
elevator ani muscle
bull To avoid dyschezia and chronic
pelvic pain
bull Sacrocolpopexy should only be performed by board certified eligible surgeons (ObGyn or Urology)
bull Knowledge surgical skills and experience in reconstructive pelvic surgery
FPMRS fellowship
CME documentation
Proctoring on 10 cases
gt 50 practice in reconstructive surgery
bull Outcomes and complications of should be monitored by annual internal audit
bull Informed consent should highlight
Alternatives to ASC including pessary
Complications of ASC
Complications of mesh
AUGS Guidelines on Sacrocolpopexy Privileges(March 2013)
Source wwwaugsorg
Conclusion
bull The technique and expertise are
fundamental
bull Laparoscopic colposacropexy can safely
be offered to women with symptomatic
POP
bull Conventional LSCP = Open Way =
robotic way
bull Conventional LSCP gt Vaginal Way
Post ndash OP MORBIDITY
LAPAROSCOPIC SACROCOLPOPEXY FOR FEMALE GENITAL PROLAPSE A COMPREHENSIVE REVIEW
Bruno DEVALa and al
(Submitted)
Complication TOTAL
Urinary infection 69 (25)
Voiding dysfunctionᵜ 1772721 (65)
Related to trocar site 82721 (03)
Wound infection 9 (033)
Mechanical ileus 9 (033)
Septical peritonitis 1 (003)
Bleeding 132721 (047)
Recurrent acute cystitis 1 (003)
Low back pain or sciatica 192721 (069)
Nerve lesion 3 (01)
Pain related to mesh 552721(22)
Detachment of mesh 32721(01)
Vault infection 2(0073)
Mesh infection 6(022)
Lombosacral spondylodiscitis 72721(025)
Suture erosion 5(018)
Mesh erosion 652721(24)
Rectovaginal fistula 1(003)
Vesicovaginal fistula 32721(01)
anal pain 5(018)
phlebitis 22721(0073)
fever 10(036)
stool incontinence 1(003)
LEARNING CURVE AND EVIDENCE
0
1000
2000
3000
4000
5000
6000
surgery laparoscopy robotic vaginal colorectal SCP
Prospectiv Study n= 206 patients
175 mn after 90 cases
ANALYSIS OF THE LEARNING PROCESS FOR LAPAROSCOPIC SACROCOLPOPEXY
IDENTIFICATION OF CHALLENGING STEPS
Claerhout et al Int j Urogynecol J ndash 2014 25
bull Prospectiv Study POP stade II
ndash Fellow n = 60 cases vs senior-teacher n= 30 cases
bull Fellow senior + Pelvitrainer
bull 5 Steps
bull 30 cases step 1-2
bull 30 to 50 cases steps 3-4
bull Last 10 cases full procedure
bull Comparativ itmes ndash Time
ndash Score
ndash morbidity
ndash Result
LAPAROSCOPIC SURGICAL BOX MODEL TRAINING FOR SURGICAL TRAINEES
WITH NO PRIOR LAPAROSCOPIC EXPERIENCE
Myura Nagendran et al
bull Authors included randomised clinical trials comparing
boxmodel trainers versus no training in surgical trainees
with no prior laparoscopic experience
bull 16 trials (464 participants) provided data for meta-analysis
of box training (248 participants) versus no supplementary
training (216 participants)
bull All the 16 trials in this comparison used video trainers
bull The meta-analysis showed that the time taken for task
completion was significantly shorter in the box trainer
group than the control group
bull Compared with the control group the box trainer group
also had lower error score better accuracy score and
better composite performance scores
bull Laparoscopic box model training appears to improve
technical skills compared with no training in trainees
with no previous laparoscopic experience
Laparoscopic surgical box model training for surgical trainees
with no prior laparoscopic experience
Myura Nagendran et al
Power Point slide deck adapted from
Canadian Agency for Drugs and Technologies in Health
Robot-Assisted Surgery Compared with Open Surgery and Laparoscopic Surgery Clinical Effectiveness and Economic Analyses
Chuong Ho MDEva Tsakonas BA MSc
Khai Tran MSc PhDKaren Cimon
Melissa Severn MIStMonika Mierzwinski-Urban BA MLIS
Jacques Corcos MDStephen Pautler MD FRCSC
September 2014
Adapted by Michael Fung-Kee-Fung MBBS FRCSC MBA
Nancy Jaworski BComm MHA
Walter Gotlieb MD PhD
Adapted from CADTH Technology Report on Robot-Assisted Surgery 2011
Indications for Robot Use ndash Disease Prevalence
bull 24700 new cases of prostate cancer diagnosed in Canada in 2008
bull 219 of patients lt60 years old will choose prostatectomy as initial treatmentUrology
bull 36000 hysterectomies performed in Canada in 200708
bull Hysterectomy is performed for several indications Gynecology
bull 5 year prevalence (2005) 482100000 male amp 318100000 female
bull Surgery is the primary treatment for localized renal cell carcinomaNephrology
bull An estimated 20000 coronary artery bypass graft (CABG) surgeries were performed in Canada in 200001
Cardiac Surgery
Adapted from CADTH Technology Report on Robot-Assisted Surgery 2011
Economic Analysis
bull Robot-Assisted vs Laparoscopic
Economic Model Base Case (Robot not donated)
Hospital Budget Impact
Hospital Budget Impact
ANATOMY OF THE PRESACRAL SPACE
STRUCTURES TO BE
RESPECTED
FOR A SAFE FIXATION
OF THE MESH
RATE OF
BLOOD TRANSFUSION
02
ANATOMICAL VARIATIONS
OF THE LEFT COMMON ILIAC VEIN MIDDLE PART PROMONTORY
bull Distances between the left common iliac vein and the midsacral promontory
bull Dissection of 52 cadavers
bull Mean of d1 = 27 mm (9 - 52)
bull Mean of d2 = 22 mm (9 - 35)
Wieslander CK et al Vascular anatomy of the presacral space in unembalmedfemale cadaversAmerican journal of obstetrics and gynecology 2006 195 1736
d1
RATE OF
BLOOD TRANSFUSION
02
ANATOMICAL VARIATIONS OF PRESACRAL VESSELS
MIDDLE PART PROMONTORY
bull Presacral vesselsndash Middle sacral vein
Oslash= 2mm (1- 4)
double (80)
left to P= 33
right to P= 52
crossing P= 5
mean of d3 = 7 mm (0-17)
P
d3
Wieslander CK et al Vascular anatomy of the presacral space in unembalmed female cadavers American journal of obstetrics and gynecology 2006 195 1736
ANATOMICAL VARIATIONS OF PRESACRAL VESSELS
MIDDLE PART PROMONTORY
bull Presacral vesselsndash Middle sacral artery
Oslash= 2mm (1- 4)
Left to P= 62
Right to P= 30
Crossing P= 8
Mean of d4 = 4 mm (0-15)
Pd4
Wieslander CK et al Vascular anatomy of the presacral space in unembalmed female cadavers American journal of obstetrics and gynecology 2006 195 1736
ANATOMICAL VARIATIONS OF PRESACRAL VESSELS
MIDDLE PART PROMONTORY
bull Presacral space avascular areas
bull Overlay of vascular structures
bull (10 cadavers)
Flynn MK et al Vascular anatomy of the presacral space a freshtissue cadaver dissectionAmerican journal of obstetrics and gynecology2005 192 1501
rarr Dissection right to the medline = safer
ANATOMICAL VARIATIONS OF THE RIGHT URETER
MIDDLE PART PROMONTORY
Flynn MK et al Vascular anatomy of the presacral space a fresh tissue cadaver dissectionAmerican journal of obstetrics and gynecology 2005 192 1501
bull Distances between the right ureter and the midsacral promontory
bull Dissection of 10 cadavers
ANATOMICAL VARIATIONS
OF THE
SUPERIOR HYPOGASTRIC PLEXUS
bull SHP sympathetic plexus connected to IHP
Shiozawa T et al Nerve-preserving sacrocolpopexy anatomical study and surgical approachEuropean journal of obstetrics and gynecology and reproductive biology2010 152 103
ANATOMICAL VARIATIONS OF SUPERIOR HYPOGASTRIC PLEXUS
bull Right hypogastric nerve
Wieslander CK et al Vascular anatomy of the presacral space in unembalmed female cadaversAmerican journal of obstetrics and gynecology 2006 195 1736
d6bull Mean of d6 = 7 mm (0 - 17)
Nerve-preserving sacrocolpopexy anatomical study and surgical approach
Shiozawa T1 et al
By protecting the superiorhypogastric plexus and the part of thepresacral area below the promontorywe can preserve the hypogastricnerves the sacral and pelvicsplanchnic nerves and thus theautonomic innervation of the pelvicorgans
ANATOMICAL VARIATIONS OF LVCA
bull Fixation into the anterior longitudinal
ligament
ANATOMICAL VARIATIONS OF LVCA
Boukkerou M et alPromontofixation procedures use of non-absorbable sutures or tackers Journal de gyneacutecologie obsteacutetrique et biologie de la reproduction2003 32 54
bull Fixation into the anterior longitudinal ligament
and NOT into the disc
ANATOMICAL VARIATIONS OF LVCA
bull Tackers go deep into the bone
Boukkerou M et alPromontofixation procedures use of non-absorbable sutures or tackers Journal de gyneacutecologie obsteacutetrique et biologie de la reproduction2003 32 54
Spondilithis03
ndash Preacutevention bull Asepsie and per-op antibioprophylaxy
ndash Diagnosis ndash Lombalgia fever tence neurologic diseases
ndash Inflammatory Syndrome (CRP)
ndash Radiologic signs (IRM)
bull Immobilisation
bull Antibiotheacuterapie prolongeacutee +- ponction discale
bull Ablation des prothegraveses
bull +- Arthrodegravese laminectomie
Posterior Dissection ndash DENONVILLIERS FASCIA
Since Charles-PierreDenonvilliers first discoveredthe firm membranousstructure between the rectumand prostate or bladder in1836 now calledldquoDenonvilliersrsquo fasciardquo (DF)the origin of DF has remainedcontroversial
Posterior Dissection ndash DENONVILLIERS FASCIA
Based on the evidencesurgeons should be awareof variations and search forthem to create a suitabledissection plane to avoidiatrogenic positive marginsand rectal injury
Rectal Injury04
ndash Sub-peacuteritoneacuteal rectum
bull There is a recto-vaginal space
bull Horizontal Position ++
bull Close to the post face of the vagina on the distal points
bull Danger on the proximal part of the Recto-Vaginal Septum
ndash Preacutevention
bull Follow the post-face of the vagina
bull Systeacutematic pre-operativ preparation
ndash NORMACOL reg
bull Maleable Retractor
ndash Treatment
bull Immeacutediat Suture
bull Mesh contra-Indication
Vaginal Injury04
ndash Preacuteventionbull Ant Vaginal Length - 6 cm ( 4 ndash 75) Jayle et al Masson 1918
bull Post Vaginal Lenght- 9cm (65 ndash 115) Jayle et al Masson 1918
bull There is no difference between the anterior and posteriorvagina thickness
bull If the vagina is too thin ndash Plicature of the vagina
ndash Treatmentbull If Vagina Injury Suture of the vagina
bull There is no contra indication to fix the meshes
RISK OF URETERAL
INJURY lt 11000
ndash Preacutevention
bull Parietal Uretera
ndash Cross between right extern iliac artery and uterine artery
bull Visceral Uretera
ndash Behind the ligaments
ndash Under the bladder
ndash In contact with the bladder
ndash Treatment
bull Per-op
ndash Per-op Bleu carmin en IV
ndash Ureteacuteral Catheter
bull Post-op
ndash Uro-scanner
ndash JJ Ureteral
Bladder
Collection
Sagittal T2
Vagina
Uterus
Ureter ariving in urinoma
Axial T2
Coronale T2
Bladder Injury2
ndash Sub-peacuteritoneacuteal Bladder
bull Vertical Position ++
bull Close to the ant face of the vagina
bull There is NO space
ndash Preacutevention
bull Following the Ant- Face of the vagina
bull Maleable Retractor
ndash Treatment
bull Immeacutediat Suture
bull Mesh Indication
bull Bladder Catheterisation 5 days
Small and Large Bowel Injury
bull Occur when adhesiolysis has to be undertaken
bull Avoid distended bowel at surgery by 48 hours pre op bowel prep
bull Avoid nitrous oxide during surgery as it causes bowel distension
bull If small bowel injured
ndash Repair laparoscopically
ndash Mesh can still be placed
bull Antibiotic cover for 7 days post op
CONCLUSION 1
1 To open the peritoneum tigh-it
2 Dissection on the right side of the mid-sacral ligament
3 Repair carefuly the vessels and the Right ureter
4 Try to preserve the right hypogatsric nerve
5 Fix your needle 1 cm below the promontory
MESH SELECTIONPERTINENT MESH SCIENCEWHY USE A CERTAIN MESH
Pr Bruno DEVAL MD Geoffroy Saint-Hilaire ndash Clinic
Hotel ndashDieu de Paris
Paris V University
MESH STIFFNESS
bullIncreased fibrosis and deposits of unorganized collagen create an increased stiffness
bull (Klinge 1999)
bullStiffness has been linked to clinical complications-heavier stiffer meshes having higher complications
bull (Dietz 2003)
bullStiffer meshes showed decreases in smooth muscle collagen and structural proteins following implantation
bull (Moalli P AUGS 2011)
bullHeavier stiffer meshes showed a greater propensity for stress shielding which in turn could cause reoccurrences of prolapse
bull (Moalli P AUGS 2011)
IMPACT OF VAGINAL SYNTHETIC PROLAPSE MESHES ON THE MECHANICS
OF THE HOST TISSUE RESPONSE
Feola Andrew J 02 February 2012 Doctoral Dissertation University of Pittsburgh
ldquoImplantation of the stiffest mesh in the non human primate
resulted in an exhibition of a stress-shielding response
manifested by inferior biomechanical properties of the
abdominal and vaginal tissues
Less stiff meshes resulted in preservation of tissue
propertiesrdquo
Wolffrsquos Law ndash remodeling of bone in response to stress
MESH CHARACTERISTICS
Density - Filament size ndash Elasticity - Pore size
Surface area ndash Overall ldquomesh loadrdquo
Biomechanical engineers working with type-1
polypropylene have focused on reducing overall
ldquomesh loadrdquo while maintaining durability
bullOptimal tissue incorporation and collagen growthbullNo erosionbullNo palpable mesh to patient and her partnerbullVaginal elasticity
TO OBTAIN
So lighter is better
WHAT KIND OF MESH
bull To date polypropylene meshes are the best type on the market
bull Absorbable meshes do not work
bull There is an evidence to use Polypropylene vs polyesther
bull PTFE and NW meshes are contra ndash indicated in the POP Repair
ULTRA- LIGHT POLYPROPYLENE
bull Physiologically compatible 19 gsm1
bull Ultra lightweightbull Lowest weight available for pelvic restoration
bull 18 millimeter macropores1
ndash Consistent size throughout the mesh
bull 100 micron interstitial Smartporestrade 1ndash Simultaneously encourages both collagen growth and
bacteria fighting propertiesbull Fibroblasts will enter holes that are 50 to 200 microns in size23
bull Macrophages and neutrophils will enter holes that are 50 to 120 microns in size23
bull Reduce inflammation1 Data on file2 Greca FH et at (2007) The influence of porosity on integration histology of two polypropylene meshes for the treatment of abdominal wall
defects in dogs Hernia (12) 45-493 Marois Y et all (2000) Biostability inflammatory response and healing characteristics flourpassivated polyester-knit mesh in the repair of
experimental abdominal hernias Artif Organs 24533-543
ULTRA ndash LIGHT CLINICAL EVIDENCE
SUMMARY
bull Rates of Erosion and Exposurebull Less than 1 erosion rate1
bull Anterior exposure rate 172
bull Posterior exposure rate 052
bull Greater tissue strength 3 months post-op ndash 71 more collagen growth3
bull Mature vaginal elastin decrease was not observed with Smartmesh4
bull Smartmesh did not induce a negative change in collagen metabolism5
bull Smartmesh had similar innervation density as sham 6
bull Low incidence of de novo dyspareunia71 Alinsod R et al (2008) Long term outcomes of vaginal pelvic floor repair using an ultra lightweight mesh AAGL (2008)2 Alinsod R Et al (2012) Durability and Complications of an Ultra Lightweight Transvaginal Mesh in the Treatment of Pelvic Organ Prolapse Presented at the 37th Annual Meeting of IUGA3 Greca FH et al (2007) The influence of porosity on the integration histology of two polypropylene meshes for the treatment of abdominal wall defects in dogs Hernia (12) 45-494 Moalli et al (2012) Mesh implantation negatively impacts vagina elastin metabolism Female Pelvic Medicine amp Reconstructive Surgery Vol 18 (Suppl 2)S258-9 SeptOct paper 235 Moalli et al (2012) Increasing mesh stiffness negatively impacts vaginal collagen metabolism Female Pelvic Medicine amp Reconstructive Surgery Vol 18 (Suppl 2)S258-9 SeptOct paper 246 Moalli et al (2012) The impact of mesh implantation on vaginal smooth muscle innervation Female Pelvic Medicine amp Reconstructive Surgery Vol 18 (Suppl 2)S258-9 SeptOct paper 257 Hawthorn R et al (2007) Use of ultra lightweight mesh in vaginal vault repairs to minimize complications A two centre observation study British International Congress of Obstetrics amp Gynaecology
PRE FORMED Y-MESH VS CUTTING MESH AND MAKING IT TO FIT PATIENTS
Pr Bruno DEVAL MD Geoffroy Saint-Hilaire ndash Clinic
Hotel ndashDieu de Paris
Paris V University
Mesh and operative handling
The shape and weight of the mesh can help us during
laparoscopic procedure
A large Y mesh is a good choice for vaginal vault shape
Better intra-operative manipulation and suturing
Lower mesh mass accommodates easy passage through narrow
laparoscopic ports
Use re-absorbable sutures on the vagina
bull Stitch erosions are reported
bull Folding and wrinkling can cause
erosions and dyspaurenia
Avoid folding and wrinkling the
mesh must be well stretched
DO WE NEED TO DISSECT POSTERIOR DOWN TO PERINEUM OR
IN WHICH PATIENTS THIS IS INDICATED
Pr Bruno DEVAL MD Geoffroy Saint-Hilaire ndash Clinic
Hotel ndashDieu de Paris
Paris V University
Fix the mesh on the posterior
vaginal wall and not on the
elevator ani muscle
bull To avoid dyschezia and chronic
pelvic pain
bull Sacrocolpopexy should only be performed by board certified eligible surgeons (ObGyn or Urology)
bull Knowledge surgical skills and experience in reconstructive pelvic surgery
FPMRS fellowship
CME documentation
Proctoring on 10 cases
gt 50 practice in reconstructive surgery
bull Outcomes and complications of should be monitored by annual internal audit
bull Informed consent should highlight
Alternatives to ASC including pessary
Complications of ASC
Complications of mesh
AUGS Guidelines on Sacrocolpopexy Privileges(March 2013)
Source wwwaugsorg
Conclusion
bull The technique and expertise are
fundamental
bull Laparoscopic colposacropexy can safely
be offered to women with symptomatic
POP
bull Conventional LSCP = Open Way =
robotic way
bull Conventional LSCP gt Vaginal Way
LEARNING CURVE AND EVIDENCE
0
1000
2000
3000
4000
5000
6000
surgery laparoscopy robotic vaginal colorectal SCP
Prospectiv Study n= 206 patients
175 mn after 90 cases
ANALYSIS OF THE LEARNING PROCESS FOR LAPAROSCOPIC SACROCOLPOPEXY
IDENTIFICATION OF CHALLENGING STEPS
Claerhout et al Int j Urogynecol J ndash 2014 25
bull Prospectiv Study POP stade II
ndash Fellow n = 60 cases vs senior-teacher n= 30 cases
bull Fellow senior + Pelvitrainer
bull 5 Steps
bull 30 cases step 1-2
bull 30 to 50 cases steps 3-4
bull Last 10 cases full procedure
bull Comparativ itmes ndash Time
ndash Score
ndash morbidity
ndash Result
LAPAROSCOPIC SURGICAL BOX MODEL TRAINING FOR SURGICAL TRAINEES
WITH NO PRIOR LAPAROSCOPIC EXPERIENCE
Myura Nagendran et al
bull Authors included randomised clinical trials comparing
boxmodel trainers versus no training in surgical trainees
with no prior laparoscopic experience
bull 16 trials (464 participants) provided data for meta-analysis
of box training (248 participants) versus no supplementary
training (216 participants)
bull All the 16 trials in this comparison used video trainers
bull The meta-analysis showed that the time taken for task
completion was significantly shorter in the box trainer
group than the control group
bull Compared with the control group the box trainer group
also had lower error score better accuracy score and
better composite performance scores
bull Laparoscopic box model training appears to improve
technical skills compared with no training in trainees
with no previous laparoscopic experience
Laparoscopic surgical box model training for surgical trainees
with no prior laparoscopic experience
Myura Nagendran et al
Power Point slide deck adapted from
Canadian Agency for Drugs and Technologies in Health
Robot-Assisted Surgery Compared with Open Surgery and Laparoscopic Surgery Clinical Effectiveness and Economic Analyses
Chuong Ho MDEva Tsakonas BA MSc
Khai Tran MSc PhDKaren Cimon
Melissa Severn MIStMonika Mierzwinski-Urban BA MLIS
Jacques Corcos MDStephen Pautler MD FRCSC
September 2014
Adapted by Michael Fung-Kee-Fung MBBS FRCSC MBA
Nancy Jaworski BComm MHA
Walter Gotlieb MD PhD
Adapted from CADTH Technology Report on Robot-Assisted Surgery 2011
Indications for Robot Use ndash Disease Prevalence
bull 24700 new cases of prostate cancer diagnosed in Canada in 2008
bull 219 of patients lt60 years old will choose prostatectomy as initial treatmentUrology
bull 36000 hysterectomies performed in Canada in 200708
bull Hysterectomy is performed for several indications Gynecology
bull 5 year prevalence (2005) 482100000 male amp 318100000 female
bull Surgery is the primary treatment for localized renal cell carcinomaNephrology
bull An estimated 20000 coronary artery bypass graft (CABG) surgeries were performed in Canada in 200001
Cardiac Surgery
Adapted from CADTH Technology Report on Robot-Assisted Surgery 2011
Economic Analysis
bull Robot-Assisted vs Laparoscopic
Economic Model Base Case (Robot not donated)
Hospital Budget Impact
Hospital Budget Impact
ANATOMY OF THE PRESACRAL SPACE
STRUCTURES TO BE
RESPECTED
FOR A SAFE FIXATION
OF THE MESH
RATE OF
BLOOD TRANSFUSION
02
ANATOMICAL VARIATIONS
OF THE LEFT COMMON ILIAC VEIN MIDDLE PART PROMONTORY
bull Distances between the left common iliac vein and the midsacral promontory
bull Dissection of 52 cadavers
bull Mean of d1 = 27 mm (9 - 52)
bull Mean of d2 = 22 mm (9 - 35)
Wieslander CK et al Vascular anatomy of the presacral space in unembalmedfemale cadaversAmerican journal of obstetrics and gynecology 2006 195 1736
d1
RATE OF
BLOOD TRANSFUSION
02
ANATOMICAL VARIATIONS OF PRESACRAL VESSELS
MIDDLE PART PROMONTORY
bull Presacral vesselsndash Middle sacral vein
Oslash= 2mm (1- 4)
double (80)
left to P= 33
right to P= 52
crossing P= 5
mean of d3 = 7 mm (0-17)
P
d3
Wieslander CK et al Vascular anatomy of the presacral space in unembalmed female cadavers American journal of obstetrics and gynecology 2006 195 1736
ANATOMICAL VARIATIONS OF PRESACRAL VESSELS
MIDDLE PART PROMONTORY
bull Presacral vesselsndash Middle sacral artery
Oslash= 2mm (1- 4)
Left to P= 62
Right to P= 30
Crossing P= 8
Mean of d4 = 4 mm (0-15)
Pd4
Wieslander CK et al Vascular anatomy of the presacral space in unembalmed female cadavers American journal of obstetrics and gynecology 2006 195 1736
ANATOMICAL VARIATIONS OF PRESACRAL VESSELS
MIDDLE PART PROMONTORY
bull Presacral space avascular areas
bull Overlay of vascular structures
bull (10 cadavers)
Flynn MK et al Vascular anatomy of the presacral space a freshtissue cadaver dissectionAmerican journal of obstetrics and gynecology2005 192 1501
rarr Dissection right to the medline = safer
ANATOMICAL VARIATIONS OF THE RIGHT URETER
MIDDLE PART PROMONTORY
Flynn MK et al Vascular anatomy of the presacral space a fresh tissue cadaver dissectionAmerican journal of obstetrics and gynecology 2005 192 1501
bull Distances between the right ureter and the midsacral promontory
bull Dissection of 10 cadavers
ANATOMICAL VARIATIONS
OF THE
SUPERIOR HYPOGASTRIC PLEXUS
bull SHP sympathetic plexus connected to IHP
Shiozawa T et al Nerve-preserving sacrocolpopexy anatomical study and surgical approachEuropean journal of obstetrics and gynecology and reproductive biology2010 152 103
ANATOMICAL VARIATIONS OF SUPERIOR HYPOGASTRIC PLEXUS
bull Right hypogastric nerve
Wieslander CK et al Vascular anatomy of the presacral space in unembalmed female cadaversAmerican journal of obstetrics and gynecology 2006 195 1736
d6bull Mean of d6 = 7 mm (0 - 17)
Nerve-preserving sacrocolpopexy anatomical study and surgical approach
Shiozawa T1 et al
By protecting the superiorhypogastric plexus and the part of thepresacral area below the promontorywe can preserve the hypogastricnerves the sacral and pelvicsplanchnic nerves and thus theautonomic innervation of the pelvicorgans
ANATOMICAL VARIATIONS OF LVCA
bull Fixation into the anterior longitudinal
ligament
ANATOMICAL VARIATIONS OF LVCA
Boukkerou M et alPromontofixation procedures use of non-absorbable sutures or tackers Journal de gyneacutecologie obsteacutetrique et biologie de la reproduction2003 32 54
bull Fixation into the anterior longitudinal ligament
and NOT into the disc
ANATOMICAL VARIATIONS OF LVCA
bull Tackers go deep into the bone
Boukkerou M et alPromontofixation procedures use of non-absorbable sutures or tackers Journal de gyneacutecologie obsteacutetrique et biologie de la reproduction2003 32 54
Spondilithis03
ndash Preacutevention bull Asepsie and per-op antibioprophylaxy
ndash Diagnosis ndash Lombalgia fever tence neurologic diseases
ndash Inflammatory Syndrome (CRP)
ndash Radiologic signs (IRM)
bull Immobilisation
bull Antibiotheacuterapie prolongeacutee +- ponction discale
bull Ablation des prothegraveses
bull +- Arthrodegravese laminectomie
Posterior Dissection ndash DENONVILLIERS FASCIA
Since Charles-PierreDenonvilliers first discoveredthe firm membranousstructure between the rectumand prostate or bladder in1836 now calledldquoDenonvilliersrsquo fasciardquo (DF)the origin of DF has remainedcontroversial
Posterior Dissection ndash DENONVILLIERS FASCIA
Based on the evidencesurgeons should be awareof variations and search forthem to create a suitabledissection plane to avoidiatrogenic positive marginsand rectal injury
Rectal Injury04
ndash Sub-peacuteritoneacuteal rectum
bull There is a recto-vaginal space
bull Horizontal Position ++
bull Close to the post face of the vagina on the distal points
bull Danger on the proximal part of the Recto-Vaginal Septum
ndash Preacutevention
bull Follow the post-face of the vagina
bull Systeacutematic pre-operativ preparation
ndash NORMACOL reg
bull Maleable Retractor
ndash Treatment
bull Immeacutediat Suture
bull Mesh contra-Indication
Vaginal Injury04
ndash Preacuteventionbull Ant Vaginal Length - 6 cm ( 4 ndash 75) Jayle et al Masson 1918
bull Post Vaginal Lenght- 9cm (65 ndash 115) Jayle et al Masson 1918
bull There is no difference between the anterior and posteriorvagina thickness
bull If the vagina is too thin ndash Plicature of the vagina
ndash Treatmentbull If Vagina Injury Suture of the vagina
bull There is no contra indication to fix the meshes
RISK OF URETERAL
INJURY lt 11000
ndash Preacutevention
bull Parietal Uretera
ndash Cross between right extern iliac artery and uterine artery
bull Visceral Uretera
ndash Behind the ligaments
ndash Under the bladder
ndash In contact with the bladder
ndash Treatment
bull Per-op
ndash Per-op Bleu carmin en IV
ndash Ureteacuteral Catheter
bull Post-op
ndash Uro-scanner
ndash JJ Ureteral
Bladder
Collection
Sagittal T2
Vagina
Uterus
Ureter ariving in urinoma
Axial T2
Coronale T2
Bladder Injury2
ndash Sub-peacuteritoneacuteal Bladder
bull Vertical Position ++
bull Close to the ant face of the vagina
bull There is NO space
ndash Preacutevention
bull Following the Ant- Face of the vagina
bull Maleable Retractor
ndash Treatment
bull Immeacutediat Suture
bull Mesh Indication
bull Bladder Catheterisation 5 days
Small and Large Bowel Injury
bull Occur when adhesiolysis has to be undertaken
bull Avoid distended bowel at surgery by 48 hours pre op bowel prep
bull Avoid nitrous oxide during surgery as it causes bowel distension
bull If small bowel injured
ndash Repair laparoscopically
ndash Mesh can still be placed
bull Antibiotic cover for 7 days post op
CONCLUSION 1
1 To open the peritoneum tigh-it
2 Dissection on the right side of the mid-sacral ligament
3 Repair carefuly the vessels and the Right ureter
4 Try to preserve the right hypogatsric nerve
5 Fix your needle 1 cm below the promontory
MESH SELECTIONPERTINENT MESH SCIENCEWHY USE A CERTAIN MESH
Pr Bruno DEVAL MD Geoffroy Saint-Hilaire ndash Clinic
Hotel ndashDieu de Paris
Paris V University
MESH STIFFNESS
bullIncreased fibrosis and deposits of unorganized collagen create an increased stiffness
bull (Klinge 1999)
bullStiffness has been linked to clinical complications-heavier stiffer meshes having higher complications
bull (Dietz 2003)
bullStiffer meshes showed decreases in smooth muscle collagen and structural proteins following implantation
bull (Moalli P AUGS 2011)
bullHeavier stiffer meshes showed a greater propensity for stress shielding which in turn could cause reoccurrences of prolapse
bull (Moalli P AUGS 2011)
IMPACT OF VAGINAL SYNTHETIC PROLAPSE MESHES ON THE MECHANICS
OF THE HOST TISSUE RESPONSE
Feola Andrew J 02 February 2012 Doctoral Dissertation University of Pittsburgh
ldquoImplantation of the stiffest mesh in the non human primate
resulted in an exhibition of a stress-shielding response
manifested by inferior biomechanical properties of the
abdominal and vaginal tissues
Less stiff meshes resulted in preservation of tissue
propertiesrdquo
Wolffrsquos Law ndash remodeling of bone in response to stress
MESH CHARACTERISTICS
Density - Filament size ndash Elasticity - Pore size
Surface area ndash Overall ldquomesh loadrdquo
Biomechanical engineers working with type-1
polypropylene have focused on reducing overall
ldquomesh loadrdquo while maintaining durability
bullOptimal tissue incorporation and collagen growthbullNo erosionbullNo palpable mesh to patient and her partnerbullVaginal elasticity
TO OBTAIN
So lighter is better
WHAT KIND OF MESH
bull To date polypropylene meshes are the best type on the market
bull Absorbable meshes do not work
bull There is an evidence to use Polypropylene vs polyesther
bull PTFE and NW meshes are contra ndash indicated in the POP Repair
ULTRA- LIGHT POLYPROPYLENE
bull Physiologically compatible 19 gsm1
bull Ultra lightweightbull Lowest weight available for pelvic restoration
bull 18 millimeter macropores1
ndash Consistent size throughout the mesh
bull 100 micron interstitial Smartporestrade 1ndash Simultaneously encourages both collagen growth and
bacteria fighting propertiesbull Fibroblasts will enter holes that are 50 to 200 microns in size23
bull Macrophages and neutrophils will enter holes that are 50 to 120 microns in size23
bull Reduce inflammation1 Data on file2 Greca FH et at (2007) The influence of porosity on integration histology of two polypropylene meshes for the treatment of abdominal wall
defects in dogs Hernia (12) 45-493 Marois Y et all (2000) Biostability inflammatory response and healing characteristics flourpassivated polyester-knit mesh in the repair of
experimental abdominal hernias Artif Organs 24533-543
ULTRA ndash LIGHT CLINICAL EVIDENCE
SUMMARY
bull Rates of Erosion and Exposurebull Less than 1 erosion rate1
bull Anterior exposure rate 172
bull Posterior exposure rate 052
bull Greater tissue strength 3 months post-op ndash 71 more collagen growth3
bull Mature vaginal elastin decrease was not observed with Smartmesh4
bull Smartmesh did not induce a negative change in collagen metabolism5
bull Smartmesh had similar innervation density as sham 6
bull Low incidence of de novo dyspareunia71 Alinsod R et al (2008) Long term outcomes of vaginal pelvic floor repair using an ultra lightweight mesh AAGL (2008)2 Alinsod R Et al (2012) Durability and Complications of an Ultra Lightweight Transvaginal Mesh in the Treatment of Pelvic Organ Prolapse Presented at the 37th Annual Meeting of IUGA3 Greca FH et al (2007) The influence of porosity on the integration histology of two polypropylene meshes for the treatment of abdominal wall defects in dogs Hernia (12) 45-494 Moalli et al (2012) Mesh implantation negatively impacts vagina elastin metabolism Female Pelvic Medicine amp Reconstructive Surgery Vol 18 (Suppl 2)S258-9 SeptOct paper 235 Moalli et al (2012) Increasing mesh stiffness negatively impacts vaginal collagen metabolism Female Pelvic Medicine amp Reconstructive Surgery Vol 18 (Suppl 2)S258-9 SeptOct paper 246 Moalli et al (2012) The impact of mesh implantation on vaginal smooth muscle innervation Female Pelvic Medicine amp Reconstructive Surgery Vol 18 (Suppl 2)S258-9 SeptOct paper 257 Hawthorn R et al (2007) Use of ultra lightweight mesh in vaginal vault repairs to minimize complications A two centre observation study British International Congress of Obstetrics amp Gynaecology
PRE FORMED Y-MESH VS CUTTING MESH AND MAKING IT TO FIT PATIENTS
Pr Bruno DEVAL MD Geoffroy Saint-Hilaire ndash Clinic
Hotel ndashDieu de Paris
Paris V University
Mesh and operative handling
The shape and weight of the mesh can help us during
laparoscopic procedure
A large Y mesh is a good choice for vaginal vault shape
Better intra-operative manipulation and suturing
Lower mesh mass accommodates easy passage through narrow
laparoscopic ports
Use re-absorbable sutures on the vagina
bull Stitch erosions are reported
bull Folding and wrinkling can cause
erosions and dyspaurenia
Avoid folding and wrinkling the
mesh must be well stretched
DO WE NEED TO DISSECT POSTERIOR DOWN TO PERINEUM OR
IN WHICH PATIENTS THIS IS INDICATED
Pr Bruno DEVAL MD Geoffroy Saint-Hilaire ndash Clinic
Hotel ndashDieu de Paris
Paris V University
Fix the mesh on the posterior
vaginal wall and not on the
elevator ani muscle
bull To avoid dyschezia and chronic
pelvic pain
bull Sacrocolpopexy should only be performed by board certified eligible surgeons (ObGyn or Urology)
bull Knowledge surgical skills and experience in reconstructive pelvic surgery
FPMRS fellowship
CME documentation
Proctoring on 10 cases
gt 50 practice in reconstructive surgery
bull Outcomes and complications of should be monitored by annual internal audit
bull Informed consent should highlight
Alternatives to ASC including pessary
Complications of ASC
Complications of mesh
AUGS Guidelines on Sacrocolpopexy Privileges(March 2013)
Source wwwaugsorg
Conclusion
bull The technique and expertise are
fundamental
bull Laparoscopic colposacropexy can safely
be offered to women with symptomatic
POP
bull Conventional LSCP = Open Way =
robotic way
bull Conventional LSCP gt Vaginal Way
Prospectiv Study n= 206 patients
175 mn after 90 cases
ANALYSIS OF THE LEARNING PROCESS FOR LAPAROSCOPIC SACROCOLPOPEXY
IDENTIFICATION OF CHALLENGING STEPS
Claerhout et al Int j Urogynecol J ndash 2014 25
bull Prospectiv Study POP stade II
ndash Fellow n = 60 cases vs senior-teacher n= 30 cases
bull Fellow senior + Pelvitrainer
bull 5 Steps
bull 30 cases step 1-2
bull 30 to 50 cases steps 3-4
bull Last 10 cases full procedure
bull Comparativ itmes ndash Time
ndash Score
ndash morbidity
ndash Result
LAPAROSCOPIC SURGICAL BOX MODEL TRAINING FOR SURGICAL TRAINEES
WITH NO PRIOR LAPAROSCOPIC EXPERIENCE
Myura Nagendran et al
bull Authors included randomised clinical trials comparing
boxmodel trainers versus no training in surgical trainees
with no prior laparoscopic experience
bull 16 trials (464 participants) provided data for meta-analysis
of box training (248 participants) versus no supplementary
training (216 participants)
bull All the 16 trials in this comparison used video trainers
bull The meta-analysis showed that the time taken for task
completion was significantly shorter in the box trainer
group than the control group
bull Compared with the control group the box trainer group
also had lower error score better accuracy score and
better composite performance scores
bull Laparoscopic box model training appears to improve
technical skills compared with no training in trainees
with no previous laparoscopic experience
Laparoscopic surgical box model training for surgical trainees
with no prior laparoscopic experience
Myura Nagendran et al
Power Point slide deck adapted from
Canadian Agency for Drugs and Technologies in Health
Robot-Assisted Surgery Compared with Open Surgery and Laparoscopic Surgery Clinical Effectiveness and Economic Analyses
Chuong Ho MDEva Tsakonas BA MSc
Khai Tran MSc PhDKaren Cimon
Melissa Severn MIStMonika Mierzwinski-Urban BA MLIS
Jacques Corcos MDStephen Pautler MD FRCSC
September 2014
Adapted by Michael Fung-Kee-Fung MBBS FRCSC MBA
Nancy Jaworski BComm MHA
Walter Gotlieb MD PhD
Adapted from CADTH Technology Report on Robot-Assisted Surgery 2011
Indications for Robot Use ndash Disease Prevalence
bull 24700 new cases of prostate cancer diagnosed in Canada in 2008
bull 219 of patients lt60 years old will choose prostatectomy as initial treatmentUrology
bull 36000 hysterectomies performed in Canada in 200708
bull Hysterectomy is performed for several indications Gynecology
bull 5 year prevalence (2005) 482100000 male amp 318100000 female
bull Surgery is the primary treatment for localized renal cell carcinomaNephrology
bull An estimated 20000 coronary artery bypass graft (CABG) surgeries were performed in Canada in 200001
Cardiac Surgery
Adapted from CADTH Technology Report on Robot-Assisted Surgery 2011
Economic Analysis
bull Robot-Assisted vs Laparoscopic
Economic Model Base Case (Robot not donated)
Hospital Budget Impact
Hospital Budget Impact
ANATOMY OF THE PRESACRAL SPACE
STRUCTURES TO BE
RESPECTED
FOR A SAFE FIXATION
OF THE MESH
RATE OF
BLOOD TRANSFUSION
02
ANATOMICAL VARIATIONS
OF THE LEFT COMMON ILIAC VEIN MIDDLE PART PROMONTORY
bull Distances between the left common iliac vein and the midsacral promontory
bull Dissection of 52 cadavers
bull Mean of d1 = 27 mm (9 - 52)
bull Mean of d2 = 22 mm (9 - 35)
Wieslander CK et al Vascular anatomy of the presacral space in unembalmedfemale cadaversAmerican journal of obstetrics and gynecology 2006 195 1736
d1
RATE OF
BLOOD TRANSFUSION
02
ANATOMICAL VARIATIONS OF PRESACRAL VESSELS
MIDDLE PART PROMONTORY
bull Presacral vesselsndash Middle sacral vein
Oslash= 2mm (1- 4)
double (80)
left to P= 33
right to P= 52
crossing P= 5
mean of d3 = 7 mm (0-17)
P
d3
Wieslander CK et al Vascular anatomy of the presacral space in unembalmed female cadavers American journal of obstetrics and gynecology 2006 195 1736
ANATOMICAL VARIATIONS OF PRESACRAL VESSELS
MIDDLE PART PROMONTORY
bull Presacral vesselsndash Middle sacral artery
Oslash= 2mm (1- 4)
Left to P= 62
Right to P= 30
Crossing P= 8
Mean of d4 = 4 mm (0-15)
Pd4
Wieslander CK et al Vascular anatomy of the presacral space in unembalmed female cadavers American journal of obstetrics and gynecology 2006 195 1736
ANATOMICAL VARIATIONS OF PRESACRAL VESSELS
MIDDLE PART PROMONTORY
bull Presacral space avascular areas
bull Overlay of vascular structures
bull (10 cadavers)
Flynn MK et al Vascular anatomy of the presacral space a freshtissue cadaver dissectionAmerican journal of obstetrics and gynecology2005 192 1501
rarr Dissection right to the medline = safer
ANATOMICAL VARIATIONS OF THE RIGHT URETER
MIDDLE PART PROMONTORY
Flynn MK et al Vascular anatomy of the presacral space a fresh tissue cadaver dissectionAmerican journal of obstetrics and gynecology 2005 192 1501
bull Distances between the right ureter and the midsacral promontory
bull Dissection of 10 cadavers
ANATOMICAL VARIATIONS
OF THE
SUPERIOR HYPOGASTRIC PLEXUS
bull SHP sympathetic plexus connected to IHP
Shiozawa T et al Nerve-preserving sacrocolpopexy anatomical study and surgical approachEuropean journal of obstetrics and gynecology and reproductive biology2010 152 103
ANATOMICAL VARIATIONS OF SUPERIOR HYPOGASTRIC PLEXUS
bull Right hypogastric nerve
Wieslander CK et al Vascular anatomy of the presacral space in unembalmed female cadaversAmerican journal of obstetrics and gynecology 2006 195 1736
d6bull Mean of d6 = 7 mm (0 - 17)
Nerve-preserving sacrocolpopexy anatomical study and surgical approach
Shiozawa T1 et al
By protecting the superiorhypogastric plexus and the part of thepresacral area below the promontorywe can preserve the hypogastricnerves the sacral and pelvicsplanchnic nerves and thus theautonomic innervation of the pelvicorgans
ANATOMICAL VARIATIONS OF LVCA
bull Fixation into the anterior longitudinal
ligament
ANATOMICAL VARIATIONS OF LVCA
Boukkerou M et alPromontofixation procedures use of non-absorbable sutures or tackers Journal de gyneacutecologie obsteacutetrique et biologie de la reproduction2003 32 54
bull Fixation into the anterior longitudinal ligament
and NOT into the disc
ANATOMICAL VARIATIONS OF LVCA
bull Tackers go deep into the bone
Boukkerou M et alPromontofixation procedures use of non-absorbable sutures or tackers Journal de gyneacutecologie obsteacutetrique et biologie de la reproduction2003 32 54
Spondilithis03
ndash Preacutevention bull Asepsie and per-op antibioprophylaxy
ndash Diagnosis ndash Lombalgia fever tence neurologic diseases
ndash Inflammatory Syndrome (CRP)
ndash Radiologic signs (IRM)
bull Immobilisation
bull Antibiotheacuterapie prolongeacutee +- ponction discale
bull Ablation des prothegraveses
bull +- Arthrodegravese laminectomie
Posterior Dissection ndash DENONVILLIERS FASCIA
Since Charles-PierreDenonvilliers first discoveredthe firm membranousstructure between the rectumand prostate or bladder in1836 now calledldquoDenonvilliersrsquo fasciardquo (DF)the origin of DF has remainedcontroversial
Posterior Dissection ndash DENONVILLIERS FASCIA
Based on the evidencesurgeons should be awareof variations and search forthem to create a suitabledissection plane to avoidiatrogenic positive marginsand rectal injury
Rectal Injury04
ndash Sub-peacuteritoneacuteal rectum
bull There is a recto-vaginal space
bull Horizontal Position ++
bull Close to the post face of the vagina on the distal points
bull Danger on the proximal part of the Recto-Vaginal Septum
ndash Preacutevention
bull Follow the post-face of the vagina
bull Systeacutematic pre-operativ preparation
ndash NORMACOL reg
bull Maleable Retractor
ndash Treatment
bull Immeacutediat Suture
bull Mesh contra-Indication
Vaginal Injury04
ndash Preacuteventionbull Ant Vaginal Length - 6 cm ( 4 ndash 75) Jayle et al Masson 1918
bull Post Vaginal Lenght- 9cm (65 ndash 115) Jayle et al Masson 1918
bull There is no difference between the anterior and posteriorvagina thickness
bull If the vagina is too thin ndash Plicature of the vagina
ndash Treatmentbull If Vagina Injury Suture of the vagina
bull There is no contra indication to fix the meshes
RISK OF URETERAL
INJURY lt 11000
ndash Preacutevention
bull Parietal Uretera
ndash Cross between right extern iliac artery and uterine artery
bull Visceral Uretera
ndash Behind the ligaments
ndash Under the bladder
ndash In contact with the bladder
ndash Treatment
bull Per-op
ndash Per-op Bleu carmin en IV
ndash Ureteacuteral Catheter
bull Post-op
ndash Uro-scanner
ndash JJ Ureteral
Bladder
Collection
Sagittal T2
Vagina
Uterus
Ureter ariving in urinoma
Axial T2
Coronale T2
Bladder Injury2
ndash Sub-peacuteritoneacuteal Bladder
bull Vertical Position ++
bull Close to the ant face of the vagina
bull There is NO space
ndash Preacutevention
bull Following the Ant- Face of the vagina
bull Maleable Retractor
ndash Treatment
bull Immeacutediat Suture
bull Mesh Indication
bull Bladder Catheterisation 5 days
Small and Large Bowel Injury
bull Occur when adhesiolysis has to be undertaken
bull Avoid distended bowel at surgery by 48 hours pre op bowel prep
bull Avoid nitrous oxide during surgery as it causes bowel distension
bull If small bowel injured
ndash Repair laparoscopically
ndash Mesh can still be placed
bull Antibiotic cover for 7 days post op
CONCLUSION 1
1 To open the peritoneum tigh-it
2 Dissection on the right side of the mid-sacral ligament
3 Repair carefuly the vessels and the Right ureter
4 Try to preserve the right hypogatsric nerve
5 Fix your needle 1 cm below the promontory
MESH SELECTIONPERTINENT MESH SCIENCEWHY USE A CERTAIN MESH
Pr Bruno DEVAL MD Geoffroy Saint-Hilaire ndash Clinic
Hotel ndashDieu de Paris
Paris V University
MESH STIFFNESS
bullIncreased fibrosis and deposits of unorganized collagen create an increased stiffness
bull (Klinge 1999)
bullStiffness has been linked to clinical complications-heavier stiffer meshes having higher complications
bull (Dietz 2003)
bullStiffer meshes showed decreases in smooth muscle collagen and structural proteins following implantation
bull (Moalli P AUGS 2011)
bullHeavier stiffer meshes showed a greater propensity for stress shielding which in turn could cause reoccurrences of prolapse
bull (Moalli P AUGS 2011)
IMPACT OF VAGINAL SYNTHETIC PROLAPSE MESHES ON THE MECHANICS
OF THE HOST TISSUE RESPONSE
Feola Andrew J 02 February 2012 Doctoral Dissertation University of Pittsburgh
ldquoImplantation of the stiffest mesh in the non human primate
resulted in an exhibition of a stress-shielding response
manifested by inferior biomechanical properties of the
abdominal and vaginal tissues
Less stiff meshes resulted in preservation of tissue
propertiesrdquo
Wolffrsquos Law ndash remodeling of bone in response to stress
MESH CHARACTERISTICS
Density - Filament size ndash Elasticity - Pore size
Surface area ndash Overall ldquomesh loadrdquo
Biomechanical engineers working with type-1
polypropylene have focused on reducing overall
ldquomesh loadrdquo while maintaining durability
bullOptimal tissue incorporation and collagen growthbullNo erosionbullNo palpable mesh to patient and her partnerbullVaginal elasticity
TO OBTAIN
So lighter is better
WHAT KIND OF MESH
bull To date polypropylene meshes are the best type on the market
bull Absorbable meshes do not work
bull There is an evidence to use Polypropylene vs polyesther
bull PTFE and NW meshes are contra ndash indicated in the POP Repair
ULTRA- LIGHT POLYPROPYLENE
bull Physiologically compatible 19 gsm1
bull Ultra lightweightbull Lowest weight available for pelvic restoration
bull 18 millimeter macropores1
ndash Consistent size throughout the mesh
bull 100 micron interstitial Smartporestrade 1ndash Simultaneously encourages both collagen growth and
bacteria fighting propertiesbull Fibroblasts will enter holes that are 50 to 200 microns in size23
bull Macrophages and neutrophils will enter holes that are 50 to 120 microns in size23
bull Reduce inflammation1 Data on file2 Greca FH et at (2007) The influence of porosity on integration histology of two polypropylene meshes for the treatment of abdominal wall
defects in dogs Hernia (12) 45-493 Marois Y et all (2000) Biostability inflammatory response and healing characteristics flourpassivated polyester-knit mesh in the repair of
experimental abdominal hernias Artif Organs 24533-543
ULTRA ndash LIGHT CLINICAL EVIDENCE
SUMMARY
bull Rates of Erosion and Exposurebull Less than 1 erosion rate1
bull Anterior exposure rate 172
bull Posterior exposure rate 052
bull Greater tissue strength 3 months post-op ndash 71 more collagen growth3
bull Mature vaginal elastin decrease was not observed with Smartmesh4
bull Smartmesh did not induce a negative change in collagen metabolism5
bull Smartmesh had similar innervation density as sham 6
bull Low incidence of de novo dyspareunia71 Alinsod R et al (2008) Long term outcomes of vaginal pelvic floor repair using an ultra lightweight mesh AAGL (2008)2 Alinsod R Et al (2012) Durability and Complications of an Ultra Lightweight Transvaginal Mesh in the Treatment of Pelvic Organ Prolapse Presented at the 37th Annual Meeting of IUGA3 Greca FH et al (2007) The influence of porosity on the integration histology of two polypropylene meshes for the treatment of abdominal wall defects in dogs Hernia (12) 45-494 Moalli et al (2012) Mesh implantation negatively impacts vagina elastin metabolism Female Pelvic Medicine amp Reconstructive Surgery Vol 18 (Suppl 2)S258-9 SeptOct paper 235 Moalli et al (2012) Increasing mesh stiffness negatively impacts vaginal collagen metabolism Female Pelvic Medicine amp Reconstructive Surgery Vol 18 (Suppl 2)S258-9 SeptOct paper 246 Moalli et al (2012) The impact of mesh implantation on vaginal smooth muscle innervation Female Pelvic Medicine amp Reconstructive Surgery Vol 18 (Suppl 2)S258-9 SeptOct paper 257 Hawthorn R et al (2007) Use of ultra lightweight mesh in vaginal vault repairs to minimize complications A two centre observation study British International Congress of Obstetrics amp Gynaecology
PRE FORMED Y-MESH VS CUTTING MESH AND MAKING IT TO FIT PATIENTS
Pr Bruno DEVAL MD Geoffroy Saint-Hilaire ndash Clinic
Hotel ndashDieu de Paris
Paris V University
Mesh and operative handling
The shape and weight of the mesh can help us during
laparoscopic procedure
A large Y mesh is a good choice for vaginal vault shape
Better intra-operative manipulation and suturing
Lower mesh mass accommodates easy passage through narrow
laparoscopic ports
Use re-absorbable sutures on the vagina
bull Stitch erosions are reported
bull Folding and wrinkling can cause
erosions and dyspaurenia
Avoid folding and wrinkling the
mesh must be well stretched
DO WE NEED TO DISSECT POSTERIOR DOWN TO PERINEUM OR
IN WHICH PATIENTS THIS IS INDICATED
Pr Bruno DEVAL MD Geoffroy Saint-Hilaire ndash Clinic
Hotel ndashDieu de Paris
Paris V University
Fix the mesh on the posterior
vaginal wall and not on the
elevator ani muscle
bull To avoid dyschezia and chronic
pelvic pain
bull Sacrocolpopexy should only be performed by board certified eligible surgeons (ObGyn or Urology)
bull Knowledge surgical skills and experience in reconstructive pelvic surgery
FPMRS fellowship
CME documentation
Proctoring on 10 cases
gt 50 practice in reconstructive surgery
bull Outcomes and complications of should be monitored by annual internal audit
bull Informed consent should highlight
Alternatives to ASC including pessary
Complications of ASC
Complications of mesh
AUGS Guidelines on Sacrocolpopexy Privileges(March 2013)
Source wwwaugsorg
Conclusion
bull The technique and expertise are
fundamental
bull Laparoscopic colposacropexy can safely
be offered to women with symptomatic
POP
bull Conventional LSCP = Open Way =
robotic way
bull Conventional LSCP gt Vaginal Way
ANALYSIS OF THE LEARNING PROCESS FOR LAPAROSCOPIC SACROCOLPOPEXY
IDENTIFICATION OF CHALLENGING STEPS
Claerhout et al Int j Urogynecol J ndash 2014 25
bull Prospectiv Study POP stade II
ndash Fellow n = 60 cases vs senior-teacher n= 30 cases
bull Fellow senior + Pelvitrainer
bull 5 Steps
bull 30 cases step 1-2
bull 30 to 50 cases steps 3-4
bull Last 10 cases full procedure
bull Comparativ itmes ndash Time
ndash Score
ndash morbidity
ndash Result
LAPAROSCOPIC SURGICAL BOX MODEL TRAINING FOR SURGICAL TRAINEES
WITH NO PRIOR LAPAROSCOPIC EXPERIENCE
Myura Nagendran et al
bull Authors included randomised clinical trials comparing
boxmodel trainers versus no training in surgical trainees
with no prior laparoscopic experience
bull 16 trials (464 participants) provided data for meta-analysis
of box training (248 participants) versus no supplementary
training (216 participants)
bull All the 16 trials in this comparison used video trainers
bull The meta-analysis showed that the time taken for task
completion was significantly shorter in the box trainer
group than the control group
bull Compared with the control group the box trainer group
also had lower error score better accuracy score and
better composite performance scores
bull Laparoscopic box model training appears to improve
technical skills compared with no training in trainees
with no previous laparoscopic experience
Laparoscopic surgical box model training for surgical trainees
with no prior laparoscopic experience
Myura Nagendran et al
Power Point slide deck adapted from
Canadian Agency for Drugs and Technologies in Health
Robot-Assisted Surgery Compared with Open Surgery and Laparoscopic Surgery Clinical Effectiveness and Economic Analyses
Chuong Ho MDEva Tsakonas BA MSc
Khai Tran MSc PhDKaren Cimon
Melissa Severn MIStMonika Mierzwinski-Urban BA MLIS
Jacques Corcos MDStephen Pautler MD FRCSC
September 2014
Adapted by Michael Fung-Kee-Fung MBBS FRCSC MBA
Nancy Jaworski BComm MHA
Walter Gotlieb MD PhD
Adapted from CADTH Technology Report on Robot-Assisted Surgery 2011
Indications for Robot Use ndash Disease Prevalence
bull 24700 new cases of prostate cancer diagnosed in Canada in 2008
bull 219 of patients lt60 years old will choose prostatectomy as initial treatmentUrology
bull 36000 hysterectomies performed in Canada in 200708
bull Hysterectomy is performed for several indications Gynecology
bull 5 year prevalence (2005) 482100000 male amp 318100000 female
bull Surgery is the primary treatment for localized renal cell carcinomaNephrology
bull An estimated 20000 coronary artery bypass graft (CABG) surgeries were performed in Canada in 200001
Cardiac Surgery
Adapted from CADTH Technology Report on Robot-Assisted Surgery 2011
Economic Analysis
bull Robot-Assisted vs Laparoscopic
Economic Model Base Case (Robot not donated)
Hospital Budget Impact
Hospital Budget Impact
ANATOMY OF THE PRESACRAL SPACE
STRUCTURES TO BE
RESPECTED
FOR A SAFE FIXATION
OF THE MESH
RATE OF
BLOOD TRANSFUSION
02
ANATOMICAL VARIATIONS
OF THE LEFT COMMON ILIAC VEIN MIDDLE PART PROMONTORY
bull Distances between the left common iliac vein and the midsacral promontory
bull Dissection of 52 cadavers
bull Mean of d1 = 27 mm (9 - 52)
bull Mean of d2 = 22 mm (9 - 35)
Wieslander CK et al Vascular anatomy of the presacral space in unembalmedfemale cadaversAmerican journal of obstetrics and gynecology 2006 195 1736
d1
RATE OF
BLOOD TRANSFUSION
02
ANATOMICAL VARIATIONS OF PRESACRAL VESSELS
MIDDLE PART PROMONTORY
bull Presacral vesselsndash Middle sacral vein
Oslash= 2mm (1- 4)
double (80)
left to P= 33
right to P= 52
crossing P= 5
mean of d3 = 7 mm (0-17)
P
d3
Wieslander CK et al Vascular anatomy of the presacral space in unembalmed female cadavers American journal of obstetrics and gynecology 2006 195 1736
ANATOMICAL VARIATIONS OF PRESACRAL VESSELS
MIDDLE PART PROMONTORY
bull Presacral vesselsndash Middle sacral artery
Oslash= 2mm (1- 4)
Left to P= 62
Right to P= 30
Crossing P= 8
Mean of d4 = 4 mm (0-15)
Pd4
Wieslander CK et al Vascular anatomy of the presacral space in unembalmed female cadavers American journal of obstetrics and gynecology 2006 195 1736
ANATOMICAL VARIATIONS OF PRESACRAL VESSELS
MIDDLE PART PROMONTORY
bull Presacral space avascular areas
bull Overlay of vascular structures
bull (10 cadavers)
Flynn MK et al Vascular anatomy of the presacral space a freshtissue cadaver dissectionAmerican journal of obstetrics and gynecology2005 192 1501
rarr Dissection right to the medline = safer
ANATOMICAL VARIATIONS OF THE RIGHT URETER
MIDDLE PART PROMONTORY
Flynn MK et al Vascular anatomy of the presacral space a fresh tissue cadaver dissectionAmerican journal of obstetrics and gynecology 2005 192 1501
bull Distances between the right ureter and the midsacral promontory
bull Dissection of 10 cadavers
ANATOMICAL VARIATIONS
OF THE
SUPERIOR HYPOGASTRIC PLEXUS
bull SHP sympathetic plexus connected to IHP
Shiozawa T et al Nerve-preserving sacrocolpopexy anatomical study and surgical approachEuropean journal of obstetrics and gynecology and reproductive biology2010 152 103
ANATOMICAL VARIATIONS OF SUPERIOR HYPOGASTRIC PLEXUS
bull Right hypogastric nerve
Wieslander CK et al Vascular anatomy of the presacral space in unembalmed female cadaversAmerican journal of obstetrics and gynecology 2006 195 1736
d6bull Mean of d6 = 7 mm (0 - 17)
Nerve-preserving sacrocolpopexy anatomical study and surgical approach
Shiozawa T1 et al
By protecting the superiorhypogastric plexus and the part of thepresacral area below the promontorywe can preserve the hypogastricnerves the sacral and pelvicsplanchnic nerves and thus theautonomic innervation of the pelvicorgans
ANATOMICAL VARIATIONS OF LVCA
bull Fixation into the anterior longitudinal
ligament
ANATOMICAL VARIATIONS OF LVCA
Boukkerou M et alPromontofixation procedures use of non-absorbable sutures or tackers Journal de gyneacutecologie obsteacutetrique et biologie de la reproduction2003 32 54
bull Fixation into the anterior longitudinal ligament
and NOT into the disc
ANATOMICAL VARIATIONS OF LVCA
bull Tackers go deep into the bone
Boukkerou M et alPromontofixation procedures use of non-absorbable sutures or tackers Journal de gyneacutecologie obsteacutetrique et biologie de la reproduction2003 32 54
Spondilithis03
ndash Preacutevention bull Asepsie and per-op antibioprophylaxy
ndash Diagnosis ndash Lombalgia fever tence neurologic diseases
ndash Inflammatory Syndrome (CRP)
ndash Radiologic signs (IRM)
bull Immobilisation
bull Antibiotheacuterapie prolongeacutee +- ponction discale
bull Ablation des prothegraveses
bull +- Arthrodegravese laminectomie
Posterior Dissection ndash DENONVILLIERS FASCIA
Since Charles-PierreDenonvilliers first discoveredthe firm membranousstructure between the rectumand prostate or bladder in1836 now calledldquoDenonvilliersrsquo fasciardquo (DF)the origin of DF has remainedcontroversial
Posterior Dissection ndash DENONVILLIERS FASCIA
Based on the evidencesurgeons should be awareof variations and search forthem to create a suitabledissection plane to avoidiatrogenic positive marginsand rectal injury
Rectal Injury04
ndash Sub-peacuteritoneacuteal rectum
bull There is a recto-vaginal space
bull Horizontal Position ++
bull Close to the post face of the vagina on the distal points
bull Danger on the proximal part of the Recto-Vaginal Septum
ndash Preacutevention
bull Follow the post-face of the vagina
bull Systeacutematic pre-operativ preparation
ndash NORMACOL reg
bull Maleable Retractor
ndash Treatment
bull Immeacutediat Suture
bull Mesh contra-Indication
Vaginal Injury04
ndash Preacuteventionbull Ant Vaginal Length - 6 cm ( 4 ndash 75) Jayle et al Masson 1918
bull Post Vaginal Lenght- 9cm (65 ndash 115) Jayle et al Masson 1918
bull There is no difference between the anterior and posteriorvagina thickness
bull If the vagina is too thin ndash Plicature of the vagina
ndash Treatmentbull If Vagina Injury Suture of the vagina
bull There is no contra indication to fix the meshes
RISK OF URETERAL
INJURY lt 11000
ndash Preacutevention
bull Parietal Uretera
ndash Cross between right extern iliac artery and uterine artery
bull Visceral Uretera
ndash Behind the ligaments
ndash Under the bladder
ndash In contact with the bladder
ndash Treatment
bull Per-op
ndash Per-op Bleu carmin en IV
ndash Ureteacuteral Catheter
bull Post-op
ndash Uro-scanner
ndash JJ Ureteral
Bladder
Collection
Sagittal T2
Vagina
Uterus
Ureter ariving in urinoma
Axial T2
Coronale T2
Bladder Injury2
ndash Sub-peacuteritoneacuteal Bladder
bull Vertical Position ++
bull Close to the ant face of the vagina
bull There is NO space
ndash Preacutevention
bull Following the Ant- Face of the vagina
bull Maleable Retractor
ndash Treatment
bull Immeacutediat Suture
bull Mesh Indication
bull Bladder Catheterisation 5 days
Small and Large Bowel Injury
bull Occur when adhesiolysis has to be undertaken
bull Avoid distended bowel at surgery by 48 hours pre op bowel prep
bull Avoid nitrous oxide during surgery as it causes bowel distension
bull If small bowel injured
ndash Repair laparoscopically
ndash Mesh can still be placed
bull Antibiotic cover for 7 days post op
CONCLUSION 1
1 To open the peritoneum tigh-it
2 Dissection on the right side of the mid-sacral ligament
3 Repair carefuly the vessels and the Right ureter
4 Try to preserve the right hypogatsric nerve
5 Fix your needle 1 cm below the promontory
MESH SELECTIONPERTINENT MESH SCIENCEWHY USE A CERTAIN MESH
Pr Bruno DEVAL MD Geoffroy Saint-Hilaire ndash Clinic
Hotel ndashDieu de Paris
Paris V University
MESH STIFFNESS
bullIncreased fibrosis and deposits of unorganized collagen create an increased stiffness
bull (Klinge 1999)
bullStiffness has been linked to clinical complications-heavier stiffer meshes having higher complications
bull (Dietz 2003)
bullStiffer meshes showed decreases in smooth muscle collagen and structural proteins following implantation
bull (Moalli P AUGS 2011)
bullHeavier stiffer meshes showed a greater propensity for stress shielding which in turn could cause reoccurrences of prolapse
bull (Moalli P AUGS 2011)
IMPACT OF VAGINAL SYNTHETIC PROLAPSE MESHES ON THE MECHANICS
OF THE HOST TISSUE RESPONSE
Feola Andrew J 02 February 2012 Doctoral Dissertation University of Pittsburgh
ldquoImplantation of the stiffest mesh in the non human primate
resulted in an exhibition of a stress-shielding response
manifested by inferior biomechanical properties of the
abdominal and vaginal tissues
Less stiff meshes resulted in preservation of tissue
propertiesrdquo
Wolffrsquos Law ndash remodeling of bone in response to stress
MESH CHARACTERISTICS
Density - Filament size ndash Elasticity - Pore size
Surface area ndash Overall ldquomesh loadrdquo
Biomechanical engineers working with type-1
polypropylene have focused on reducing overall
ldquomesh loadrdquo while maintaining durability
bullOptimal tissue incorporation and collagen growthbullNo erosionbullNo palpable mesh to patient and her partnerbullVaginal elasticity
TO OBTAIN
So lighter is better
WHAT KIND OF MESH
bull To date polypropylene meshes are the best type on the market
bull Absorbable meshes do not work
bull There is an evidence to use Polypropylene vs polyesther
bull PTFE and NW meshes are contra ndash indicated in the POP Repair
ULTRA- LIGHT POLYPROPYLENE
bull Physiologically compatible 19 gsm1
bull Ultra lightweightbull Lowest weight available for pelvic restoration
bull 18 millimeter macropores1
ndash Consistent size throughout the mesh
bull 100 micron interstitial Smartporestrade 1ndash Simultaneously encourages both collagen growth and
bacteria fighting propertiesbull Fibroblasts will enter holes that are 50 to 200 microns in size23
bull Macrophages and neutrophils will enter holes that are 50 to 120 microns in size23
bull Reduce inflammation1 Data on file2 Greca FH et at (2007) The influence of porosity on integration histology of two polypropylene meshes for the treatment of abdominal wall
defects in dogs Hernia (12) 45-493 Marois Y et all (2000) Biostability inflammatory response and healing characteristics flourpassivated polyester-knit mesh in the repair of
experimental abdominal hernias Artif Organs 24533-543
ULTRA ndash LIGHT CLINICAL EVIDENCE
SUMMARY
bull Rates of Erosion and Exposurebull Less than 1 erosion rate1
bull Anterior exposure rate 172
bull Posterior exposure rate 052
bull Greater tissue strength 3 months post-op ndash 71 more collagen growth3
bull Mature vaginal elastin decrease was not observed with Smartmesh4
bull Smartmesh did not induce a negative change in collagen metabolism5
bull Smartmesh had similar innervation density as sham 6
bull Low incidence of de novo dyspareunia71 Alinsod R et al (2008) Long term outcomes of vaginal pelvic floor repair using an ultra lightweight mesh AAGL (2008)2 Alinsod R Et al (2012) Durability and Complications of an Ultra Lightweight Transvaginal Mesh in the Treatment of Pelvic Organ Prolapse Presented at the 37th Annual Meeting of IUGA3 Greca FH et al (2007) The influence of porosity on the integration histology of two polypropylene meshes for the treatment of abdominal wall defects in dogs Hernia (12) 45-494 Moalli et al (2012) Mesh implantation negatively impacts vagina elastin metabolism Female Pelvic Medicine amp Reconstructive Surgery Vol 18 (Suppl 2)S258-9 SeptOct paper 235 Moalli et al (2012) Increasing mesh stiffness negatively impacts vaginal collagen metabolism Female Pelvic Medicine amp Reconstructive Surgery Vol 18 (Suppl 2)S258-9 SeptOct paper 246 Moalli et al (2012) The impact of mesh implantation on vaginal smooth muscle innervation Female Pelvic Medicine amp Reconstructive Surgery Vol 18 (Suppl 2)S258-9 SeptOct paper 257 Hawthorn R et al (2007) Use of ultra lightweight mesh in vaginal vault repairs to minimize complications A two centre observation study British International Congress of Obstetrics amp Gynaecology
PRE FORMED Y-MESH VS CUTTING MESH AND MAKING IT TO FIT PATIENTS
Pr Bruno DEVAL MD Geoffroy Saint-Hilaire ndash Clinic
Hotel ndashDieu de Paris
Paris V University
Mesh and operative handling
The shape and weight of the mesh can help us during
laparoscopic procedure
A large Y mesh is a good choice for vaginal vault shape
Better intra-operative manipulation and suturing
Lower mesh mass accommodates easy passage through narrow
laparoscopic ports
Use re-absorbable sutures on the vagina
bull Stitch erosions are reported
bull Folding and wrinkling can cause
erosions and dyspaurenia
Avoid folding and wrinkling the
mesh must be well stretched
DO WE NEED TO DISSECT POSTERIOR DOWN TO PERINEUM OR
IN WHICH PATIENTS THIS IS INDICATED
Pr Bruno DEVAL MD Geoffroy Saint-Hilaire ndash Clinic
Hotel ndashDieu de Paris
Paris V University
Fix the mesh on the posterior
vaginal wall and not on the
elevator ani muscle
bull To avoid dyschezia and chronic
pelvic pain
bull Sacrocolpopexy should only be performed by board certified eligible surgeons (ObGyn or Urology)
bull Knowledge surgical skills and experience in reconstructive pelvic surgery
FPMRS fellowship
CME documentation
Proctoring on 10 cases
gt 50 practice in reconstructive surgery
bull Outcomes and complications of should be monitored by annual internal audit
bull Informed consent should highlight
Alternatives to ASC including pessary
Complications of ASC
Complications of mesh
AUGS Guidelines on Sacrocolpopexy Privileges(March 2013)
Source wwwaugsorg
Conclusion
bull The technique and expertise are
fundamental
bull Laparoscopic colposacropexy can safely
be offered to women with symptomatic
POP
bull Conventional LSCP = Open Way =
robotic way
bull Conventional LSCP gt Vaginal Way
LAPAROSCOPIC SURGICAL BOX MODEL TRAINING FOR SURGICAL TRAINEES
WITH NO PRIOR LAPAROSCOPIC EXPERIENCE
Myura Nagendran et al
bull Authors included randomised clinical trials comparing
boxmodel trainers versus no training in surgical trainees
with no prior laparoscopic experience
bull 16 trials (464 participants) provided data for meta-analysis
of box training (248 participants) versus no supplementary
training (216 participants)
bull All the 16 trials in this comparison used video trainers
bull The meta-analysis showed that the time taken for task
completion was significantly shorter in the box trainer
group than the control group
bull Compared with the control group the box trainer group
also had lower error score better accuracy score and
better composite performance scores
bull Laparoscopic box model training appears to improve
technical skills compared with no training in trainees
with no previous laparoscopic experience
Laparoscopic surgical box model training for surgical trainees
with no prior laparoscopic experience
Myura Nagendran et al
Power Point slide deck adapted from
Canadian Agency for Drugs and Technologies in Health
Robot-Assisted Surgery Compared with Open Surgery and Laparoscopic Surgery Clinical Effectiveness and Economic Analyses
Chuong Ho MDEva Tsakonas BA MSc
Khai Tran MSc PhDKaren Cimon
Melissa Severn MIStMonika Mierzwinski-Urban BA MLIS
Jacques Corcos MDStephen Pautler MD FRCSC
September 2014
Adapted by Michael Fung-Kee-Fung MBBS FRCSC MBA
Nancy Jaworski BComm MHA
Walter Gotlieb MD PhD
Adapted from CADTH Technology Report on Robot-Assisted Surgery 2011
Indications for Robot Use ndash Disease Prevalence
bull 24700 new cases of prostate cancer diagnosed in Canada in 2008
bull 219 of patients lt60 years old will choose prostatectomy as initial treatmentUrology
bull 36000 hysterectomies performed in Canada in 200708
bull Hysterectomy is performed for several indications Gynecology
bull 5 year prevalence (2005) 482100000 male amp 318100000 female
bull Surgery is the primary treatment for localized renal cell carcinomaNephrology
bull An estimated 20000 coronary artery bypass graft (CABG) surgeries were performed in Canada in 200001
Cardiac Surgery
Adapted from CADTH Technology Report on Robot-Assisted Surgery 2011
Economic Analysis
bull Robot-Assisted vs Laparoscopic
Economic Model Base Case (Robot not donated)
Hospital Budget Impact
Hospital Budget Impact
ANATOMY OF THE PRESACRAL SPACE
STRUCTURES TO BE
RESPECTED
FOR A SAFE FIXATION
OF THE MESH
RATE OF
BLOOD TRANSFUSION
02
ANATOMICAL VARIATIONS
OF THE LEFT COMMON ILIAC VEIN MIDDLE PART PROMONTORY
bull Distances between the left common iliac vein and the midsacral promontory
bull Dissection of 52 cadavers
bull Mean of d1 = 27 mm (9 - 52)
bull Mean of d2 = 22 mm (9 - 35)
Wieslander CK et al Vascular anatomy of the presacral space in unembalmedfemale cadaversAmerican journal of obstetrics and gynecology 2006 195 1736
d1
RATE OF
BLOOD TRANSFUSION
02
ANATOMICAL VARIATIONS OF PRESACRAL VESSELS
MIDDLE PART PROMONTORY
bull Presacral vesselsndash Middle sacral vein
Oslash= 2mm (1- 4)
double (80)
left to P= 33
right to P= 52
crossing P= 5
mean of d3 = 7 mm (0-17)
P
d3
Wieslander CK et al Vascular anatomy of the presacral space in unembalmed female cadavers American journal of obstetrics and gynecology 2006 195 1736
ANATOMICAL VARIATIONS OF PRESACRAL VESSELS
MIDDLE PART PROMONTORY
bull Presacral vesselsndash Middle sacral artery
Oslash= 2mm (1- 4)
Left to P= 62
Right to P= 30
Crossing P= 8
Mean of d4 = 4 mm (0-15)
Pd4
Wieslander CK et al Vascular anatomy of the presacral space in unembalmed female cadavers American journal of obstetrics and gynecology 2006 195 1736
ANATOMICAL VARIATIONS OF PRESACRAL VESSELS
MIDDLE PART PROMONTORY
bull Presacral space avascular areas
bull Overlay of vascular structures
bull (10 cadavers)
Flynn MK et al Vascular anatomy of the presacral space a freshtissue cadaver dissectionAmerican journal of obstetrics and gynecology2005 192 1501
rarr Dissection right to the medline = safer
ANATOMICAL VARIATIONS OF THE RIGHT URETER
MIDDLE PART PROMONTORY
Flynn MK et al Vascular anatomy of the presacral space a fresh tissue cadaver dissectionAmerican journal of obstetrics and gynecology 2005 192 1501
bull Distances between the right ureter and the midsacral promontory
bull Dissection of 10 cadavers
ANATOMICAL VARIATIONS
OF THE
SUPERIOR HYPOGASTRIC PLEXUS
bull SHP sympathetic plexus connected to IHP
Shiozawa T et al Nerve-preserving sacrocolpopexy anatomical study and surgical approachEuropean journal of obstetrics and gynecology and reproductive biology2010 152 103
ANATOMICAL VARIATIONS OF SUPERIOR HYPOGASTRIC PLEXUS
bull Right hypogastric nerve
Wieslander CK et al Vascular anatomy of the presacral space in unembalmed female cadaversAmerican journal of obstetrics and gynecology 2006 195 1736
d6bull Mean of d6 = 7 mm (0 - 17)
Nerve-preserving sacrocolpopexy anatomical study and surgical approach
Shiozawa T1 et al
By protecting the superiorhypogastric plexus and the part of thepresacral area below the promontorywe can preserve the hypogastricnerves the sacral and pelvicsplanchnic nerves and thus theautonomic innervation of the pelvicorgans
ANATOMICAL VARIATIONS OF LVCA
bull Fixation into the anterior longitudinal
ligament
ANATOMICAL VARIATIONS OF LVCA
Boukkerou M et alPromontofixation procedures use of non-absorbable sutures or tackers Journal de gyneacutecologie obsteacutetrique et biologie de la reproduction2003 32 54
bull Fixation into the anterior longitudinal ligament
and NOT into the disc
ANATOMICAL VARIATIONS OF LVCA
bull Tackers go deep into the bone
Boukkerou M et alPromontofixation procedures use of non-absorbable sutures or tackers Journal de gyneacutecologie obsteacutetrique et biologie de la reproduction2003 32 54
Spondilithis03
ndash Preacutevention bull Asepsie and per-op antibioprophylaxy
ndash Diagnosis ndash Lombalgia fever tence neurologic diseases
ndash Inflammatory Syndrome (CRP)
ndash Radiologic signs (IRM)
bull Immobilisation
bull Antibiotheacuterapie prolongeacutee +- ponction discale
bull Ablation des prothegraveses
bull +- Arthrodegravese laminectomie
Posterior Dissection ndash DENONVILLIERS FASCIA
Since Charles-PierreDenonvilliers first discoveredthe firm membranousstructure between the rectumand prostate or bladder in1836 now calledldquoDenonvilliersrsquo fasciardquo (DF)the origin of DF has remainedcontroversial
Posterior Dissection ndash DENONVILLIERS FASCIA
Based on the evidencesurgeons should be awareof variations and search forthem to create a suitabledissection plane to avoidiatrogenic positive marginsand rectal injury
Rectal Injury04
ndash Sub-peacuteritoneacuteal rectum
bull There is a recto-vaginal space
bull Horizontal Position ++
bull Close to the post face of the vagina on the distal points
bull Danger on the proximal part of the Recto-Vaginal Septum
ndash Preacutevention
bull Follow the post-face of the vagina
bull Systeacutematic pre-operativ preparation
ndash NORMACOL reg
bull Maleable Retractor
ndash Treatment
bull Immeacutediat Suture
bull Mesh contra-Indication
Vaginal Injury04
ndash Preacuteventionbull Ant Vaginal Length - 6 cm ( 4 ndash 75) Jayle et al Masson 1918
bull Post Vaginal Lenght- 9cm (65 ndash 115) Jayle et al Masson 1918
bull There is no difference between the anterior and posteriorvagina thickness
bull If the vagina is too thin ndash Plicature of the vagina
ndash Treatmentbull If Vagina Injury Suture of the vagina
bull There is no contra indication to fix the meshes
RISK OF URETERAL
INJURY lt 11000
ndash Preacutevention
bull Parietal Uretera
ndash Cross between right extern iliac artery and uterine artery
bull Visceral Uretera
ndash Behind the ligaments
ndash Under the bladder
ndash In contact with the bladder
ndash Treatment
bull Per-op
ndash Per-op Bleu carmin en IV
ndash Ureteacuteral Catheter
bull Post-op
ndash Uro-scanner
ndash JJ Ureteral
Bladder
Collection
Sagittal T2
Vagina
Uterus
Ureter ariving in urinoma
Axial T2
Coronale T2
Bladder Injury2
ndash Sub-peacuteritoneacuteal Bladder
bull Vertical Position ++
bull Close to the ant face of the vagina
bull There is NO space
ndash Preacutevention
bull Following the Ant- Face of the vagina
bull Maleable Retractor
ndash Treatment
bull Immeacutediat Suture
bull Mesh Indication
bull Bladder Catheterisation 5 days
Small and Large Bowel Injury
bull Occur when adhesiolysis has to be undertaken
bull Avoid distended bowel at surgery by 48 hours pre op bowel prep
bull Avoid nitrous oxide during surgery as it causes bowel distension
bull If small bowel injured
ndash Repair laparoscopically
ndash Mesh can still be placed
bull Antibiotic cover for 7 days post op
CONCLUSION 1
1 To open the peritoneum tigh-it
2 Dissection on the right side of the mid-sacral ligament
3 Repair carefuly the vessels and the Right ureter
4 Try to preserve the right hypogatsric nerve
5 Fix your needle 1 cm below the promontory
MESH SELECTIONPERTINENT MESH SCIENCEWHY USE A CERTAIN MESH
Pr Bruno DEVAL MD Geoffroy Saint-Hilaire ndash Clinic
Hotel ndashDieu de Paris
Paris V University
MESH STIFFNESS
bullIncreased fibrosis and deposits of unorganized collagen create an increased stiffness
bull (Klinge 1999)
bullStiffness has been linked to clinical complications-heavier stiffer meshes having higher complications
bull (Dietz 2003)
bullStiffer meshes showed decreases in smooth muscle collagen and structural proteins following implantation
bull (Moalli P AUGS 2011)
bullHeavier stiffer meshes showed a greater propensity for stress shielding which in turn could cause reoccurrences of prolapse
bull (Moalli P AUGS 2011)
IMPACT OF VAGINAL SYNTHETIC PROLAPSE MESHES ON THE MECHANICS
OF THE HOST TISSUE RESPONSE
Feola Andrew J 02 February 2012 Doctoral Dissertation University of Pittsburgh
ldquoImplantation of the stiffest mesh in the non human primate
resulted in an exhibition of a stress-shielding response
manifested by inferior biomechanical properties of the
abdominal and vaginal tissues
Less stiff meshes resulted in preservation of tissue
propertiesrdquo
Wolffrsquos Law ndash remodeling of bone in response to stress
MESH CHARACTERISTICS
Density - Filament size ndash Elasticity - Pore size
Surface area ndash Overall ldquomesh loadrdquo
Biomechanical engineers working with type-1
polypropylene have focused on reducing overall
ldquomesh loadrdquo while maintaining durability
bullOptimal tissue incorporation and collagen growthbullNo erosionbullNo palpable mesh to patient and her partnerbullVaginal elasticity
TO OBTAIN
So lighter is better
WHAT KIND OF MESH
bull To date polypropylene meshes are the best type on the market
bull Absorbable meshes do not work
bull There is an evidence to use Polypropylene vs polyesther
bull PTFE and NW meshes are contra ndash indicated in the POP Repair
ULTRA- LIGHT POLYPROPYLENE
bull Physiologically compatible 19 gsm1
bull Ultra lightweightbull Lowest weight available for pelvic restoration
bull 18 millimeter macropores1
ndash Consistent size throughout the mesh
bull 100 micron interstitial Smartporestrade 1ndash Simultaneously encourages both collagen growth and
bacteria fighting propertiesbull Fibroblasts will enter holes that are 50 to 200 microns in size23
bull Macrophages and neutrophils will enter holes that are 50 to 120 microns in size23
bull Reduce inflammation1 Data on file2 Greca FH et at (2007) The influence of porosity on integration histology of two polypropylene meshes for the treatment of abdominal wall
defects in dogs Hernia (12) 45-493 Marois Y et all (2000) Biostability inflammatory response and healing characteristics flourpassivated polyester-knit mesh in the repair of
experimental abdominal hernias Artif Organs 24533-543
ULTRA ndash LIGHT CLINICAL EVIDENCE
SUMMARY
bull Rates of Erosion and Exposurebull Less than 1 erosion rate1
bull Anterior exposure rate 172
bull Posterior exposure rate 052
bull Greater tissue strength 3 months post-op ndash 71 more collagen growth3
bull Mature vaginal elastin decrease was not observed with Smartmesh4
bull Smartmesh did not induce a negative change in collagen metabolism5
bull Smartmesh had similar innervation density as sham 6
bull Low incidence of de novo dyspareunia71 Alinsod R et al (2008) Long term outcomes of vaginal pelvic floor repair using an ultra lightweight mesh AAGL (2008)2 Alinsod R Et al (2012) Durability and Complications of an Ultra Lightweight Transvaginal Mesh in the Treatment of Pelvic Organ Prolapse Presented at the 37th Annual Meeting of IUGA3 Greca FH et al (2007) The influence of porosity on the integration histology of two polypropylene meshes for the treatment of abdominal wall defects in dogs Hernia (12) 45-494 Moalli et al (2012) Mesh implantation negatively impacts vagina elastin metabolism Female Pelvic Medicine amp Reconstructive Surgery Vol 18 (Suppl 2)S258-9 SeptOct paper 235 Moalli et al (2012) Increasing mesh stiffness negatively impacts vaginal collagen metabolism Female Pelvic Medicine amp Reconstructive Surgery Vol 18 (Suppl 2)S258-9 SeptOct paper 246 Moalli et al (2012) The impact of mesh implantation on vaginal smooth muscle innervation Female Pelvic Medicine amp Reconstructive Surgery Vol 18 (Suppl 2)S258-9 SeptOct paper 257 Hawthorn R et al (2007) Use of ultra lightweight mesh in vaginal vault repairs to minimize complications A two centre observation study British International Congress of Obstetrics amp Gynaecology
PRE FORMED Y-MESH VS CUTTING MESH AND MAKING IT TO FIT PATIENTS
Pr Bruno DEVAL MD Geoffroy Saint-Hilaire ndash Clinic
Hotel ndashDieu de Paris
Paris V University
Mesh and operative handling
The shape and weight of the mesh can help us during
laparoscopic procedure
A large Y mesh is a good choice for vaginal vault shape
Better intra-operative manipulation and suturing
Lower mesh mass accommodates easy passage through narrow
laparoscopic ports
Use re-absorbable sutures on the vagina
bull Stitch erosions are reported
bull Folding and wrinkling can cause
erosions and dyspaurenia
Avoid folding and wrinkling the
mesh must be well stretched
DO WE NEED TO DISSECT POSTERIOR DOWN TO PERINEUM OR
IN WHICH PATIENTS THIS IS INDICATED
Pr Bruno DEVAL MD Geoffroy Saint-Hilaire ndash Clinic
Hotel ndashDieu de Paris
Paris V University
Fix the mesh on the posterior
vaginal wall and not on the
elevator ani muscle
bull To avoid dyschezia and chronic
pelvic pain
bull Sacrocolpopexy should only be performed by board certified eligible surgeons (ObGyn or Urology)
bull Knowledge surgical skills and experience in reconstructive pelvic surgery
FPMRS fellowship
CME documentation
Proctoring on 10 cases
gt 50 practice in reconstructive surgery
bull Outcomes and complications of should be monitored by annual internal audit
bull Informed consent should highlight
Alternatives to ASC including pessary
Complications of ASC
Complications of mesh
AUGS Guidelines on Sacrocolpopexy Privileges(March 2013)
Source wwwaugsorg
Conclusion
bull The technique and expertise are
fundamental
bull Laparoscopic colposacropexy can safely
be offered to women with symptomatic
POP
bull Conventional LSCP = Open Way =
robotic way
bull Conventional LSCP gt Vaginal Way
bull The meta-analysis showed that the time taken for task
completion was significantly shorter in the box trainer
group than the control group
bull Compared with the control group the box trainer group
also had lower error score better accuracy score and
better composite performance scores
bull Laparoscopic box model training appears to improve
technical skills compared with no training in trainees
with no previous laparoscopic experience
Laparoscopic surgical box model training for surgical trainees
with no prior laparoscopic experience
Myura Nagendran et al
Power Point slide deck adapted from
Canadian Agency for Drugs and Technologies in Health
Robot-Assisted Surgery Compared with Open Surgery and Laparoscopic Surgery Clinical Effectiveness and Economic Analyses
Chuong Ho MDEva Tsakonas BA MSc
Khai Tran MSc PhDKaren Cimon
Melissa Severn MIStMonika Mierzwinski-Urban BA MLIS
Jacques Corcos MDStephen Pautler MD FRCSC
September 2014
Adapted by Michael Fung-Kee-Fung MBBS FRCSC MBA
Nancy Jaworski BComm MHA
Walter Gotlieb MD PhD
Adapted from CADTH Technology Report on Robot-Assisted Surgery 2011
Indications for Robot Use ndash Disease Prevalence
bull 24700 new cases of prostate cancer diagnosed in Canada in 2008
bull 219 of patients lt60 years old will choose prostatectomy as initial treatmentUrology
bull 36000 hysterectomies performed in Canada in 200708
bull Hysterectomy is performed for several indications Gynecology
bull 5 year prevalence (2005) 482100000 male amp 318100000 female
bull Surgery is the primary treatment for localized renal cell carcinomaNephrology
bull An estimated 20000 coronary artery bypass graft (CABG) surgeries were performed in Canada in 200001
Cardiac Surgery
Adapted from CADTH Technology Report on Robot-Assisted Surgery 2011
Economic Analysis
bull Robot-Assisted vs Laparoscopic
Economic Model Base Case (Robot not donated)
Hospital Budget Impact
Hospital Budget Impact
ANATOMY OF THE PRESACRAL SPACE
STRUCTURES TO BE
RESPECTED
FOR A SAFE FIXATION
OF THE MESH
RATE OF
BLOOD TRANSFUSION
02
ANATOMICAL VARIATIONS
OF THE LEFT COMMON ILIAC VEIN MIDDLE PART PROMONTORY
bull Distances between the left common iliac vein and the midsacral promontory
bull Dissection of 52 cadavers
bull Mean of d1 = 27 mm (9 - 52)
bull Mean of d2 = 22 mm (9 - 35)
Wieslander CK et al Vascular anatomy of the presacral space in unembalmedfemale cadaversAmerican journal of obstetrics and gynecology 2006 195 1736
d1
RATE OF
BLOOD TRANSFUSION
02
ANATOMICAL VARIATIONS OF PRESACRAL VESSELS
MIDDLE PART PROMONTORY
bull Presacral vesselsndash Middle sacral vein
Oslash= 2mm (1- 4)
double (80)
left to P= 33
right to P= 52
crossing P= 5
mean of d3 = 7 mm (0-17)
P
d3
Wieslander CK et al Vascular anatomy of the presacral space in unembalmed female cadavers American journal of obstetrics and gynecology 2006 195 1736
ANATOMICAL VARIATIONS OF PRESACRAL VESSELS
MIDDLE PART PROMONTORY
bull Presacral vesselsndash Middle sacral artery
Oslash= 2mm (1- 4)
Left to P= 62
Right to P= 30
Crossing P= 8
Mean of d4 = 4 mm (0-15)
Pd4
Wieslander CK et al Vascular anatomy of the presacral space in unembalmed female cadavers American journal of obstetrics and gynecology 2006 195 1736
ANATOMICAL VARIATIONS OF PRESACRAL VESSELS
MIDDLE PART PROMONTORY
bull Presacral space avascular areas
bull Overlay of vascular structures
bull (10 cadavers)
Flynn MK et al Vascular anatomy of the presacral space a freshtissue cadaver dissectionAmerican journal of obstetrics and gynecology2005 192 1501
rarr Dissection right to the medline = safer
ANATOMICAL VARIATIONS OF THE RIGHT URETER
MIDDLE PART PROMONTORY
Flynn MK et al Vascular anatomy of the presacral space a fresh tissue cadaver dissectionAmerican journal of obstetrics and gynecology 2005 192 1501
bull Distances between the right ureter and the midsacral promontory
bull Dissection of 10 cadavers
ANATOMICAL VARIATIONS
OF THE
SUPERIOR HYPOGASTRIC PLEXUS
bull SHP sympathetic plexus connected to IHP
Shiozawa T et al Nerve-preserving sacrocolpopexy anatomical study and surgical approachEuropean journal of obstetrics and gynecology and reproductive biology2010 152 103
ANATOMICAL VARIATIONS OF SUPERIOR HYPOGASTRIC PLEXUS
bull Right hypogastric nerve
Wieslander CK et al Vascular anatomy of the presacral space in unembalmed female cadaversAmerican journal of obstetrics and gynecology 2006 195 1736
d6bull Mean of d6 = 7 mm (0 - 17)
Nerve-preserving sacrocolpopexy anatomical study and surgical approach
Shiozawa T1 et al
By protecting the superiorhypogastric plexus and the part of thepresacral area below the promontorywe can preserve the hypogastricnerves the sacral and pelvicsplanchnic nerves and thus theautonomic innervation of the pelvicorgans
ANATOMICAL VARIATIONS OF LVCA
bull Fixation into the anterior longitudinal
ligament
ANATOMICAL VARIATIONS OF LVCA
Boukkerou M et alPromontofixation procedures use of non-absorbable sutures or tackers Journal de gyneacutecologie obsteacutetrique et biologie de la reproduction2003 32 54
bull Fixation into the anterior longitudinal ligament
and NOT into the disc
ANATOMICAL VARIATIONS OF LVCA
bull Tackers go deep into the bone
Boukkerou M et alPromontofixation procedures use of non-absorbable sutures or tackers Journal de gyneacutecologie obsteacutetrique et biologie de la reproduction2003 32 54
Spondilithis03
ndash Preacutevention bull Asepsie and per-op antibioprophylaxy
ndash Diagnosis ndash Lombalgia fever tence neurologic diseases
ndash Inflammatory Syndrome (CRP)
ndash Radiologic signs (IRM)
bull Immobilisation
bull Antibiotheacuterapie prolongeacutee +- ponction discale
bull Ablation des prothegraveses
bull +- Arthrodegravese laminectomie
Posterior Dissection ndash DENONVILLIERS FASCIA
Since Charles-PierreDenonvilliers first discoveredthe firm membranousstructure between the rectumand prostate or bladder in1836 now calledldquoDenonvilliersrsquo fasciardquo (DF)the origin of DF has remainedcontroversial
Posterior Dissection ndash DENONVILLIERS FASCIA
Based on the evidencesurgeons should be awareof variations and search forthem to create a suitabledissection plane to avoidiatrogenic positive marginsand rectal injury
Rectal Injury04
ndash Sub-peacuteritoneacuteal rectum
bull There is a recto-vaginal space
bull Horizontal Position ++
bull Close to the post face of the vagina on the distal points
bull Danger on the proximal part of the Recto-Vaginal Septum
ndash Preacutevention
bull Follow the post-face of the vagina
bull Systeacutematic pre-operativ preparation
ndash NORMACOL reg
bull Maleable Retractor
ndash Treatment
bull Immeacutediat Suture
bull Mesh contra-Indication
Vaginal Injury04
ndash Preacuteventionbull Ant Vaginal Length - 6 cm ( 4 ndash 75) Jayle et al Masson 1918
bull Post Vaginal Lenght- 9cm (65 ndash 115) Jayle et al Masson 1918
bull There is no difference between the anterior and posteriorvagina thickness
bull If the vagina is too thin ndash Plicature of the vagina
ndash Treatmentbull If Vagina Injury Suture of the vagina
bull There is no contra indication to fix the meshes
RISK OF URETERAL
INJURY lt 11000
ndash Preacutevention
bull Parietal Uretera
ndash Cross between right extern iliac artery and uterine artery
bull Visceral Uretera
ndash Behind the ligaments
ndash Under the bladder
ndash In contact with the bladder
ndash Treatment
bull Per-op
ndash Per-op Bleu carmin en IV
ndash Ureteacuteral Catheter
bull Post-op
ndash Uro-scanner
ndash JJ Ureteral
Bladder
Collection
Sagittal T2
Vagina
Uterus
Ureter ariving in urinoma
Axial T2
Coronale T2
Bladder Injury2
ndash Sub-peacuteritoneacuteal Bladder
bull Vertical Position ++
bull Close to the ant face of the vagina
bull There is NO space
ndash Preacutevention
bull Following the Ant- Face of the vagina
bull Maleable Retractor
ndash Treatment
bull Immeacutediat Suture
bull Mesh Indication
bull Bladder Catheterisation 5 days
Small and Large Bowel Injury
bull Occur when adhesiolysis has to be undertaken
bull Avoid distended bowel at surgery by 48 hours pre op bowel prep
bull Avoid nitrous oxide during surgery as it causes bowel distension
bull If small bowel injured
ndash Repair laparoscopically
ndash Mesh can still be placed
bull Antibiotic cover for 7 days post op
CONCLUSION 1
1 To open the peritoneum tigh-it
2 Dissection on the right side of the mid-sacral ligament
3 Repair carefuly the vessels and the Right ureter
4 Try to preserve the right hypogatsric nerve
5 Fix your needle 1 cm below the promontory
MESH SELECTIONPERTINENT MESH SCIENCEWHY USE A CERTAIN MESH
Pr Bruno DEVAL MD Geoffroy Saint-Hilaire ndash Clinic
Hotel ndashDieu de Paris
Paris V University
MESH STIFFNESS
bullIncreased fibrosis and deposits of unorganized collagen create an increased stiffness
bull (Klinge 1999)
bullStiffness has been linked to clinical complications-heavier stiffer meshes having higher complications
bull (Dietz 2003)
bullStiffer meshes showed decreases in smooth muscle collagen and structural proteins following implantation
bull (Moalli P AUGS 2011)
bullHeavier stiffer meshes showed a greater propensity for stress shielding which in turn could cause reoccurrences of prolapse
bull (Moalli P AUGS 2011)
IMPACT OF VAGINAL SYNTHETIC PROLAPSE MESHES ON THE MECHANICS
OF THE HOST TISSUE RESPONSE
Feola Andrew J 02 February 2012 Doctoral Dissertation University of Pittsburgh
ldquoImplantation of the stiffest mesh in the non human primate
resulted in an exhibition of a stress-shielding response
manifested by inferior biomechanical properties of the
abdominal and vaginal tissues
Less stiff meshes resulted in preservation of tissue
propertiesrdquo
Wolffrsquos Law ndash remodeling of bone in response to stress
MESH CHARACTERISTICS
Density - Filament size ndash Elasticity - Pore size
Surface area ndash Overall ldquomesh loadrdquo
Biomechanical engineers working with type-1
polypropylene have focused on reducing overall
ldquomesh loadrdquo while maintaining durability
bullOptimal tissue incorporation and collagen growthbullNo erosionbullNo palpable mesh to patient and her partnerbullVaginal elasticity
TO OBTAIN
So lighter is better
WHAT KIND OF MESH
bull To date polypropylene meshes are the best type on the market
bull Absorbable meshes do not work
bull There is an evidence to use Polypropylene vs polyesther
bull PTFE and NW meshes are contra ndash indicated in the POP Repair
ULTRA- LIGHT POLYPROPYLENE
bull Physiologically compatible 19 gsm1
bull Ultra lightweightbull Lowest weight available for pelvic restoration
bull 18 millimeter macropores1
ndash Consistent size throughout the mesh
bull 100 micron interstitial Smartporestrade 1ndash Simultaneously encourages both collagen growth and
bacteria fighting propertiesbull Fibroblasts will enter holes that are 50 to 200 microns in size23
bull Macrophages and neutrophils will enter holes that are 50 to 120 microns in size23
bull Reduce inflammation1 Data on file2 Greca FH et at (2007) The influence of porosity on integration histology of two polypropylene meshes for the treatment of abdominal wall
defects in dogs Hernia (12) 45-493 Marois Y et all (2000) Biostability inflammatory response and healing characteristics flourpassivated polyester-knit mesh in the repair of
experimental abdominal hernias Artif Organs 24533-543
ULTRA ndash LIGHT CLINICAL EVIDENCE
SUMMARY
bull Rates of Erosion and Exposurebull Less than 1 erosion rate1
bull Anterior exposure rate 172
bull Posterior exposure rate 052
bull Greater tissue strength 3 months post-op ndash 71 more collagen growth3
bull Mature vaginal elastin decrease was not observed with Smartmesh4
bull Smartmesh did not induce a negative change in collagen metabolism5
bull Smartmesh had similar innervation density as sham 6
bull Low incidence of de novo dyspareunia71 Alinsod R et al (2008) Long term outcomes of vaginal pelvic floor repair using an ultra lightweight mesh AAGL (2008)2 Alinsod R Et al (2012) Durability and Complications of an Ultra Lightweight Transvaginal Mesh in the Treatment of Pelvic Organ Prolapse Presented at the 37th Annual Meeting of IUGA3 Greca FH et al (2007) The influence of porosity on the integration histology of two polypropylene meshes for the treatment of abdominal wall defects in dogs Hernia (12) 45-494 Moalli et al (2012) Mesh implantation negatively impacts vagina elastin metabolism Female Pelvic Medicine amp Reconstructive Surgery Vol 18 (Suppl 2)S258-9 SeptOct paper 235 Moalli et al (2012) Increasing mesh stiffness negatively impacts vaginal collagen metabolism Female Pelvic Medicine amp Reconstructive Surgery Vol 18 (Suppl 2)S258-9 SeptOct paper 246 Moalli et al (2012) The impact of mesh implantation on vaginal smooth muscle innervation Female Pelvic Medicine amp Reconstructive Surgery Vol 18 (Suppl 2)S258-9 SeptOct paper 257 Hawthorn R et al (2007) Use of ultra lightweight mesh in vaginal vault repairs to minimize complications A two centre observation study British International Congress of Obstetrics amp Gynaecology
PRE FORMED Y-MESH VS CUTTING MESH AND MAKING IT TO FIT PATIENTS
Pr Bruno DEVAL MD Geoffroy Saint-Hilaire ndash Clinic
Hotel ndashDieu de Paris
Paris V University
Mesh and operative handling
The shape and weight of the mesh can help us during
laparoscopic procedure
A large Y mesh is a good choice for vaginal vault shape
Better intra-operative manipulation and suturing
Lower mesh mass accommodates easy passage through narrow
laparoscopic ports
Use re-absorbable sutures on the vagina
bull Stitch erosions are reported
bull Folding and wrinkling can cause
erosions and dyspaurenia
Avoid folding and wrinkling the
mesh must be well stretched
DO WE NEED TO DISSECT POSTERIOR DOWN TO PERINEUM OR
IN WHICH PATIENTS THIS IS INDICATED
Pr Bruno DEVAL MD Geoffroy Saint-Hilaire ndash Clinic
Hotel ndashDieu de Paris
Paris V University
Fix the mesh on the posterior
vaginal wall and not on the
elevator ani muscle
bull To avoid dyschezia and chronic
pelvic pain
bull Sacrocolpopexy should only be performed by board certified eligible surgeons (ObGyn or Urology)
bull Knowledge surgical skills and experience in reconstructive pelvic surgery
FPMRS fellowship
CME documentation
Proctoring on 10 cases
gt 50 practice in reconstructive surgery
bull Outcomes and complications of should be monitored by annual internal audit
bull Informed consent should highlight
Alternatives to ASC including pessary
Complications of ASC
Complications of mesh
AUGS Guidelines on Sacrocolpopexy Privileges(March 2013)
Source wwwaugsorg
Conclusion
bull The technique and expertise are
fundamental
bull Laparoscopic colposacropexy can safely
be offered to women with symptomatic
POP
bull Conventional LSCP = Open Way =
robotic way
bull Conventional LSCP gt Vaginal Way
Power Point slide deck adapted from
Canadian Agency for Drugs and Technologies in Health
Robot-Assisted Surgery Compared with Open Surgery and Laparoscopic Surgery Clinical Effectiveness and Economic Analyses
Chuong Ho MDEva Tsakonas BA MSc
Khai Tran MSc PhDKaren Cimon
Melissa Severn MIStMonika Mierzwinski-Urban BA MLIS
Jacques Corcos MDStephen Pautler MD FRCSC
September 2014
Adapted by Michael Fung-Kee-Fung MBBS FRCSC MBA
Nancy Jaworski BComm MHA
Walter Gotlieb MD PhD
Adapted from CADTH Technology Report on Robot-Assisted Surgery 2011
Indications for Robot Use ndash Disease Prevalence
bull 24700 new cases of prostate cancer diagnosed in Canada in 2008
bull 219 of patients lt60 years old will choose prostatectomy as initial treatmentUrology
bull 36000 hysterectomies performed in Canada in 200708
bull Hysterectomy is performed for several indications Gynecology
bull 5 year prevalence (2005) 482100000 male amp 318100000 female
bull Surgery is the primary treatment for localized renal cell carcinomaNephrology
bull An estimated 20000 coronary artery bypass graft (CABG) surgeries were performed in Canada in 200001
Cardiac Surgery
Adapted from CADTH Technology Report on Robot-Assisted Surgery 2011
Economic Analysis
bull Robot-Assisted vs Laparoscopic
Economic Model Base Case (Robot not donated)
Hospital Budget Impact
Hospital Budget Impact
ANATOMY OF THE PRESACRAL SPACE
STRUCTURES TO BE
RESPECTED
FOR A SAFE FIXATION
OF THE MESH
RATE OF
BLOOD TRANSFUSION
02
ANATOMICAL VARIATIONS
OF THE LEFT COMMON ILIAC VEIN MIDDLE PART PROMONTORY
bull Distances between the left common iliac vein and the midsacral promontory
bull Dissection of 52 cadavers
bull Mean of d1 = 27 mm (9 - 52)
bull Mean of d2 = 22 mm (9 - 35)
Wieslander CK et al Vascular anatomy of the presacral space in unembalmedfemale cadaversAmerican journal of obstetrics and gynecology 2006 195 1736
d1
RATE OF
BLOOD TRANSFUSION
02
ANATOMICAL VARIATIONS OF PRESACRAL VESSELS
MIDDLE PART PROMONTORY
bull Presacral vesselsndash Middle sacral vein
Oslash= 2mm (1- 4)
double (80)
left to P= 33
right to P= 52
crossing P= 5
mean of d3 = 7 mm (0-17)
P
d3
Wieslander CK et al Vascular anatomy of the presacral space in unembalmed female cadavers American journal of obstetrics and gynecology 2006 195 1736
ANATOMICAL VARIATIONS OF PRESACRAL VESSELS
MIDDLE PART PROMONTORY
bull Presacral vesselsndash Middle sacral artery
Oslash= 2mm (1- 4)
Left to P= 62
Right to P= 30
Crossing P= 8
Mean of d4 = 4 mm (0-15)
Pd4
Wieslander CK et al Vascular anatomy of the presacral space in unembalmed female cadavers American journal of obstetrics and gynecology 2006 195 1736
ANATOMICAL VARIATIONS OF PRESACRAL VESSELS
MIDDLE PART PROMONTORY
bull Presacral space avascular areas
bull Overlay of vascular structures
bull (10 cadavers)
Flynn MK et al Vascular anatomy of the presacral space a freshtissue cadaver dissectionAmerican journal of obstetrics and gynecology2005 192 1501
rarr Dissection right to the medline = safer
ANATOMICAL VARIATIONS OF THE RIGHT URETER
MIDDLE PART PROMONTORY
Flynn MK et al Vascular anatomy of the presacral space a fresh tissue cadaver dissectionAmerican journal of obstetrics and gynecology 2005 192 1501
bull Distances between the right ureter and the midsacral promontory
bull Dissection of 10 cadavers
ANATOMICAL VARIATIONS
OF THE
SUPERIOR HYPOGASTRIC PLEXUS
bull SHP sympathetic plexus connected to IHP
Shiozawa T et al Nerve-preserving sacrocolpopexy anatomical study and surgical approachEuropean journal of obstetrics and gynecology and reproductive biology2010 152 103
ANATOMICAL VARIATIONS OF SUPERIOR HYPOGASTRIC PLEXUS
bull Right hypogastric nerve
Wieslander CK et al Vascular anatomy of the presacral space in unembalmed female cadaversAmerican journal of obstetrics and gynecology 2006 195 1736
d6bull Mean of d6 = 7 mm (0 - 17)
Nerve-preserving sacrocolpopexy anatomical study and surgical approach
Shiozawa T1 et al
By protecting the superiorhypogastric plexus and the part of thepresacral area below the promontorywe can preserve the hypogastricnerves the sacral and pelvicsplanchnic nerves and thus theautonomic innervation of the pelvicorgans
ANATOMICAL VARIATIONS OF LVCA
bull Fixation into the anterior longitudinal
ligament
ANATOMICAL VARIATIONS OF LVCA
Boukkerou M et alPromontofixation procedures use of non-absorbable sutures or tackers Journal de gyneacutecologie obsteacutetrique et biologie de la reproduction2003 32 54
bull Fixation into the anterior longitudinal ligament
and NOT into the disc
ANATOMICAL VARIATIONS OF LVCA
bull Tackers go deep into the bone
Boukkerou M et alPromontofixation procedures use of non-absorbable sutures or tackers Journal de gyneacutecologie obsteacutetrique et biologie de la reproduction2003 32 54
Spondilithis03
ndash Preacutevention bull Asepsie and per-op antibioprophylaxy
ndash Diagnosis ndash Lombalgia fever tence neurologic diseases
ndash Inflammatory Syndrome (CRP)
ndash Radiologic signs (IRM)
bull Immobilisation
bull Antibiotheacuterapie prolongeacutee +- ponction discale
bull Ablation des prothegraveses
bull +- Arthrodegravese laminectomie
Posterior Dissection ndash DENONVILLIERS FASCIA
Since Charles-PierreDenonvilliers first discoveredthe firm membranousstructure between the rectumand prostate or bladder in1836 now calledldquoDenonvilliersrsquo fasciardquo (DF)the origin of DF has remainedcontroversial
Posterior Dissection ndash DENONVILLIERS FASCIA
Based on the evidencesurgeons should be awareof variations and search forthem to create a suitabledissection plane to avoidiatrogenic positive marginsand rectal injury
Rectal Injury04
ndash Sub-peacuteritoneacuteal rectum
bull There is a recto-vaginal space
bull Horizontal Position ++
bull Close to the post face of the vagina on the distal points
bull Danger on the proximal part of the Recto-Vaginal Septum
ndash Preacutevention
bull Follow the post-face of the vagina
bull Systeacutematic pre-operativ preparation
ndash NORMACOL reg
bull Maleable Retractor
ndash Treatment
bull Immeacutediat Suture
bull Mesh contra-Indication
Vaginal Injury04
ndash Preacuteventionbull Ant Vaginal Length - 6 cm ( 4 ndash 75) Jayle et al Masson 1918
bull Post Vaginal Lenght- 9cm (65 ndash 115) Jayle et al Masson 1918
bull There is no difference between the anterior and posteriorvagina thickness
bull If the vagina is too thin ndash Plicature of the vagina
ndash Treatmentbull If Vagina Injury Suture of the vagina
bull There is no contra indication to fix the meshes
RISK OF URETERAL
INJURY lt 11000
ndash Preacutevention
bull Parietal Uretera
ndash Cross between right extern iliac artery and uterine artery
bull Visceral Uretera
ndash Behind the ligaments
ndash Under the bladder
ndash In contact with the bladder
ndash Treatment
bull Per-op
ndash Per-op Bleu carmin en IV
ndash Ureteacuteral Catheter
bull Post-op
ndash Uro-scanner
ndash JJ Ureteral
Bladder
Collection
Sagittal T2
Vagina
Uterus
Ureter ariving in urinoma
Axial T2
Coronale T2
Bladder Injury2
ndash Sub-peacuteritoneacuteal Bladder
bull Vertical Position ++
bull Close to the ant face of the vagina
bull There is NO space
ndash Preacutevention
bull Following the Ant- Face of the vagina
bull Maleable Retractor
ndash Treatment
bull Immeacutediat Suture
bull Mesh Indication
bull Bladder Catheterisation 5 days
Small and Large Bowel Injury
bull Occur when adhesiolysis has to be undertaken
bull Avoid distended bowel at surgery by 48 hours pre op bowel prep
bull Avoid nitrous oxide during surgery as it causes bowel distension
bull If small bowel injured
ndash Repair laparoscopically
ndash Mesh can still be placed
bull Antibiotic cover for 7 days post op
CONCLUSION 1
1 To open the peritoneum tigh-it
2 Dissection on the right side of the mid-sacral ligament
3 Repair carefuly the vessels and the Right ureter
4 Try to preserve the right hypogatsric nerve
5 Fix your needle 1 cm below the promontory
MESH SELECTIONPERTINENT MESH SCIENCEWHY USE A CERTAIN MESH
Pr Bruno DEVAL MD Geoffroy Saint-Hilaire ndash Clinic
Hotel ndashDieu de Paris
Paris V University
MESH STIFFNESS
bullIncreased fibrosis and deposits of unorganized collagen create an increased stiffness
bull (Klinge 1999)
bullStiffness has been linked to clinical complications-heavier stiffer meshes having higher complications
bull (Dietz 2003)
bullStiffer meshes showed decreases in smooth muscle collagen and structural proteins following implantation
bull (Moalli P AUGS 2011)
bullHeavier stiffer meshes showed a greater propensity for stress shielding which in turn could cause reoccurrences of prolapse
bull (Moalli P AUGS 2011)
IMPACT OF VAGINAL SYNTHETIC PROLAPSE MESHES ON THE MECHANICS
OF THE HOST TISSUE RESPONSE
Feola Andrew J 02 February 2012 Doctoral Dissertation University of Pittsburgh
ldquoImplantation of the stiffest mesh in the non human primate
resulted in an exhibition of a stress-shielding response
manifested by inferior biomechanical properties of the
abdominal and vaginal tissues
Less stiff meshes resulted in preservation of tissue
propertiesrdquo
Wolffrsquos Law ndash remodeling of bone in response to stress
MESH CHARACTERISTICS
Density - Filament size ndash Elasticity - Pore size
Surface area ndash Overall ldquomesh loadrdquo
Biomechanical engineers working with type-1
polypropylene have focused on reducing overall
ldquomesh loadrdquo while maintaining durability
bullOptimal tissue incorporation and collagen growthbullNo erosionbullNo palpable mesh to patient and her partnerbullVaginal elasticity
TO OBTAIN
So lighter is better
WHAT KIND OF MESH
bull To date polypropylene meshes are the best type on the market
bull Absorbable meshes do not work
bull There is an evidence to use Polypropylene vs polyesther
bull PTFE and NW meshes are contra ndash indicated in the POP Repair
ULTRA- LIGHT POLYPROPYLENE
bull Physiologically compatible 19 gsm1
bull Ultra lightweightbull Lowest weight available for pelvic restoration
bull 18 millimeter macropores1
ndash Consistent size throughout the mesh
bull 100 micron interstitial Smartporestrade 1ndash Simultaneously encourages both collagen growth and
bacteria fighting propertiesbull Fibroblasts will enter holes that are 50 to 200 microns in size23
bull Macrophages and neutrophils will enter holes that are 50 to 120 microns in size23
bull Reduce inflammation1 Data on file2 Greca FH et at (2007) The influence of porosity on integration histology of two polypropylene meshes for the treatment of abdominal wall
defects in dogs Hernia (12) 45-493 Marois Y et all (2000) Biostability inflammatory response and healing characteristics flourpassivated polyester-knit mesh in the repair of
experimental abdominal hernias Artif Organs 24533-543
ULTRA ndash LIGHT CLINICAL EVIDENCE
SUMMARY
bull Rates of Erosion and Exposurebull Less than 1 erosion rate1
bull Anterior exposure rate 172
bull Posterior exposure rate 052
bull Greater tissue strength 3 months post-op ndash 71 more collagen growth3
bull Mature vaginal elastin decrease was not observed with Smartmesh4
bull Smartmesh did not induce a negative change in collagen metabolism5
bull Smartmesh had similar innervation density as sham 6
bull Low incidence of de novo dyspareunia71 Alinsod R et al (2008) Long term outcomes of vaginal pelvic floor repair using an ultra lightweight mesh AAGL (2008)2 Alinsod R Et al (2012) Durability and Complications of an Ultra Lightweight Transvaginal Mesh in the Treatment of Pelvic Organ Prolapse Presented at the 37th Annual Meeting of IUGA3 Greca FH et al (2007) The influence of porosity on the integration histology of two polypropylene meshes for the treatment of abdominal wall defects in dogs Hernia (12) 45-494 Moalli et al (2012) Mesh implantation negatively impacts vagina elastin metabolism Female Pelvic Medicine amp Reconstructive Surgery Vol 18 (Suppl 2)S258-9 SeptOct paper 235 Moalli et al (2012) Increasing mesh stiffness negatively impacts vaginal collagen metabolism Female Pelvic Medicine amp Reconstructive Surgery Vol 18 (Suppl 2)S258-9 SeptOct paper 246 Moalli et al (2012) The impact of mesh implantation on vaginal smooth muscle innervation Female Pelvic Medicine amp Reconstructive Surgery Vol 18 (Suppl 2)S258-9 SeptOct paper 257 Hawthorn R et al (2007) Use of ultra lightweight mesh in vaginal vault repairs to minimize complications A two centre observation study British International Congress of Obstetrics amp Gynaecology
PRE FORMED Y-MESH VS CUTTING MESH AND MAKING IT TO FIT PATIENTS
Pr Bruno DEVAL MD Geoffroy Saint-Hilaire ndash Clinic
Hotel ndashDieu de Paris
Paris V University
Mesh and operative handling
The shape and weight of the mesh can help us during
laparoscopic procedure
A large Y mesh is a good choice for vaginal vault shape
Better intra-operative manipulation and suturing
Lower mesh mass accommodates easy passage through narrow
laparoscopic ports
Use re-absorbable sutures on the vagina
bull Stitch erosions are reported
bull Folding and wrinkling can cause
erosions and dyspaurenia
Avoid folding and wrinkling the
mesh must be well stretched
DO WE NEED TO DISSECT POSTERIOR DOWN TO PERINEUM OR
IN WHICH PATIENTS THIS IS INDICATED
Pr Bruno DEVAL MD Geoffroy Saint-Hilaire ndash Clinic
Hotel ndashDieu de Paris
Paris V University
Fix the mesh on the posterior
vaginal wall and not on the
elevator ani muscle
bull To avoid dyschezia and chronic
pelvic pain
bull Sacrocolpopexy should only be performed by board certified eligible surgeons (ObGyn or Urology)
bull Knowledge surgical skills and experience in reconstructive pelvic surgery
FPMRS fellowship
CME documentation
Proctoring on 10 cases
gt 50 practice in reconstructive surgery
bull Outcomes and complications of should be monitored by annual internal audit
bull Informed consent should highlight
Alternatives to ASC including pessary
Complications of ASC
Complications of mesh
AUGS Guidelines on Sacrocolpopexy Privileges(March 2013)
Source wwwaugsorg
Conclusion
bull The technique and expertise are
fundamental
bull Laparoscopic colposacropexy can safely
be offered to women with symptomatic
POP
bull Conventional LSCP = Open Way =
robotic way
bull Conventional LSCP gt Vaginal Way
Indications for Robot Use ndash Disease Prevalence
bull 24700 new cases of prostate cancer diagnosed in Canada in 2008
bull 219 of patients lt60 years old will choose prostatectomy as initial treatmentUrology
bull 36000 hysterectomies performed in Canada in 200708
bull Hysterectomy is performed for several indications Gynecology
bull 5 year prevalence (2005) 482100000 male amp 318100000 female
bull Surgery is the primary treatment for localized renal cell carcinomaNephrology
bull An estimated 20000 coronary artery bypass graft (CABG) surgeries were performed in Canada in 200001
Cardiac Surgery
Adapted from CADTH Technology Report on Robot-Assisted Surgery 2011
Economic Analysis
bull Robot-Assisted vs Laparoscopic
Economic Model Base Case (Robot not donated)
Hospital Budget Impact
Hospital Budget Impact
ANATOMY OF THE PRESACRAL SPACE
STRUCTURES TO BE
RESPECTED
FOR A SAFE FIXATION
OF THE MESH
RATE OF
BLOOD TRANSFUSION
02
ANATOMICAL VARIATIONS
OF THE LEFT COMMON ILIAC VEIN MIDDLE PART PROMONTORY
bull Distances between the left common iliac vein and the midsacral promontory
bull Dissection of 52 cadavers
bull Mean of d1 = 27 mm (9 - 52)
bull Mean of d2 = 22 mm (9 - 35)
Wieslander CK et al Vascular anatomy of the presacral space in unembalmedfemale cadaversAmerican journal of obstetrics and gynecology 2006 195 1736
d1
RATE OF
BLOOD TRANSFUSION
02
ANATOMICAL VARIATIONS OF PRESACRAL VESSELS
MIDDLE PART PROMONTORY
bull Presacral vesselsndash Middle sacral vein
Oslash= 2mm (1- 4)
double (80)
left to P= 33
right to P= 52
crossing P= 5
mean of d3 = 7 mm (0-17)
P
d3
Wieslander CK et al Vascular anatomy of the presacral space in unembalmed female cadavers American journal of obstetrics and gynecology 2006 195 1736
ANATOMICAL VARIATIONS OF PRESACRAL VESSELS
MIDDLE PART PROMONTORY
bull Presacral vesselsndash Middle sacral artery
Oslash= 2mm (1- 4)
Left to P= 62
Right to P= 30
Crossing P= 8
Mean of d4 = 4 mm (0-15)
Pd4
Wieslander CK et al Vascular anatomy of the presacral space in unembalmed female cadavers American journal of obstetrics and gynecology 2006 195 1736
ANATOMICAL VARIATIONS OF PRESACRAL VESSELS
MIDDLE PART PROMONTORY
bull Presacral space avascular areas
bull Overlay of vascular structures
bull (10 cadavers)
Flynn MK et al Vascular anatomy of the presacral space a freshtissue cadaver dissectionAmerican journal of obstetrics and gynecology2005 192 1501
rarr Dissection right to the medline = safer
ANATOMICAL VARIATIONS OF THE RIGHT URETER
MIDDLE PART PROMONTORY
Flynn MK et al Vascular anatomy of the presacral space a fresh tissue cadaver dissectionAmerican journal of obstetrics and gynecology 2005 192 1501
bull Distances between the right ureter and the midsacral promontory
bull Dissection of 10 cadavers
ANATOMICAL VARIATIONS
OF THE
SUPERIOR HYPOGASTRIC PLEXUS
bull SHP sympathetic plexus connected to IHP
Shiozawa T et al Nerve-preserving sacrocolpopexy anatomical study and surgical approachEuropean journal of obstetrics and gynecology and reproductive biology2010 152 103
ANATOMICAL VARIATIONS OF SUPERIOR HYPOGASTRIC PLEXUS
bull Right hypogastric nerve
Wieslander CK et al Vascular anatomy of the presacral space in unembalmed female cadaversAmerican journal of obstetrics and gynecology 2006 195 1736
d6bull Mean of d6 = 7 mm (0 - 17)
Nerve-preserving sacrocolpopexy anatomical study and surgical approach
Shiozawa T1 et al
By protecting the superiorhypogastric plexus and the part of thepresacral area below the promontorywe can preserve the hypogastricnerves the sacral and pelvicsplanchnic nerves and thus theautonomic innervation of the pelvicorgans
ANATOMICAL VARIATIONS OF LVCA
bull Fixation into the anterior longitudinal
ligament
ANATOMICAL VARIATIONS OF LVCA
Boukkerou M et alPromontofixation procedures use of non-absorbable sutures or tackers Journal de gyneacutecologie obsteacutetrique et biologie de la reproduction2003 32 54
bull Fixation into the anterior longitudinal ligament
and NOT into the disc
ANATOMICAL VARIATIONS OF LVCA
bull Tackers go deep into the bone
Boukkerou M et alPromontofixation procedures use of non-absorbable sutures or tackers Journal de gyneacutecologie obsteacutetrique et biologie de la reproduction2003 32 54
Spondilithis03
ndash Preacutevention bull Asepsie and per-op antibioprophylaxy
ndash Diagnosis ndash Lombalgia fever tence neurologic diseases
ndash Inflammatory Syndrome (CRP)
ndash Radiologic signs (IRM)
bull Immobilisation
bull Antibiotheacuterapie prolongeacutee +- ponction discale
bull Ablation des prothegraveses
bull +- Arthrodegravese laminectomie
Posterior Dissection ndash DENONVILLIERS FASCIA
Since Charles-PierreDenonvilliers first discoveredthe firm membranousstructure between the rectumand prostate or bladder in1836 now calledldquoDenonvilliersrsquo fasciardquo (DF)the origin of DF has remainedcontroversial
Posterior Dissection ndash DENONVILLIERS FASCIA
Based on the evidencesurgeons should be awareof variations and search forthem to create a suitabledissection plane to avoidiatrogenic positive marginsand rectal injury
Rectal Injury04
ndash Sub-peacuteritoneacuteal rectum
bull There is a recto-vaginal space
bull Horizontal Position ++
bull Close to the post face of the vagina on the distal points
bull Danger on the proximal part of the Recto-Vaginal Septum
ndash Preacutevention
bull Follow the post-face of the vagina
bull Systeacutematic pre-operativ preparation
ndash NORMACOL reg
bull Maleable Retractor
ndash Treatment
bull Immeacutediat Suture
bull Mesh contra-Indication
Vaginal Injury04
ndash Preacuteventionbull Ant Vaginal Length - 6 cm ( 4 ndash 75) Jayle et al Masson 1918
bull Post Vaginal Lenght- 9cm (65 ndash 115) Jayle et al Masson 1918
bull There is no difference between the anterior and posteriorvagina thickness
bull If the vagina is too thin ndash Plicature of the vagina
ndash Treatmentbull If Vagina Injury Suture of the vagina
bull There is no contra indication to fix the meshes
RISK OF URETERAL
INJURY lt 11000
ndash Preacutevention
bull Parietal Uretera
ndash Cross between right extern iliac artery and uterine artery
bull Visceral Uretera
ndash Behind the ligaments
ndash Under the bladder
ndash In contact with the bladder
ndash Treatment
bull Per-op
ndash Per-op Bleu carmin en IV
ndash Ureteacuteral Catheter
bull Post-op
ndash Uro-scanner
ndash JJ Ureteral
Bladder
Collection
Sagittal T2
Vagina
Uterus
Ureter ariving in urinoma
Axial T2
Coronale T2
Bladder Injury2
ndash Sub-peacuteritoneacuteal Bladder
bull Vertical Position ++
bull Close to the ant face of the vagina
bull There is NO space
ndash Preacutevention
bull Following the Ant- Face of the vagina
bull Maleable Retractor
ndash Treatment
bull Immeacutediat Suture
bull Mesh Indication
bull Bladder Catheterisation 5 days
Small and Large Bowel Injury
bull Occur when adhesiolysis has to be undertaken
bull Avoid distended bowel at surgery by 48 hours pre op bowel prep
bull Avoid nitrous oxide during surgery as it causes bowel distension
bull If small bowel injured
ndash Repair laparoscopically
ndash Mesh can still be placed
bull Antibiotic cover for 7 days post op
CONCLUSION 1
1 To open the peritoneum tigh-it
2 Dissection on the right side of the mid-sacral ligament
3 Repair carefuly the vessels and the Right ureter
4 Try to preserve the right hypogatsric nerve
5 Fix your needle 1 cm below the promontory
MESH SELECTIONPERTINENT MESH SCIENCEWHY USE A CERTAIN MESH
Pr Bruno DEVAL MD Geoffroy Saint-Hilaire ndash Clinic
Hotel ndashDieu de Paris
Paris V University
MESH STIFFNESS
bullIncreased fibrosis and deposits of unorganized collagen create an increased stiffness
bull (Klinge 1999)
bullStiffness has been linked to clinical complications-heavier stiffer meshes having higher complications
bull (Dietz 2003)
bullStiffer meshes showed decreases in smooth muscle collagen and structural proteins following implantation
bull (Moalli P AUGS 2011)
bullHeavier stiffer meshes showed a greater propensity for stress shielding which in turn could cause reoccurrences of prolapse
bull (Moalli P AUGS 2011)
IMPACT OF VAGINAL SYNTHETIC PROLAPSE MESHES ON THE MECHANICS
OF THE HOST TISSUE RESPONSE
Feola Andrew J 02 February 2012 Doctoral Dissertation University of Pittsburgh
ldquoImplantation of the stiffest mesh in the non human primate
resulted in an exhibition of a stress-shielding response
manifested by inferior biomechanical properties of the
abdominal and vaginal tissues
Less stiff meshes resulted in preservation of tissue
propertiesrdquo
Wolffrsquos Law ndash remodeling of bone in response to stress
MESH CHARACTERISTICS
Density - Filament size ndash Elasticity - Pore size
Surface area ndash Overall ldquomesh loadrdquo
Biomechanical engineers working with type-1
polypropylene have focused on reducing overall
ldquomesh loadrdquo while maintaining durability
bullOptimal tissue incorporation and collagen growthbullNo erosionbullNo palpable mesh to patient and her partnerbullVaginal elasticity
TO OBTAIN
So lighter is better
WHAT KIND OF MESH
bull To date polypropylene meshes are the best type on the market
bull Absorbable meshes do not work
bull There is an evidence to use Polypropylene vs polyesther
bull PTFE and NW meshes are contra ndash indicated in the POP Repair
ULTRA- LIGHT POLYPROPYLENE
bull Physiologically compatible 19 gsm1
bull Ultra lightweightbull Lowest weight available for pelvic restoration
bull 18 millimeter macropores1
ndash Consistent size throughout the mesh
bull 100 micron interstitial Smartporestrade 1ndash Simultaneously encourages both collagen growth and
bacteria fighting propertiesbull Fibroblasts will enter holes that are 50 to 200 microns in size23
bull Macrophages and neutrophils will enter holes that are 50 to 120 microns in size23
bull Reduce inflammation1 Data on file2 Greca FH et at (2007) The influence of porosity on integration histology of two polypropylene meshes for the treatment of abdominal wall
defects in dogs Hernia (12) 45-493 Marois Y et all (2000) Biostability inflammatory response and healing characteristics flourpassivated polyester-knit mesh in the repair of
experimental abdominal hernias Artif Organs 24533-543
ULTRA ndash LIGHT CLINICAL EVIDENCE
SUMMARY
bull Rates of Erosion and Exposurebull Less than 1 erosion rate1
bull Anterior exposure rate 172
bull Posterior exposure rate 052
bull Greater tissue strength 3 months post-op ndash 71 more collagen growth3
bull Mature vaginal elastin decrease was not observed with Smartmesh4
bull Smartmesh did not induce a negative change in collagen metabolism5
bull Smartmesh had similar innervation density as sham 6
bull Low incidence of de novo dyspareunia71 Alinsod R et al (2008) Long term outcomes of vaginal pelvic floor repair using an ultra lightweight mesh AAGL (2008)2 Alinsod R Et al (2012) Durability and Complications of an Ultra Lightweight Transvaginal Mesh in the Treatment of Pelvic Organ Prolapse Presented at the 37th Annual Meeting of IUGA3 Greca FH et al (2007) The influence of porosity on the integration histology of two polypropylene meshes for the treatment of abdominal wall defects in dogs Hernia (12) 45-494 Moalli et al (2012) Mesh implantation negatively impacts vagina elastin metabolism Female Pelvic Medicine amp Reconstructive Surgery Vol 18 (Suppl 2)S258-9 SeptOct paper 235 Moalli et al (2012) Increasing mesh stiffness negatively impacts vaginal collagen metabolism Female Pelvic Medicine amp Reconstructive Surgery Vol 18 (Suppl 2)S258-9 SeptOct paper 246 Moalli et al (2012) The impact of mesh implantation on vaginal smooth muscle innervation Female Pelvic Medicine amp Reconstructive Surgery Vol 18 (Suppl 2)S258-9 SeptOct paper 257 Hawthorn R et al (2007) Use of ultra lightweight mesh in vaginal vault repairs to minimize complications A two centre observation study British International Congress of Obstetrics amp Gynaecology
PRE FORMED Y-MESH VS CUTTING MESH AND MAKING IT TO FIT PATIENTS
Pr Bruno DEVAL MD Geoffroy Saint-Hilaire ndash Clinic
Hotel ndashDieu de Paris
Paris V University
Mesh and operative handling
The shape and weight of the mesh can help us during
laparoscopic procedure
A large Y mesh is a good choice for vaginal vault shape
Better intra-operative manipulation and suturing
Lower mesh mass accommodates easy passage through narrow
laparoscopic ports
Use re-absorbable sutures on the vagina
bull Stitch erosions are reported
bull Folding and wrinkling can cause
erosions and dyspaurenia
Avoid folding and wrinkling the
mesh must be well stretched
DO WE NEED TO DISSECT POSTERIOR DOWN TO PERINEUM OR
IN WHICH PATIENTS THIS IS INDICATED
Pr Bruno DEVAL MD Geoffroy Saint-Hilaire ndash Clinic
Hotel ndashDieu de Paris
Paris V University
Fix the mesh on the posterior
vaginal wall and not on the
elevator ani muscle
bull To avoid dyschezia and chronic
pelvic pain
bull Sacrocolpopexy should only be performed by board certified eligible surgeons (ObGyn or Urology)
bull Knowledge surgical skills and experience in reconstructive pelvic surgery
FPMRS fellowship
CME documentation
Proctoring on 10 cases
gt 50 practice in reconstructive surgery
bull Outcomes and complications of should be monitored by annual internal audit
bull Informed consent should highlight
Alternatives to ASC including pessary
Complications of ASC
Complications of mesh
AUGS Guidelines on Sacrocolpopexy Privileges(March 2013)
Source wwwaugsorg
Conclusion
bull The technique and expertise are
fundamental
bull Laparoscopic colposacropexy can safely
be offered to women with symptomatic
POP
bull Conventional LSCP = Open Way =
robotic way
bull Conventional LSCP gt Vaginal Way
Economic Analysis
bull Robot-Assisted vs Laparoscopic
Economic Model Base Case (Robot not donated)
Hospital Budget Impact
Hospital Budget Impact
ANATOMY OF THE PRESACRAL SPACE
STRUCTURES TO BE
RESPECTED
FOR A SAFE FIXATION
OF THE MESH
RATE OF
BLOOD TRANSFUSION
02
ANATOMICAL VARIATIONS
OF THE LEFT COMMON ILIAC VEIN MIDDLE PART PROMONTORY
bull Distances between the left common iliac vein and the midsacral promontory
bull Dissection of 52 cadavers
bull Mean of d1 = 27 mm (9 - 52)
bull Mean of d2 = 22 mm (9 - 35)
Wieslander CK et al Vascular anatomy of the presacral space in unembalmedfemale cadaversAmerican journal of obstetrics and gynecology 2006 195 1736
d1
RATE OF
BLOOD TRANSFUSION
02
ANATOMICAL VARIATIONS OF PRESACRAL VESSELS
MIDDLE PART PROMONTORY
bull Presacral vesselsndash Middle sacral vein
Oslash= 2mm (1- 4)
double (80)
left to P= 33
right to P= 52
crossing P= 5
mean of d3 = 7 mm (0-17)
P
d3
Wieslander CK et al Vascular anatomy of the presacral space in unembalmed female cadavers American journal of obstetrics and gynecology 2006 195 1736
ANATOMICAL VARIATIONS OF PRESACRAL VESSELS
MIDDLE PART PROMONTORY
bull Presacral vesselsndash Middle sacral artery
Oslash= 2mm (1- 4)
Left to P= 62
Right to P= 30
Crossing P= 8
Mean of d4 = 4 mm (0-15)
Pd4
Wieslander CK et al Vascular anatomy of the presacral space in unembalmed female cadavers American journal of obstetrics and gynecology 2006 195 1736
ANATOMICAL VARIATIONS OF PRESACRAL VESSELS
MIDDLE PART PROMONTORY
bull Presacral space avascular areas
bull Overlay of vascular structures
bull (10 cadavers)
Flynn MK et al Vascular anatomy of the presacral space a freshtissue cadaver dissectionAmerican journal of obstetrics and gynecology2005 192 1501
rarr Dissection right to the medline = safer
ANATOMICAL VARIATIONS OF THE RIGHT URETER
MIDDLE PART PROMONTORY
Flynn MK et al Vascular anatomy of the presacral space a fresh tissue cadaver dissectionAmerican journal of obstetrics and gynecology 2005 192 1501
bull Distances between the right ureter and the midsacral promontory
bull Dissection of 10 cadavers
ANATOMICAL VARIATIONS
OF THE
SUPERIOR HYPOGASTRIC PLEXUS
bull SHP sympathetic plexus connected to IHP
Shiozawa T et al Nerve-preserving sacrocolpopexy anatomical study and surgical approachEuropean journal of obstetrics and gynecology and reproductive biology2010 152 103
ANATOMICAL VARIATIONS OF SUPERIOR HYPOGASTRIC PLEXUS
bull Right hypogastric nerve
Wieslander CK et al Vascular anatomy of the presacral space in unembalmed female cadaversAmerican journal of obstetrics and gynecology 2006 195 1736
d6bull Mean of d6 = 7 mm (0 - 17)
Nerve-preserving sacrocolpopexy anatomical study and surgical approach
Shiozawa T1 et al
By protecting the superiorhypogastric plexus and the part of thepresacral area below the promontorywe can preserve the hypogastricnerves the sacral and pelvicsplanchnic nerves and thus theautonomic innervation of the pelvicorgans
ANATOMICAL VARIATIONS OF LVCA
bull Fixation into the anterior longitudinal
ligament
ANATOMICAL VARIATIONS OF LVCA
Boukkerou M et alPromontofixation procedures use of non-absorbable sutures or tackers Journal de gyneacutecologie obsteacutetrique et biologie de la reproduction2003 32 54
bull Fixation into the anterior longitudinal ligament
and NOT into the disc
ANATOMICAL VARIATIONS OF LVCA
bull Tackers go deep into the bone
Boukkerou M et alPromontofixation procedures use of non-absorbable sutures or tackers Journal de gyneacutecologie obsteacutetrique et biologie de la reproduction2003 32 54
Spondilithis03
ndash Preacutevention bull Asepsie and per-op antibioprophylaxy
ndash Diagnosis ndash Lombalgia fever tence neurologic diseases
ndash Inflammatory Syndrome (CRP)
ndash Radiologic signs (IRM)
bull Immobilisation
bull Antibiotheacuterapie prolongeacutee +- ponction discale
bull Ablation des prothegraveses
bull +- Arthrodegravese laminectomie
Posterior Dissection ndash DENONVILLIERS FASCIA
Since Charles-PierreDenonvilliers first discoveredthe firm membranousstructure between the rectumand prostate or bladder in1836 now calledldquoDenonvilliersrsquo fasciardquo (DF)the origin of DF has remainedcontroversial
Posterior Dissection ndash DENONVILLIERS FASCIA
Based on the evidencesurgeons should be awareof variations and search forthem to create a suitabledissection plane to avoidiatrogenic positive marginsand rectal injury
Rectal Injury04
ndash Sub-peacuteritoneacuteal rectum
bull There is a recto-vaginal space
bull Horizontal Position ++
bull Close to the post face of the vagina on the distal points
bull Danger on the proximal part of the Recto-Vaginal Septum
ndash Preacutevention
bull Follow the post-face of the vagina
bull Systeacutematic pre-operativ preparation
ndash NORMACOL reg
bull Maleable Retractor
ndash Treatment
bull Immeacutediat Suture
bull Mesh contra-Indication
Vaginal Injury04
ndash Preacuteventionbull Ant Vaginal Length - 6 cm ( 4 ndash 75) Jayle et al Masson 1918
bull Post Vaginal Lenght- 9cm (65 ndash 115) Jayle et al Masson 1918
bull There is no difference between the anterior and posteriorvagina thickness
bull If the vagina is too thin ndash Plicature of the vagina
ndash Treatmentbull If Vagina Injury Suture of the vagina
bull There is no contra indication to fix the meshes
RISK OF URETERAL
INJURY lt 11000
ndash Preacutevention
bull Parietal Uretera
ndash Cross between right extern iliac artery and uterine artery
bull Visceral Uretera
ndash Behind the ligaments
ndash Under the bladder
ndash In contact with the bladder
ndash Treatment
bull Per-op
ndash Per-op Bleu carmin en IV
ndash Ureteacuteral Catheter
bull Post-op
ndash Uro-scanner
ndash JJ Ureteral
Bladder
Collection
Sagittal T2
Vagina
Uterus
Ureter ariving in urinoma
Axial T2
Coronale T2
Bladder Injury2
ndash Sub-peacuteritoneacuteal Bladder
bull Vertical Position ++
bull Close to the ant face of the vagina
bull There is NO space
ndash Preacutevention
bull Following the Ant- Face of the vagina
bull Maleable Retractor
ndash Treatment
bull Immeacutediat Suture
bull Mesh Indication
bull Bladder Catheterisation 5 days
Small and Large Bowel Injury
bull Occur when adhesiolysis has to be undertaken
bull Avoid distended bowel at surgery by 48 hours pre op bowel prep
bull Avoid nitrous oxide during surgery as it causes bowel distension
bull If small bowel injured
ndash Repair laparoscopically
ndash Mesh can still be placed
bull Antibiotic cover for 7 days post op
CONCLUSION 1
1 To open the peritoneum tigh-it
2 Dissection on the right side of the mid-sacral ligament
3 Repair carefuly the vessels and the Right ureter
4 Try to preserve the right hypogatsric nerve
5 Fix your needle 1 cm below the promontory
MESH SELECTIONPERTINENT MESH SCIENCEWHY USE A CERTAIN MESH
Pr Bruno DEVAL MD Geoffroy Saint-Hilaire ndash Clinic
Hotel ndashDieu de Paris
Paris V University
MESH STIFFNESS
bullIncreased fibrosis and deposits of unorganized collagen create an increased stiffness
bull (Klinge 1999)
bullStiffness has been linked to clinical complications-heavier stiffer meshes having higher complications
bull (Dietz 2003)
bullStiffer meshes showed decreases in smooth muscle collagen and structural proteins following implantation
bull (Moalli P AUGS 2011)
bullHeavier stiffer meshes showed a greater propensity for stress shielding which in turn could cause reoccurrences of prolapse
bull (Moalli P AUGS 2011)
IMPACT OF VAGINAL SYNTHETIC PROLAPSE MESHES ON THE MECHANICS
OF THE HOST TISSUE RESPONSE
Feola Andrew J 02 February 2012 Doctoral Dissertation University of Pittsburgh
ldquoImplantation of the stiffest mesh in the non human primate
resulted in an exhibition of a stress-shielding response
manifested by inferior biomechanical properties of the
abdominal and vaginal tissues
Less stiff meshes resulted in preservation of tissue
propertiesrdquo
Wolffrsquos Law ndash remodeling of bone in response to stress
MESH CHARACTERISTICS
Density - Filament size ndash Elasticity - Pore size
Surface area ndash Overall ldquomesh loadrdquo
Biomechanical engineers working with type-1
polypropylene have focused on reducing overall
ldquomesh loadrdquo while maintaining durability
bullOptimal tissue incorporation and collagen growthbullNo erosionbullNo palpable mesh to patient and her partnerbullVaginal elasticity
TO OBTAIN
So lighter is better
WHAT KIND OF MESH
bull To date polypropylene meshes are the best type on the market
bull Absorbable meshes do not work
bull There is an evidence to use Polypropylene vs polyesther
bull PTFE and NW meshes are contra ndash indicated in the POP Repair
ULTRA- LIGHT POLYPROPYLENE
bull Physiologically compatible 19 gsm1
bull Ultra lightweightbull Lowest weight available for pelvic restoration
bull 18 millimeter macropores1
ndash Consistent size throughout the mesh
bull 100 micron interstitial Smartporestrade 1ndash Simultaneously encourages both collagen growth and
bacteria fighting propertiesbull Fibroblasts will enter holes that are 50 to 200 microns in size23
bull Macrophages and neutrophils will enter holes that are 50 to 120 microns in size23
bull Reduce inflammation1 Data on file2 Greca FH et at (2007) The influence of porosity on integration histology of two polypropylene meshes for the treatment of abdominal wall
defects in dogs Hernia (12) 45-493 Marois Y et all (2000) Biostability inflammatory response and healing characteristics flourpassivated polyester-knit mesh in the repair of
experimental abdominal hernias Artif Organs 24533-543
ULTRA ndash LIGHT CLINICAL EVIDENCE
SUMMARY
bull Rates of Erosion and Exposurebull Less than 1 erosion rate1
bull Anterior exposure rate 172
bull Posterior exposure rate 052
bull Greater tissue strength 3 months post-op ndash 71 more collagen growth3
bull Mature vaginal elastin decrease was not observed with Smartmesh4
bull Smartmesh did not induce a negative change in collagen metabolism5
bull Smartmesh had similar innervation density as sham 6
bull Low incidence of de novo dyspareunia71 Alinsod R et al (2008) Long term outcomes of vaginal pelvic floor repair using an ultra lightweight mesh AAGL (2008)2 Alinsod R Et al (2012) Durability and Complications of an Ultra Lightweight Transvaginal Mesh in the Treatment of Pelvic Organ Prolapse Presented at the 37th Annual Meeting of IUGA3 Greca FH et al (2007) The influence of porosity on the integration histology of two polypropylene meshes for the treatment of abdominal wall defects in dogs Hernia (12) 45-494 Moalli et al (2012) Mesh implantation negatively impacts vagina elastin metabolism Female Pelvic Medicine amp Reconstructive Surgery Vol 18 (Suppl 2)S258-9 SeptOct paper 235 Moalli et al (2012) Increasing mesh stiffness negatively impacts vaginal collagen metabolism Female Pelvic Medicine amp Reconstructive Surgery Vol 18 (Suppl 2)S258-9 SeptOct paper 246 Moalli et al (2012) The impact of mesh implantation on vaginal smooth muscle innervation Female Pelvic Medicine amp Reconstructive Surgery Vol 18 (Suppl 2)S258-9 SeptOct paper 257 Hawthorn R et al (2007) Use of ultra lightweight mesh in vaginal vault repairs to minimize complications A two centre observation study British International Congress of Obstetrics amp Gynaecology
PRE FORMED Y-MESH VS CUTTING MESH AND MAKING IT TO FIT PATIENTS
Pr Bruno DEVAL MD Geoffroy Saint-Hilaire ndash Clinic
Hotel ndashDieu de Paris
Paris V University
Mesh and operative handling
The shape and weight of the mesh can help us during
laparoscopic procedure
A large Y mesh is a good choice for vaginal vault shape
Better intra-operative manipulation and suturing
Lower mesh mass accommodates easy passage through narrow
laparoscopic ports
Use re-absorbable sutures on the vagina
bull Stitch erosions are reported
bull Folding and wrinkling can cause
erosions and dyspaurenia
Avoid folding and wrinkling the
mesh must be well stretched
DO WE NEED TO DISSECT POSTERIOR DOWN TO PERINEUM OR
IN WHICH PATIENTS THIS IS INDICATED
Pr Bruno DEVAL MD Geoffroy Saint-Hilaire ndash Clinic
Hotel ndashDieu de Paris
Paris V University
Fix the mesh on the posterior
vaginal wall and not on the
elevator ani muscle
bull To avoid dyschezia and chronic
pelvic pain
bull Sacrocolpopexy should only be performed by board certified eligible surgeons (ObGyn or Urology)
bull Knowledge surgical skills and experience in reconstructive pelvic surgery
FPMRS fellowship
CME documentation
Proctoring on 10 cases
gt 50 practice in reconstructive surgery
bull Outcomes and complications of should be monitored by annual internal audit
bull Informed consent should highlight
Alternatives to ASC including pessary
Complications of ASC
Complications of mesh
AUGS Guidelines on Sacrocolpopexy Privileges(March 2013)
Source wwwaugsorg
Conclusion
bull The technique and expertise are
fundamental
bull Laparoscopic colposacropexy can safely
be offered to women with symptomatic
POP
bull Conventional LSCP = Open Way =
robotic way
bull Conventional LSCP gt Vaginal Way
bull Robot-Assisted vs Laparoscopic
Economic Model Base Case (Robot not donated)
Hospital Budget Impact
Hospital Budget Impact
ANATOMY OF THE PRESACRAL SPACE
STRUCTURES TO BE
RESPECTED
FOR A SAFE FIXATION
OF THE MESH
RATE OF
BLOOD TRANSFUSION
02
ANATOMICAL VARIATIONS
OF THE LEFT COMMON ILIAC VEIN MIDDLE PART PROMONTORY
bull Distances between the left common iliac vein and the midsacral promontory
bull Dissection of 52 cadavers
bull Mean of d1 = 27 mm (9 - 52)
bull Mean of d2 = 22 mm (9 - 35)
Wieslander CK et al Vascular anatomy of the presacral space in unembalmedfemale cadaversAmerican journal of obstetrics and gynecology 2006 195 1736
d1
RATE OF
BLOOD TRANSFUSION
02
ANATOMICAL VARIATIONS OF PRESACRAL VESSELS
MIDDLE PART PROMONTORY
bull Presacral vesselsndash Middle sacral vein
Oslash= 2mm (1- 4)
double (80)
left to P= 33
right to P= 52
crossing P= 5
mean of d3 = 7 mm (0-17)
P
d3
Wieslander CK et al Vascular anatomy of the presacral space in unembalmed female cadavers American journal of obstetrics and gynecology 2006 195 1736
ANATOMICAL VARIATIONS OF PRESACRAL VESSELS
MIDDLE PART PROMONTORY
bull Presacral vesselsndash Middle sacral artery
Oslash= 2mm (1- 4)
Left to P= 62
Right to P= 30
Crossing P= 8
Mean of d4 = 4 mm (0-15)
Pd4
Wieslander CK et al Vascular anatomy of the presacral space in unembalmed female cadavers American journal of obstetrics and gynecology 2006 195 1736
ANATOMICAL VARIATIONS OF PRESACRAL VESSELS
MIDDLE PART PROMONTORY
bull Presacral space avascular areas
bull Overlay of vascular structures
bull (10 cadavers)
Flynn MK et al Vascular anatomy of the presacral space a freshtissue cadaver dissectionAmerican journal of obstetrics and gynecology2005 192 1501
rarr Dissection right to the medline = safer
ANATOMICAL VARIATIONS OF THE RIGHT URETER
MIDDLE PART PROMONTORY
Flynn MK et al Vascular anatomy of the presacral space a fresh tissue cadaver dissectionAmerican journal of obstetrics and gynecology 2005 192 1501
bull Distances between the right ureter and the midsacral promontory
bull Dissection of 10 cadavers
ANATOMICAL VARIATIONS
OF THE
SUPERIOR HYPOGASTRIC PLEXUS
bull SHP sympathetic plexus connected to IHP
Shiozawa T et al Nerve-preserving sacrocolpopexy anatomical study and surgical approachEuropean journal of obstetrics and gynecology and reproductive biology2010 152 103
ANATOMICAL VARIATIONS OF SUPERIOR HYPOGASTRIC PLEXUS
bull Right hypogastric nerve
Wieslander CK et al Vascular anatomy of the presacral space in unembalmed female cadaversAmerican journal of obstetrics and gynecology 2006 195 1736
d6bull Mean of d6 = 7 mm (0 - 17)
Nerve-preserving sacrocolpopexy anatomical study and surgical approach
Shiozawa T1 et al
By protecting the superiorhypogastric plexus and the part of thepresacral area below the promontorywe can preserve the hypogastricnerves the sacral and pelvicsplanchnic nerves and thus theautonomic innervation of the pelvicorgans
ANATOMICAL VARIATIONS OF LVCA
bull Fixation into the anterior longitudinal
ligament
ANATOMICAL VARIATIONS OF LVCA
Boukkerou M et alPromontofixation procedures use of non-absorbable sutures or tackers Journal de gyneacutecologie obsteacutetrique et biologie de la reproduction2003 32 54
bull Fixation into the anterior longitudinal ligament
and NOT into the disc
ANATOMICAL VARIATIONS OF LVCA
bull Tackers go deep into the bone
Boukkerou M et alPromontofixation procedures use of non-absorbable sutures or tackers Journal de gyneacutecologie obsteacutetrique et biologie de la reproduction2003 32 54
Spondilithis03
ndash Preacutevention bull Asepsie and per-op antibioprophylaxy
ndash Diagnosis ndash Lombalgia fever tence neurologic diseases
ndash Inflammatory Syndrome (CRP)
ndash Radiologic signs (IRM)
bull Immobilisation
bull Antibiotheacuterapie prolongeacutee +- ponction discale
bull Ablation des prothegraveses
bull +- Arthrodegravese laminectomie
Posterior Dissection ndash DENONVILLIERS FASCIA
Since Charles-PierreDenonvilliers first discoveredthe firm membranousstructure between the rectumand prostate or bladder in1836 now calledldquoDenonvilliersrsquo fasciardquo (DF)the origin of DF has remainedcontroversial
Posterior Dissection ndash DENONVILLIERS FASCIA
Based on the evidencesurgeons should be awareof variations and search forthem to create a suitabledissection plane to avoidiatrogenic positive marginsand rectal injury
Rectal Injury04
ndash Sub-peacuteritoneacuteal rectum
bull There is a recto-vaginal space
bull Horizontal Position ++
bull Close to the post face of the vagina on the distal points
bull Danger on the proximal part of the Recto-Vaginal Septum
ndash Preacutevention
bull Follow the post-face of the vagina
bull Systeacutematic pre-operativ preparation
ndash NORMACOL reg
bull Maleable Retractor
ndash Treatment
bull Immeacutediat Suture
bull Mesh contra-Indication
Vaginal Injury04
ndash Preacuteventionbull Ant Vaginal Length - 6 cm ( 4 ndash 75) Jayle et al Masson 1918
bull Post Vaginal Lenght- 9cm (65 ndash 115) Jayle et al Masson 1918
bull There is no difference between the anterior and posteriorvagina thickness
bull If the vagina is too thin ndash Plicature of the vagina
ndash Treatmentbull If Vagina Injury Suture of the vagina
bull There is no contra indication to fix the meshes
RISK OF URETERAL
INJURY lt 11000
ndash Preacutevention
bull Parietal Uretera
ndash Cross between right extern iliac artery and uterine artery
bull Visceral Uretera
ndash Behind the ligaments
ndash Under the bladder
ndash In contact with the bladder
ndash Treatment
bull Per-op
ndash Per-op Bleu carmin en IV
ndash Ureteacuteral Catheter
bull Post-op
ndash Uro-scanner
ndash JJ Ureteral
Bladder
Collection
Sagittal T2
Vagina
Uterus
Ureter ariving in urinoma
Axial T2
Coronale T2
Bladder Injury2
ndash Sub-peacuteritoneacuteal Bladder
bull Vertical Position ++
bull Close to the ant face of the vagina
bull There is NO space
ndash Preacutevention
bull Following the Ant- Face of the vagina
bull Maleable Retractor
ndash Treatment
bull Immeacutediat Suture
bull Mesh Indication
bull Bladder Catheterisation 5 days
Small and Large Bowel Injury
bull Occur when adhesiolysis has to be undertaken
bull Avoid distended bowel at surgery by 48 hours pre op bowel prep
bull Avoid nitrous oxide during surgery as it causes bowel distension
bull If small bowel injured
ndash Repair laparoscopically
ndash Mesh can still be placed
bull Antibiotic cover for 7 days post op
CONCLUSION 1
1 To open the peritoneum tigh-it
2 Dissection on the right side of the mid-sacral ligament
3 Repair carefuly the vessels and the Right ureter
4 Try to preserve the right hypogatsric nerve
5 Fix your needle 1 cm below the promontory
MESH SELECTIONPERTINENT MESH SCIENCEWHY USE A CERTAIN MESH
Pr Bruno DEVAL MD Geoffroy Saint-Hilaire ndash Clinic
Hotel ndashDieu de Paris
Paris V University
MESH STIFFNESS
bullIncreased fibrosis and deposits of unorganized collagen create an increased stiffness
bull (Klinge 1999)
bullStiffness has been linked to clinical complications-heavier stiffer meshes having higher complications
bull (Dietz 2003)
bullStiffer meshes showed decreases in smooth muscle collagen and structural proteins following implantation
bull (Moalli P AUGS 2011)
bullHeavier stiffer meshes showed a greater propensity for stress shielding which in turn could cause reoccurrences of prolapse
bull (Moalli P AUGS 2011)
IMPACT OF VAGINAL SYNTHETIC PROLAPSE MESHES ON THE MECHANICS
OF THE HOST TISSUE RESPONSE
Feola Andrew J 02 February 2012 Doctoral Dissertation University of Pittsburgh
ldquoImplantation of the stiffest mesh in the non human primate
resulted in an exhibition of a stress-shielding response
manifested by inferior biomechanical properties of the
abdominal and vaginal tissues
Less stiff meshes resulted in preservation of tissue
propertiesrdquo
Wolffrsquos Law ndash remodeling of bone in response to stress
MESH CHARACTERISTICS
Density - Filament size ndash Elasticity - Pore size
Surface area ndash Overall ldquomesh loadrdquo
Biomechanical engineers working with type-1
polypropylene have focused on reducing overall
ldquomesh loadrdquo while maintaining durability
bullOptimal tissue incorporation and collagen growthbullNo erosionbullNo palpable mesh to patient and her partnerbullVaginal elasticity
TO OBTAIN
So lighter is better
WHAT KIND OF MESH
bull To date polypropylene meshes are the best type on the market
bull Absorbable meshes do not work
bull There is an evidence to use Polypropylene vs polyesther
bull PTFE and NW meshes are contra ndash indicated in the POP Repair
ULTRA- LIGHT POLYPROPYLENE
bull Physiologically compatible 19 gsm1
bull Ultra lightweightbull Lowest weight available for pelvic restoration
bull 18 millimeter macropores1
ndash Consistent size throughout the mesh
bull 100 micron interstitial Smartporestrade 1ndash Simultaneously encourages both collagen growth and
bacteria fighting propertiesbull Fibroblasts will enter holes that are 50 to 200 microns in size23
bull Macrophages and neutrophils will enter holes that are 50 to 120 microns in size23
bull Reduce inflammation1 Data on file2 Greca FH et at (2007) The influence of porosity on integration histology of two polypropylene meshes for the treatment of abdominal wall
defects in dogs Hernia (12) 45-493 Marois Y et all (2000) Biostability inflammatory response and healing characteristics flourpassivated polyester-knit mesh in the repair of
experimental abdominal hernias Artif Organs 24533-543
ULTRA ndash LIGHT CLINICAL EVIDENCE
SUMMARY
bull Rates of Erosion and Exposurebull Less than 1 erosion rate1
bull Anterior exposure rate 172
bull Posterior exposure rate 052
bull Greater tissue strength 3 months post-op ndash 71 more collagen growth3
bull Mature vaginal elastin decrease was not observed with Smartmesh4
bull Smartmesh did not induce a negative change in collagen metabolism5
bull Smartmesh had similar innervation density as sham 6
bull Low incidence of de novo dyspareunia71 Alinsod R et al (2008) Long term outcomes of vaginal pelvic floor repair using an ultra lightweight mesh AAGL (2008)2 Alinsod R Et al (2012) Durability and Complications of an Ultra Lightweight Transvaginal Mesh in the Treatment of Pelvic Organ Prolapse Presented at the 37th Annual Meeting of IUGA3 Greca FH et al (2007) The influence of porosity on the integration histology of two polypropylene meshes for the treatment of abdominal wall defects in dogs Hernia (12) 45-494 Moalli et al (2012) Mesh implantation negatively impacts vagina elastin metabolism Female Pelvic Medicine amp Reconstructive Surgery Vol 18 (Suppl 2)S258-9 SeptOct paper 235 Moalli et al (2012) Increasing mesh stiffness negatively impacts vaginal collagen metabolism Female Pelvic Medicine amp Reconstructive Surgery Vol 18 (Suppl 2)S258-9 SeptOct paper 246 Moalli et al (2012) The impact of mesh implantation on vaginal smooth muscle innervation Female Pelvic Medicine amp Reconstructive Surgery Vol 18 (Suppl 2)S258-9 SeptOct paper 257 Hawthorn R et al (2007) Use of ultra lightweight mesh in vaginal vault repairs to minimize complications A two centre observation study British International Congress of Obstetrics amp Gynaecology
PRE FORMED Y-MESH VS CUTTING MESH AND MAKING IT TO FIT PATIENTS
Pr Bruno DEVAL MD Geoffroy Saint-Hilaire ndash Clinic
Hotel ndashDieu de Paris
Paris V University
Mesh and operative handling
The shape and weight of the mesh can help us during
laparoscopic procedure
A large Y mesh is a good choice for vaginal vault shape
Better intra-operative manipulation and suturing
Lower mesh mass accommodates easy passage through narrow
laparoscopic ports
Use re-absorbable sutures on the vagina
bull Stitch erosions are reported
bull Folding and wrinkling can cause
erosions and dyspaurenia
Avoid folding and wrinkling the
mesh must be well stretched
DO WE NEED TO DISSECT POSTERIOR DOWN TO PERINEUM OR
IN WHICH PATIENTS THIS IS INDICATED
Pr Bruno DEVAL MD Geoffroy Saint-Hilaire ndash Clinic
Hotel ndashDieu de Paris
Paris V University
Fix the mesh on the posterior
vaginal wall and not on the
elevator ani muscle
bull To avoid dyschezia and chronic
pelvic pain
bull Sacrocolpopexy should only be performed by board certified eligible surgeons (ObGyn or Urology)
bull Knowledge surgical skills and experience in reconstructive pelvic surgery
FPMRS fellowship
CME documentation
Proctoring on 10 cases
gt 50 practice in reconstructive surgery
bull Outcomes and complications of should be monitored by annual internal audit
bull Informed consent should highlight
Alternatives to ASC including pessary
Complications of ASC
Complications of mesh
AUGS Guidelines on Sacrocolpopexy Privileges(March 2013)
Source wwwaugsorg
Conclusion
bull The technique and expertise are
fundamental
bull Laparoscopic colposacropexy can safely
be offered to women with symptomatic
POP
bull Conventional LSCP = Open Way =
robotic way
bull Conventional LSCP gt Vaginal Way
Hospital Budget Impact
Hospital Budget Impact
ANATOMY OF THE PRESACRAL SPACE
STRUCTURES TO BE
RESPECTED
FOR A SAFE FIXATION
OF THE MESH
RATE OF
BLOOD TRANSFUSION
02
ANATOMICAL VARIATIONS
OF THE LEFT COMMON ILIAC VEIN MIDDLE PART PROMONTORY
bull Distances between the left common iliac vein and the midsacral promontory
bull Dissection of 52 cadavers
bull Mean of d1 = 27 mm (9 - 52)
bull Mean of d2 = 22 mm (9 - 35)
Wieslander CK et al Vascular anatomy of the presacral space in unembalmedfemale cadaversAmerican journal of obstetrics and gynecology 2006 195 1736
d1
RATE OF
BLOOD TRANSFUSION
02
ANATOMICAL VARIATIONS OF PRESACRAL VESSELS
MIDDLE PART PROMONTORY
bull Presacral vesselsndash Middle sacral vein
Oslash= 2mm (1- 4)
double (80)
left to P= 33
right to P= 52
crossing P= 5
mean of d3 = 7 mm (0-17)
P
d3
Wieslander CK et al Vascular anatomy of the presacral space in unembalmed female cadavers American journal of obstetrics and gynecology 2006 195 1736
ANATOMICAL VARIATIONS OF PRESACRAL VESSELS
MIDDLE PART PROMONTORY
bull Presacral vesselsndash Middle sacral artery
Oslash= 2mm (1- 4)
Left to P= 62
Right to P= 30
Crossing P= 8
Mean of d4 = 4 mm (0-15)
Pd4
Wieslander CK et al Vascular anatomy of the presacral space in unembalmed female cadavers American journal of obstetrics and gynecology 2006 195 1736
ANATOMICAL VARIATIONS OF PRESACRAL VESSELS
MIDDLE PART PROMONTORY
bull Presacral space avascular areas
bull Overlay of vascular structures
bull (10 cadavers)
Flynn MK et al Vascular anatomy of the presacral space a freshtissue cadaver dissectionAmerican journal of obstetrics and gynecology2005 192 1501
rarr Dissection right to the medline = safer
ANATOMICAL VARIATIONS OF THE RIGHT URETER
MIDDLE PART PROMONTORY
Flynn MK et al Vascular anatomy of the presacral space a fresh tissue cadaver dissectionAmerican journal of obstetrics and gynecology 2005 192 1501
bull Distances between the right ureter and the midsacral promontory
bull Dissection of 10 cadavers
ANATOMICAL VARIATIONS
OF THE
SUPERIOR HYPOGASTRIC PLEXUS
bull SHP sympathetic plexus connected to IHP
Shiozawa T et al Nerve-preserving sacrocolpopexy anatomical study and surgical approachEuropean journal of obstetrics and gynecology and reproductive biology2010 152 103
ANATOMICAL VARIATIONS OF SUPERIOR HYPOGASTRIC PLEXUS
bull Right hypogastric nerve
Wieslander CK et al Vascular anatomy of the presacral space in unembalmed female cadaversAmerican journal of obstetrics and gynecology 2006 195 1736
d6bull Mean of d6 = 7 mm (0 - 17)
Nerve-preserving sacrocolpopexy anatomical study and surgical approach
Shiozawa T1 et al
By protecting the superiorhypogastric plexus and the part of thepresacral area below the promontorywe can preserve the hypogastricnerves the sacral and pelvicsplanchnic nerves and thus theautonomic innervation of the pelvicorgans
ANATOMICAL VARIATIONS OF LVCA
bull Fixation into the anterior longitudinal
ligament
ANATOMICAL VARIATIONS OF LVCA
Boukkerou M et alPromontofixation procedures use of non-absorbable sutures or tackers Journal de gyneacutecologie obsteacutetrique et biologie de la reproduction2003 32 54
bull Fixation into the anterior longitudinal ligament
and NOT into the disc
ANATOMICAL VARIATIONS OF LVCA
bull Tackers go deep into the bone
Boukkerou M et alPromontofixation procedures use of non-absorbable sutures or tackers Journal de gyneacutecologie obsteacutetrique et biologie de la reproduction2003 32 54
Spondilithis03
ndash Preacutevention bull Asepsie and per-op antibioprophylaxy
ndash Diagnosis ndash Lombalgia fever tence neurologic diseases
ndash Inflammatory Syndrome (CRP)
ndash Radiologic signs (IRM)
bull Immobilisation
bull Antibiotheacuterapie prolongeacutee +- ponction discale
bull Ablation des prothegraveses
bull +- Arthrodegravese laminectomie
Posterior Dissection ndash DENONVILLIERS FASCIA
Since Charles-PierreDenonvilliers first discoveredthe firm membranousstructure between the rectumand prostate or bladder in1836 now calledldquoDenonvilliersrsquo fasciardquo (DF)the origin of DF has remainedcontroversial
Posterior Dissection ndash DENONVILLIERS FASCIA
Based on the evidencesurgeons should be awareof variations and search forthem to create a suitabledissection plane to avoidiatrogenic positive marginsand rectal injury
Rectal Injury04
ndash Sub-peacuteritoneacuteal rectum
bull There is a recto-vaginal space
bull Horizontal Position ++
bull Close to the post face of the vagina on the distal points
bull Danger on the proximal part of the Recto-Vaginal Septum
ndash Preacutevention
bull Follow the post-face of the vagina
bull Systeacutematic pre-operativ preparation
ndash NORMACOL reg
bull Maleable Retractor
ndash Treatment
bull Immeacutediat Suture
bull Mesh contra-Indication
Vaginal Injury04
ndash Preacuteventionbull Ant Vaginal Length - 6 cm ( 4 ndash 75) Jayle et al Masson 1918
bull Post Vaginal Lenght- 9cm (65 ndash 115) Jayle et al Masson 1918
bull There is no difference between the anterior and posteriorvagina thickness
bull If the vagina is too thin ndash Plicature of the vagina
ndash Treatmentbull If Vagina Injury Suture of the vagina
bull There is no contra indication to fix the meshes
RISK OF URETERAL
INJURY lt 11000
ndash Preacutevention
bull Parietal Uretera
ndash Cross between right extern iliac artery and uterine artery
bull Visceral Uretera
ndash Behind the ligaments
ndash Under the bladder
ndash In contact with the bladder
ndash Treatment
bull Per-op
ndash Per-op Bleu carmin en IV
ndash Ureteacuteral Catheter
bull Post-op
ndash Uro-scanner
ndash JJ Ureteral
Bladder
Collection
Sagittal T2
Vagina
Uterus
Ureter ariving in urinoma
Axial T2
Coronale T2
Bladder Injury2
ndash Sub-peacuteritoneacuteal Bladder
bull Vertical Position ++
bull Close to the ant face of the vagina
bull There is NO space
ndash Preacutevention
bull Following the Ant- Face of the vagina
bull Maleable Retractor
ndash Treatment
bull Immeacutediat Suture
bull Mesh Indication
bull Bladder Catheterisation 5 days
Small and Large Bowel Injury
bull Occur when adhesiolysis has to be undertaken
bull Avoid distended bowel at surgery by 48 hours pre op bowel prep
bull Avoid nitrous oxide during surgery as it causes bowel distension
bull If small bowel injured
ndash Repair laparoscopically
ndash Mesh can still be placed
bull Antibiotic cover for 7 days post op
CONCLUSION 1
1 To open the peritoneum tigh-it
2 Dissection on the right side of the mid-sacral ligament
3 Repair carefuly the vessels and the Right ureter
4 Try to preserve the right hypogatsric nerve
5 Fix your needle 1 cm below the promontory
MESH SELECTIONPERTINENT MESH SCIENCEWHY USE A CERTAIN MESH
Pr Bruno DEVAL MD Geoffroy Saint-Hilaire ndash Clinic
Hotel ndashDieu de Paris
Paris V University
MESH STIFFNESS
bullIncreased fibrosis and deposits of unorganized collagen create an increased stiffness
bull (Klinge 1999)
bullStiffness has been linked to clinical complications-heavier stiffer meshes having higher complications
bull (Dietz 2003)
bullStiffer meshes showed decreases in smooth muscle collagen and structural proteins following implantation
bull (Moalli P AUGS 2011)
bullHeavier stiffer meshes showed a greater propensity for stress shielding which in turn could cause reoccurrences of prolapse
bull (Moalli P AUGS 2011)
IMPACT OF VAGINAL SYNTHETIC PROLAPSE MESHES ON THE MECHANICS
OF THE HOST TISSUE RESPONSE
Feola Andrew J 02 February 2012 Doctoral Dissertation University of Pittsburgh
ldquoImplantation of the stiffest mesh in the non human primate
resulted in an exhibition of a stress-shielding response
manifested by inferior biomechanical properties of the
abdominal and vaginal tissues
Less stiff meshes resulted in preservation of tissue
propertiesrdquo
Wolffrsquos Law ndash remodeling of bone in response to stress
MESH CHARACTERISTICS
Density - Filament size ndash Elasticity - Pore size
Surface area ndash Overall ldquomesh loadrdquo
Biomechanical engineers working with type-1
polypropylene have focused on reducing overall
ldquomesh loadrdquo while maintaining durability
bullOptimal tissue incorporation and collagen growthbullNo erosionbullNo palpable mesh to patient and her partnerbullVaginal elasticity
TO OBTAIN
So lighter is better
WHAT KIND OF MESH
bull To date polypropylene meshes are the best type on the market
bull Absorbable meshes do not work
bull There is an evidence to use Polypropylene vs polyesther
bull PTFE and NW meshes are contra ndash indicated in the POP Repair
ULTRA- LIGHT POLYPROPYLENE
bull Physiologically compatible 19 gsm1
bull Ultra lightweightbull Lowest weight available for pelvic restoration
bull 18 millimeter macropores1
ndash Consistent size throughout the mesh
bull 100 micron interstitial Smartporestrade 1ndash Simultaneously encourages both collagen growth and
bacteria fighting propertiesbull Fibroblasts will enter holes that are 50 to 200 microns in size23
bull Macrophages and neutrophils will enter holes that are 50 to 120 microns in size23
bull Reduce inflammation1 Data on file2 Greca FH et at (2007) The influence of porosity on integration histology of two polypropylene meshes for the treatment of abdominal wall
defects in dogs Hernia (12) 45-493 Marois Y et all (2000) Biostability inflammatory response and healing characteristics flourpassivated polyester-knit mesh in the repair of
experimental abdominal hernias Artif Organs 24533-543
ULTRA ndash LIGHT CLINICAL EVIDENCE
SUMMARY
bull Rates of Erosion and Exposurebull Less than 1 erosion rate1
bull Anterior exposure rate 172
bull Posterior exposure rate 052
bull Greater tissue strength 3 months post-op ndash 71 more collagen growth3
bull Mature vaginal elastin decrease was not observed with Smartmesh4
bull Smartmesh did not induce a negative change in collagen metabolism5
bull Smartmesh had similar innervation density as sham 6
bull Low incidence of de novo dyspareunia71 Alinsod R et al (2008) Long term outcomes of vaginal pelvic floor repair using an ultra lightweight mesh AAGL (2008)2 Alinsod R Et al (2012) Durability and Complications of an Ultra Lightweight Transvaginal Mesh in the Treatment of Pelvic Organ Prolapse Presented at the 37th Annual Meeting of IUGA3 Greca FH et al (2007) The influence of porosity on the integration histology of two polypropylene meshes for the treatment of abdominal wall defects in dogs Hernia (12) 45-494 Moalli et al (2012) Mesh implantation negatively impacts vagina elastin metabolism Female Pelvic Medicine amp Reconstructive Surgery Vol 18 (Suppl 2)S258-9 SeptOct paper 235 Moalli et al (2012) Increasing mesh stiffness negatively impacts vaginal collagen metabolism Female Pelvic Medicine amp Reconstructive Surgery Vol 18 (Suppl 2)S258-9 SeptOct paper 246 Moalli et al (2012) The impact of mesh implantation on vaginal smooth muscle innervation Female Pelvic Medicine amp Reconstructive Surgery Vol 18 (Suppl 2)S258-9 SeptOct paper 257 Hawthorn R et al (2007) Use of ultra lightweight mesh in vaginal vault repairs to minimize complications A two centre observation study British International Congress of Obstetrics amp Gynaecology
PRE FORMED Y-MESH VS CUTTING MESH AND MAKING IT TO FIT PATIENTS
Pr Bruno DEVAL MD Geoffroy Saint-Hilaire ndash Clinic
Hotel ndashDieu de Paris
Paris V University
Mesh and operative handling
The shape and weight of the mesh can help us during
laparoscopic procedure
A large Y mesh is a good choice for vaginal vault shape
Better intra-operative manipulation and suturing
Lower mesh mass accommodates easy passage through narrow
laparoscopic ports
Use re-absorbable sutures on the vagina
bull Stitch erosions are reported
bull Folding and wrinkling can cause
erosions and dyspaurenia
Avoid folding and wrinkling the
mesh must be well stretched
DO WE NEED TO DISSECT POSTERIOR DOWN TO PERINEUM OR
IN WHICH PATIENTS THIS IS INDICATED
Pr Bruno DEVAL MD Geoffroy Saint-Hilaire ndash Clinic
Hotel ndashDieu de Paris
Paris V University
Fix the mesh on the posterior
vaginal wall and not on the
elevator ani muscle
bull To avoid dyschezia and chronic
pelvic pain
bull Sacrocolpopexy should only be performed by board certified eligible surgeons (ObGyn or Urology)
bull Knowledge surgical skills and experience in reconstructive pelvic surgery
FPMRS fellowship
CME documentation
Proctoring on 10 cases
gt 50 practice in reconstructive surgery
bull Outcomes and complications of should be monitored by annual internal audit
bull Informed consent should highlight
Alternatives to ASC including pessary
Complications of ASC
Complications of mesh
AUGS Guidelines on Sacrocolpopexy Privileges(March 2013)
Source wwwaugsorg
Conclusion
bull The technique and expertise are
fundamental
bull Laparoscopic colposacropexy can safely
be offered to women with symptomatic
POP
bull Conventional LSCP = Open Way =
robotic way
bull Conventional LSCP gt Vaginal Way
Hospital Budget Impact
ANATOMY OF THE PRESACRAL SPACE
STRUCTURES TO BE
RESPECTED
FOR A SAFE FIXATION
OF THE MESH
RATE OF
BLOOD TRANSFUSION
02
ANATOMICAL VARIATIONS
OF THE LEFT COMMON ILIAC VEIN MIDDLE PART PROMONTORY
bull Distances between the left common iliac vein and the midsacral promontory
bull Dissection of 52 cadavers
bull Mean of d1 = 27 mm (9 - 52)
bull Mean of d2 = 22 mm (9 - 35)
Wieslander CK et al Vascular anatomy of the presacral space in unembalmedfemale cadaversAmerican journal of obstetrics and gynecology 2006 195 1736
d1
RATE OF
BLOOD TRANSFUSION
02
ANATOMICAL VARIATIONS OF PRESACRAL VESSELS
MIDDLE PART PROMONTORY
bull Presacral vesselsndash Middle sacral vein
Oslash= 2mm (1- 4)
double (80)
left to P= 33
right to P= 52
crossing P= 5
mean of d3 = 7 mm (0-17)
P
d3
Wieslander CK et al Vascular anatomy of the presacral space in unembalmed female cadavers American journal of obstetrics and gynecology 2006 195 1736
ANATOMICAL VARIATIONS OF PRESACRAL VESSELS
MIDDLE PART PROMONTORY
bull Presacral vesselsndash Middle sacral artery
Oslash= 2mm (1- 4)
Left to P= 62
Right to P= 30
Crossing P= 8
Mean of d4 = 4 mm (0-15)
Pd4
Wieslander CK et al Vascular anatomy of the presacral space in unembalmed female cadavers American journal of obstetrics and gynecology 2006 195 1736
ANATOMICAL VARIATIONS OF PRESACRAL VESSELS
MIDDLE PART PROMONTORY
bull Presacral space avascular areas
bull Overlay of vascular structures
bull (10 cadavers)
Flynn MK et al Vascular anatomy of the presacral space a freshtissue cadaver dissectionAmerican journal of obstetrics and gynecology2005 192 1501
rarr Dissection right to the medline = safer
ANATOMICAL VARIATIONS OF THE RIGHT URETER
MIDDLE PART PROMONTORY
Flynn MK et al Vascular anatomy of the presacral space a fresh tissue cadaver dissectionAmerican journal of obstetrics and gynecology 2005 192 1501
bull Distances between the right ureter and the midsacral promontory
bull Dissection of 10 cadavers
ANATOMICAL VARIATIONS
OF THE
SUPERIOR HYPOGASTRIC PLEXUS
bull SHP sympathetic plexus connected to IHP
Shiozawa T et al Nerve-preserving sacrocolpopexy anatomical study and surgical approachEuropean journal of obstetrics and gynecology and reproductive biology2010 152 103
ANATOMICAL VARIATIONS OF SUPERIOR HYPOGASTRIC PLEXUS
bull Right hypogastric nerve
Wieslander CK et al Vascular anatomy of the presacral space in unembalmed female cadaversAmerican journal of obstetrics and gynecology 2006 195 1736
d6bull Mean of d6 = 7 mm (0 - 17)
Nerve-preserving sacrocolpopexy anatomical study and surgical approach
Shiozawa T1 et al
By protecting the superiorhypogastric plexus and the part of thepresacral area below the promontorywe can preserve the hypogastricnerves the sacral and pelvicsplanchnic nerves and thus theautonomic innervation of the pelvicorgans
ANATOMICAL VARIATIONS OF LVCA
bull Fixation into the anterior longitudinal
ligament
ANATOMICAL VARIATIONS OF LVCA
Boukkerou M et alPromontofixation procedures use of non-absorbable sutures or tackers Journal de gyneacutecologie obsteacutetrique et biologie de la reproduction2003 32 54
bull Fixation into the anterior longitudinal ligament
and NOT into the disc
ANATOMICAL VARIATIONS OF LVCA
bull Tackers go deep into the bone
Boukkerou M et alPromontofixation procedures use of non-absorbable sutures or tackers Journal de gyneacutecologie obsteacutetrique et biologie de la reproduction2003 32 54
Spondilithis03
ndash Preacutevention bull Asepsie and per-op antibioprophylaxy
ndash Diagnosis ndash Lombalgia fever tence neurologic diseases
ndash Inflammatory Syndrome (CRP)
ndash Radiologic signs (IRM)
bull Immobilisation
bull Antibiotheacuterapie prolongeacutee +- ponction discale
bull Ablation des prothegraveses
bull +- Arthrodegravese laminectomie
Posterior Dissection ndash DENONVILLIERS FASCIA
Since Charles-PierreDenonvilliers first discoveredthe firm membranousstructure between the rectumand prostate or bladder in1836 now calledldquoDenonvilliersrsquo fasciardquo (DF)the origin of DF has remainedcontroversial
Posterior Dissection ndash DENONVILLIERS FASCIA
Based on the evidencesurgeons should be awareof variations and search forthem to create a suitabledissection plane to avoidiatrogenic positive marginsand rectal injury
Rectal Injury04
ndash Sub-peacuteritoneacuteal rectum
bull There is a recto-vaginal space
bull Horizontal Position ++
bull Close to the post face of the vagina on the distal points
bull Danger on the proximal part of the Recto-Vaginal Septum
ndash Preacutevention
bull Follow the post-face of the vagina
bull Systeacutematic pre-operativ preparation
ndash NORMACOL reg
bull Maleable Retractor
ndash Treatment
bull Immeacutediat Suture
bull Mesh contra-Indication
Vaginal Injury04
ndash Preacuteventionbull Ant Vaginal Length - 6 cm ( 4 ndash 75) Jayle et al Masson 1918
bull Post Vaginal Lenght- 9cm (65 ndash 115) Jayle et al Masson 1918
bull There is no difference between the anterior and posteriorvagina thickness
bull If the vagina is too thin ndash Plicature of the vagina
ndash Treatmentbull If Vagina Injury Suture of the vagina
bull There is no contra indication to fix the meshes
RISK OF URETERAL
INJURY lt 11000
ndash Preacutevention
bull Parietal Uretera
ndash Cross between right extern iliac artery and uterine artery
bull Visceral Uretera
ndash Behind the ligaments
ndash Under the bladder
ndash In contact with the bladder
ndash Treatment
bull Per-op
ndash Per-op Bleu carmin en IV
ndash Ureteacuteral Catheter
bull Post-op
ndash Uro-scanner
ndash JJ Ureteral
Bladder
Collection
Sagittal T2
Vagina
Uterus
Ureter ariving in urinoma
Axial T2
Coronale T2
Bladder Injury2
ndash Sub-peacuteritoneacuteal Bladder
bull Vertical Position ++
bull Close to the ant face of the vagina
bull There is NO space
ndash Preacutevention
bull Following the Ant- Face of the vagina
bull Maleable Retractor
ndash Treatment
bull Immeacutediat Suture
bull Mesh Indication
bull Bladder Catheterisation 5 days
Small and Large Bowel Injury
bull Occur when adhesiolysis has to be undertaken
bull Avoid distended bowel at surgery by 48 hours pre op bowel prep
bull Avoid nitrous oxide during surgery as it causes bowel distension
bull If small bowel injured
ndash Repair laparoscopically
ndash Mesh can still be placed
bull Antibiotic cover for 7 days post op
CONCLUSION 1
1 To open the peritoneum tigh-it
2 Dissection on the right side of the mid-sacral ligament
3 Repair carefuly the vessels and the Right ureter
4 Try to preserve the right hypogatsric nerve
5 Fix your needle 1 cm below the promontory
MESH SELECTIONPERTINENT MESH SCIENCEWHY USE A CERTAIN MESH
Pr Bruno DEVAL MD Geoffroy Saint-Hilaire ndash Clinic
Hotel ndashDieu de Paris
Paris V University
MESH STIFFNESS
bullIncreased fibrosis and deposits of unorganized collagen create an increased stiffness
bull (Klinge 1999)
bullStiffness has been linked to clinical complications-heavier stiffer meshes having higher complications
bull (Dietz 2003)
bullStiffer meshes showed decreases in smooth muscle collagen and structural proteins following implantation
bull (Moalli P AUGS 2011)
bullHeavier stiffer meshes showed a greater propensity for stress shielding which in turn could cause reoccurrences of prolapse
bull (Moalli P AUGS 2011)
IMPACT OF VAGINAL SYNTHETIC PROLAPSE MESHES ON THE MECHANICS
OF THE HOST TISSUE RESPONSE
Feola Andrew J 02 February 2012 Doctoral Dissertation University of Pittsburgh
ldquoImplantation of the stiffest mesh in the non human primate
resulted in an exhibition of a stress-shielding response
manifested by inferior biomechanical properties of the
abdominal and vaginal tissues
Less stiff meshes resulted in preservation of tissue
propertiesrdquo
Wolffrsquos Law ndash remodeling of bone in response to stress
MESH CHARACTERISTICS
Density - Filament size ndash Elasticity - Pore size
Surface area ndash Overall ldquomesh loadrdquo
Biomechanical engineers working with type-1
polypropylene have focused on reducing overall
ldquomesh loadrdquo while maintaining durability
bullOptimal tissue incorporation and collagen growthbullNo erosionbullNo palpable mesh to patient and her partnerbullVaginal elasticity
TO OBTAIN
So lighter is better
WHAT KIND OF MESH
bull To date polypropylene meshes are the best type on the market
bull Absorbable meshes do not work
bull There is an evidence to use Polypropylene vs polyesther
bull PTFE and NW meshes are contra ndash indicated in the POP Repair
ULTRA- LIGHT POLYPROPYLENE
bull Physiologically compatible 19 gsm1
bull Ultra lightweightbull Lowest weight available for pelvic restoration
bull 18 millimeter macropores1
ndash Consistent size throughout the mesh
bull 100 micron interstitial Smartporestrade 1ndash Simultaneously encourages both collagen growth and
bacteria fighting propertiesbull Fibroblasts will enter holes that are 50 to 200 microns in size23
bull Macrophages and neutrophils will enter holes that are 50 to 120 microns in size23
bull Reduce inflammation1 Data on file2 Greca FH et at (2007) The influence of porosity on integration histology of two polypropylene meshes for the treatment of abdominal wall
defects in dogs Hernia (12) 45-493 Marois Y et all (2000) Biostability inflammatory response and healing characteristics flourpassivated polyester-knit mesh in the repair of
experimental abdominal hernias Artif Organs 24533-543
ULTRA ndash LIGHT CLINICAL EVIDENCE
SUMMARY
bull Rates of Erosion and Exposurebull Less than 1 erosion rate1
bull Anterior exposure rate 172
bull Posterior exposure rate 052
bull Greater tissue strength 3 months post-op ndash 71 more collagen growth3
bull Mature vaginal elastin decrease was not observed with Smartmesh4
bull Smartmesh did not induce a negative change in collagen metabolism5
bull Smartmesh had similar innervation density as sham 6
bull Low incidence of de novo dyspareunia71 Alinsod R et al (2008) Long term outcomes of vaginal pelvic floor repair using an ultra lightweight mesh AAGL (2008)2 Alinsod R Et al (2012) Durability and Complications of an Ultra Lightweight Transvaginal Mesh in the Treatment of Pelvic Organ Prolapse Presented at the 37th Annual Meeting of IUGA3 Greca FH et al (2007) The influence of porosity on the integration histology of two polypropylene meshes for the treatment of abdominal wall defects in dogs Hernia (12) 45-494 Moalli et al (2012) Mesh implantation negatively impacts vagina elastin metabolism Female Pelvic Medicine amp Reconstructive Surgery Vol 18 (Suppl 2)S258-9 SeptOct paper 235 Moalli et al (2012) Increasing mesh stiffness negatively impacts vaginal collagen metabolism Female Pelvic Medicine amp Reconstructive Surgery Vol 18 (Suppl 2)S258-9 SeptOct paper 246 Moalli et al (2012) The impact of mesh implantation on vaginal smooth muscle innervation Female Pelvic Medicine amp Reconstructive Surgery Vol 18 (Suppl 2)S258-9 SeptOct paper 257 Hawthorn R et al (2007) Use of ultra lightweight mesh in vaginal vault repairs to minimize complications A two centre observation study British International Congress of Obstetrics amp Gynaecology
PRE FORMED Y-MESH VS CUTTING MESH AND MAKING IT TO FIT PATIENTS
Pr Bruno DEVAL MD Geoffroy Saint-Hilaire ndash Clinic
Hotel ndashDieu de Paris
Paris V University
Mesh and operative handling
The shape and weight of the mesh can help us during
laparoscopic procedure
A large Y mesh is a good choice for vaginal vault shape
Better intra-operative manipulation and suturing
Lower mesh mass accommodates easy passage through narrow
laparoscopic ports
Use re-absorbable sutures on the vagina
bull Stitch erosions are reported
bull Folding and wrinkling can cause
erosions and dyspaurenia
Avoid folding and wrinkling the
mesh must be well stretched
DO WE NEED TO DISSECT POSTERIOR DOWN TO PERINEUM OR
IN WHICH PATIENTS THIS IS INDICATED
Pr Bruno DEVAL MD Geoffroy Saint-Hilaire ndash Clinic
Hotel ndashDieu de Paris
Paris V University
Fix the mesh on the posterior
vaginal wall and not on the
elevator ani muscle
bull To avoid dyschezia and chronic
pelvic pain
bull Sacrocolpopexy should only be performed by board certified eligible surgeons (ObGyn or Urology)
bull Knowledge surgical skills and experience in reconstructive pelvic surgery
FPMRS fellowship
CME documentation
Proctoring on 10 cases
gt 50 practice in reconstructive surgery
bull Outcomes and complications of should be monitored by annual internal audit
bull Informed consent should highlight
Alternatives to ASC including pessary
Complications of ASC
Complications of mesh
AUGS Guidelines on Sacrocolpopexy Privileges(March 2013)
Source wwwaugsorg
Conclusion
bull The technique and expertise are
fundamental
bull Laparoscopic colposacropexy can safely
be offered to women with symptomatic
POP
bull Conventional LSCP = Open Way =
robotic way
bull Conventional LSCP gt Vaginal Way
ANATOMY OF THE PRESACRAL SPACE
STRUCTURES TO BE
RESPECTED
FOR A SAFE FIXATION
OF THE MESH
RATE OF
BLOOD TRANSFUSION
02
ANATOMICAL VARIATIONS
OF THE LEFT COMMON ILIAC VEIN MIDDLE PART PROMONTORY
bull Distances between the left common iliac vein and the midsacral promontory
bull Dissection of 52 cadavers
bull Mean of d1 = 27 mm (9 - 52)
bull Mean of d2 = 22 mm (9 - 35)
Wieslander CK et al Vascular anatomy of the presacral space in unembalmedfemale cadaversAmerican journal of obstetrics and gynecology 2006 195 1736
d1
RATE OF
BLOOD TRANSFUSION
02
ANATOMICAL VARIATIONS OF PRESACRAL VESSELS
MIDDLE PART PROMONTORY
bull Presacral vesselsndash Middle sacral vein
Oslash= 2mm (1- 4)
double (80)
left to P= 33
right to P= 52
crossing P= 5
mean of d3 = 7 mm (0-17)
P
d3
Wieslander CK et al Vascular anatomy of the presacral space in unembalmed female cadavers American journal of obstetrics and gynecology 2006 195 1736
ANATOMICAL VARIATIONS OF PRESACRAL VESSELS
MIDDLE PART PROMONTORY
bull Presacral vesselsndash Middle sacral artery
Oslash= 2mm (1- 4)
Left to P= 62
Right to P= 30
Crossing P= 8
Mean of d4 = 4 mm (0-15)
Pd4
Wieslander CK et al Vascular anatomy of the presacral space in unembalmed female cadavers American journal of obstetrics and gynecology 2006 195 1736
ANATOMICAL VARIATIONS OF PRESACRAL VESSELS
MIDDLE PART PROMONTORY
bull Presacral space avascular areas
bull Overlay of vascular structures
bull (10 cadavers)
Flynn MK et al Vascular anatomy of the presacral space a freshtissue cadaver dissectionAmerican journal of obstetrics and gynecology2005 192 1501
rarr Dissection right to the medline = safer
ANATOMICAL VARIATIONS OF THE RIGHT URETER
MIDDLE PART PROMONTORY
Flynn MK et al Vascular anatomy of the presacral space a fresh tissue cadaver dissectionAmerican journal of obstetrics and gynecology 2005 192 1501
bull Distances between the right ureter and the midsacral promontory
bull Dissection of 10 cadavers
ANATOMICAL VARIATIONS
OF THE
SUPERIOR HYPOGASTRIC PLEXUS
bull SHP sympathetic plexus connected to IHP
Shiozawa T et al Nerve-preserving sacrocolpopexy anatomical study and surgical approachEuropean journal of obstetrics and gynecology and reproductive biology2010 152 103
ANATOMICAL VARIATIONS OF SUPERIOR HYPOGASTRIC PLEXUS
bull Right hypogastric nerve
Wieslander CK et al Vascular anatomy of the presacral space in unembalmed female cadaversAmerican journal of obstetrics and gynecology 2006 195 1736
d6bull Mean of d6 = 7 mm (0 - 17)
Nerve-preserving sacrocolpopexy anatomical study and surgical approach
Shiozawa T1 et al
By protecting the superiorhypogastric plexus and the part of thepresacral area below the promontorywe can preserve the hypogastricnerves the sacral and pelvicsplanchnic nerves and thus theautonomic innervation of the pelvicorgans
ANATOMICAL VARIATIONS OF LVCA
bull Fixation into the anterior longitudinal
ligament
ANATOMICAL VARIATIONS OF LVCA
Boukkerou M et alPromontofixation procedures use of non-absorbable sutures or tackers Journal de gyneacutecologie obsteacutetrique et biologie de la reproduction2003 32 54
bull Fixation into the anterior longitudinal ligament
and NOT into the disc
ANATOMICAL VARIATIONS OF LVCA
bull Tackers go deep into the bone
Boukkerou M et alPromontofixation procedures use of non-absorbable sutures or tackers Journal de gyneacutecologie obsteacutetrique et biologie de la reproduction2003 32 54
Spondilithis03
ndash Preacutevention bull Asepsie and per-op antibioprophylaxy
ndash Diagnosis ndash Lombalgia fever tence neurologic diseases
ndash Inflammatory Syndrome (CRP)
ndash Radiologic signs (IRM)
bull Immobilisation
bull Antibiotheacuterapie prolongeacutee +- ponction discale
bull Ablation des prothegraveses
bull +- Arthrodegravese laminectomie
Posterior Dissection ndash DENONVILLIERS FASCIA
Since Charles-PierreDenonvilliers first discoveredthe firm membranousstructure between the rectumand prostate or bladder in1836 now calledldquoDenonvilliersrsquo fasciardquo (DF)the origin of DF has remainedcontroversial
Posterior Dissection ndash DENONVILLIERS FASCIA
Based on the evidencesurgeons should be awareof variations and search forthem to create a suitabledissection plane to avoidiatrogenic positive marginsand rectal injury
Rectal Injury04
ndash Sub-peacuteritoneacuteal rectum
bull There is a recto-vaginal space
bull Horizontal Position ++
bull Close to the post face of the vagina on the distal points
bull Danger on the proximal part of the Recto-Vaginal Septum
ndash Preacutevention
bull Follow the post-face of the vagina
bull Systeacutematic pre-operativ preparation
ndash NORMACOL reg
bull Maleable Retractor
ndash Treatment
bull Immeacutediat Suture
bull Mesh contra-Indication
Vaginal Injury04
ndash Preacuteventionbull Ant Vaginal Length - 6 cm ( 4 ndash 75) Jayle et al Masson 1918
bull Post Vaginal Lenght- 9cm (65 ndash 115) Jayle et al Masson 1918
bull There is no difference between the anterior and posteriorvagina thickness
bull If the vagina is too thin ndash Plicature of the vagina
ndash Treatmentbull If Vagina Injury Suture of the vagina
bull There is no contra indication to fix the meshes
RISK OF URETERAL
INJURY lt 11000
ndash Preacutevention
bull Parietal Uretera
ndash Cross between right extern iliac artery and uterine artery
bull Visceral Uretera
ndash Behind the ligaments
ndash Under the bladder
ndash In contact with the bladder
ndash Treatment
bull Per-op
ndash Per-op Bleu carmin en IV
ndash Ureteacuteral Catheter
bull Post-op
ndash Uro-scanner
ndash JJ Ureteral
Bladder
Collection
Sagittal T2
Vagina
Uterus
Ureter ariving in urinoma
Axial T2
Coronale T2
Bladder Injury2
ndash Sub-peacuteritoneacuteal Bladder
bull Vertical Position ++
bull Close to the ant face of the vagina
bull There is NO space
ndash Preacutevention
bull Following the Ant- Face of the vagina
bull Maleable Retractor
ndash Treatment
bull Immeacutediat Suture
bull Mesh Indication
bull Bladder Catheterisation 5 days
Small and Large Bowel Injury
bull Occur when adhesiolysis has to be undertaken
bull Avoid distended bowel at surgery by 48 hours pre op bowel prep
bull Avoid nitrous oxide during surgery as it causes bowel distension
bull If small bowel injured
ndash Repair laparoscopically
ndash Mesh can still be placed
bull Antibiotic cover for 7 days post op
CONCLUSION 1
1 To open the peritoneum tigh-it
2 Dissection on the right side of the mid-sacral ligament
3 Repair carefuly the vessels and the Right ureter
4 Try to preserve the right hypogatsric nerve
5 Fix your needle 1 cm below the promontory
MESH SELECTIONPERTINENT MESH SCIENCEWHY USE A CERTAIN MESH
Pr Bruno DEVAL MD Geoffroy Saint-Hilaire ndash Clinic
Hotel ndashDieu de Paris
Paris V University
MESH STIFFNESS
bullIncreased fibrosis and deposits of unorganized collagen create an increased stiffness
bull (Klinge 1999)
bullStiffness has been linked to clinical complications-heavier stiffer meshes having higher complications
bull (Dietz 2003)
bullStiffer meshes showed decreases in smooth muscle collagen and structural proteins following implantation
bull (Moalli P AUGS 2011)
bullHeavier stiffer meshes showed a greater propensity for stress shielding which in turn could cause reoccurrences of prolapse
bull (Moalli P AUGS 2011)
IMPACT OF VAGINAL SYNTHETIC PROLAPSE MESHES ON THE MECHANICS
OF THE HOST TISSUE RESPONSE
Feola Andrew J 02 February 2012 Doctoral Dissertation University of Pittsburgh
ldquoImplantation of the stiffest mesh in the non human primate
resulted in an exhibition of a stress-shielding response
manifested by inferior biomechanical properties of the
abdominal and vaginal tissues
Less stiff meshes resulted in preservation of tissue
propertiesrdquo
Wolffrsquos Law ndash remodeling of bone in response to stress
MESH CHARACTERISTICS
Density - Filament size ndash Elasticity - Pore size
Surface area ndash Overall ldquomesh loadrdquo
Biomechanical engineers working with type-1
polypropylene have focused on reducing overall
ldquomesh loadrdquo while maintaining durability
bullOptimal tissue incorporation and collagen growthbullNo erosionbullNo palpable mesh to patient and her partnerbullVaginal elasticity
TO OBTAIN
So lighter is better
WHAT KIND OF MESH
bull To date polypropylene meshes are the best type on the market
bull Absorbable meshes do not work
bull There is an evidence to use Polypropylene vs polyesther
bull PTFE and NW meshes are contra ndash indicated in the POP Repair
ULTRA- LIGHT POLYPROPYLENE
bull Physiologically compatible 19 gsm1
bull Ultra lightweightbull Lowest weight available for pelvic restoration
bull 18 millimeter macropores1
ndash Consistent size throughout the mesh
bull 100 micron interstitial Smartporestrade 1ndash Simultaneously encourages both collagen growth and
bacteria fighting propertiesbull Fibroblasts will enter holes that are 50 to 200 microns in size23
bull Macrophages and neutrophils will enter holes that are 50 to 120 microns in size23
bull Reduce inflammation1 Data on file2 Greca FH et at (2007) The influence of porosity on integration histology of two polypropylene meshes for the treatment of abdominal wall
defects in dogs Hernia (12) 45-493 Marois Y et all (2000) Biostability inflammatory response and healing characteristics flourpassivated polyester-knit mesh in the repair of
experimental abdominal hernias Artif Organs 24533-543
ULTRA ndash LIGHT CLINICAL EVIDENCE
SUMMARY
bull Rates of Erosion and Exposurebull Less than 1 erosion rate1
bull Anterior exposure rate 172
bull Posterior exposure rate 052
bull Greater tissue strength 3 months post-op ndash 71 more collagen growth3
bull Mature vaginal elastin decrease was not observed with Smartmesh4
bull Smartmesh did not induce a negative change in collagen metabolism5
bull Smartmesh had similar innervation density as sham 6
bull Low incidence of de novo dyspareunia71 Alinsod R et al (2008) Long term outcomes of vaginal pelvic floor repair using an ultra lightweight mesh AAGL (2008)2 Alinsod R Et al (2012) Durability and Complications of an Ultra Lightweight Transvaginal Mesh in the Treatment of Pelvic Organ Prolapse Presented at the 37th Annual Meeting of IUGA3 Greca FH et al (2007) The influence of porosity on the integration histology of two polypropylene meshes for the treatment of abdominal wall defects in dogs Hernia (12) 45-494 Moalli et al (2012) Mesh implantation negatively impacts vagina elastin metabolism Female Pelvic Medicine amp Reconstructive Surgery Vol 18 (Suppl 2)S258-9 SeptOct paper 235 Moalli et al (2012) Increasing mesh stiffness negatively impacts vaginal collagen metabolism Female Pelvic Medicine amp Reconstructive Surgery Vol 18 (Suppl 2)S258-9 SeptOct paper 246 Moalli et al (2012) The impact of mesh implantation on vaginal smooth muscle innervation Female Pelvic Medicine amp Reconstructive Surgery Vol 18 (Suppl 2)S258-9 SeptOct paper 257 Hawthorn R et al (2007) Use of ultra lightweight mesh in vaginal vault repairs to minimize complications A two centre observation study British International Congress of Obstetrics amp Gynaecology
PRE FORMED Y-MESH VS CUTTING MESH AND MAKING IT TO FIT PATIENTS
Pr Bruno DEVAL MD Geoffroy Saint-Hilaire ndash Clinic
Hotel ndashDieu de Paris
Paris V University
Mesh and operative handling
The shape and weight of the mesh can help us during
laparoscopic procedure
A large Y mesh is a good choice for vaginal vault shape
Better intra-operative manipulation and suturing
Lower mesh mass accommodates easy passage through narrow
laparoscopic ports
Use re-absorbable sutures on the vagina
bull Stitch erosions are reported
bull Folding and wrinkling can cause
erosions and dyspaurenia
Avoid folding and wrinkling the
mesh must be well stretched
DO WE NEED TO DISSECT POSTERIOR DOWN TO PERINEUM OR
IN WHICH PATIENTS THIS IS INDICATED
Pr Bruno DEVAL MD Geoffroy Saint-Hilaire ndash Clinic
Hotel ndashDieu de Paris
Paris V University
Fix the mesh on the posterior
vaginal wall and not on the
elevator ani muscle
bull To avoid dyschezia and chronic
pelvic pain
bull Sacrocolpopexy should only be performed by board certified eligible surgeons (ObGyn or Urology)
bull Knowledge surgical skills and experience in reconstructive pelvic surgery
FPMRS fellowship
CME documentation
Proctoring on 10 cases
gt 50 practice in reconstructive surgery
bull Outcomes and complications of should be monitored by annual internal audit
bull Informed consent should highlight
Alternatives to ASC including pessary
Complications of ASC
Complications of mesh
AUGS Guidelines on Sacrocolpopexy Privileges(March 2013)
Source wwwaugsorg
Conclusion
bull The technique and expertise are
fundamental
bull Laparoscopic colposacropexy can safely
be offered to women with symptomatic
POP
bull Conventional LSCP = Open Way =
robotic way
bull Conventional LSCP gt Vaginal Way
RATE OF
BLOOD TRANSFUSION
02
ANATOMICAL VARIATIONS
OF THE LEFT COMMON ILIAC VEIN MIDDLE PART PROMONTORY
bull Distances between the left common iliac vein and the midsacral promontory
bull Dissection of 52 cadavers
bull Mean of d1 = 27 mm (9 - 52)
bull Mean of d2 = 22 mm (9 - 35)
Wieslander CK et al Vascular anatomy of the presacral space in unembalmedfemale cadaversAmerican journal of obstetrics and gynecology 2006 195 1736
d1
RATE OF
BLOOD TRANSFUSION
02
ANATOMICAL VARIATIONS OF PRESACRAL VESSELS
MIDDLE PART PROMONTORY
bull Presacral vesselsndash Middle sacral vein
Oslash= 2mm (1- 4)
double (80)
left to P= 33
right to P= 52
crossing P= 5
mean of d3 = 7 mm (0-17)
P
d3
Wieslander CK et al Vascular anatomy of the presacral space in unembalmed female cadavers American journal of obstetrics and gynecology 2006 195 1736
ANATOMICAL VARIATIONS OF PRESACRAL VESSELS
MIDDLE PART PROMONTORY
bull Presacral vesselsndash Middle sacral artery
Oslash= 2mm (1- 4)
Left to P= 62
Right to P= 30
Crossing P= 8
Mean of d4 = 4 mm (0-15)
Pd4
Wieslander CK et al Vascular anatomy of the presacral space in unembalmed female cadavers American journal of obstetrics and gynecology 2006 195 1736
ANATOMICAL VARIATIONS OF PRESACRAL VESSELS
MIDDLE PART PROMONTORY
bull Presacral space avascular areas
bull Overlay of vascular structures
bull (10 cadavers)
Flynn MK et al Vascular anatomy of the presacral space a freshtissue cadaver dissectionAmerican journal of obstetrics and gynecology2005 192 1501
rarr Dissection right to the medline = safer
ANATOMICAL VARIATIONS OF THE RIGHT URETER
MIDDLE PART PROMONTORY
Flynn MK et al Vascular anatomy of the presacral space a fresh tissue cadaver dissectionAmerican journal of obstetrics and gynecology 2005 192 1501
bull Distances between the right ureter and the midsacral promontory
bull Dissection of 10 cadavers
ANATOMICAL VARIATIONS
OF THE
SUPERIOR HYPOGASTRIC PLEXUS
bull SHP sympathetic plexus connected to IHP
Shiozawa T et al Nerve-preserving sacrocolpopexy anatomical study and surgical approachEuropean journal of obstetrics and gynecology and reproductive biology2010 152 103
ANATOMICAL VARIATIONS OF SUPERIOR HYPOGASTRIC PLEXUS
bull Right hypogastric nerve
Wieslander CK et al Vascular anatomy of the presacral space in unembalmed female cadaversAmerican journal of obstetrics and gynecology 2006 195 1736
d6bull Mean of d6 = 7 mm (0 - 17)
Nerve-preserving sacrocolpopexy anatomical study and surgical approach
Shiozawa T1 et al
By protecting the superiorhypogastric plexus and the part of thepresacral area below the promontorywe can preserve the hypogastricnerves the sacral and pelvicsplanchnic nerves and thus theautonomic innervation of the pelvicorgans
ANATOMICAL VARIATIONS OF LVCA
bull Fixation into the anterior longitudinal
ligament
ANATOMICAL VARIATIONS OF LVCA
Boukkerou M et alPromontofixation procedures use of non-absorbable sutures or tackers Journal de gyneacutecologie obsteacutetrique et biologie de la reproduction2003 32 54
bull Fixation into the anterior longitudinal ligament
and NOT into the disc
ANATOMICAL VARIATIONS OF LVCA
bull Tackers go deep into the bone
Boukkerou M et alPromontofixation procedures use of non-absorbable sutures or tackers Journal de gyneacutecologie obsteacutetrique et biologie de la reproduction2003 32 54
Spondilithis03
ndash Preacutevention bull Asepsie and per-op antibioprophylaxy
ndash Diagnosis ndash Lombalgia fever tence neurologic diseases
ndash Inflammatory Syndrome (CRP)
ndash Radiologic signs (IRM)
bull Immobilisation
bull Antibiotheacuterapie prolongeacutee +- ponction discale
bull Ablation des prothegraveses
bull +- Arthrodegravese laminectomie
Posterior Dissection ndash DENONVILLIERS FASCIA
Since Charles-PierreDenonvilliers first discoveredthe firm membranousstructure between the rectumand prostate or bladder in1836 now calledldquoDenonvilliersrsquo fasciardquo (DF)the origin of DF has remainedcontroversial
Posterior Dissection ndash DENONVILLIERS FASCIA
Based on the evidencesurgeons should be awareof variations and search forthem to create a suitabledissection plane to avoidiatrogenic positive marginsand rectal injury
Rectal Injury04
ndash Sub-peacuteritoneacuteal rectum
bull There is a recto-vaginal space
bull Horizontal Position ++
bull Close to the post face of the vagina on the distal points
bull Danger on the proximal part of the Recto-Vaginal Septum
ndash Preacutevention
bull Follow the post-face of the vagina
bull Systeacutematic pre-operativ preparation
ndash NORMACOL reg
bull Maleable Retractor
ndash Treatment
bull Immeacutediat Suture
bull Mesh contra-Indication
Vaginal Injury04
ndash Preacuteventionbull Ant Vaginal Length - 6 cm ( 4 ndash 75) Jayle et al Masson 1918
bull Post Vaginal Lenght- 9cm (65 ndash 115) Jayle et al Masson 1918
bull There is no difference between the anterior and posteriorvagina thickness
bull If the vagina is too thin ndash Plicature of the vagina
ndash Treatmentbull If Vagina Injury Suture of the vagina
bull There is no contra indication to fix the meshes
RISK OF URETERAL
INJURY lt 11000
ndash Preacutevention
bull Parietal Uretera
ndash Cross between right extern iliac artery and uterine artery
bull Visceral Uretera
ndash Behind the ligaments
ndash Under the bladder
ndash In contact with the bladder
ndash Treatment
bull Per-op
ndash Per-op Bleu carmin en IV
ndash Ureteacuteral Catheter
bull Post-op
ndash Uro-scanner
ndash JJ Ureteral
Bladder
Collection
Sagittal T2
Vagina
Uterus
Ureter ariving in urinoma
Axial T2
Coronale T2
Bladder Injury2
ndash Sub-peacuteritoneacuteal Bladder
bull Vertical Position ++
bull Close to the ant face of the vagina
bull There is NO space
ndash Preacutevention
bull Following the Ant- Face of the vagina
bull Maleable Retractor
ndash Treatment
bull Immeacutediat Suture
bull Mesh Indication
bull Bladder Catheterisation 5 days
Small and Large Bowel Injury
bull Occur when adhesiolysis has to be undertaken
bull Avoid distended bowel at surgery by 48 hours pre op bowel prep
bull Avoid nitrous oxide during surgery as it causes bowel distension
bull If small bowel injured
ndash Repair laparoscopically
ndash Mesh can still be placed
bull Antibiotic cover for 7 days post op
CONCLUSION 1
1 To open the peritoneum tigh-it
2 Dissection on the right side of the mid-sacral ligament
3 Repair carefuly the vessels and the Right ureter
4 Try to preserve the right hypogatsric nerve
5 Fix your needle 1 cm below the promontory
MESH SELECTIONPERTINENT MESH SCIENCEWHY USE A CERTAIN MESH
Pr Bruno DEVAL MD Geoffroy Saint-Hilaire ndash Clinic
Hotel ndashDieu de Paris
Paris V University
MESH STIFFNESS
bullIncreased fibrosis and deposits of unorganized collagen create an increased stiffness
bull (Klinge 1999)
bullStiffness has been linked to clinical complications-heavier stiffer meshes having higher complications
bull (Dietz 2003)
bullStiffer meshes showed decreases in smooth muscle collagen and structural proteins following implantation
bull (Moalli P AUGS 2011)
bullHeavier stiffer meshes showed a greater propensity for stress shielding which in turn could cause reoccurrences of prolapse
bull (Moalli P AUGS 2011)
IMPACT OF VAGINAL SYNTHETIC PROLAPSE MESHES ON THE MECHANICS
OF THE HOST TISSUE RESPONSE
Feola Andrew J 02 February 2012 Doctoral Dissertation University of Pittsburgh
ldquoImplantation of the stiffest mesh in the non human primate
resulted in an exhibition of a stress-shielding response
manifested by inferior biomechanical properties of the
abdominal and vaginal tissues
Less stiff meshes resulted in preservation of tissue
propertiesrdquo
Wolffrsquos Law ndash remodeling of bone in response to stress
MESH CHARACTERISTICS
Density - Filament size ndash Elasticity - Pore size
Surface area ndash Overall ldquomesh loadrdquo
Biomechanical engineers working with type-1
polypropylene have focused on reducing overall
ldquomesh loadrdquo while maintaining durability
bullOptimal tissue incorporation and collagen growthbullNo erosionbullNo palpable mesh to patient and her partnerbullVaginal elasticity
TO OBTAIN
So lighter is better
WHAT KIND OF MESH
bull To date polypropylene meshes are the best type on the market
bull Absorbable meshes do not work
bull There is an evidence to use Polypropylene vs polyesther
bull PTFE and NW meshes are contra ndash indicated in the POP Repair
ULTRA- LIGHT POLYPROPYLENE
bull Physiologically compatible 19 gsm1
bull Ultra lightweightbull Lowest weight available for pelvic restoration
bull 18 millimeter macropores1
ndash Consistent size throughout the mesh
bull 100 micron interstitial Smartporestrade 1ndash Simultaneously encourages both collagen growth and
bacteria fighting propertiesbull Fibroblasts will enter holes that are 50 to 200 microns in size23
bull Macrophages and neutrophils will enter holes that are 50 to 120 microns in size23
bull Reduce inflammation1 Data on file2 Greca FH et at (2007) The influence of porosity on integration histology of two polypropylene meshes for the treatment of abdominal wall
defects in dogs Hernia (12) 45-493 Marois Y et all (2000) Biostability inflammatory response and healing characteristics flourpassivated polyester-knit mesh in the repair of
experimental abdominal hernias Artif Organs 24533-543
ULTRA ndash LIGHT CLINICAL EVIDENCE
SUMMARY
bull Rates of Erosion and Exposurebull Less than 1 erosion rate1
bull Anterior exposure rate 172
bull Posterior exposure rate 052
bull Greater tissue strength 3 months post-op ndash 71 more collagen growth3
bull Mature vaginal elastin decrease was not observed with Smartmesh4
bull Smartmesh did not induce a negative change in collagen metabolism5
bull Smartmesh had similar innervation density as sham 6
bull Low incidence of de novo dyspareunia71 Alinsod R et al (2008) Long term outcomes of vaginal pelvic floor repair using an ultra lightweight mesh AAGL (2008)2 Alinsod R Et al (2012) Durability and Complications of an Ultra Lightweight Transvaginal Mesh in the Treatment of Pelvic Organ Prolapse Presented at the 37th Annual Meeting of IUGA3 Greca FH et al (2007) The influence of porosity on the integration histology of two polypropylene meshes for the treatment of abdominal wall defects in dogs Hernia (12) 45-494 Moalli et al (2012) Mesh implantation negatively impacts vagina elastin metabolism Female Pelvic Medicine amp Reconstructive Surgery Vol 18 (Suppl 2)S258-9 SeptOct paper 235 Moalli et al (2012) Increasing mesh stiffness negatively impacts vaginal collagen metabolism Female Pelvic Medicine amp Reconstructive Surgery Vol 18 (Suppl 2)S258-9 SeptOct paper 246 Moalli et al (2012) The impact of mesh implantation on vaginal smooth muscle innervation Female Pelvic Medicine amp Reconstructive Surgery Vol 18 (Suppl 2)S258-9 SeptOct paper 257 Hawthorn R et al (2007) Use of ultra lightweight mesh in vaginal vault repairs to minimize complications A two centre observation study British International Congress of Obstetrics amp Gynaecology
PRE FORMED Y-MESH VS CUTTING MESH AND MAKING IT TO FIT PATIENTS
Pr Bruno DEVAL MD Geoffroy Saint-Hilaire ndash Clinic
Hotel ndashDieu de Paris
Paris V University
Mesh and operative handling
The shape and weight of the mesh can help us during
laparoscopic procedure
A large Y mesh is a good choice for vaginal vault shape
Better intra-operative manipulation and suturing
Lower mesh mass accommodates easy passage through narrow
laparoscopic ports
Use re-absorbable sutures on the vagina
bull Stitch erosions are reported
bull Folding and wrinkling can cause
erosions and dyspaurenia
Avoid folding and wrinkling the
mesh must be well stretched
DO WE NEED TO DISSECT POSTERIOR DOWN TO PERINEUM OR
IN WHICH PATIENTS THIS IS INDICATED
Pr Bruno DEVAL MD Geoffroy Saint-Hilaire ndash Clinic
Hotel ndashDieu de Paris
Paris V University
Fix the mesh on the posterior
vaginal wall and not on the
elevator ani muscle
bull To avoid dyschezia and chronic
pelvic pain
bull Sacrocolpopexy should only be performed by board certified eligible surgeons (ObGyn or Urology)
bull Knowledge surgical skills and experience in reconstructive pelvic surgery
FPMRS fellowship
CME documentation
Proctoring on 10 cases
gt 50 practice in reconstructive surgery
bull Outcomes and complications of should be monitored by annual internal audit
bull Informed consent should highlight
Alternatives to ASC including pessary
Complications of ASC
Complications of mesh
AUGS Guidelines on Sacrocolpopexy Privileges(March 2013)
Source wwwaugsorg
Conclusion
bull The technique and expertise are
fundamental
bull Laparoscopic colposacropexy can safely
be offered to women with symptomatic
POP
bull Conventional LSCP = Open Way =
robotic way
bull Conventional LSCP gt Vaginal Way
RATE OF
BLOOD TRANSFUSION
02
ANATOMICAL VARIATIONS OF PRESACRAL VESSELS
MIDDLE PART PROMONTORY
bull Presacral vesselsndash Middle sacral vein
Oslash= 2mm (1- 4)
double (80)
left to P= 33
right to P= 52
crossing P= 5
mean of d3 = 7 mm (0-17)
P
d3
Wieslander CK et al Vascular anatomy of the presacral space in unembalmed female cadavers American journal of obstetrics and gynecology 2006 195 1736
ANATOMICAL VARIATIONS OF PRESACRAL VESSELS
MIDDLE PART PROMONTORY
bull Presacral vesselsndash Middle sacral artery
Oslash= 2mm (1- 4)
Left to P= 62
Right to P= 30
Crossing P= 8
Mean of d4 = 4 mm (0-15)
Pd4
Wieslander CK et al Vascular anatomy of the presacral space in unembalmed female cadavers American journal of obstetrics and gynecology 2006 195 1736
ANATOMICAL VARIATIONS OF PRESACRAL VESSELS
MIDDLE PART PROMONTORY
bull Presacral space avascular areas
bull Overlay of vascular structures
bull (10 cadavers)
Flynn MK et al Vascular anatomy of the presacral space a freshtissue cadaver dissectionAmerican journal of obstetrics and gynecology2005 192 1501
rarr Dissection right to the medline = safer
ANATOMICAL VARIATIONS OF THE RIGHT URETER
MIDDLE PART PROMONTORY
Flynn MK et al Vascular anatomy of the presacral space a fresh tissue cadaver dissectionAmerican journal of obstetrics and gynecology 2005 192 1501
bull Distances between the right ureter and the midsacral promontory
bull Dissection of 10 cadavers
ANATOMICAL VARIATIONS
OF THE
SUPERIOR HYPOGASTRIC PLEXUS
bull SHP sympathetic plexus connected to IHP
Shiozawa T et al Nerve-preserving sacrocolpopexy anatomical study and surgical approachEuropean journal of obstetrics and gynecology and reproductive biology2010 152 103
ANATOMICAL VARIATIONS OF SUPERIOR HYPOGASTRIC PLEXUS
bull Right hypogastric nerve
Wieslander CK et al Vascular anatomy of the presacral space in unembalmed female cadaversAmerican journal of obstetrics and gynecology 2006 195 1736
d6bull Mean of d6 = 7 mm (0 - 17)
Nerve-preserving sacrocolpopexy anatomical study and surgical approach
Shiozawa T1 et al
By protecting the superiorhypogastric plexus and the part of thepresacral area below the promontorywe can preserve the hypogastricnerves the sacral and pelvicsplanchnic nerves and thus theautonomic innervation of the pelvicorgans
ANATOMICAL VARIATIONS OF LVCA
bull Fixation into the anterior longitudinal
ligament
ANATOMICAL VARIATIONS OF LVCA
Boukkerou M et alPromontofixation procedures use of non-absorbable sutures or tackers Journal de gyneacutecologie obsteacutetrique et biologie de la reproduction2003 32 54
bull Fixation into the anterior longitudinal ligament
and NOT into the disc
ANATOMICAL VARIATIONS OF LVCA
bull Tackers go deep into the bone
Boukkerou M et alPromontofixation procedures use of non-absorbable sutures or tackers Journal de gyneacutecologie obsteacutetrique et biologie de la reproduction2003 32 54
Spondilithis03
ndash Preacutevention bull Asepsie and per-op antibioprophylaxy
ndash Diagnosis ndash Lombalgia fever tence neurologic diseases
ndash Inflammatory Syndrome (CRP)
ndash Radiologic signs (IRM)
bull Immobilisation
bull Antibiotheacuterapie prolongeacutee +- ponction discale
bull Ablation des prothegraveses
bull +- Arthrodegravese laminectomie
Posterior Dissection ndash DENONVILLIERS FASCIA
Since Charles-PierreDenonvilliers first discoveredthe firm membranousstructure between the rectumand prostate or bladder in1836 now calledldquoDenonvilliersrsquo fasciardquo (DF)the origin of DF has remainedcontroversial
Posterior Dissection ndash DENONVILLIERS FASCIA
Based on the evidencesurgeons should be awareof variations and search forthem to create a suitabledissection plane to avoidiatrogenic positive marginsand rectal injury
Rectal Injury04
ndash Sub-peacuteritoneacuteal rectum
bull There is a recto-vaginal space
bull Horizontal Position ++
bull Close to the post face of the vagina on the distal points
bull Danger on the proximal part of the Recto-Vaginal Septum
ndash Preacutevention
bull Follow the post-face of the vagina
bull Systeacutematic pre-operativ preparation
ndash NORMACOL reg
bull Maleable Retractor
ndash Treatment
bull Immeacutediat Suture
bull Mesh contra-Indication
Vaginal Injury04
ndash Preacuteventionbull Ant Vaginal Length - 6 cm ( 4 ndash 75) Jayle et al Masson 1918
bull Post Vaginal Lenght- 9cm (65 ndash 115) Jayle et al Masson 1918
bull There is no difference between the anterior and posteriorvagina thickness
bull If the vagina is too thin ndash Plicature of the vagina
ndash Treatmentbull If Vagina Injury Suture of the vagina
bull There is no contra indication to fix the meshes
RISK OF URETERAL
INJURY lt 11000
ndash Preacutevention
bull Parietal Uretera
ndash Cross between right extern iliac artery and uterine artery
bull Visceral Uretera
ndash Behind the ligaments
ndash Under the bladder
ndash In contact with the bladder
ndash Treatment
bull Per-op
ndash Per-op Bleu carmin en IV
ndash Ureteacuteral Catheter
bull Post-op
ndash Uro-scanner
ndash JJ Ureteral
Bladder
Collection
Sagittal T2
Vagina
Uterus
Ureter ariving in urinoma
Axial T2
Coronale T2
Bladder Injury2
ndash Sub-peacuteritoneacuteal Bladder
bull Vertical Position ++
bull Close to the ant face of the vagina
bull There is NO space
ndash Preacutevention
bull Following the Ant- Face of the vagina
bull Maleable Retractor
ndash Treatment
bull Immeacutediat Suture
bull Mesh Indication
bull Bladder Catheterisation 5 days
Small and Large Bowel Injury
bull Occur when adhesiolysis has to be undertaken
bull Avoid distended bowel at surgery by 48 hours pre op bowel prep
bull Avoid nitrous oxide during surgery as it causes bowel distension
bull If small bowel injured
ndash Repair laparoscopically
ndash Mesh can still be placed
bull Antibiotic cover for 7 days post op
CONCLUSION 1
1 To open the peritoneum tigh-it
2 Dissection on the right side of the mid-sacral ligament
3 Repair carefuly the vessels and the Right ureter
4 Try to preserve the right hypogatsric nerve
5 Fix your needle 1 cm below the promontory
MESH SELECTIONPERTINENT MESH SCIENCEWHY USE A CERTAIN MESH
Pr Bruno DEVAL MD Geoffroy Saint-Hilaire ndash Clinic
Hotel ndashDieu de Paris
Paris V University
MESH STIFFNESS
bullIncreased fibrosis and deposits of unorganized collagen create an increased stiffness
bull (Klinge 1999)
bullStiffness has been linked to clinical complications-heavier stiffer meshes having higher complications
bull (Dietz 2003)
bullStiffer meshes showed decreases in smooth muscle collagen and structural proteins following implantation
bull (Moalli P AUGS 2011)
bullHeavier stiffer meshes showed a greater propensity for stress shielding which in turn could cause reoccurrences of prolapse
bull (Moalli P AUGS 2011)
IMPACT OF VAGINAL SYNTHETIC PROLAPSE MESHES ON THE MECHANICS
OF THE HOST TISSUE RESPONSE
Feola Andrew J 02 February 2012 Doctoral Dissertation University of Pittsburgh
ldquoImplantation of the stiffest mesh in the non human primate
resulted in an exhibition of a stress-shielding response
manifested by inferior biomechanical properties of the
abdominal and vaginal tissues
Less stiff meshes resulted in preservation of tissue
propertiesrdquo
Wolffrsquos Law ndash remodeling of bone in response to stress
MESH CHARACTERISTICS
Density - Filament size ndash Elasticity - Pore size
Surface area ndash Overall ldquomesh loadrdquo
Biomechanical engineers working with type-1
polypropylene have focused on reducing overall
ldquomesh loadrdquo while maintaining durability
bullOptimal tissue incorporation and collagen growthbullNo erosionbullNo palpable mesh to patient and her partnerbullVaginal elasticity
TO OBTAIN
So lighter is better
WHAT KIND OF MESH
bull To date polypropylene meshes are the best type on the market
bull Absorbable meshes do not work
bull There is an evidence to use Polypropylene vs polyesther
bull PTFE and NW meshes are contra ndash indicated in the POP Repair
ULTRA- LIGHT POLYPROPYLENE
bull Physiologically compatible 19 gsm1
bull Ultra lightweightbull Lowest weight available for pelvic restoration
bull 18 millimeter macropores1
ndash Consistent size throughout the mesh
bull 100 micron interstitial Smartporestrade 1ndash Simultaneously encourages both collagen growth and
bacteria fighting propertiesbull Fibroblasts will enter holes that are 50 to 200 microns in size23
bull Macrophages and neutrophils will enter holes that are 50 to 120 microns in size23
bull Reduce inflammation1 Data on file2 Greca FH et at (2007) The influence of porosity on integration histology of two polypropylene meshes for the treatment of abdominal wall
defects in dogs Hernia (12) 45-493 Marois Y et all (2000) Biostability inflammatory response and healing characteristics flourpassivated polyester-knit mesh in the repair of
experimental abdominal hernias Artif Organs 24533-543
ULTRA ndash LIGHT CLINICAL EVIDENCE
SUMMARY
bull Rates of Erosion and Exposurebull Less than 1 erosion rate1
bull Anterior exposure rate 172
bull Posterior exposure rate 052
bull Greater tissue strength 3 months post-op ndash 71 more collagen growth3
bull Mature vaginal elastin decrease was not observed with Smartmesh4
bull Smartmesh did not induce a negative change in collagen metabolism5
bull Smartmesh had similar innervation density as sham 6
bull Low incidence of de novo dyspareunia71 Alinsod R et al (2008) Long term outcomes of vaginal pelvic floor repair using an ultra lightweight mesh AAGL (2008)2 Alinsod R Et al (2012) Durability and Complications of an Ultra Lightweight Transvaginal Mesh in the Treatment of Pelvic Organ Prolapse Presented at the 37th Annual Meeting of IUGA3 Greca FH et al (2007) The influence of porosity on the integration histology of two polypropylene meshes for the treatment of abdominal wall defects in dogs Hernia (12) 45-494 Moalli et al (2012) Mesh implantation negatively impacts vagina elastin metabolism Female Pelvic Medicine amp Reconstructive Surgery Vol 18 (Suppl 2)S258-9 SeptOct paper 235 Moalli et al (2012) Increasing mesh stiffness negatively impacts vaginal collagen metabolism Female Pelvic Medicine amp Reconstructive Surgery Vol 18 (Suppl 2)S258-9 SeptOct paper 246 Moalli et al (2012) The impact of mesh implantation on vaginal smooth muscle innervation Female Pelvic Medicine amp Reconstructive Surgery Vol 18 (Suppl 2)S258-9 SeptOct paper 257 Hawthorn R et al (2007) Use of ultra lightweight mesh in vaginal vault repairs to minimize complications A two centre observation study British International Congress of Obstetrics amp Gynaecology
PRE FORMED Y-MESH VS CUTTING MESH AND MAKING IT TO FIT PATIENTS
Pr Bruno DEVAL MD Geoffroy Saint-Hilaire ndash Clinic
Hotel ndashDieu de Paris
Paris V University
Mesh and operative handling
The shape and weight of the mesh can help us during
laparoscopic procedure
A large Y mesh is a good choice for vaginal vault shape
Better intra-operative manipulation and suturing
Lower mesh mass accommodates easy passage through narrow
laparoscopic ports
Use re-absorbable sutures on the vagina
bull Stitch erosions are reported
bull Folding and wrinkling can cause
erosions and dyspaurenia
Avoid folding and wrinkling the
mesh must be well stretched
DO WE NEED TO DISSECT POSTERIOR DOWN TO PERINEUM OR
IN WHICH PATIENTS THIS IS INDICATED
Pr Bruno DEVAL MD Geoffroy Saint-Hilaire ndash Clinic
Hotel ndashDieu de Paris
Paris V University
Fix the mesh on the posterior
vaginal wall and not on the
elevator ani muscle
bull To avoid dyschezia and chronic
pelvic pain
bull Sacrocolpopexy should only be performed by board certified eligible surgeons (ObGyn or Urology)
bull Knowledge surgical skills and experience in reconstructive pelvic surgery
FPMRS fellowship
CME documentation
Proctoring on 10 cases
gt 50 practice in reconstructive surgery
bull Outcomes and complications of should be monitored by annual internal audit
bull Informed consent should highlight
Alternatives to ASC including pessary
Complications of ASC
Complications of mesh
AUGS Guidelines on Sacrocolpopexy Privileges(March 2013)
Source wwwaugsorg
Conclusion
bull The technique and expertise are
fundamental
bull Laparoscopic colposacropexy can safely
be offered to women with symptomatic
POP
bull Conventional LSCP = Open Way =
robotic way
bull Conventional LSCP gt Vaginal Way
ANATOMICAL VARIATIONS OF PRESACRAL VESSELS
MIDDLE PART PROMONTORY
bull Presacral vesselsndash Middle sacral artery
Oslash= 2mm (1- 4)
Left to P= 62
Right to P= 30
Crossing P= 8
Mean of d4 = 4 mm (0-15)
Pd4
Wieslander CK et al Vascular anatomy of the presacral space in unembalmed female cadavers American journal of obstetrics and gynecology 2006 195 1736
ANATOMICAL VARIATIONS OF PRESACRAL VESSELS
MIDDLE PART PROMONTORY
bull Presacral space avascular areas
bull Overlay of vascular structures
bull (10 cadavers)
Flynn MK et al Vascular anatomy of the presacral space a freshtissue cadaver dissectionAmerican journal of obstetrics and gynecology2005 192 1501
rarr Dissection right to the medline = safer
ANATOMICAL VARIATIONS OF THE RIGHT URETER
MIDDLE PART PROMONTORY
Flynn MK et al Vascular anatomy of the presacral space a fresh tissue cadaver dissectionAmerican journal of obstetrics and gynecology 2005 192 1501
bull Distances between the right ureter and the midsacral promontory
bull Dissection of 10 cadavers
ANATOMICAL VARIATIONS
OF THE
SUPERIOR HYPOGASTRIC PLEXUS
bull SHP sympathetic plexus connected to IHP
Shiozawa T et al Nerve-preserving sacrocolpopexy anatomical study and surgical approachEuropean journal of obstetrics and gynecology and reproductive biology2010 152 103
ANATOMICAL VARIATIONS OF SUPERIOR HYPOGASTRIC PLEXUS
bull Right hypogastric nerve
Wieslander CK et al Vascular anatomy of the presacral space in unembalmed female cadaversAmerican journal of obstetrics and gynecology 2006 195 1736
d6bull Mean of d6 = 7 mm (0 - 17)
Nerve-preserving sacrocolpopexy anatomical study and surgical approach
Shiozawa T1 et al
By protecting the superiorhypogastric plexus and the part of thepresacral area below the promontorywe can preserve the hypogastricnerves the sacral and pelvicsplanchnic nerves and thus theautonomic innervation of the pelvicorgans
ANATOMICAL VARIATIONS OF LVCA
bull Fixation into the anterior longitudinal
ligament
ANATOMICAL VARIATIONS OF LVCA
Boukkerou M et alPromontofixation procedures use of non-absorbable sutures or tackers Journal de gyneacutecologie obsteacutetrique et biologie de la reproduction2003 32 54
bull Fixation into the anterior longitudinal ligament
and NOT into the disc
ANATOMICAL VARIATIONS OF LVCA
bull Tackers go deep into the bone
Boukkerou M et alPromontofixation procedures use of non-absorbable sutures or tackers Journal de gyneacutecologie obsteacutetrique et biologie de la reproduction2003 32 54
Spondilithis03
ndash Preacutevention bull Asepsie and per-op antibioprophylaxy
ndash Diagnosis ndash Lombalgia fever tence neurologic diseases
ndash Inflammatory Syndrome (CRP)
ndash Radiologic signs (IRM)
bull Immobilisation
bull Antibiotheacuterapie prolongeacutee +- ponction discale
bull Ablation des prothegraveses
bull +- Arthrodegravese laminectomie
Posterior Dissection ndash DENONVILLIERS FASCIA
Since Charles-PierreDenonvilliers first discoveredthe firm membranousstructure between the rectumand prostate or bladder in1836 now calledldquoDenonvilliersrsquo fasciardquo (DF)the origin of DF has remainedcontroversial
Posterior Dissection ndash DENONVILLIERS FASCIA
Based on the evidencesurgeons should be awareof variations and search forthem to create a suitabledissection plane to avoidiatrogenic positive marginsand rectal injury
Rectal Injury04
ndash Sub-peacuteritoneacuteal rectum
bull There is a recto-vaginal space
bull Horizontal Position ++
bull Close to the post face of the vagina on the distal points
bull Danger on the proximal part of the Recto-Vaginal Septum
ndash Preacutevention
bull Follow the post-face of the vagina
bull Systeacutematic pre-operativ preparation
ndash NORMACOL reg
bull Maleable Retractor
ndash Treatment
bull Immeacutediat Suture
bull Mesh contra-Indication
Vaginal Injury04
ndash Preacuteventionbull Ant Vaginal Length - 6 cm ( 4 ndash 75) Jayle et al Masson 1918
bull Post Vaginal Lenght- 9cm (65 ndash 115) Jayle et al Masson 1918
bull There is no difference between the anterior and posteriorvagina thickness
bull If the vagina is too thin ndash Plicature of the vagina
ndash Treatmentbull If Vagina Injury Suture of the vagina
bull There is no contra indication to fix the meshes
RISK OF URETERAL
INJURY lt 11000
ndash Preacutevention
bull Parietal Uretera
ndash Cross between right extern iliac artery and uterine artery
bull Visceral Uretera
ndash Behind the ligaments
ndash Under the bladder
ndash In contact with the bladder
ndash Treatment
bull Per-op
ndash Per-op Bleu carmin en IV
ndash Ureteacuteral Catheter
bull Post-op
ndash Uro-scanner
ndash JJ Ureteral
Bladder
Collection
Sagittal T2
Vagina
Uterus
Ureter ariving in urinoma
Axial T2
Coronale T2
Bladder Injury2
ndash Sub-peacuteritoneacuteal Bladder
bull Vertical Position ++
bull Close to the ant face of the vagina
bull There is NO space
ndash Preacutevention
bull Following the Ant- Face of the vagina
bull Maleable Retractor
ndash Treatment
bull Immeacutediat Suture
bull Mesh Indication
bull Bladder Catheterisation 5 days
Small and Large Bowel Injury
bull Occur when adhesiolysis has to be undertaken
bull Avoid distended bowel at surgery by 48 hours pre op bowel prep
bull Avoid nitrous oxide during surgery as it causes bowel distension
bull If small bowel injured
ndash Repair laparoscopically
ndash Mesh can still be placed
bull Antibiotic cover for 7 days post op
CONCLUSION 1
1 To open the peritoneum tigh-it
2 Dissection on the right side of the mid-sacral ligament
3 Repair carefuly the vessels and the Right ureter
4 Try to preserve the right hypogatsric nerve
5 Fix your needle 1 cm below the promontory
MESH SELECTIONPERTINENT MESH SCIENCEWHY USE A CERTAIN MESH
Pr Bruno DEVAL MD Geoffroy Saint-Hilaire ndash Clinic
Hotel ndashDieu de Paris
Paris V University
MESH STIFFNESS
bullIncreased fibrosis and deposits of unorganized collagen create an increased stiffness
bull (Klinge 1999)
bullStiffness has been linked to clinical complications-heavier stiffer meshes having higher complications
bull (Dietz 2003)
bullStiffer meshes showed decreases in smooth muscle collagen and structural proteins following implantation
bull (Moalli P AUGS 2011)
bullHeavier stiffer meshes showed a greater propensity for stress shielding which in turn could cause reoccurrences of prolapse
bull (Moalli P AUGS 2011)
IMPACT OF VAGINAL SYNTHETIC PROLAPSE MESHES ON THE MECHANICS
OF THE HOST TISSUE RESPONSE
Feola Andrew J 02 February 2012 Doctoral Dissertation University of Pittsburgh
ldquoImplantation of the stiffest mesh in the non human primate
resulted in an exhibition of a stress-shielding response
manifested by inferior biomechanical properties of the
abdominal and vaginal tissues
Less stiff meshes resulted in preservation of tissue
propertiesrdquo
Wolffrsquos Law ndash remodeling of bone in response to stress
MESH CHARACTERISTICS
Density - Filament size ndash Elasticity - Pore size
Surface area ndash Overall ldquomesh loadrdquo
Biomechanical engineers working with type-1
polypropylene have focused on reducing overall
ldquomesh loadrdquo while maintaining durability
bullOptimal tissue incorporation and collagen growthbullNo erosionbullNo palpable mesh to patient and her partnerbullVaginal elasticity
TO OBTAIN
So lighter is better
WHAT KIND OF MESH
bull To date polypropylene meshes are the best type on the market
bull Absorbable meshes do not work
bull There is an evidence to use Polypropylene vs polyesther
bull PTFE and NW meshes are contra ndash indicated in the POP Repair
ULTRA- LIGHT POLYPROPYLENE
bull Physiologically compatible 19 gsm1
bull Ultra lightweightbull Lowest weight available for pelvic restoration
bull 18 millimeter macropores1
ndash Consistent size throughout the mesh
bull 100 micron interstitial Smartporestrade 1ndash Simultaneously encourages both collagen growth and
bacteria fighting propertiesbull Fibroblasts will enter holes that are 50 to 200 microns in size23
bull Macrophages and neutrophils will enter holes that are 50 to 120 microns in size23
bull Reduce inflammation1 Data on file2 Greca FH et at (2007) The influence of porosity on integration histology of two polypropylene meshes for the treatment of abdominal wall
defects in dogs Hernia (12) 45-493 Marois Y et all (2000) Biostability inflammatory response and healing characteristics flourpassivated polyester-knit mesh in the repair of
experimental abdominal hernias Artif Organs 24533-543
ULTRA ndash LIGHT CLINICAL EVIDENCE
SUMMARY
bull Rates of Erosion and Exposurebull Less than 1 erosion rate1
bull Anterior exposure rate 172
bull Posterior exposure rate 052
bull Greater tissue strength 3 months post-op ndash 71 more collagen growth3
bull Mature vaginal elastin decrease was not observed with Smartmesh4
bull Smartmesh did not induce a negative change in collagen metabolism5
bull Smartmesh had similar innervation density as sham 6
bull Low incidence of de novo dyspareunia71 Alinsod R et al (2008) Long term outcomes of vaginal pelvic floor repair using an ultra lightweight mesh AAGL (2008)2 Alinsod R Et al (2012) Durability and Complications of an Ultra Lightweight Transvaginal Mesh in the Treatment of Pelvic Organ Prolapse Presented at the 37th Annual Meeting of IUGA3 Greca FH et al (2007) The influence of porosity on the integration histology of two polypropylene meshes for the treatment of abdominal wall defects in dogs Hernia (12) 45-494 Moalli et al (2012) Mesh implantation negatively impacts vagina elastin metabolism Female Pelvic Medicine amp Reconstructive Surgery Vol 18 (Suppl 2)S258-9 SeptOct paper 235 Moalli et al (2012) Increasing mesh stiffness negatively impacts vaginal collagen metabolism Female Pelvic Medicine amp Reconstructive Surgery Vol 18 (Suppl 2)S258-9 SeptOct paper 246 Moalli et al (2012) The impact of mesh implantation on vaginal smooth muscle innervation Female Pelvic Medicine amp Reconstructive Surgery Vol 18 (Suppl 2)S258-9 SeptOct paper 257 Hawthorn R et al (2007) Use of ultra lightweight mesh in vaginal vault repairs to minimize complications A two centre observation study British International Congress of Obstetrics amp Gynaecology
PRE FORMED Y-MESH VS CUTTING MESH AND MAKING IT TO FIT PATIENTS
Pr Bruno DEVAL MD Geoffroy Saint-Hilaire ndash Clinic
Hotel ndashDieu de Paris
Paris V University
Mesh and operative handling
The shape and weight of the mesh can help us during
laparoscopic procedure
A large Y mesh is a good choice for vaginal vault shape
Better intra-operative manipulation and suturing
Lower mesh mass accommodates easy passage through narrow
laparoscopic ports
Use re-absorbable sutures on the vagina
bull Stitch erosions are reported
bull Folding and wrinkling can cause
erosions and dyspaurenia
Avoid folding and wrinkling the
mesh must be well stretched
DO WE NEED TO DISSECT POSTERIOR DOWN TO PERINEUM OR
IN WHICH PATIENTS THIS IS INDICATED
Pr Bruno DEVAL MD Geoffroy Saint-Hilaire ndash Clinic
Hotel ndashDieu de Paris
Paris V University
Fix the mesh on the posterior
vaginal wall and not on the
elevator ani muscle
bull To avoid dyschezia and chronic
pelvic pain
bull Sacrocolpopexy should only be performed by board certified eligible surgeons (ObGyn or Urology)
bull Knowledge surgical skills and experience in reconstructive pelvic surgery
FPMRS fellowship
CME documentation
Proctoring on 10 cases
gt 50 practice in reconstructive surgery
bull Outcomes and complications of should be monitored by annual internal audit
bull Informed consent should highlight
Alternatives to ASC including pessary
Complications of ASC
Complications of mesh
AUGS Guidelines on Sacrocolpopexy Privileges(March 2013)
Source wwwaugsorg
Conclusion
bull The technique and expertise are
fundamental
bull Laparoscopic colposacropexy can safely
be offered to women with symptomatic
POP
bull Conventional LSCP = Open Way =
robotic way
bull Conventional LSCP gt Vaginal Way
ANATOMICAL VARIATIONS OF PRESACRAL VESSELS
MIDDLE PART PROMONTORY
bull Presacral space avascular areas
bull Overlay of vascular structures
bull (10 cadavers)
Flynn MK et al Vascular anatomy of the presacral space a freshtissue cadaver dissectionAmerican journal of obstetrics and gynecology2005 192 1501
rarr Dissection right to the medline = safer
ANATOMICAL VARIATIONS OF THE RIGHT URETER
MIDDLE PART PROMONTORY
Flynn MK et al Vascular anatomy of the presacral space a fresh tissue cadaver dissectionAmerican journal of obstetrics and gynecology 2005 192 1501
bull Distances between the right ureter and the midsacral promontory
bull Dissection of 10 cadavers
ANATOMICAL VARIATIONS
OF THE
SUPERIOR HYPOGASTRIC PLEXUS
bull SHP sympathetic plexus connected to IHP
Shiozawa T et al Nerve-preserving sacrocolpopexy anatomical study and surgical approachEuropean journal of obstetrics and gynecology and reproductive biology2010 152 103
ANATOMICAL VARIATIONS OF SUPERIOR HYPOGASTRIC PLEXUS
bull Right hypogastric nerve
Wieslander CK et al Vascular anatomy of the presacral space in unembalmed female cadaversAmerican journal of obstetrics and gynecology 2006 195 1736
d6bull Mean of d6 = 7 mm (0 - 17)
Nerve-preserving sacrocolpopexy anatomical study and surgical approach
Shiozawa T1 et al
By protecting the superiorhypogastric plexus and the part of thepresacral area below the promontorywe can preserve the hypogastricnerves the sacral and pelvicsplanchnic nerves and thus theautonomic innervation of the pelvicorgans
ANATOMICAL VARIATIONS OF LVCA
bull Fixation into the anterior longitudinal
ligament
ANATOMICAL VARIATIONS OF LVCA
Boukkerou M et alPromontofixation procedures use of non-absorbable sutures or tackers Journal de gyneacutecologie obsteacutetrique et biologie de la reproduction2003 32 54
bull Fixation into the anterior longitudinal ligament
and NOT into the disc
ANATOMICAL VARIATIONS OF LVCA
bull Tackers go deep into the bone
Boukkerou M et alPromontofixation procedures use of non-absorbable sutures or tackers Journal de gyneacutecologie obsteacutetrique et biologie de la reproduction2003 32 54
Spondilithis03
ndash Preacutevention bull Asepsie and per-op antibioprophylaxy
ndash Diagnosis ndash Lombalgia fever tence neurologic diseases
ndash Inflammatory Syndrome (CRP)
ndash Radiologic signs (IRM)
bull Immobilisation
bull Antibiotheacuterapie prolongeacutee +- ponction discale
bull Ablation des prothegraveses
bull +- Arthrodegravese laminectomie
Posterior Dissection ndash DENONVILLIERS FASCIA
Since Charles-PierreDenonvilliers first discoveredthe firm membranousstructure between the rectumand prostate or bladder in1836 now calledldquoDenonvilliersrsquo fasciardquo (DF)the origin of DF has remainedcontroversial
Posterior Dissection ndash DENONVILLIERS FASCIA
Based on the evidencesurgeons should be awareof variations and search forthem to create a suitabledissection plane to avoidiatrogenic positive marginsand rectal injury
Rectal Injury04
ndash Sub-peacuteritoneacuteal rectum
bull There is a recto-vaginal space
bull Horizontal Position ++
bull Close to the post face of the vagina on the distal points
bull Danger on the proximal part of the Recto-Vaginal Septum
ndash Preacutevention
bull Follow the post-face of the vagina
bull Systeacutematic pre-operativ preparation
ndash NORMACOL reg
bull Maleable Retractor
ndash Treatment
bull Immeacutediat Suture
bull Mesh contra-Indication
Vaginal Injury04
ndash Preacuteventionbull Ant Vaginal Length - 6 cm ( 4 ndash 75) Jayle et al Masson 1918
bull Post Vaginal Lenght- 9cm (65 ndash 115) Jayle et al Masson 1918
bull There is no difference between the anterior and posteriorvagina thickness
bull If the vagina is too thin ndash Plicature of the vagina
ndash Treatmentbull If Vagina Injury Suture of the vagina
bull There is no contra indication to fix the meshes
RISK OF URETERAL
INJURY lt 11000
ndash Preacutevention
bull Parietal Uretera
ndash Cross between right extern iliac artery and uterine artery
bull Visceral Uretera
ndash Behind the ligaments
ndash Under the bladder
ndash In contact with the bladder
ndash Treatment
bull Per-op
ndash Per-op Bleu carmin en IV
ndash Ureteacuteral Catheter
bull Post-op
ndash Uro-scanner
ndash JJ Ureteral
Bladder
Collection
Sagittal T2
Vagina
Uterus
Ureter ariving in urinoma
Axial T2
Coronale T2
Bladder Injury2
ndash Sub-peacuteritoneacuteal Bladder
bull Vertical Position ++
bull Close to the ant face of the vagina
bull There is NO space
ndash Preacutevention
bull Following the Ant- Face of the vagina
bull Maleable Retractor
ndash Treatment
bull Immeacutediat Suture
bull Mesh Indication
bull Bladder Catheterisation 5 days
Small and Large Bowel Injury
bull Occur when adhesiolysis has to be undertaken
bull Avoid distended bowel at surgery by 48 hours pre op bowel prep
bull Avoid nitrous oxide during surgery as it causes bowel distension
bull If small bowel injured
ndash Repair laparoscopically
ndash Mesh can still be placed
bull Antibiotic cover for 7 days post op
CONCLUSION 1
1 To open the peritoneum tigh-it
2 Dissection on the right side of the mid-sacral ligament
3 Repair carefuly the vessels and the Right ureter
4 Try to preserve the right hypogatsric nerve
5 Fix your needle 1 cm below the promontory
MESH SELECTIONPERTINENT MESH SCIENCEWHY USE A CERTAIN MESH
Pr Bruno DEVAL MD Geoffroy Saint-Hilaire ndash Clinic
Hotel ndashDieu de Paris
Paris V University
MESH STIFFNESS
bullIncreased fibrosis and deposits of unorganized collagen create an increased stiffness
bull (Klinge 1999)
bullStiffness has been linked to clinical complications-heavier stiffer meshes having higher complications
bull (Dietz 2003)
bullStiffer meshes showed decreases in smooth muscle collagen and structural proteins following implantation
bull (Moalli P AUGS 2011)
bullHeavier stiffer meshes showed a greater propensity for stress shielding which in turn could cause reoccurrences of prolapse
bull (Moalli P AUGS 2011)
IMPACT OF VAGINAL SYNTHETIC PROLAPSE MESHES ON THE MECHANICS
OF THE HOST TISSUE RESPONSE
Feola Andrew J 02 February 2012 Doctoral Dissertation University of Pittsburgh
ldquoImplantation of the stiffest mesh in the non human primate
resulted in an exhibition of a stress-shielding response
manifested by inferior biomechanical properties of the
abdominal and vaginal tissues
Less stiff meshes resulted in preservation of tissue
propertiesrdquo
Wolffrsquos Law ndash remodeling of bone in response to stress
MESH CHARACTERISTICS
Density - Filament size ndash Elasticity - Pore size
Surface area ndash Overall ldquomesh loadrdquo
Biomechanical engineers working with type-1
polypropylene have focused on reducing overall
ldquomesh loadrdquo while maintaining durability
bullOptimal tissue incorporation and collagen growthbullNo erosionbullNo palpable mesh to patient and her partnerbullVaginal elasticity
TO OBTAIN
So lighter is better
WHAT KIND OF MESH
bull To date polypropylene meshes are the best type on the market
bull Absorbable meshes do not work
bull There is an evidence to use Polypropylene vs polyesther
bull PTFE and NW meshes are contra ndash indicated in the POP Repair
ULTRA- LIGHT POLYPROPYLENE
bull Physiologically compatible 19 gsm1
bull Ultra lightweightbull Lowest weight available for pelvic restoration
bull 18 millimeter macropores1
ndash Consistent size throughout the mesh
bull 100 micron interstitial Smartporestrade 1ndash Simultaneously encourages both collagen growth and
bacteria fighting propertiesbull Fibroblasts will enter holes that are 50 to 200 microns in size23
bull Macrophages and neutrophils will enter holes that are 50 to 120 microns in size23
bull Reduce inflammation1 Data on file2 Greca FH et at (2007) The influence of porosity on integration histology of two polypropylene meshes for the treatment of abdominal wall
defects in dogs Hernia (12) 45-493 Marois Y et all (2000) Biostability inflammatory response and healing characteristics flourpassivated polyester-knit mesh in the repair of
experimental abdominal hernias Artif Organs 24533-543
ULTRA ndash LIGHT CLINICAL EVIDENCE
SUMMARY
bull Rates of Erosion and Exposurebull Less than 1 erosion rate1
bull Anterior exposure rate 172
bull Posterior exposure rate 052
bull Greater tissue strength 3 months post-op ndash 71 more collagen growth3
bull Mature vaginal elastin decrease was not observed with Smartmesh4
bull Smartmesh did not induce a negative change in collagen metabolism5
bull Smartmesh had similar innervation density as sham 6
bull Low incidence of de novo dyspareunia71 Alinsod R et al (2008) Long term outcomes of vaginal pelvic floor repair using an ultra lightweight mesh AAGL (2008)2 Alinsod R Et al (2012) Durability and Complications of an Ultra Lightweight Transvaginal Mesh in the Treatment of Pelvic Organ Prolapse Presented at the 37th Annual Meeting of IUGA3 Greca FH et al (2007) The influence of porosity on the integration histology of two polypropylene meshes for the treatment of abdominal wall defects in dogs Hernia (12) 45-494 Moalli et al (2012) Mesh implantation negatively impacts vagina elastin metabolism Female Pelvic Medicine amp Reconstructive Surgery Vol 18 (Suppl 2)S258-9 SeptOct paper 235 Moalli et al (2012) Increasing mesh stiffness negatively impacts vaginal collagen metabolism Female Pelvic Medicine amp Reconstructive Surgery Vol 18 (Suppl 2)S258-9 SeptOct paper 246 Moalli et al (2012) The impact of mesh implantation on vaginal smooth muscle innervation Female Pelvic Medicine amp Reconstructive Surgery Vol 18 (Suppl 2)S258-9 SeptOct paper 257 Hawthorn R et al (2007) Use of ultra lightweight mesh in vaginal vault repairs to minimize complications A two centre observation study British International Congress of Obstetrics amp Gynaecology
PRE FORMED Y-MESH VS CUTTING MESH AND MAKING IT TO FIT PATIENTS
Pr Bruno DEVAL MD Geoffroy Saint-Hilaire ndash Clinic
Hotel ndashDieu de Paris
Paris V University
Mesh and operative handling
The shape and weight of the mesh can help us during
laparoscopic procedure
A large Y mesh is a good choice for vaginal vault shape
Better intra-operative manipulation and suturing
Lower mesh mass accommodates easy passage through narrow
laparoscopic ports
Use re-absorbable sutures on the vagina
bull Stitch erosions are reported
bull Folding and wrinkling can cause
erosions and dyspaurenia
Avoid folding and wrinkling the
mesh must be well stretched
DO WE NEED TO DISSECT POSTERIOR DOWN TO PERINEUM OR
IN WHICH PATIENTS THIS IS INDICATED
Pr Bruno DEVAL MD Geoffroy Saint-Hilaire ndash Clinic
Hotel ndashDieu de Paris
Paris V University
Fix the mesh on the posterior
vaginal wall and not on the
elevator ani muscle
bull To avoid dyschezia and chronic
pelvic pain
bull Sacrocolpopexy should only be performed by board certified eligible surgeons (ObGyn or Urology)
bull Knowledge surgical skills and experience in reconstructive pelvic surgery
FPMRS fellowship
CME documentation
Proctoring on 10 cases
gt 50 practice in reconstructive surgery
bull Outcomes and complications of should be monitored by annual internal audit
bull Informed consent should highlight
Alternatives to ASC including pessary
Complications of ASC
Complications of mesh
AUGS Guidelines on Sacrocolpopexy Privileges(March 2013)
Source wwwaugsorg
Conclusion
bull The technique and expertise are
fundamental
bull Laparoscopic colposacropexy can safely
be offered to women with symptomatic
POP
bull Conventional LSCP = Open Way =
robotic way
bull Conventional LSCP gt Vaginal Way
ANATOMICAL VARIATIONS OF THE RIGHT URETER
MIDDLE PART PROMONTORY
Flynn MK et al Vascular anatomy of the presacral space a fresh tissue cadaver dissectionAmerican journal of obstetrics and gynecology 2005 192 1501
bull Distances between the right ureter and the midsacral promontory
bull Dissection of 10 cadavers
ANATOMICAL VARIATIONS
OF THE
SUPERIOR HYPOGASTRIC PLEXUS
bull SHP sympathetic plexus connected to IHP
Shiozawa T et al Nerve-preserving sacrocolpopexy anatomical study and surgical approachEuropean journal of obstetrics and gynecology and reproductive biology2010 152 103
ANATOMICAL VARIATIONS OF SUPERIOR HYPOGASTRIC PLEXUS
bull Right hypogastric nerve
Wieslander CK et al Vascular anatomy of the presacral space in unembalmed female cadaversAmerican journal of obstetrics and gynecology 2006 195 1736
d6bull Mean of d6 = 7 mm (0 - 17)
Nerve-preserving sacrocolpopexy anatomical study and surgical approach
Shiozawa T1 et al
By protecting the superiorhypogastric plexus and the part of thepresacral area below the promontorywe can preserve the hypogastricnerves the sacral and pelvicsplanchnic nerves and thus theautonomic innervation of the pelvicorgans
ANATOMICAL VARIATIONS OF LVCA
bull Fixation into the anterior longitudinal
ligament
ANATOMICAL VARIATIONS OF LVCA
Boukkerou M et alPromontofixation procedures use of non-absorbable sutures or tackers Journal de gyneacutecologie obsteacutetrique et biologie de la reproduction2003 32 54
bull Fixation into the anterior longitudinal ligament
and NOT into the disc
ANATOMICAL VARIATIONS OF LVCA
bull Tackers go deep into the bone
Boukkerou M et alPromontofixation procedures use of non-absorbable sutures or tackers Journal de gyneacutecologie obsteacutetrique et biologie de la reproduction2003 32 54
Spondilithis03
ndash Preacutevention bull Asepsie and per-op antibioprophylaxy
ndash Diagnosis ndash Lombalgia fever tence neurologic diseases
ndash Inflammatory Syndrome (CRP)
ndash Radiologic signs (IRM)
bull Immobilisation
bull Antibiotheacuterapie prolongeacutee +- ponction discale
bull Ablation des prothegraveses
bull +- Arthrodegravese laminectomie
Posterior Dissection ndash DENONVILLIERS FASCIA
Since Charles-PierreDenonvilliers first discoveredthe firm membranousstructure between the rectumand prostate or bladder in1836 now calledldquoDenonvilliersrsquo fasciardquo (DF)the origin of DF has remainedcontroversial
Posterior Dissection ndash DENONVILLIERS FASCIA
Based on the evidencesurgeons should be awareof variations and search forthem to create a suitabledissection plane to avoidiatrogenic positive marginsand rectal injury
Rectal Injury04
ndash Sub-peacuteritoneacuteal rectum
bull There is a recto-vaginal space
bull Horizontal Position ++
bull Close to the post face of the vagina on the distal points
bull Danger on the proximal part of the Recto-Vaginal Septum
ndash Preacutevention
bull Follow the post-face of the vagina
bull Systeacutematic pre-operativ preparation
ndash NORMACOL reg
bull Maleable Retractor
ndash Treatment
bull Immeacutediat Suture
bull Mesh contra-Indication
Vaginal Injury04
ndash Preacuteventionbull Ant Vaginal Length - 6 cm ( 4 ndash 75) Jayle et al Masson 1918
bull Post Vaginal Lenght- 9cm (65 ndash 115) Jayle et al Masson 1918
bull There is no difference between the anterior and posteriorvagina thickness
bull If the vagina is too thin ndash Plicature of the vagina
ndash Treatmentbull If Vagina Injury Suture of the vagina
bull There is no contra indication to fix the meshes
RISK OF URETERAL
INJURY lt 11000
ndash Preacutevention
bull Parietal Uretera
ndash Cross between right extern iliac artery and uterine artery
bull Visceral Uretera
ndash Behind the ligaments
ndash Under the bladder
ndash In contact with the bladder
ndash Treatment
bull Per-op
ndash Per-op Bleu carmin en IV
ndash Ureteacuteral Catheter
bull Post-op
ndash Uro-scanner
ndash JJ Ureteral
Bladder
Collection
Sagittal T2
Vagina
Uterus
Ureter ariving in urinoma
Axial T2
Coronale T2
Bladder Injury2
ndash Sub-peacuteritoneacuteal Bladder
bull Vertical Position ++
bull Close to the ant face of the vagina
bull There is NO space
ndash Preacutevention
bull Following the Ant- Face of the vagina
bull Maleable Retractor
ndash Treatment
bull Immeacutediat Suture
bull Mesh Indication
bull Bladder Catheterisation 5 days
Small and Large Bowel Injury
bull Occur when adhesiolysis has to be undertaken
bull Avoid distended bowel at surgery by 48 hours pre op bowel prep
bull Avoid nitrous oxide during surgery as it causes bowel distension
bull If small bowel injured
ndash Repair laparoscopically
ndash Mesh can still be placed
bull Antibiotic cover for 7 days post op
CONCLUSION 1
1 To open the peritoneum tigh-it
2 Dissection on the right side of the mid-sacral ligament
3 Repair carefuly the vessels and the Right ureter
4 Try to preserve the right hypogatsric nerve
5 Fix your needle 1 cm below the promontory
MESH SELECTIONPERTINENT MESH SCIENCEWHY USE A CERTAIN MESH
Pr Bruno DEVAL MD Geoffroy Saint-Hilaire ndash Clinic
Hotel ndashDieu de Paris
Paris V University
MESH STIFFNESS
bullIncreased fibrosis and deposits of unorganized collagen create an increased stiffness
bull (Klinge 1999)
bullStiffness has been linked to clinical complications-heavier stiffer meshes having higher complications
bull (Dietz 2003)
bullStiffer meshes showed decreases in smooth muscle collagen and structural proteins following implantation
bull (Moalli P AUGS 2011)
bullHeavier stiffer meshes showed a greater propensity for stress shielding which in turn could cause reoccurrences of prolapse
bull (Moalli P AUGS 2011)
IMPACT OF VAGINAL SYNTHETIC PROLAPSE MESHES ON THE MECHANICS
OF THE HOST TISSUE RESPONSE
Feola Andrew J 02 February 2012 Doctoral Dissertation University of Pittsburgh
ldquoImplantation of the stiffest mesh in the non human primate
resulted in an exhibition of a stress-shielding response
manifested by inferior biomechanical properties of the
abdominal and vaginal tissues
Less stiff meshes resulted in preservation of tissue
propertiesrdquo
Wolffrsquos Law ndash remodeling of bone in response to stress
MESH CHARACTERISTICS
Density - Filament size ndash Elasticity - Pore size
Surface area ndash Overall ldquomesh loadrdquo
Biomechanical engineers working with type-1
polypropylene have focused on reducing overall
ldquomesh loadrdquo while maintaining durability
bullOptimal tissue incorporation and collagen growthbullNo erosionbullNo palpable mesh to patient and her partnerbullVaginal elasticity
TO OBTAIN
So lighter is better
WHAT KIND OF MESH
bull To date polypropylene meshes are the best type on the market
bull Absorbable meshes do not work
bull There is an evidence to use Polypropylene vs polyesther
bull PTFE and NW meshes are contra ndash indicated in the POP Repair
ULTRA- LIGHT POLYPROPYLENE
bull Physiologically compatible 19 gsm1
bull Ultra lightweightbull Lowest weight available for pelvic restoration
bull 18 millimeter macropores1
ndash Consistent size throughout the mesh
bull 100 micron interstitial Smartporestrade 1ndash Simultaneously encourages both collagen growth and
bacteria fighting propertiesbull Fibroblasts will enter holes that are 50 to 200 microns in size23
bull Macrophages and neutrophils will enter holes that are 50 to 120 microns in size23
bull Reduce inflammation1 Data on file2 Greca FH et at (2007) The influence of porosity on integration histology of two polypropylene meshes for the treatment of abdominal wall
defects in dogs Hernia (12) 45-493 Marois Y et all (2000) Biostability inflammatory response and healing characteristics flourpassivated polyester-knit mesh in the repair of
experimental abdominal hernias Artif Organs 24533-543
ULTRA ndash LIGHT CLINICAL EVIDENCE
SUMMARY
bull Rates of Erosion and Exposurebull Less than 1 erosion rate1
bull Anterior exposure rate 172
bull Posterior exposure rate 052
bull Greater tissue strength 3 months post-op ndash 71 more collagen growth3
bull Mature vaginal elastin decrease was not observed with Smartmesh4
bull Smartmesh did not induce a negative change in collagen metabolism5
bull Smartmesh had similar innervation density as sham 6
bull Low incidence of de novo dyspareunia71 Alinsod R et al (2008) Long term outcomes of vaginal pelvic floor repair using an ultra lightweight mesh AAGL (2008)2 Alinsod R Et al (2012) Durability and Complications of an Ultra Lightweight Transvaginal Mesh in the Treatment of Pelvic Organ Prolapse Presented at the 37th Annual Meeting of IUGA3 Greca FH et al (2007) The influence of porosity on the integration histology of two polypropylene meshes for the treatment of abdominal wall defects in dogs Hernia (12) 45-494 Moalli et al (2012) Mesh implantation negatively impacts vagina elastin metabolism Female Pelvic Medicine amp Reconstructive Surgery Vol 18 (Suppl 2)S258-9 SeptOct paper 235 Moalli et al (2012) Increasing mesh stiffness negatively impacts vaginal collagen metabolism Female Pelvic Medicine amp Reconstructive Surgery Vol 18 (Suppl 2)S258-9 SeptOct paper 246 Moalli et al (2012) The impact of mesh implantation on vaginal smooth muscle innervation Female Pelvic Medicine amp Reconstructive Surgery Vol 18 (Suppl 2)S258-9 SeptOct paper 257 Hawthorn R et al (2007) Use of ultra lightweight mesh in vaginal vault repairs to minimize complications A two centre observation study British International Congress of Obstetrics amp Gynaecology
PRE FORMED Y-MESH VS CUTTING MESH AND MAKING IT TO FIT PATIENTS
Pr Bruno DEVAL MD Geoffroy Saint-Hilaire ndash Clinic
Hotel ndashDieu de Paris
Paris V University
Mesh and operative handling
The shape and weight of the mesh can help us during
laparoscopic procedure
A large Y mesh is a good choice for vaginal vault shape
Better intra-operative manipulation and suturing
Lower mesh mass accommodates easy passage through narrow
laparoscopic ports
Use re-absorbable sutures on the vagina
bull Stitch erosions are reported
bull Folding and wrinkling can cause
erosions and dyspaurenia
Avoid folding and wrinkling the
mesh must be well stretched
DO WE NEED TO DISSECT POSTERIOR DOWN TO PERINEUM OR
IN WHICH PATIENTS THIS IS INDICATED
Pr Bruno DEVAL MD Geoffroy Saint-Hilaire ndash Clinic
Hotel ndashDieu de Paris
Paris V University
Fix the mesh on the posterior
vaginal wall and not on the
elevator ani muscle
bull To avoid dyschezia and chronic
pelvic pain
bull Sacrocolpopexy should only be performed by board certified eligible surgeons (ObGyn or Urology)
bull Knowledge surgical skills and experience in reconstructive pelvic surgery
FPMRS fellowship
CME documentation
Proctoring on 10 cases
gt 50 practice in reconstructive surgery
bull Outcomes and complications of should be monitored by annual internal audit
bull Informed consent should highlight
Alternatives to ASC including pessary
Complications of ASC
Complications of mesh
AUGS Guidelines on Sacrocolpopexy Privileges(March 2013)
Source wwwaugsorg
Conclusion
bull The technique and expertise are
fundamental
bull Laparoscopic colposacropexy can safely
be offered to women with symptomatic
POP
bull Conventional LSCP = Open Way =
robotic way
bull Conventional LSCP gt Vaginal Way
ANATOMICAL VARIATIONS
OF THE
SUPERIOR HYPOGASTRIC PLEXUS
bull SHP sympathetic plexus connected to IHP
Shiozawa T et al Nerve-preserving sacrocolpopexy anatomical study and surgical approachEuropean journal of obstetrics and gynecology and reproductive biology2010 152 103
ANATOMICAL VARIATIONS OF SUPERIOR HYPOGASTRIC PLEXUS
bull Right hypogastric nerve
Wieslander CK et al Vascular anatomy of the presacral space in unembalmed female cadaversAmerican journal of obstetrics and gynecology 2006 195 1736
d6bull Mean of d6 = 7 mm (0 - 17)
Nerve-preserving sacrocolpopexy anatomical study and surgical approach
Shiozawa T1 et al
By protecting the superiorhypogastric plexus and the part of thepresacral area below the promontorywe can preserve the hypogastricnerves the sacral and pelvicsplanchnic nerves and thus theautonomic innervation of the pelvicorgans
ANATOMICAL VARIATIONS OF LVCA
bull Fixation into the anterior longitudinal
ligament
ANATOMICAL VARIATIONS OF LVCA
Boukkerou M et alPromontofixation procedures use of non-absorbable sutures or tackers Journal de gyneacutecologie obsteacutetrique et biologie de la reproduction2003 32 54
bull Fixation into the anterior longitudinal ligament
and NOT into the disc
ANATOMICAL VARIATIONS OF LVCA
bull Tackers go deep into the bone
Boukkerou M et alPromontofixation procedures use of non-absorbable sutures or tackers Journal de gyneacutecologie obsteacutetrique et biologie de la reproduction2003 32 54
Spondilithis03
ndash Preacutevention bull Asepsie and per-op antibioprophylaxy
ndash Diagnosis ndash Lombalgia fever tence neurologic diseases
ndash Inflammatory Syndrome (CRP)
ndash Radiologic signs (IRM)
bull Immobilisation
bull Antibiotheacuterapie prolongeacutee +- ponction discale
bull Ablation des prothegraveses
bull +- Arthrodegravese laminectomie
Posterior Dissection ndash DENONVILLIERS FASCIA
Since Charles-PierreDenonvilliers first discoveredthe firm membranousstructure between the rectumand prostate or bladder in1836 now calledldquoDenonvilliersrsquo fasciardquo (DF)the origin of DF has remainedcontroversial
Posterior Dissection ndash DENONVILLIERS FASCIA
Based on the evidencesurgeons should be awareof variations and search forthem to create a suitabledissection plane to avoidiatrogenic positive marginsand rectal injury
Rectal Injury04
ndash Sub-peacuteritoneacuteal rectum
bull There is a recto-vaginal space
bull Horizontal Position ++
bull Close to the post face of the vagina on the distal points
bull Danger on the proximal part of the Recto-Vaginal Septum
ndash Preacutevention
bull Follow the post-face of the vagina
bull Systeacutematic pre-operativ preparation
ndash NORMACOL reg
bull Maleable Retractor
ndash Treatment
bull Immeacutediat Suture
bull Mesh contra-Indication
Vaginal Injury04
ndash Preacuteventionbull Ant Vaginal Length - 6 cm ( 4 ndash 75) Jayle et al Masson 1918
bull Post Vaginal Lenght- 9cm (65 ndash 115) Jayle et al Masson 1918
bull There is no difference between the anterior and posteriorvagina thickness
bull If the vagina is too thin ndash Plicature of the vagina
ndash Treatmentbull If Vagina Injury Suture of the vagina
bull There is no contra indication to fix the meshes
RISK OF URETERAL
INJURY lt 11000
ndash Preacutevention
bull Parietal Uretera
ndash Cross between right extern iliac artery and uterine artery
bull Visceral Uretera
ndash Behind the ligaments
ndash Under the bladder
ndash In contact with the bladder
ndash Treatment
bull Per-op
ndash Per-op Bleu carmin en IV
ndash Ureteacuteral Catheter
bull Post-op
ndash Uro-scanner
ndash JJ Ureteral
Bladder
Collection
Sagittal T2
Vagina
Uterus
Ureter ariving in urinoma
Axial T2
Coronale T2
Bladder Injury2
ndash Sub-peacuteritoneacuteal Bladder
bull Vertical Position ++
bull Close to the ant face of the vagina
bull There is NO space
ndash Preacutevention
bull Following the Ant- Face of the vagina
bull Maleable Retractor
ndash Treatment
bull Immeacutediat Suture
bull Mesh Indication
bull Bladder Catheterisation 5 days
Small and Large Bowel Injury
bull Occur when adhesiolysis has to be undertaken
bull Avoid distended bowel at surgery by 48 hours pre op bowel prep
bull Avoid nitrous oxide during surgery as it causes bowel distension
bull If small bowel injured
ndash Repair laparoscopically
ndash Mesh can still be placed
bull Antibiotic cover for 7 days post op
CONCLUSION 1
1 To open the peritoneum tigh-it
2 Dissection on the right side of the mid-sacral ligament
3 Repair carefuly the vessels and the Right ureter
4 Try to preserve the right hypogatsric nerve
5 Fix your needle 1 cm below the promontory
MESH SELECTIONPERTINENT MESH SCIENCEWHY USE A CERTAIN MESH
Pr Bruno DEVAL MD Geoffroy Saint-Hilaire ndash Clinic
Hotel ndashDieu de Paris
Paris V University
MESH STIFFNESS
bullIncreased fibrosis and deposits of unorganized collagen create an increased stiffness
bull (Klinge 1999)
bullStiffness has been linked to clinical complications-heavier stiffer meshes having higher complications
bull (Dietz 2003)
bullStiffer meshes showed decreases in smooth muscle collagen and structural proteins following implantation
bull (Moalli P AUGS 2011)
bullHeavier stiffer meshes showed a greater propensity for stress shielding which in turn could cause reoccurrences of prolapse
bull (Moalli P AUGS 2011)
IMPACT OF VAGINAL SYNTHETIC PROLAPSE MESHES ON THE MECHANICS
OF THE HOST TISSUE RESPONSE
Feola Andrew J 02 February 2012 Doctoral Dissertation University of Pittsburgh
ldquoImplantation of the stiffest mesh in the non human primate
resulted in an exhibition of a stress-shielding response
manifested by inferior biomechanical properties of the
abdominal and vaginal tissues
Less stiff meshes resulted in preservation of tissue
propertiesrdquo
Wolffrsquos Law ndash remodeling of bone in response to stress
MESH CHARACTERISTICS
Density - Filament size ndash Elasticity - Pore size
Surface area ndash Overall ldquomesh loadrdquo
Biomechanical engineers working with type-1
polypropylene have focused on reducing overall
ldquomesh loadrdquo while maintaining durability
bullOptimal tissue incorporation and collagen growthbullNo erosionbullNo palpable mesh to patient and her partnerbullVaginal elasticity
TO OBTAIN
So lighter is better
WHAT KIND OF MESH
bull To date polypropylene meshes are the best type on the market
bull Absorbable meshes do not work
bull There is an evidence to use Polypropylene vs polyesther
bull PTFE and NW meshes are contra ndash indicated in the POP Repair
ULTRA- LIGHT POLYPROPYLENE
bull Physiologically compatible 19 gsm1
bull Ultra lightweightbull Lowest weight available for pelvic restoration
bull 18 millimeter macropores1
ndash Consistent size throughout the mesh
bull 100 micron interstitial Smartporestrade 1ndash Simultaneously encourages both collagen growth and
bacteria fighting propertiesbull Fibroblasts will enter holes that are 50 to 200 microns in size23
bull Macrophages and neutrophils will enter holes that are 50 to 120 microns in size23
bull Reduce inflammation1 Data on file2 Greca FH et at (2007) The influence of porosity on integration histology of two polypropylene meshes for the treatment of abdominal wall
defects in dogs Hernia (12) 45-493 Marois Y et all (2000) Biostability inflammatory response and healing characteristics flourpassivated polyester-knit mesh in the repair of
experimental abdominal hernias Artif Organs 24533-543
ULTRA ndash LIGHT CLINICAL EVIDENCE
SUMMARY
bull Rates of Erosion and Exposurebull Less than 1 erosion rate1
bull Anterior exposure rate 172
bull Posterior exposure rate 052
bull Greater tissue strength 3 months post-op ndash 71 more collagen growth3
bull Mature vaginal elastin decrease was not observed with Smartmesh4
bull Smartmesh did not induce a negative change in collagen metabolism5
bull Smartmesh had similar innervation density as sham 6
bull Low incidence of de novo dyspareunia71 Alinsod R et al (2008) Long term outcomes of vaginal pelvic floor repair using an ultra lightweight mesh AAGL (2008)2 Alinsod R Et al (2012) Durability and Complications of an Ultra Lightweight Transvaginal Mesh in the Treatment of Pelvic Organ Prolapse Presented at the 37th Annual Meeting of IUGA3 Greca FH et al (2007) The influence of porosity on the integration histology of two polypropylene meshes for the treatment of abdominal wall defects in dogs Hernia (12) 45-494 Moalli et al (2012) Mesh implantation negatively impacts vagina elastin metabolism Female Pelvic Medicine amp Reconstructive Surgery Vol 18 (Suppl 2)S258-9 SeptOct paper 235 Moalli et al (2012) Increasing mesh stiffness negatively impacts vaginal collagen metabolism Female Pelvic Medicine amp Reconstructive Surgery Vol 18 (Suppl 2)S258-9 SeptOct paper 246 Moalli et al (2012) The impact of mesh implantation on vaginal smooth muscle innervation Female Pelvic Medicine amp Reconstructive Surgery Vol 18 (Suppl 2)S258-9 SeptOct paper 257 Hawthorn R et al (2007) Use of ultra lightweight mesh in vaginal vault repairs to minimize complications A two centre observation study British International Congress of Obstetrics amp Gynaecology
PRE FORMED Y-MESH VS CUTTING MESH AND MAKING IT TO FIT PATIENTS
Pr Bruno DEVAL MD Geoffroy Saint-Hilaire ndash Clinic
Hotel ndashDieu de Paris
Paris V University
Mesh and operative handling
The shape and weight of the mesh can help us during
laparoscopic procedure
A large Y mesh is a good choice for vaginal vault shape
Better intra-operative manipulation and suturing
Lower mesh mass accommodates easy passage through narrow
laparoscopic ports
Use re-absorbable sutures on the vagina
bull Stitch erosions are reported
bull Folding and wrinkling can cause
erosions and dyspaurenia
Avoid folding and wrinkling the
mesh must be well stretched
DO WE NEED TO DISSECT POSTERIOR DOWN TO PERINEUM OR
IN WHICH PATIENTS THIS IS INDICATED
Pr Bruno DEVAL MD Geoffroy Saint-Hilaire ndash Clinic
Hotel ndashDieu de Paris
Paris V University
Fix the mesh on the posterior
vaginal wall and not on the
elevator ani muscle
bull To avoid dyschezia and chronic
pelvic pain
bull Sacrocolpopexy should only be performed by board certified eligible surgeons (ObGyn or Urology)
bull Knowledge surgical skills and experience in reconstructive pelvic surgery
FPMRS fellowship
CME documentation
Proctoring on 10 cases
gt 50 practice in reconstructive surgery
bull Outcomes and complications of should be monitored by annual internal audit
bull Informed consent should highlight
Alternatives to ASC including pessary
Complications of ASC
Complications of mesh
AUGS Guidelines on Sacrocolpopexy Privileges(March 2013)
Source wwwaugsorg
Conclusion
bull The technique and expertise are
fundamental
bull Laparoscopic colposacropexy can safely
be offered to women with symptomatic
POP
bull Conventional LSCP = Open Way =
robotic way
bull Conventional LSCP gt Vaginal Way
ANATOMICAL VARIATIONS OF SUPERIOR HYPOGASTRIC PLEXUS
bull Right hypogastric nerve
Wieslander CK et al Vascular anatomy of the presacral space in unembalmed female cadaversAmerican journal of obstetrics and gynecology 2006 195 1736
d6bull Mean of d6 = 7 mm (0 - 17)
Nerve-preserving sacrocolpopexy anatomical study and surgical approach
Shiozawa T1 et al
By protecting the superiorhypogastric plexus and the part of thepresacral area below the promontorywe can preserve the hypogastricnerves the sacral and pelvicsplanchnic nerves and thus theautonomic innervation of the pelvicorgans
ANATOMICAL VARIATIONS OF LVCA
bull Fixation into the anterior longitudinal
ligament
ANATOMICAL VARIATIONS OF LVCA
Boukkerou M et alPromontofixation procedures use of non-absorbable sutures or tackers Journal de gyneacutecologie obsteacutetrique et biologie de la reproduction2003 32 54
bull Fixation into the anterior longitudinal ligament
and NOT into the disc
ANATOMICAL VARIATIONS OF LVCA
bull Tackers go deep into the bone
Boukkerou M et alPromontofixation procedures use of non-absorbable sutures or tackers Journal de gyneacutecologie obsteacutetrique et biologie de la reproduction2003 32 54
Spondilithis03
ndash Preacutevention bull Asepsie and per-op antibioprophylaxy
ndash Diagnosis ndash Lombalgia fever tence neurologic diseases
ndash Inflammatory Syndrome (CRP)
ndash Radiologic signs (IRM)
bull Immobilisation
bull Antibiotheacuterapie prolongeacutee +- ponction discale
bull Ablation des prothegraveses
bull +- Arthrodegravese laminectomie
Posterior Dissection ndash DENONVILLIERS FASCIA
Since Charles-PierreDenonvilliers first discoveredthe firm membranousstructure between the rectumand prostate or bladder in1836 now calledldquoDenonvilliersrsquo fasciardquo (DF)the origin of DF has remainedcontroversial
Posterior Dissection ndash DENONVILLIERS FASCIA
Based on the evidencesurgeons should be awareof variations and search forthem to create a suitabledissection plane to avoidiatrogenic positive marginsand rectal injury
Rectal Injury04
ndash Sub-peacuteritoneacuteal rectum
bull There is a recto-vaginal space
bull Horizontal Position ++
bull Close to the post face of the vagina on the distal points
bull Danger on the proximal part of the Recto-Vaginal Septum
ndash Preacutevention
bull Follow the post-face of the vagina
bull Systeacutematic pre-operativ preparation
ndash NORMACOL reg
bull Maleable Retractor
ndash Treatment
bull Immeacutediat Suture
bull Mesh contra-Indication
Vaginal Injury04
ndash Preacuteventionbull Ant Vaginal Length - 6 cm ( 4 ndash 75) Jayle et al Masson 1918
bull Post Vaginal Lenght- 9cm (65 ndash 115) Jayle et al Masson 1918
bull There is no difference between the anterior and posteriorvagina thickness
bull If the vagina is too thin ndash Plicature of the vagina
ndash Treatmentbull If Vagina Injury Suture of the vagina
bull There is no contra indication to fix the meshes
RISK OF URETERAL
INJURY lt 11000
ndash Preacutevention
bull Parietal Uretera
ndash Cross between right extern iliac artery and uterine artery
bull Visceral Uretera
ndash Behind the ligaments
ndash Under the bladder
ndash In contact with the bladder
ndash Treatment
bull Per-op
ndash Per-op Bleu carmin en IV
ndash Ureteacuteral Catheter
bull Post-op
ndash Uro-scanner
ndash JJ Ureteral
Bladder
Collection
Sagittal T2
Vagina
Uterus
Ureter ariving in urinoma
Axial T2
Coronale T2
Bladder Injury2
ndash Sub-peacuteritoneacuteal Bladder
bull Vertical Position ++
bull Close to the ant face of the vagina
bull There is NO space
ndash Preacutevention
bull Following the Ant- Face of the vagina
bull Maleable Retractor
ndash Treatment
bull Immeacutediat Suture
bull Mesh Indication
bull Bladder Catheterisation 5 days
Small and Large Bowel Injury
bull Occur when adhesiolysis has to be undertaken
bull Avoid distended bowel at surgery by 48 hours pre op bowel prep
bull Avoid nitrous oxide during surgery as it causes bowel distension
bull If small bowel injured
ndash Repair laparoscopically
ndash Mesh can still be placed
bull Antibiotic cover for 7 days post op
CONCLUSION 1
1 To open the peritoneum tigh-it
2 Dissection on the right side of the mid-sacral ligament
3 Repair carefuly the vessels and the Right ureter
4 Try to preserve the right hypogatsric nerve
5 Fix your needle 1 cm below the promontory
MESH SELECTIONPERTINENT MESH SCIENCEWHY USE A CERTAIN MESH
Pr Bruno DEVAL MD Geoffroy Saint-Hilaire ndash Clinic
Hotel ndashDieu de Paris
Paris V University
MESH STIFFNESS
bullIncreased fibrosis and deposits of unorganized collagen create an increased stiffness
bull (Klinge 1999)
bullStiffness has been linked to clinical complications-heavier stiffer meshes having higher complications
bull (Dietz 2003)
bullStiffer meshes showed decreases in smooth muscle collagen and structural proteins following implantation
bull (Moalli P AUGS 2011)
bullHeavier stiffer meshes showed a greater propensity for stress shielding which in turn could cause reoccurrences of prolapse
bull (Moalli P AUGS 2011)
IMPACT OF VAGINAL SYNTHETIC PROLAPSE MESHES ON THE MECHANICS
OF THE HOST TISSUE RESPONSE
Feola Andrew J 02 February 2012 Doctoral Dissertation University of Pittsburgh
ldquoImplantation of the stiffest mesh in the non human primate
resulted in an exhibition of a stress-shielding response
manifested by inferior biomechanical properties of the
abdominal and vaginal tissues
Less stiff meshes resulted in preservation of tissue
propertiesrdquo
Wolffrsquos Law ndash remodeling of bone in response to stress
MESH CHARACTERISTICS
Density - Filament size ndash Elasticity - Pore size
Surface area ndash Overall ldquomesh loadrdquo
Biomechanical engineers working with type-1
polypropylene have focused on reducing overall
ldquomesh loadrdquo while maintaining durability
bullOptimal tissue incorporation and collagen growthbullNo erosionbullNo palpable mesh to patient and her partnerbullVaginal elasticity
TO OBTAIN
So lighter is better
WHAT KIND OF MESH
bull To date polypropylene meshes are the best type on the market
bull Absorbable meshes do not work
bull There is an evidence to use Polypropylene vs polyesther
bull PTFE and NW meshes are contra ndash indicated in the POP Repair
ULTRA- LIGHT POLYPROPYLENE
bull Physiologically compatible 19 gsm1
bull Ultra lightweightbull Lowest weight available for pelvic restoration
bull 18 millimeter macropores1
ndash Consistent size throughout the mesh
bull 100 micron interstitial Smartporestrade 1ndash Simultaneously encourages both collagen growth and
bacteria fighting propertiesbull Fibroblasts will enter holes that are 50 to 200 microns in size23
bull Macrophages and neutrophils will enter holes that are 50 to 120 microns in size23
bull Reduce inflammation1 Data on file2 Greca FH et at (2007) The influence of porosity on integration histology of two polypropylene meshes for the treatment of abdominal wall
defects in dogs Hernia (12) 45-493 Marois Y et all (2000) Biostability inflammatory response and healing characteristics flourpassivated polyester-knit mesh in the repair of
experimental abdominal hernias Artif Organs 24533-543
ULTRA ndash LIGHT CLINICAL EVIDENCE
SUMMARY
bull Rates of Erosion and Exposurebull Less than 1 erosion rate1
bull Anterior exposure rate 172
bull Posterior exposure rate 052
bull Greater tissue strength 3 months post-op ndash 71 more collagen growth3
bull Mature vaginal elastin decrease was not observed with Smartmesh4
bull Smartmesh did not induce a negative change in collagen metabolism5
bull Smartmesh had similar innervation density as sham 6
bull Low incidence of de novo dyspareunia71 Alinsod R et al (2008) Long term outcomes of vaginal pelvic floor repair using an ultra lightweight mesh AAGL (2008)2 Alinsod R Et al (2012) Durability and Complications of an Ultra Lightweight Transvaginal Mesh in the Treatment of Pelvic Organ Prolapse Presented at the 37th Annual Meeting of IUGA3 Greca FH et al (2007) The influence of porosity on the integration histology of two polypropylene meshes for the treatment of abdominal wall defects in dogs Hernia (12) 45-494 Moalli et al (2012) Mesh implantation negatively impacts vagina elastin metabolism Female Pelvic Medicine amp Reconstructive Surgery Vol 18 (Suppl 2)S258-9 SeptOct paper 235 Moalli et al (2012) Increasing mesh stiffness negatively impacts vaginal collagen metabolism Female Pelvic Medicine amp Reconstructive Surgery Vol 18 (Suppl 2)S258-9 SeptOct paper 246 Moalli et al (2012) The impact of mesh implantation on vaginal smooth muscle innervation Female Pelvic Medicine amp Reconstructive Surgery Vol 18 (Suppl 2)S258-9 SeptOct paper 257 Hawthorn R et al (2007) Use of ultra lightweight mesh in vaginal vault repairs to minimize complications A two centre observation study British International Congress of Obstetrics amp Gynaecology
PRE FORMED Y-MESH VS CUTTING MESH AND MAKING IT TO FIT PATIENTS
Pr Bruno DEVAL MD Geoffroy Saint-Hilaire ndash Clinic
Hotel ndashDieu de Paris
Paris V University
Mesh and operative handling
The shape and weight of the mesh can help us during
laparoscopic procedure
A large Y mesh is a good choice for vaginal vault shape
Better intra-operative manipulation and suturing
Lower mesh mass accommodates easy passage through narrow
laparoscopic ports
Use re-absorbable sutures on the vagina
bull Stitch erosions are reported
bull Folding and wrinkling can cause
erosions and dyspaurenia
Avoid folding and wrinkling the
mesh must be well stretched
DO WE NEED TO DISSECT POSTERIOR DOWN TO PERINEUM OR
IN WHICH PATIENTS THIS IS INDICATED
Pr Bruno DEVAL MD Geoffroy Saint-Hilaire ndash Clinic
Hotel ndashDieu de Paris
Paris V University
Fix the mesh on the posterior
vaginal wall and not on the
elevator ani muscle
bull To avoid dyschezia and chronic
pelvic pain
bull Sacrocolpopexy should only be performed by board certified eligible surgeons (ObGyn or Urology)
bull Knowledge surgical skills and experience in reconstructive pelvic surgery
FPMRS fellowship
CME documentation
Proctoring on 10 cases
gt 50 practice in reconstructive surgery
bull Outcomes and complications of should be monitored by annual internal audit
bull Informed consent should highlight
Alternatives to ASC including pessary
Complications of ASC
Complications of mesh
AUGS Guidelines on Sacrocolpopexy Privileges(March 2013)
Source wwwaugsorg
Conclusion
bull The technique and expertise are
fundamental
bull Laparoscopic colposacropexy can safely
be offered to women with symptomatic
POP
bull Conventional LSCP = Open Way =
robotic way
bull Conventional LSCP gt Vaginal Way
Nerve-preserving sacrocolpopexy anatomical study and surgical approach
Shiozawa T1 et al
By protecting the superiorhypogastric plexus and the part of thepresacral area below the promontorywe can preserve the hypogastricnerves the sacral and pelvicsplanchnic nerves and thus theautonomic innervation of the pelvicorgans
ANATOMICAL VARIATIONS OF LVCA
bull Fixation into the anterior longitudinal
ligament
ANATOMICAL VARIATIONS OF LVCA
Boukkerou M et alPromontofixation procedures use of non-absorbable sutures or tackers Journal de gyneacutecologie obsteacutetrique et biologie de la reproduction2003 32 54
bull Fixation into the anterior longitudinal ligament
and NOT into the disc
ANATOMICAL VARIATIONS OF LVCA
bull Tackers go deep into the bone
Boukkerou M et alPromontofixation procedures use of non-absorbable sutures or tackers Journal de gyneacutecologie obsteacutetrique et biologie de la reproduction2003 32 54
Spondilithis03
ndash Preacutevention bull Asepsie and per-op antibioprophylaxy
ndash Diagnosis ndash Lombalgia fever tence neurologic diseases
ndash Inflammatory Syndrome (CRP)
ndash Radiologic signs (IRM)
bull Immobilisation
bull Antibiotheacuterapie prolongeacutee +- ponction discale
bull Ablation des prothegraveses
bull +- Arthrodegravese laminectomie
Posterior Dissection ndash DENONVILLIERS FASCIA
Since Charles-PierreDenonvilliers first discoveredthe firm membranousstructure between the rectumand prostate or bladder in1836 now calledldquoDenonvilliersrsquo fasciardquo (DF)the origin of DF has remainedcontroversial
Posterior Dissection ndash DENONVILLIERS FASCIA
Based on the evidencesurgeons should be awareof variations and search forthem to create a suitabledissection plane to avoidiatrogenic positive marginsand rectal injury
Rectal Injury04
ndash Sub-peacuteritoneacuteal rectum
bull There is a recto-vaginal space
bull Horizontal Position ++
bull Close to the post face of the vagina on the distal points
bull Danger on the proximal part of the Recto-Vaginal Septum
ndash Preacutevention
bull Follow the post-face of the vagina
bull Systeacutematic pre-operativ preparation
ndash NORMACOL reg
bull Maleable Retractor
ndash Treatment
bull Immeacutediat Suture
bull Mesh contra-Indication
Vaginal Injury04
ndash Preacuteventionbull Ant Vaginal Length - 6 cm ( 4 ndash 75) Jayle et al Masson 1918
bull Post Vaginal Lenght- 9cm (65 ndash 115) Jayle et al Masson 1918
bull There is no difference between the anterior and posteriorvagina thickness
bull If the vagina is too thin ndash Plicature of the vagina
ndash Treatmentbull If Vagina Injury Suture of the vagina
bull There is no contra indication to fix the meshes
RISK OF URETERAL
INJURY lt 11000
ndash Preacutevention
bull Parietal Uretera
ndash Cross between right extern iliac artery and uterine artery
bull Visceral Uretera
ndash Behind the ligaments
ndash Under the bladder
ndash In contact with the bladder
ndash Treatment
bull Per-op
ndash Per-op Bleu carmin en IV
ndash Ureteacuteral Catheter
bull Post-op
ndash Uro-scanner
ndash JJ Ureteral
Bladder
Collection
Sagittal T2
Vagina
Uterus
Ureter ariving in urinoma
Axial T2
Coronale T2
Bladder Injury2
ndash Sub-peacuteritoneacuteal Bladder
bull Vertical Position ++
bull Close to the ant face of the vagina
bull There is NO space
ndash Preacutevention
bull Following the Ant- Face of the vagina
bull Maleable Retractor
ndash Treatment
bull Immeacutediat Suture
bull Mesh Indication
bull Bladder Catheterisation 5 days
Small and Large Bowel Injury
bull Occur when adhesiolysis has to be undertaken
bull Avoid distended bowel at surgery by 48 hours pre op bowel prep
bull Avoid nitrous oxide during surgery as it causes bowel distension
bull If small bowel injured
ndash Repair laparoscopically
ndash Mesh can still be placed
bull Antibiotic cover for 7 days post op
CONCLUSION 1
1 To open the peritoneum tigh-it
2 Dissection on the right side of the mid-sacral ligament
3 Repair carefuly the vessels and the Right ureter
4 Try to preserve the right hypogatsric nerve
5 Fix your needle 1 cm below the promontory
MESH SELECTIONPERTINENT MESH SCIENCEWHY USE A CERTAIN MESH
Pr Bruno DEVAL MD Geoffroy Saint-Hilaire ndash Clinic
Hotel ndashDieu de Paris
Paris V University
MESH STIFFNESS
bullIncreased fibrosis and deposits of unorganized collagen create an increased stiffness
bull (Klinge 1999)
bullStiffness has been linked to clinical complications-heavier stiffer meshes having higher complications
bull (Dietz 2003)
bullStiffer meshes showed decreases in smooth muscle collagen and structural proteins following implantation
bull (Moalli P AUGS 2011)
bullHeavier stiffer meshes showed a greater propensity for stress shielding which in turn could cause reoccurrences of prolapse
bull (Moalli P AUGS 2011)
IMPACT OF VAGINAL SYNTHETIC PROLAPSE MESHES ON THE MECHANICS
OF THE HOST TISSUE RESPONSE
Feola Andrew J 02 February 2012 Doctoral Dissertation University of Pittsburgh
ldquoImplantation of the stiffest mesh in the non human primate
resulted in an exhibition of a stress-shielding response
manifested by inferior biomechanical properties of the
abdominal and vaginal tissues
Less stiff meshes resulted in preservation of tissue
propertiesrdquo
Wolffrsquos Law ndash remodeling of bone in response to stress
MESH CHARACTERISTICS
Density - Filament size ndash Elasticity - Pore size
Surface area ndash Overall ldquomesh loadrdquo
Biomechanical engineers working with type-1
polypropylene have focused on reducing overall
ldquomesh loadrdquo while maintaining durability
bullOptimal tissue incorporation and collagen growthbullNo erosionbullNo palpable mesh to patient and her partnerbullVaginal elasticity
TO OBTAIN
So lighter is better
WHAT KIND OF MESH
bull To date polypropylene meshes are the best type on the market
bull Absorbable meshes do not work
bull There is an evidence to use Polypropylene vs polyesther
bull PTFE and NW meshes are contra ndash indicated in the POP Repair
ULTRA- LIGHT POLYPROPYLENE
bull Physiologically compatible 19 gsm1
bull Ultra lightweightbull Lowest weight available for pelvic restoration
bull 18 millimeter macropores1
ndash Consistent size throughout the mesh
bull 100 micron interstitial Smartporestrade 1ndash Simultaneously encourages both collagen growth and
bacteria fighting propertiesbull Fibroblasts will enter holes that are 50 to 200 microns in size23
bull Macrophages and neutrophils will enter holes that are 50 to 120 microns in size23
bull Reduce inflammation1 Data on file2 Greca FH et at (2007) The influence of porosity on integration histology of two polypropylene meshes for the treatment of abdominal wall
defects in dogs Hernia (12) 45-493 Marois Y et all (2000) Biostability inflammatory response and healing characteristics flourpassivated polyester-knit mesh in the repair of
experimental abdominal hernias Artif Organs 24533-543
ULTRA ndash LIGHT CLINICAL EVIDENCE
SUMMARY
bull Rates of Erosion and Exposurebull Less than 1 erosion rate1
bull Anterior exposure rate 172
bull Posterior exposure rate 052
bull Greater tissue strength 3 months post-op ndash 71 more collagen growth3
bull Mature vaginal elastin decrease was not observed with Smartmesh4
bull Smartmesh did not induce a negative change in collagen metabolism5
bull Smartmesh had similar innervation density as sham 6
bull Low incidence of de novo dyspareunia71 Alinsod R et al (2008) Long term outcomes of vaginal pelvic floor repair using an ultra lightweight mesh AAGL (2008)2 Alinsod R Et al (2012) Durability and Complications of an Ultra Lightweight Transvaginal Mesh in the Treatment of Pelvic Organ Prolapse Presented at the 37th Annual Meeting of IUGA3 Greca FH et al (2007) The influence of porosity on the integration histology of two polypropylene meshes for the treatment of abdominal wall defects in dogs Hernia (12) 45-494 Moalli et al (2012) Mesh implantation negatively impacts vagina elastin metabolism Female Pelvic Medicine amp Reconstructive Surgery Vol 18 (Suppl 2)S258-9 SeptOct paper 235 Moalli et al (2012) Increasing mesh stiffness negatively impacts vaginal collagen metabolism Female Pelvic Medicine amp Reconstructive Surgery Vol 18 (Suppl 2)S258-9 SeptOct paper 246 Moalli et al (2012) The impact of mesh implantation on vaginal smooth muscle innervation Female Pelvic Medicine amp Reconstructive Surgery Vol 18 (Suppl 2)S258-9 SeptOct paper 257 Hawthorn R et al (2007) Use of ultra lightweight mesh in vaginal vault repairs to minimize complications A two centre observation study British International Congress of Obstetrics amp Gynaecology
PRE FORMED Y-MESH VS CUTTING MESH AND MAKING IT TO FIT PATIENTS
Pr Bruno DEVAL MD Geoffroy Saint-Hilaire ndash Clinic
Hotel ndashDieu de Paris
Paris V University
Mesh and operative handling
The shape and weight of the mesh can help us during
laparoscopic procedure
A large Y mesh is a good choice for vaginal vault shape
Better intra-operative manipulation and suturing
Lower mesh mass accommodates easy passage through narrow
laparoscopic ports
Use re-absorbable sutures on the vagina
bull Stitch erosions are reported
bull Folding and wrinkling can cause
erosions and dyspaurenia
Avoid folding and wrinkling the
mesh must be well stretched
DO WE NEED TO DISSECT POSTERIOR DOWN TO PERINEUM OR
IN WHICH PATIENTS THIS IS INDICATED
Pr Bruno DEVAL MD Geoffroy Saint-Hilaire ndash Clinic
Hotel ndashDieu de Paris
Paris V University
Fix the mesh on the posterior
vaginal wall and not on the
elevator ani muscle
bull To avoid dyschezia and chronic
pelvic pain
bull Sacrocolpopexy should only be performed by board certified eligible surgeons (ObGyn or Urology)
bull Knowledge surgical skills and experience in reconstructive pelvic surgery
FPMRS fellowship
CME documentation
Proctoring on 10 cases
gt 50 practice in reconstructive surgery
bull Outcomes and complications of should be monitored by annual internal audit
bull Informed consent should highlight
Alternatives to ASC including pessary
Complications of ASC
Complications of mesh
AUGS Guidelines on Sacrocolpopexy Privileges(March 2013)
Source wwwaugsorg
Conclusion
bull The technique and expertise are
fundamental
bull Laparoscopic colposacropexy can safely
be offered to women with symptomatic
POP
bull Conventional LSCP = Open Way =
robotic way
bull Conventional LSCP gt Vaginal Way
ANATOMICAL VARIATIONS OF LVCA
bull Fixation into the anterior longitudinal
ligament
ANATOMICAL VARIATIONS OF LVCA
Boukkerou M et alPromontofixation procedures use of non-absorbable sutures or tackers Journal de gyneacutecologie obsteacutetrique et biologie de la reproduction2003 32 54
bull Fixation into the anterior longitudinal ligament
and NOT into the disc
ANATOMICAL VARIATIONS OF LVCA
bull Tackers go deep into the bone
Boukkerou M et alPromontofixation procedures use of non-absorbable sutures or tackers Journal de gyneacutecologie obsteacutetrique et biologie de la reproduction2003 32 54
Spondilithis03
ndash Preacutevention bull Asepsie and per-op antibioprophylaxy
ndash Diagnosis ndash Lombalgia fever tence neurologic diseases
ndash Inflammatory Syndrome (CRP)
ndash Radiologic signs (IRM)
bull Immobilisation
bull Antibiotheacuterapie prolongeacutee +- ponction discale
bull Ablation des prothegraveses
bull +- Arthrodegravese laminectomie
Posterior Dissection ndash DENONVILLIERS FASCIA
Since Charles-PierreDenonvilliers first discoveredthe firm membranousstructure between the rectumand prostate or bladder in1836 now calledldquoDenonvilliersrsquo fasciardquo (DF)the origin of DF has remainedcontroversial
Posterior Dissection ndash DENONVILLIERS FASCIA
Based on the evidencesurgeons should be awareof variations and search forthem to create a suitabledissection plane to avoidiatrogenic positive marginsand rectal injury
Rectal Injury04
ndash Sub-peacuteritoneacuteal rectum
bull There is a recto-vaginal space
bull Horizontal Position ++
bull Close to the post face of the vagina on the distal points
bull Danger on the proximal part of the Recto-Vaginal Septum
ndash Preacutevention
bull Follow the post-face of the vagina
bull Systeacutematic pre-operativ preparation
ndash NORMACOL reg
bull Maleable Retractor
ndash Treatment
bull Immeacutediat Suture
bull Mesh contra-Indication
Vaginal Injury04
ndash Preacuteventionbull Ant Vaginal Length - 6 cm ( 4 ndash 75) Jayle et al Masson 1918
bull Post Vaginal Lenght- 9cm (65 ndash 115) Jayle et al Masson 1918
bull There is no difference between the anterior and posteriorvagina thickness
bull If the vagina is too thin ndash Plicature of the vagina
ndash Treatmentbull If Vagina Injury Suture of the vagina
bull There is no contra indication to fix the meshes
RISK OF URETERAL
INJURY lt 11000
ndash Preacutevention
bull Parietal Uretera
ndash Cross between right extern iliac artery and uterine artery
bull Visceral Uretera
ndash Behind the ligaments
ndash Under the bladder
ndash In contact with the bladder
ndash Treatment
bull Per-op
ndash Per-op Bleu carmin en IV
ndash Ureteacuteral Catheter
bull Post-op
ndash Uro-scanner
ndash JJ Ureteral
Bladder
Collection
Sagittal T2
Vagina
Uterus
Ureter ariving in urinoma
Axial T2
Coronale T2
Bladder Injury2
ndash Sub-peacuteritoneacuteal Bladder
bull Vertical Position ++
bull Close to the ant face of the vagina
bull There is NO space
ndash Preacutevention
bull Following the Ant- Face of the vagina
bull Maleable Retractor
ndash Treatment
bull Immeacutediat Suture
bull Mesh Indication
bull Bladder Catheterisation 5 days
Small and Large Bowel Injury
bull Occur when adhesiolysis has to be undertaken
bull Avoid distended bowel at surgery by 48 hours pre op bowel prep
bull Avoid nitrous oxide during surgery as it causes bowel distension
bull If small bowel injured
ndash Repair laparoscopically
ndash Mesh can still be placed
bull Antibiotic cover for 7 days post op
CONCLUSION 1
1 To open the peritoneum tigh-it
2 Dissection on the right side of the mid-sacral ligament
3 Repair carefuly the vessels and the Right ureter
4 Try to preserve the right hypogatsric nerve
5 Fix your needle 1 cm below the promontory
MESH SELECTIONPERTINENT MESH SCIENCEWHY USE A CERTAIN MESH
Pr Bruno DEVAL MD Geoffroy Saint-Hilaire ndash Clinic
Hotel ndashDieu de Paris
Paris V University
MESH STIFFNESS
bullIncreased fibrosis and deposits of unorganized collagen create an increased stiffness
bull (Klinge 1999)
bullStiffness has been linked to clinical complications-heavier stiffer meshes having higher complications
bull (Dietz 2003)
bullStiffer meshes showed decreases in smooth muscle collagen and structural proteins following implantation
bull (Moalli P AUGS 2011)
bullHeavier stiffer meshes showed a greater propensity for stress shielding which in turn could cause reoccurrences of prolapse
bull (Moalli P AUGS 2011)
IMPACT OF VAGINAL SYNTHETIC PROLAPSE MESHES ON THE MECHANICS
OF THE HOST TISSUE RESPONSE
Feola Andrew J 02 February 2012 Doctoral Dissertation University of Pittsburgh
ldquoImplantation of the stiffest mesh in the non human primate
resulted in an exhibition of a stress-shielding response
manifested by inferior biomechanical properties of the
abdominal and vaginal tissues
Less stiff meshes resulted in preservation of tissue
propertiesrdquo
Wolffrsquos Law ndash remodeling of bone in response to stress
MESH CHARACTERISTICS
Density - Filament size ndash Elasticity - Pore size
Surface area ndash Overall ldquomesh loadrdquo
Biomechanical engineers working with type-1
polypropylene have focused on reducing overall
ldquomesh loadrdquo while maintaining durability
bullOptimal tissue incorporation and collagen growthbullNo erosionbullNo palpable mesh to patient and her partnerbullVaginal elasticity
TO OBTAIN
So lighter is better
WHAT KIND OF MESH
bull To date polypropylene meshes are the best type on the market
bull Absorbable meshes do not work
bull There is an evidence to use Polypropylene vs polyesther
bull PTFE and NW meshes are contra ndash indicated in the POP Repair
ULTRA- LIGHT POLYPROPYLENE
bull Physiologically compatible 19 gsm1
bull Ultra lightweightbull Lowest weight available for pelvic restoration
bull 18 millimeter macropores1
ndash Consistent size throughout the mesh
bull 100 micron interstitial Smartporestrade 1ndash Simultaneously encourages both collagen growth and
bacteria fighting propertiesbull Fibroblasts will enter holes that are 50 to 200 microns in size23
bull Macrophages and neutrophils will enter holes that are 50 to 120 microns in size23
bull Reduce inflammation1 Data on file2 Greca FH et at (2007) The influence of porosity on integration histology of two polypropylene meshes for the treatment of abdominal wall
defects in dogs Hernia (12) 45-493 Marois Y et all (2000) Biostability inflammatory response and healing characteristics flourpassivated polyester-knit mesh in the repair of
experimental abdominal hernias Artif Organs 24533-543
ULTRA ndash LIGHT CLINICAL EVIDENCE
SUMMARY
bull Rates of Erosion and Exposurebull Less than 1 erosion rate1
bull Anterior exposure rate 172
bull Posterior exposure rate 052
bull Greater tissue strength 3 months post-op ndash 71 more collagen growth3
bull Mature vaginal elastin decrease was not observed with Smartmesh4
bull Smartmesh did not induce a negative change in collagen metabolism5
bull Smartmesh had similar innervation density as sham 6
bull Low incidence of de novo dyspareunia71 Alinsod R et al (2008) Long term outcomes of vaginal pelvic floor repair using an ultra lightweight mesh AAGL (2008)2 Alinsod R Et al (2012) Durability and Complications of an Ultra Lightweight Transvaginal Mesh in the Treatment of Pelvic Organ Prolapse Presented at the 37th Annual Meeting of IUGA3 Greca FH et al (2007) The influence of porosity on the integration histology of two polypropylene meshes for the treatment of abdominal wall defects in dogs Hernia (12) 45-494 Moalli et al (2012) Mesh implantation negatively impacts vagina elastin metabolism Female Pelvic Medicine amp Reconstructive Surgery Vol 18 (Suppl 2)S258-9 SeptOct paper 235 Moalli et al (2012) Increasing mesh stiffness negatively impacts vaginal collagen metabolism Female Pelvic Medicine amp Reconstructive Surgery Vol 18 (Suppl 2)S258-9 SeptOct paper 246 Moalli et al (2012) The impact of mesh implantation on vaginal smooth muscle innervation Female Pelvic Medicine amp Reconstructive Surgery Vol 18 (Suppl 2)S258-9 SeptOct paper 257 Hawthorn R et al (2007) Use of ultra lightweight mesh in vaginal vault repairs to minimize complications A two centre observation study British International Congress of Obstetrics amp Gynaecology
PRE FORMED Y-MESH VS CUTTING MESH AND MAKING IT TO FIT PATIENTS
Pr Bruno DEVAL MD Geoffroy Saint-Hilaire ndash Clinic
Hotel ndashDieu de Paris
Paris V University
Mesh and operative handling
The shape and weight of the mesh can help us during
laparoscopic procedure
A large Y mesh is a good choice for vaginal vault shape
Better intra-operative manipulation and suturing
Lower mesh mass accommodates easy passage through narrow
laparoscopic ports
Use re-absorbable sutures on the vagina
bull Stitch erosions are reported
bull Folding and wrinkling can cause
erosions and dyspaurenia
Avoid folding and wrinkling the
mesh must be well stretched
DO WE NEED TO DISSECT POSTERIOR DOWN TO PERINEUM OR
IN WHICH PATIENTS THIS IS INDICATED
Pr Bruno DEVAL MD Geoffroy Saint-Hilaire ndash Clinic
Hotel ndashDieu de Paris
Paris V University
Fix the mesh on the posterior
vaginal wall and not on the
elevator ani muscle
bull To avoid dyschezia and chronic
pelvic pain
bull Sacrocolpopexy should only be performed by board certified eligible surgeons (ObGyn or Urology)
bull Knowledge surgical skills and experience in reconstructive pelvic surgery
FPMRS fellowship
CME documentation
Proctoring on 10 cases
gt 50 practice in reconstructive surgery
bull Outcomes and complications of should be monitored by annual internal audit
bull Informed consent should highlight
Alternatives to ASC including pessary
Complications of ASC
Complications of mesh
AUGS Guidelines on Sacrocolpopexy Privileges(March 2013)
Source wwwaugsorg
Conclusion
bull The technique and expertise are
fundamental
bull Laparoscopic colposacropexy can safely
be offered to women with symptomatic
POP
bull Conventional LSCP = Open Way =
robotic way
bull Conventional LSCP gt Vaginal Way
ANATOMICAL VARIATIONS OF LVCA
Boukkerou M et alPromontofixation procedures use of non-absorbable sutures or tackers Journal de gyneacutecologie obsteacutetrique et biologie de la reproduction2003 32 54
bull Fixation into the anterior longitudinal ligament
and NOT into the disc
ANATOMICAL VARIATIONS OF LVCA
bull Tackers go deep into the bone
Boukkerou M et alPromontofixation procedures use of non-absorbable sutures or tackers Journal de gyneacutecologie obsteacutetrique et biologie de la reproduction2003 32 54
Spondilithis03
ndash Preacutevention bull Asepsie and per-op antibioprophylaxy
ndash Diagnosis ndash Lombalgia fever tence neurologic diseases
ndash Inflammatory Syndrome (CRP)
ndash Radiologic signs (IRM)
bull Immobilisation
bull Antibiotheacuterapie prolongeacutee +- ponction discale
bull Ablation des prothegraveses
bull +- Arthrodegravese laminectomie
Posterior Dissection ndash DENONVILLIERS FASCIA
Since Charles-PierreDenonvilliers first discoveredthe firm membranousstructure between the rectumand prostate or bladder in1836 now calledldquoDenonvilliersrsquo fasciardquo (DF)the origin of DF has remainedcontroversial
Posterior Dissection ndash DENONVILLIERS FASCIA
Based on the evidencesurgeons should be awareof variations and search forthem to create a suitabledissection plane to avoidiatrogenic positive marginsand rectal injury
Rectal Injury04
ndash Sub-peacuteritoneacuteal rectum
bull There is a recto-vaginal space
bull Horizontal Position ++
bull Close to the post face of the vagina on the distal points
bull Danger on the proximal part of the Recto-Vaginal Septum
ndash Preacutevention
bull Follow the post-face of the vagina
bull Systeacutematic pre-operativ preparation
ndash NORMACOL reg
bull Maleable Retractor
ndash Treatment
bull Immeacutediat Suture
bull Mesh contra-Indication
Vaginal Injury04
ndash Preacuteventionbull Ant Vaginal Length - 6 cm ( 4 ndash 75) Jayle et al Masson 1918
bull Post Vaginal Lenght- 9cm (65 ndash 115) Jayle et al Masson 1918
bull There is no difference between the anterior and posteriorvagina thickness
bull If the vagina is too thin ndash Plicature of the vagina
ndash Treatmentbull If Vagina Injury Suture of the vagina
bull There is no contra indication to fix the meshes
RISK OF URETERAL
INJURY lt 11000
ndash Preacutevention
bull Parietal Uretera
ndash Cross between right extern iliac artery and uterine artery
bull Visceral Uretera
ndash Behind the ligaments
ndash Under the bladder
ndash In contact with the bladder
ndash Treatment
bull Per-op
ndash Per-op Bleu carmin en IV
ndash Ureteacuteral Catheter
bull Post-op
ndash Uro-scanner
ndash JJ Ureteral
Bladder
Collection
Sagittal T2
Vagina
Uterus
Ureter ariving in urinoma
Axial T2
Coronale T2
Bladder Injury2
ndash Sub-peacuteritoneacuteal Bladder
bull Vertical Position ++
bull Close to the ant face of the vagina
bull There is NO space
ndash Preacutevention
bull Following the Ant- Face of the vagina
bull Maleable Retractor
ndash Treatment
bull Immeacutediat Suture
bull Mesh Indication
bull Bladder Catheterisation 5 days
Small and Large Bowel Injury
bull Occur when adhesiolysis has to be undertaken
bull Avoid distended bowel at surgery by 48 hours pre op bowel prep
bull Avoid nitrous oxide during surgery as it causes bowel distension
bull If small bowel injured
ndash Repair laparoscopically
ndash Mesh can still be placed
bull Antibiotic cover for 7 days post op
CONCLUSION 1
1 To open the peritoneum tigh-it
2 Dissection on the right side of the mid-sacral ligament
3 Repair carefuly the vessels and the Right ureter
4 Try to preserve the right hypogatsric nerve
5 Fix your needle 1 cm below the promontory
MESH SELECTIONPERTINENT MESH SCIENCEWHY USE A CERTAIN MESH
Pr Bruno DEVAL MD Geoffroy Saint-Hilaire ndash Clinic
Hotel ndashDieu de Paris
Paris V University
MESH STIFFNESS
bullIncreased fibrosis and deposits of unorganized collagen create an increased stiffness
bull (Klinge 1999)
bullStiffness has been linked to clinical complications-heavier stiffer meshes having higher complications
bull (Dietz 2003)
bullStiffer meshes showed decreases in smooth muscle collagen and structural proteins following implantation
bull (Moalli P AUGS 2011)
bullHeavier stiffer meshes showed a greater propensity for stress shielding which in turn could cause reoccurrences of prolapse
bull (Moalli P AUGS 2011)
IMPACT OF VAGINAL SYNTHETIC PROLAPSE MESHES ON THE MECHANICS
OF THE HOST TISSUE RESPONSE
Feola Andrew J 02 February 2012 Doctoral Dissertation University of Pittsburgh
ldquoImplantation of the stiffest mesh in the non human primate
resulted in an exhibition of a stress-shielding response
manifested by inferior biomechanical properties of the
abdominal and vaginal tissues
Less stiff meshes resulted in preservation of tissue
propertiesrdquo
Wolffrsquos Law ndash remodeling of bone in response to stress
MESH CHARACTERISTICS
Density - Filament size ndash Elasticity - Pore size
Surface area ndash Overall ldquomesh loadrdquo
Biomechanical engineers working with type-1
polypropylene have focused on reducing overall
ldquomesh loadrdquo while maintaining durability
bullOptimal tissue incorporation and collagen growthbullNo erosionbullNo palpable mesh to patient and her partnerbullVaginal elasticity
TO OBTAIN
So lighter is better
WHAT KIND OF MESH
bull To date polypropylene meshes are the best type on the market
bull Absorbable meshes do not work
bull There is an evidence to use Polypropylene vs polyesther
bull PTFE and NW meshes are contra ndash indicated in the POP Repair
ULTRA- LIGHT POLYPROPYLENE
bull Physiologically compatible 19 gsm1
bull Ultra lightweightbull Lowest weight available for pelvic restoration
bull 18 millimeter macropores1
ndash Consistent size throughout the mesh
bull 100 micron interstitial Smartporestrade 1ndash Simultaneously encourages both collagen growth and
bacteria fighting propertiesbull Fibroblasts will enter holes that are 50 to 200 microns in size23
bull Macrophages and neutrophils will enter holes that are 50 to 120 microns in size23
bull Reduce inflammation1 Data on file2 Greca FH et at (2007) The influence of porosity on integration histology of two polypropylene meshes for the treatment of abdominal wall
defects in dogs Hernia (12) 45-493 Marois Y et all (2000) Biostability inflammatory response and healing characteristics flourpassivated polyester-knit mesh in the repair of
experimental abdominal hernias Artif Organs 24533-543
ULTRA ndash LIGHT CLINICAL EVIDENCE
SUMMARY
bull Rates of Erosion and Exposurebull Less than 1 erosion rate1
bull Anterior exposure rate 172
bull Posterior exposure rate 052
bull Greater tissue strength 3 months post-op ndash 71 more collagen growth3
bull Mature vaginal elastin decrease was not observed with Smartmesh4
bull Smartmesh did not induce a negative change in collagen metabolism5
bull Smartmesh had similar innervation density as sham 6
bull Low incidence of de novo dyspareunia71 Alinsod R et al (2008) Long term outcomes of vaginal pelvic floor repair using an ultra lightweight mesh AAGL (2008)2 Alinsod R Et al (2012) Durability and Complications of an Ultra Lightweight Transvaginal Mesh in the Treatment of Pelvic Organ Prolapse Presented at the 37th Annual Meeting of IUGA3 Greca FH et al (2007) The influence of porosity on the integration histology of two polypropylene meshes for the treatment of abdominal wall defects in dogs Hernia (12) 45-494 Moalli et al (2012) Mesh implantation negatively impacts vagina elastin metabolism Female Pelvic Medicine amp Reconstructive Surgery Vol 18 (Suppl 2)S258-9 SeptOct paper 235 Moalli et al (2012) Increasing mesh stiffness negatively impacts vaginal collagen metabolism Female Pelvic Medicine amp Reconstructive Surgery Vol 18 (Suppl 2)S258-9 SeptOct paper 246 Moalli et al (2012) The impact of mesh implantation on vaginal smooth muscle innervation Female Pelvic Medicine amp Reconstructive Surgery Vol 18 (Suppl 2)S258-9 SeptOct paper 257 Hawthorn R et al (2007) Use of ultra lightweight mesh in vaginal vault repairs to minimize complications A two centre observation study British International Congress of Obstetrics amp Gynaecology
PRE FORMED Y-MESH VS CUTTING MESH AND MAKING IT TO FIT PATIENTS
Pr Bruno DEVAL MD Geoffroy Saint-Hilaire ndash Clinic
Hotel ndashDieu de Paris
Paris V University
Mesh and operative handling
The shape and weight of the mesh can help us during
laparoscopic procedure
A large Y mesh is a good choice for vaginal vault shape
Better intra-operative manipulation and suturing
Lower mesh mass accommodates easy passage through narrow
laparoscopic ports
Use re-absorbable sutures on the vagina
bull Stitch erosions are reported
bull Folding and wrinkling can cause
erosions and dyspaurenia
Avoid folding and wrinkling the
mesh must be well stretched
DO WE NEED TO DISSECT POSTERIOR DOWN TO PERINEUM OR
IN WHICH PATIENTS THIS IS INDICATED
Pr Bruno DEVAL MD Geoffroy Saint-Hilaire ndash Clinic
Hotel ndashDieu de Paris
Paris V University
Fix the mesh on the posterior
vaginal wall and not on the
elevator ani muscle
bull To avoid dyschezia and chronic
pelvic pain
bull Sacrocolpopexy should only be performed by board certified eligible surgeons (ObGyn or Urology)
bull Knowledge surgical skills and experience in reconstructive pelvic surgery
FPMRS fellowship
CME documentation
Proctoring on 10 cases
gt 50 practice in reconstructive surgery
bull Outcomes and complications of should be monitored by annual internal audit
bull Informed consent should highlight
Alternatives to ASC including pessary
Complications of ASC
Complications of mesh
AUGS Guidelines on Sacrocolpopexy Privileges(March 2013)
Source wwwaugsorg
Conclusion
bull The technique and expertise are
fundamental
bull Laparoscopic colposacropexy can safely
be offered to women with symptomatic
POP
bull Conventional LSCP = Open Way =
robotic way
bull Conventional LSCP gt Vaginal Way
ANATOMICAL VARIATIONS OF LVCA
bull Tackers go deep into the bone
Boukkerou M et alPromontofixation procedures use of non-absorbable sutures or tackers Journal de gyneacutecologie obsteacutetrique et biologie de la reproduction2003 32 54
Spondilithis03
ndash Preacutevention bull Asepsie and per-op antibioprophylaxy
ndash Diagnosis ndash Lombalgia fever tence neurologic diseases
ndash Inflammatory Syndrome (CRP)
ndash Radiologic signs (IRM)
bull Immobilisation
bull Antibiotheacuterapie prolongeacutee +- ponction discale
bull Ablation des prothegraveses
bull +- Arthrodegravese laminectomie
Posterior Dissection ndash DENONVILLIERS FASCIA
Since Charles-PierreDenonvilliers first discoveredthe firm membranousstructure between the rectumand prostate or bladder in1836 now calledldquoDenonvilliersrsquo fasciardquo (DF)the origin of DF has remainedcontroversial
Posterior Dissection ndash DENONVILLIERS FASCIA
Based on the evidencesurgeons should be awareof variations and search forthem to create a suitabledissection plane to avoidiatrogenic positive marginsand rectal injury
Rectal Injury04
ndash Sub-peacuteritoneacuteal rectum
bull There is a recto-vaginal space
bull Horizontal Position ++
bull Close to the post face of the vagina on the distal points
bull Danger on the proximal part of the Recto-Vaginal Septum
ndash Preacutevention
bull Follow the post-face of the vagina
bull Systeacutematic pre-operativ preparation
ndash NORMACOL reg
bull Maleable Retractor
ndash Treatment
bull Immeacutediat Suture
bull Mesh contra-Indication
Vaginal Injury04
ndash Preacuteventionbull Ant Vaginal Length - 6 cm ( 4 ndash 75) Jayle et al Masson 1918
bull Post Vaginal Lenght- 9cm (65 ndash 115) Jayle et al Masson 1918
bull There is no difference between the anterior and posteriorvagina thickness
bull If the vagina is too thin ndash Plicature of the vagina
ndash Treatmentbull If Vagina Injury Suture of the vagina
bull There is no contra indication to fix the meshes
RISK OF URETERAL
INJURY lt 11000
ndash Preacutevention
bull Parietal Uretera
ndash Cross between right extern iliac artery and uterine artery
bull Visceral Uretera
ndash Behind the ligaments
ndash Under the bladder
ndash In contact with the bladder
ndash Treatment
bull Per-op
ndash Per-op Bleu carmin en IV
ndash Ureteacuteral Catheter
bull Post-op
ndash Uro-scanner
ndash JJ Ureteral
Bladder
Collection
Sagittal T2
Vagina
Uterus
Ureter ariving in urinoma
Axial T2
Coronale T2
Bladder Injury2
ndash Sub-peacuteritoneacuteal Bladder
bull Vertical Position ++
bull Close to the ant face of the vagina
bull There is NO space
ndash Preacutevention
bull Following the Ant- Face of the vagina
bull Maleable Retractor
ndash Treatment
bull Immeacutediat Suture
bull Mesh Indication
bull Bladder Catheterisation 5 days
Small and Large Bowel Injury
bull Occur when adhesiolysis has to be undertaken
bull Avoid distended bowel at surgery by 48 hours pre op bowel prep
bull Avoid nitrous oxide during surgery as it causes bowel distension
bull If small bowel injured
ndash Repair laparoscopically
ndash Mesh can still be placed
bull Antibiotic cover for 7 days post op
CONCLUSION 1
1 To open the peritoneum tigh-it
2 Dissection on the right side of the mid-sacral ligament
3 Repair carefuly the vessels and the Right ureter
4 Try to preserve the right hypogatsric nerve
5 Fix your needle 1 cm below the promontory
MESH SELECTIONPERTINENT MESH SCIENCEWHY USE A CERTAIN MESH
Pr Bruno DEVAL MD Geoffroy Saint-Hilaire ndash Clinic
Hotel ndashDieu de Paris
Paris V University
MESH STIFFNESS
bullIncreased fibrosis and deposits of unorganized collagen create an increased stiffness
bull (Klinge 1999)
bullStiffness has been linked to clinical complications-heavier stiffer meshes having higher complications
bull (Dietz 2003)
bullStiffer meshes showed decreases in smooth muscle collagen and structural proteins following implantation
bull (Moalli P AUGS 2011)
bullHeavier stiffer meshes showed a greater propensity for stress shielding which in turn could cause reoccurrences of prolapse
bull (Moalli P AUGS 2011)
IMPACT OF VAGINAL SYNTHETIC PROLAPSE MESHES ON THE MECHANICS
OF THE HOST TISSUE RESPONSE
Feola Andrew J 02 February 2012 Doctoral Dissertation University of Pittsburgh
ldquoImplantation of the stiffest mesh in the non human primate
resulted in an exhibition of a stress-shielding response
manifested by inferior biomechanical properties of the
abdominal and vaginal tissues
Less stiff meshes resulted in preservation of tissue
propertiesrdquo
Wolffrsquos Law ndash remodeling of bone in response to stress
MESH CHARACTERISTICS
Density - Filament size ndash Elasticity - Pore size
Surface area ndash Overall ldquomesh loadrdquo
Biomechanical engineers working with type-1
polypropylene have focused on reducing overall
ldquomesh loadrdquo while maintaining durability
bullOptimal tissue incorporation and collagen growthbullNo erosionbullNo palpable mesh to patient and her partnerbullVaginal elasticity
TO OBTAIN
So lighter is better
WHAT KIND OF MESH
bull To date polypropylene meshes are the best type on the market
bull Absorbable meshes do not work
bull There is an evidence to use Polypropylene vs polyesther
bull PTFE and NW meshes are contra ndash indicated in the POP Repair
ULTRA- LIGHT POLYPROPYLENE
bull Physiologically compatible 19 gsm1
bull Ultra lightweightbull Lowest weight available for pelvic restoration
bull 18 millimeter macropores1
ndash Consistent size throughout the mesh
bull 100 micron interstitial Smartporestrade 1ndash Simultaneously encourages both collagen growth and
bacteria fighting propertiesbull Fibroblasts will enter holes that are 50 to 200 microns in size23
bull Macrophages and neutrophils will enter holes that are 50 to 120 microns in size23
bull Reduce inflammation1 Data on file2 Greca FH et at (2007) The influence of porosity on integration histology of two polypropylene meshes for the treatment of abdominal wall
defects in dogs Hernia (12) 45-493 Marois Y et all (2000) Biostability inflammatory response and healing characteristics flourpassivated polyester-knit mesh in the repair of
experimental abdominal hernias Artif Organs 24533-543
ULTRA ndash LIGHT CLINICAL EVIDENCE
SUMMARY
bull Rates of Erosion and Exposurebull Less than 1 erosion rate1
bull Anterior exposure rate 172
bull Posterior exposure rate 052
bull Greater tissue strength 3 months post-op ndash 71 more collagen growth3
bull Mature vaginal elastin decrease was not observed with Smartmesh4
bull Smartmesh did not induce a negative change in collagen metabolism5
bull Smartmesh had similar innervation density as sham 6
bull Low incidence of de novo dyspareunia71 Alinsod R et al (2008) Long term outcomes of vaginal pelvic floor repair using an ultra lightweight mesh AAGL (2008)2 Alinsod R Et al (2012) Durability and Complications of an Ultra Lightweight Transvaginal Mesh in the Treatment of Pelvic Organ Prolapse Presented at the 37th Annual Meeting of IUGA3 Greca FH et al (2007) The influence of porosity on the integration histology of two polypropylene meshes for the treatment of abdominal wall defects in dogs Hernia (12) 45-494 Moalli et al (2012) Mesh implantation negatively impacts vagina elastin metabolism Female Pelvic Medicine amp Reconstructive Surgery Vol 18 (Suppl 2)S258-9 SeptOct paper 235 Moalli et al (2012) Increasing mesh stiffness negatively impacts vaginal collagen metabolism Female Pelvic Medicine amp Reconstructive Surgery Vol 18 (Suppl 2)S258-9 SeptOct paper 246 Moalli et al (2012) The impact of mesh implantation on vaginal smooth muscle innervation Female Pelvic Medicine amp Reconstructive Surgery Vol 18 (Suppl 2)S258-9 SeptOct paper 257 Hawthorn R et al (2007) Use of ultra lightweight mesh in vaginal vault repairs to minimize complications A two centre observation study British International Congress of Obstetrics amp Gynaecology
PRE FORMED Y-MESH VS CUTTING MESH AND MAKING IT TO FIT PATIENTS
Pr Bruno DEVAL MD Geoffroy Saint-Hilaire ndash Clinic
Hotel ndashDieu de Paris
Paris V University
Mesh and operative handling
The shape and weight of the mesh can help us during
laparoscopic procedure
A large Y mesh is a good choice for vaginal vault shape
Better intra-operative manipulation and suturing
Lower mesh mass accommodates easy passage through narrow
laparoscopic ports
Use re-absorbable sutures on the vagina
bull Stitch erosions are reported
bull Folding and wrinkling can cause
erosions and dyspaurenia
Avoid folding and wrinkling the
mesh must be well stretched
DO WE NEED TO DISSECT POSTERIOR DOWN TO PERINEUM OR
IN WHICH PATIENTS THIS IS INDICATED
Pr Bruno DEVAL MD Geoffroy Saint-Hilaire ndash Clinic
Hotel ndashDieu de Paris
Paris V University
Fix the mesh on the posterior
vaginal wall and not on the
elevator ani muscle
bull To avoid dyschezia and chronic
pelvic pain
bull Sacrocolpopexy should only be performed by board certified eligible surgeons (ObGyn or Urology)
bull Knowledge surgical skills and experience in reconstructive pelvic surgery
FPMRS fellowship
CME documentation
Proctoring on 10 cases
gt 50 practice in reconstructive surgery
bull Outcomes and complications of should be monitored by annual internal audit
bull Informed consent should highlight
Alternatives to ASC including pessary
Complications of ASC
Complications of mesh
AUGS Guidelines on Sacrocolpopexy Privileges(March 2013)
Source wwwaugsorg
Conclusion
bull The technique and expertise are
fundamental
bull Laparoscopic colposacropexy can safely
be offered to women with symptomatic
POP
bull Conventional LSCP = Open Way =
robotic way
bull Conventional LSCP gt Vaginal Way
Spondilithis03
ndash Preacutevention bull Asepsie and per-op antibioprophylaxy
ndash Diagnosis ndash Lombalgia fever tence neurologic diseases
ndash Inflammatory Syndrome (CRP)
ndash Radiologic signs (IRM)
bull Immobilisation
bull Antibiotheacuterapie prolongeacutee +- ponction discale
bull Ablation des prothegraveses
bull +- Arthrodegravese laminectomie
Posterior Dissection ndash DENONVILLIERS FASCIA
Since Charles-PierreDenonvilliers first discoveredthe firm membranousstructure between the rectumand prostate or bladder in1836 now calledldquoDenonvilliersrsquo fasciardquo (DF)the origin of DF has remainedcontroversial
Posterior Dissection ndash DENONVILLIERS FASCIA
Based on the evidencesurgeons should be awareof variations and search forthem to create a suitabledissection plane to avoidiatrogenic positive marginsand rectal injury
Rectal Injury04
ndash Sub-peacuteritoneacuteal rectum
bull There is a recto-vaginal space
bull Horizontal Position ++
bull Close to the post face of the vagina on the distal points
bull Danger on the proximal part of the Recto-Vaginal Septum
ndash Preacutevention
bull Follow the post-face of the vagina
bull Systeacutematic pre-operativ preparation
ndash NORMACOL reg
bull Maleable Retractor
ndash Treatment
bull Immeacutediat Suture
bull Mesh contra-Indication
Vaginal Injury04
ndash Preacuteventionbull Ant Vaginal Length - 6 cm ( 4 ndash 75) Jayle et al Masson 1918
bull Post Vaginal Lenght- 9cm (65 ndash 115) Jayle et al Masson 1918
bull There is no difference between the anterior and posteriorvagina thickness
bull If the vagina is too thin ndash Plicature of the vagina
ndash Treatmentbull If Vagina Injury Suture of the vagina
bull There is no contra indication to fix the meshes
RISK OF URETERAL
INJURY lt 11000
ndash Preacutevention
bull Parietal Uretera
ndash Cross between right extern iliac artery and uterine artery
bull Visceral Uretera
ndash Behind the ligaments
ndash Under the bladder
ndash In contact with the bladder
ndash Treatment
bull Per-op
ndash Per-op Bleu carmin en IV
ndash Ureteacuteral Catheter
bull Post-op
ndash Uro-scanner
ndash JJ Ureteral
Bladder
Collection
Sagittal T2
Vagina
Uterus
Ureter ariving in urinoma
Axial T2
Coronale T2
Bladder Injury2
ndash Sub-peacuteritoneacuteal Bladder
bull Vertical Position ++
bull Close to the ant face of the vagina
bull There is NO space
ndash Preacutevention
bull Following the Ant- Face of the vagina
bull Maleable Retractor
ndash Treatment
bull Immeacutediat Suture
bull Mesh Indication
bull Bladder Catheterisation 5 days
Small and Large Bowel Injury
bull Occur when adhesiolysis has to be undertaken
bull Avoid distended bowel at surgery by 48 hours pre op bowel prep
bull Avoid nitrous oxide during surgery as it causes bowel distension
bull If small bowel injured
ndash Repair laparoscopically
ndash Mesh can still be placed
bull Antibiotic cover for 7 days post op
CONCLUSION 1
1 To open the peritoneum tigh-it
2 Dissection on the right side of the mid-sacral ligament
3 Repair carefuly the vessels and the Right ureter
4 Try to preserve the right hypogatsric nerve
5 Fix your needle 1 cm below the promontory
MESH SELECTIONPERTINENT MESH SCIENCEWHY USE A CERTAIN MESH
Pr Bruno DEVAL MD Geoffroy Saint-Hilaire ndash Clinic
Hotel ndashDieu de Paris
Paris V University
MESH STIFFNESS
bullIncreased fibrosis and deposits of unorganized collagen create an increased stiffness
bull (Klinge 1999)
bullStiffness has been linked to clinical complications-heavier stiffer meshes having higher complications
bull (Dietz 2003)
bullStiffer meshes showed decreases in smooth muscle collagen and structural proteins following implantation
bull (Moalli P AUGS 2011)
bullHeavier stiffer meshes showed a greater propensity for stress shielding which in turn could cause reoccurrences of prolapse
bull (Moalli P AUGS 2011)
IMPACT OF VAGINAL SYNTHETIC PROLAPSE MESHES ON THE MECHANICS
OF THE HOST TISSUE RESPONSE
Feola Andrew J 02 February 2012 Doctoral Dissertation University of Pittsburgh
ldquoImplantation of the stiffest mesh in the non human primate
resulted in an exhibition of a stress-shielding response
manifested by inferior biomechanical properties of the
abdominal and vaginal tissues
Less stiff meshes resulted in preservation of tissue
propertiesrdquo
Wolffrsquos Law ndash remodeling of bone in response to stress
MESH CHARACTERISTICS
Density - Filament size ndash Elasticity - Pore size
Surface area ndash Overall ldquomesh loadrdquo
Biomechanical engineers working with type-1
polypropylene have focused on reducing overall
ldquomesh loadrdquo while maintaining durability
bullOptimal tissue incorporation and collagen growthbullNo erosionbullNo palpable mesh to patient and her partnerbullVaginal elasticity
TO OBTAIN
So lighter is better
WHAT KIND OF MESH
bull To date polypropylene meshes are the best type on the market
bull Absorbable meshes do not work
bull There is an evidence to use Polypropylene vs polyesther
bull PTFE and NW meshes are contra ndash indicated in the POP Repair
ULTRA- LIGHT POLYPROPYLENE
bull Physiologically compatible 19 gsm1
bull Ultra lightweightbull Lowest weight available for pelvic restoration
bull 18 millimeter macropores1
ndash Consistent size throughout the mesh
bull 100 micron interstitial Smartporestrade 1ndash Simultaneously encourages both collagen growth and
bacteria fighting propertiesbull Fibroblasts will enter holes that are 50 to 200 microns in size23
bull Macrophages and neutrophils will enter holes that are 50 to 120 microns in size23
bull Reduce inflammation1 Data on file2 Greca FH et at (2007) The influence of porosity on integration histology of two polypropylene meshes for the treatment of abdominal wall
defects in dogs Hernia (12) 45-493 Marois Y et all (2000) Biostability inflammatory response and healing characteristics flourpassivated polyester-knit mesh in the repair of
experimental abdominal hernias Artif Organs 24533-543
ULTRA ndash LIGHT CLINICAL EVIDENCE
SUMMARY
bull Rates of Erosion and Exposurebull Less than 1 erosion rate1
bull Anterior exposure rate 172
bull Posterior exposure rate 052
bull Greater tissue strength 3 months post-op ndash 71 more collagen growth3
bull Mature vaginal elastin decrease was not observed with Smartmesh4
bull Smartmesh did not induce a negative change in collagen metabolism5
bull Smartmesh had similar innervation density as sham 6
bull Low incidence of de novo dyspareunia71 Alinsod R et al (2008) Long term outcomes of vaginal pelvic floor repair using an ultra lightweight mesh AAGL (2008)2 Alinsod R Et al (2012) Durability and Complications of an Ultra Lightweight Transvaginal Mesh in the Treatment of Pelvic Organ Prolapse Presented at the 37th Annual Meeting of IUGA3 Greca FH et al (2007) The influence of porosity on the integration histology of two polypropylene meshes for the treatment of abdominal wall defects in dogs Hernia (12) 45-494 Moalli et al (2012) Mesh implantation negatively impacts vagina elastin metabolism Female Pelvic Medicine amp Reconstructive Surgery Vol 18 (Suppl 2)S258-9 SeptOct paper 235 Moalli et al (2012) Increasing mesh stiffness negatively impacts vaginal collagen metabolism Female Pelvic Medicine amp Reconstructive Surgery Vol 18 (Suppl 2)S258-9 SeptOct paper 246 Moalli et al (2012) The impact of mesh implantation on vaginal smooth muscle innervation Female Pelvic Medicine amp Reconstructive Surgery Vol 18 (Suppl 2)S258-9 SeptOct paper 257 Hawthorn R et al (2007) Use of ultra lightweight mesh in vaginal vault repairs to minimize complications A two centre observation study British International Congress of Obstetrics amp Gynaecology
PRE FORMED Y-MESH VS CUTTING MESH AND MAKING IT TO FIT PATIENTS
Pr Bruno DEVAL MD Geoffroy Saint-Hilaire ndash Clinic
Hotel ndashDieu de Paris
Paris V University
Mesh and operative handling
The shape and weight of the mesh can help us during
laparoscopic procedure
A large Y mesh is a good choice for vaginal vault shape
Better intra-operative manipulation and suturing
Lower mesh mass accommodates easy passage through narrow
laparoscopic ports
Use re-absorbable sutures on the vagina
bull Stitch erosions are reported
bull Folding and wrinkling can cause
erosions and dyspaurenia
Avoid folding and wrinkling the
mesh must be well stretched
DO WE NEED TO DISSECT POSTERIOR DOWN TO PERINEUM OR
IN WHICH PATIENTS THIS IS INDICATED
Pr Bruno DEVAL MD Geoffroy Saint-Hilaire ndash Clinic
Hotel ndashDieu de Paris
Paris V University
Fix the mesh on the posterior
vaginal wall and not on the
elevator ani muscle
bull To avoid dyschezia and chronic
pelvic pain
bull Sacrocolpopexy should only be performed by board certified eligible surgeons (ObGyn or Urology)
bull Knowledge surgical skills and experience in reconstructive pelvic surgery
FPMRS fellowship
CME documentation
Proctoring on 10 cases
gt 50 practice in reconstructive surgery
bull Outcomes and complications of should be monitored by annual internal audit
bull Informed consent should highlight
Alternatives to ASC including pessary
Complications of ASC
Complications of mesh
AUGS Guidelines on Sacrocolpopexy Privileges(March 2013)
Source wwwaugsorg
Conclusion
bull The technique and expertise are
fundamental
bull Laparoscopic colposacropexy can safely
be offered to women with symptomatic
POP
bull Conventional LSCP = Open Way =
robotic way
bull Conventional LSCP gt Vaginal Way
Posterior Dissection ndash DENONVILLIERS FASCIA
Since Charles-PierreDenonvilliers first discoveredthe firm membranousstructure between the rectumand prostate or bladder in1836 now calledldquoDenonvilliersrsquo fasciardquo (DF)the origin of DF has remainedcontroversial
Posterior Dissection ndash DENONVILLIERS FASCIA
Based on the evidencesurgeons should be awareof variations and search forthem to create a suitabledissection plane to avoidiatrogenic positive marginsand rectal injury
Rectal Injury04
ndash Sub-peacuteritoneacuteal rectum
bull There is a recto-vaginal space
bull Horizontal Position ++
bull Close to the post face of the vagina on the distal points
bull Danger on the proximal part of the Recto-Vaginal Septum
ndash Preacutevention
bull Follow the post-face of the vagina
bull Systeacutematic pre-operativ preparation
ndash NORMACOL reg
bull Maleable Retractor
ndash Treatment
bull Immeacutediat Suture
bull Mesh contra-Indication
Vaginal Injury04
ndash Preacuteventionbull Ant Vaginal Length - 6 cm ( 4 ndash 75) Jayle et al Masson 1918
bull Post Vaginal Lenght- 9cm (65 ndash 115) Jayle et al Masson 1918
bull There is no difference between the anterior and posteriorvagina thickness
bull If the vagina is too thin ndash Plicature of the vagina
ndash Treatmentbull If Vagina Injury Suture of the vagina
bull There is no contra indication to fix the meshes
RISK OF URETERAL
INJURY lt 11000
ndash Preacutevention
bull Parietal Uretera
ndash Cross between right extern iliac artery and uterine artery
bull Visceral Uretera
ndash Behind the ligaments
ndash Under the bladder
ndash In contact with the bladder
ndash Treatment
bull Per-op
ndash Per-op Bleu carmin en IV
ndash Ureteacuteral Catheter
bull Post-op
ndash Uro-scanner
ndash JJ Ureteral
Bladder
Collection
Sagittal T2
Vagina
Uterus
Ureter ariving in urinoma
Axial T2
Coronale T2
Bladder Injury2
ndash Sub-peacuteritoneacuteal Bladder
bull Vertical Position ++
bull Close to the ant face of the vagina
bull There is NO space
ndash Preacutevention
bull Following the Ant- Face of the vagina
bull Maleable Retractor
ndash Treatment
bull Immeacutediat Suture
bull Mesh Indication
bull Bladder Catheterisation 5 days
Small and Large Bowel Injury
bull Occur when adhesiolysis has to be undertaken
bull Avoid distended bowel at surgery by 48 hours pre op bowel prep
bull Avoid nitrous oxide during surgery as it causes bowel distension
bull If small bowel injured
ndash Repair laparoscopically
ndash Mesh can still be placed
bull Antibiotic cover for 7 days post op
CONCLUSION 1
1 To open the peritoneum tigh-it
2 Dissection on the right side of the mid-sacral ligament
3 Repair carefuly the vessels and the Right ureter
4 Try to preserve the right hypogatsric nerve
5 Fix your needle 1 cm below the promontory
MESH SELECTIONPERTINENT MESH SCIENCEWHY USE A CERTAIN MESH
Pr Bruno DEVAL MD Geoffroy Saint-Hilaire ndash Clinic
Hotel ndashDieu de Paris
Paris V University
MESH STIFFNESS
bullIncreased fibrosis and deposits of unorganized collagen create an increased stiffness
bull (Klinge 1999)
bullStiffness has been linked to clinical complications-heavier stiffer meshes having higher complications
bull (Dietz 2003)
bullStiffer meshes showed decreases in smooth muscle collagen and structural proteins following implantation
bull (Moalli P AUGS 2011)
bullHeavier stiffer meshes showed a greater propensity for stress shielding which in turn could cause reoccurrences of prolapse
bull (Moalli P AUGS 2011)
IMPACT OF VAGINAL SYNTHETIC PROLAPSE MESHES ON THE MECHANICS
OF THE HOST TISSUE RESPONSE
Feola Andrew J 02 February 2012 Doctoral Dissertation University of Pittsburgh
ldquoImplantation of the stiffest mesh in the non human primate
resulted in an exhibition of a stress-shielding response
manifested by inferior biomechanical properties of the
abdominal and vaginal tissues
Less stiff meshes resulted in preservation of tissue
propertiesrdquo
Wolffrsquos Law ndash remodeling of bone in response to stress
MESH CHARACTERISTICS
Density - Filament size ndash Elasticity - Pore size
Surface area ndash Overall ldquomesh loadrdquo
Biomechanical engineers working with type-1
polypropylene have focused on reducing overall
ldquomesh loadrdquo while maintaining durability
bullOptimal tissue incorporation and collagen growthbullNo erosionbullNo palpable mesh to patient and her partnerbullVaginal elasticity
TO OBTAIN
So lighter is better
WHAT KIND OF MESH
bull To date polypropylene meshes are the best type on the market
bull Absorbable meshes do not work
bull There is an evidence to use Polypropylene vs polyesther
bull PTFE and NW meshes are contra ndash indicated in the POP Repair
ULTRA- LIGHT POLYPROPYLENE
bull Physiologically compatible 19 gsm1
bull Ultra lightweightbull Lowest weight available for pelvic restoration
bull 18 millimeter macropores1
ndash Consistent size throughout the mesh
bull 100 micron interstitial Smartporestrade 1ndash Simultaneously encourages both collagen growth and
bacteria fighting propertiesbull Fibroblasts will enter holes that are 50 to 200 microns in size23
bull Macrophages and neutrophils will enter holes that are 50 to 120 microns in size23
bull Reduce inflammation1 Data on file2 Greca FH et at (2007) The influence of porosity on integration histology of two polypropylene meshes for the treatment of abdominal wall
defects in dogs Hernia (12) 45-493 Marois Y et all (2000) Biostability inflammatory response and healing characteristics flourpassivated polyester-knit mesh in the repair of
experimental abdominal hernias Artif Organs 24533-543
ULTRA ndash LIGHT CLINICAL EVIDENCE
SUMMARY
bull Rates of Erosion and Exposurebull Less than 1 erosion rate1
bull Anterior exposure rate 172
bull Posterior exposure rate 052
bull Greater tissue strength 3 months post-op ndash 71 more collagen growth3
bull Mature vaginal elastin decrease was not observed with Smartmesh4
bull Smartmesh did not induce a negative change in collagen metabolism5
bull Smartmesh had similar innervation density as sham 6
bull Low incidence of de novo dyspareunia71 Alinsod R et al (2008) Long term outcomes of vaginal pelvic floor repair using an ultra lightweight mesh AAGL (2008)2 Alinsod R Et al (2012) Durability and Complications of an Ultra Lightweight Transvaginal Mesh in the Treatment of Pelvic Organ Prolapse Presented at the 37th Annual Meeting of IUGA3 Greca FH et al (2007) The influence of porosity on the integration histology of two polypropylene meshes for the treatment of abdominal wall defects in dogs Hernia (12) 45-494 Moalli et al (2012) Mesh implantation negatively impacts vagina elastin metabolism Female Pelvic Medicine amp Reconstructive Surgery Vol 18 (Suppl 2)S258-9 SeptOct paper 235 Moalli et al (2012) Increasing mesh stiffness negatively impacts vaginal collagen metabolism Female Pelvic Medicine amp Reconstructive Surgery Vol 18 (Suppl 2)S258-9 SeptOct paper 246 Moalli et al (2012) The impact of mesh implantation on vaginal smooth muscle innervation Female Pelvic Medicine amp Reconstructive Surgery Vol 18 (Suppl 2)S258-9 SeptOct paper 257 Hawthorn R et al (2007) Use of ultra lightweight mesh in vaginal vault repairs to minimize complications A two centre observation study British International Congress of Obstetrics amp Gynaecology
PRE FORMED Y-MESH VS CUTTING MESH AND MAKING IT TO FIT PATIENTS
Pr Bruno DEVAL MD Geoffroy Saint-Hilaire ndash Clinic
Hotel ndashDieu de Paris
Paris V University
Mesh and operative handling
The shape and weight of the mesh can help us during
laparoscopic procedure
A large Y mesh is a good choice for vaginal vault shape
Better intra-operative manipulation and suturing
Lower mesh mass accommodates easy passage through narrow
laparoscopic ports
Use re-absorbable sutures on the vagina
bull Stitch erosions are reported
bull Folding and wrinkling can cause
erosions and dyspaurenia
Avoid folding and wrinkling the
mesh must be well stretched
DO WE NEED TO DISSECT POSTERIOR DOWN TO PERINEUM OR
IN WHICH PATIENTS THIS IS INDICATED
Pr Bruno DEVAL MD Geoffroy Saint-Hilaire ndash Clinic
Hotel ndashDieu de Paris
Paris V University
Fix the mesh on the posterior
vaginal wall and not on the
elevator ani muscle
bull To avoid dyschezia and chronic
pelvic pain
bull Sacrocolpopexy should only be performed by board certified eligible surgeons (ObGyn or Urology)
bull Knowledge surgical skills and experience in reconstructive pelvic surgery
FPMRS fellowship
CME documentation
Proctoring on 10 cases
gt 50 practice in reconstructive surgery
bull Outcomes and complications of should be monitored by annual internal audit
bull Informed consent should highlight
Alternatives to ASC including pessary
Complications of ASC
Complications of mesh
AUGS Guidelines on Sacrocolpopexy Privileges(March 2013)
Source wwwaugsorg
Conclusion
bull The technique and expertise are
fundamental
bull Laparoscopic colposacropexy can safely
be offered to women with symptomatic
POP
bull Conventional LSCP = Open Way =
robotic way
bull Conventional LSCP gt Vaginal Way
Posterior Dissection ndash DENONVILLIERS FASCIA
Based on the evidencesurgeons should be awareof variations and search forthem to create a suitabledissection plane to avoidiatrogenic positive marginsand rectal injury
Rectal Injury04
ndash Sub-peacuteritoneacuteal rectum
bull There is a recto-vaginal space
bull Horizontal Position ++
bull Close to the post face of the vagina on the distal points
bull Danger on the proximal part of the Recto-Vaginal Septum
ndash Preacutevention
bull Follow the post-face of the vagina
bull Systeacutematic pre-operativ preparation
ndash NORMACOL reg
bull Maleable Retractor
ndash Treatment
bull Immeacutediat Suture
bull Mesh contra-Indication
Vaginal Injury04
ndash Preacuteventionbull Ant Vaginal Length - 6 cm ( 4 ndash 75) Jayle et al Masson 1918
bull Post Vaginal Lenght- 9cm (65 ndash 115) Jayle et al Masson 1918
bull There is no difference between the anterior and posteriorvagina thickness
bull If the vagina is too thin ndash Plicature of the vagina
ndash Treatmentbull If Vagina Injury Suture of the vagina
bull There is no contra indication to fix the meshes
RISK OF URETERAL
INJURY lt 11000
ndash Preacutevention
bull Parietal Uretera
ndash Cross between right extern iliac artery and uterine artery
bull Visceral Uretera
ndash Behind the ligaments
ndash Under the bladder
ndash In contact with the bladder
ndash Treatment
bull Per-op
ndash Per-op Bleu carmin en IV
ndash Ureteacuteral Catheter
bull Post-op
ndash Uro-scanner
ndash JJ Ureteral
Bladder
Collection
Sagittal T2
Vagina
Uterus
Ureter ariving in urinoma
Axial T2
Coronale T2
Bladder Injury2
ndash Sub-peacuteritoneacuteal Bladder
bull Vertical Position ++
bull Close to the ant face of the vagina
bull There is NO space
ndash Preacutevention
bull Following the Ant- Face of the vagina
bull Maleable Retractor
ndash Treatment
bull Immeacutediat Suture
bull Mesh Indication
bull Bladder Catheterisation 5 days
Small and Large Bowel Injury
bull Occur when adhesiolysis has to be undertaken
bull Avoid distended bowel at surgery by 48 hours pre op bowel prep
bull Avoid nitrous oxide during surgery as it causes bowel distension
bull If small bowel injured
ndash Repair laparoscopically
ndash Mesh can still be placed
bull Antibiotic cover for 7 days post op
CONCLUSION 1
1 To open the peritoneum tigh-it
2 Dissection on the right side of the mid-sacral ligament
3 Repair carefuly the vessels and the Right ureter
4 Try to preserve the right hypogatsric nerve
5 Fix your needle 1 cm below the promontory
MESH SELECTIONPERTINENT MESH SCIENCEWHY USE A CERTAIN MESH
Pr Bruno DEVAL MD Geoffroy Saint-Hilaire ndash Clinic
Hotel ndashDieu de Paris
Paris V University
MESH STIFFNESS
bullIncreased fibrosis and deposits of unorganized collagen create an increased stiffness
bull (Klinge 1999)
bullStiffness has been linked to clinical complications-heavier stiffer meshes having higher complications
bull (Dietz 2003)
bullStiffer meshes showed decreases in smooth muscle collagen and structural proteins following implantation
bull (Moalli P AUGS 2011)
bullHeavier stiffer meshes showed a greater propensity for stress shielding which in turn could cause reoccurrences of prolapse
bull (Moalli P AUGS 2011)
IMPACT OF VAGINAL SYNTHETIC PROLAPSE MESHES ON THE MECHANICS
OF THE HOST TISSUE RESPONSE
Feola Andrew J 02 February 2012 Doctoral Dissertation University of Pittsburgh
ldquoImplantation of the stiffest mesh in the non human primate
resulted in an exhibition of a stress-shielding response
manifested by inferior biomechanical properties of the
abdominal and vaginal tissues
Less stiff meshes resulted in preservation of tissue
propertiesrdquo
Wolffrsquos Law ndash remodeling of bone in response to stress
MESH CHARACTERISTICS
Density - Filament size ndash Elasticity - Pore size
Surface area ndash Overall ldquomesh loadrdquo
Biomechanical engineers working with type-1
polypropylene have focused on reducing overall
ldquomesh loadrdquo while maintaining durability
bullOptimal tissue incorporation and collagen growthbullNo erosionbullNo palpable mesh to patient and her partnerbullVaginal elasticity
TO OBTAIN
So lighter is better
WHAT KIND OF MESH
bull To date polypropylene meshes are the best type on the market
bull Absorbable meshes do not work
bull There is an evidence to use Polypropylene vs polyesther
bull PTFE and NW meshes are contra ndash indicated in the POP Repair
ULTRA- LIGHT POLYPROPYLENE
bull Physiologically compatible 19 gsm1
bull Ultra lightweightbull Lowest weight available for pelvic restoration
bull 18 millimeter macropores1
ndash Consistent size throughout the mesh
bull 100 micron interstitial Smartporestrade 1ndash Simultaneously encourages both collagen growth and
bacteria fighting propertiesbull Fibroblasts will enter holes that are 50 to 200 microns in size23
bull Macrophages and neutrophils will enter holes that are 50 to 120 microns in size23
bull Reduce inflammation1 Data on file2 Greca FH et at (2007) The influence of porosity on integration histology of two polypropylene meshes for the treatment of abdominal wall
defects in dogs Hernia (12) 45-493 Marois Y et all (2000) Biostability inflammatory response and healing characteristics flourpassivated polyester-knit mesh in the repair of
experimental abdominal hernias Artif Organs 24533-543
ULTRA ndash LIGHT CLINICAL EVIDENCE
SUMMARY
bull Rates of Erosion and Exposurebull Less than 1 erosion rate1
bull Anterior exposure rate 172
bull Posterior exposure rate 052
bull Greater tissue strength 3 months post-op ndash 71 more collagen growth3
bull Mature vaginal elastin decrease was not observed with Smartmesh4
bull Smartmesh did not induce a negative change in collagen metabolism5
bull Smartmesh had similar innervation density as sham 6
bull Low incidence of de novo dyspareunia71 Alinsod R et al (2008) Long term outcomes of vaginal pelvic floor repair using an ultra lightweight mesh AAGL (2008)2 Alinsod R Et al (2012) Durability and Complications of an Ultra Lightweight Transvaginal Mesh in the Treatment of Pelvic Organ Prolapse Presented at the 37th Annual Meeting of IUGA3 Greca FH et al (2007) The influence of porosity on the integration histology of two polypropylene meshes for the treatment of abdominal wall defects in dogs Hernia (12) 45-494 Moalli et al (2012) Mesh implantation negatively impacts vagina elastin metabolism Female Pelvic Medicine amp Reconstructive Surgery Vol 18 (Suppl 2)S258-9 SeptOct paper 235 Moalli et al (2012) Increasing mesh stiffness negatively impacts vaginal collagen metabolism Female Pelvic Medicine amp Reconstructive Surgery Vol 18 (Suppl 2)S258-9 SeptOct paper 246 Moalli et al (2012) The impact of mesh implantation on vaginal smooth muscle innervation Female Pelvic Medicine amp Reconstructive Surgery Vol 18 (Suppl 2)S258-9 SeptOct paper 257 Hawthorn R et al (2007) Use of ultra lightweight mesh in vaginal vault repairs to minimize complications A two centre observation study British International Congress of Obstetrics amp Gynaecology
PRE FORMED Y-MESH VS CUTTING MESH AND MAKING IT TO FIT PATIENTS
Pr Bruno DEVAL MD Geoffroy Saint-Hilaire ndash Clinic
Hotel ndashDieu de Paris
Paris V University
Mesh and operative handling
The shape and weight of the mesh can help us during
laparoscopic procedure
A large Y mesh is a good choice for vaginal vault shape
Better intra-operative manipulation and suturing
Lower mesh mass accommodates easy passage through narrow
laparoscopic ports
Use re-absorbable sutures on the vagina
bull Stitch erosions are reported
bull Folding and wrinkling can cause
erosions and dyspaurenia
Avoid folding and wrinkling the
mesh must be well stretched
DO WE NEED TO DISSECT POSTERIOR DOWN TO PERINEUM OR
IN WHICH PATIENTS THIS IS INDICATED
Pr Bruno DEVAL MD Geoffroy Saint-Hilaire ndash Clinic
Hotel ndashDieu de Paris
Paris V University
Fix the mesh on the posterior
vaginal wall and not on the
elevator ani muscle
bull To avoid dyschezia and chronic
pelvic pain
bull Sacrocolpopexy should only be performed by board certified eligible surgeons (ObGyn or Urology)
bull Knowledge surgical skills and experience in reconstructive pelvic surgery
FPMRS fellowship
CME documentation
Proctoring on 10 cases
gt 50 practice in reconstructive surgery
bull Outcomes and complications of should be monitored by annual internal audit
bull Informed consent should highlight
Alternatives to ASC including pessary
Complications of ASC
Complications of mesh
AUGS Guidelines on Sacrocolpopexy Privileges(March 2013)
Source wwwaugsorg
Conclusion
bull The technique and expertise are
fundamental
bull Laparoscopic colposacropexy can safely
be offered to women with symptomatic
POP
bull Conventional LSCP = Open Way =
robotic way
bull Conventional LSCP gt Vaginal Way
Rectal Injury04
ndash Sub-peacuteritoneacuteal rectum
bull There is a recto-vaginal space
bull Horizontal Position ++
bull Close to the post face of the vagina on the distal points
bull Danger on the proximal part of the Recto-Vaginal Septum
ndash Preacutevention
bull Follow the post-face of the vagina
bull Systeacutematic pre-operativ preparation
ndash NORMACOL reg
bull Maleable Retractor
ndash Treatment
bull Immeacutediat Suture
bull Mesh contra-Indication
Vaginal Injury04
ndash Preacuteventionbull Ant Vaginal Length - 6 cm ( 4 ndash 75) Jayle et al Masson 1918
bull Post Vaginal Lenght- 9cm (65 ndash 115) Jayle et al Masson 1918
bull There is no difference between the anterior and posteriorvagina thickness
bull If the vagina is too thin ndash Plicature of the vagina
ndash Treatmentbull If Vagina Injury Suture of the vagina
bull There is no contra indication to fix the meshes
RISK OF URETERAL
INJURY lt 11000
ndash Preacutevention
bull Parietal Uretera
ndash Cross between right extern iliac artery and uterine artery
bull Visceral Uretera
ndash Behind the ligaments
ndash Under the bladder
ndash In contact with the bladder
ndash Treatment
bull Per-op
ndash Per-op Bleu carmin en IV
ndash Ureteacuteral Catheter
bull Post-op
ndash Uro-scanner
ndash JJ Ureteral
Bladder
Collection
Sagittal T2
Vagina
Uterus
Ureter ariving in urinoma
Axial T2
Coronale T2
Bladder Injury2
ndash Sub-peacuteritoneacuteal Bladder
bull Vertical Position ++
bull Close to the ant face of the vagina
bull There is NO space
ndash Preacutevention
bull Following the Ant- Face of the vagina
bull Maleable Retractor
ndash Treatment
bull Immeacutediat Suture
bull Mesh Indication
bull Bladder Catheterisation 5 days
Small and Large Bowel Injury
bull Occur when adhesiolysis has to be undertaken
bull Avoid distended bowel at surgery by 48 hours pre op bowel prep
bull Avoid nitrous oxide during surgery as it causes bowel distension
bull If small bowel injured
ndash Repair laparoscopically
ndash Mesh can still be placed
bull Antibiotic cover for 7 days post op
CONCLUSION 1
1 To open the peritoneum tigh-it
2 Dissection on the right side of the mid-sacral ligament
3 Repair carefuly the vessels and the Right ureter
4 Try to preserve the right hypogatsric nerve
5 Fix your needle 1 cm below the promontory
MESH SELECTIONPERTINENT MESH SCIENCEWHY USE A CERTAIN MESH
Pr Bruno DEVAL MD Geoffroy Saint-Hilaire ndash Clinic
Hotel ndashDieu de Paris
Paris V University
MESH STIFFNESS
bullIncreased fibrosis and deposits of unorganized collagen create an increased stiffness
bull (Klinge 1999)
bullStiffness has been linked to clinical complications-heavier stiffer meshes having higher complications
bull (Dietz 2003)
bullStiffer meshes showed decreases in smooth muscle collagen and structural proteins following implantation
bull (Moalli P AUGS 2011)
bullHeavier stiffer meshes showed a greater propensity for stress shielding which in turn could cause reoccurrences of prolapse
bull (Moalli P AUGS 2011)
IMPACT OF VAGINAL SYNTHETIC PROLAPSE MESHES ON THE MECHANICS
OF THE HOST TISSUE RESPONSE
Feola Andrew J 02 February 2012 Doctoral Dissertation University of Pittsburgh
ldquoImplantation of the stiffest mesh in the non human primate
resulted in an exhibition of a stress-shielding response
manifested by inferior biomechanical properties of the
abdominal and vaginal tissues
Less stiff meshes resulted in preservation of tissue
propertiesrdquo
Wolffrsquos Law ndash remodeling of bone in response to stress
MESH CHARACTERISTICS
Density - Filament size ndash Elasticity - Pore size
Surface area ndash Overall ldquomesh loadrdquo
Biomechanical engineers working with type-1
polypropylene have focused on reducing overall
ldquomesh loadrdquo while maintaining durability
bullOptimal tissue incorporation and collagen growthbullNo erosionbullNo palpable mesh to patient and her partnerbullVaginal elasticity
TO OBTAIN
So lighter is better
WHAT KIND OF MESH
bull To date polypropylene meshes are the best type on the market
bull Absorbable meshes do not work
bull There is an evidence to use Polypropylene vs polyesther
bull PTFE and NW meshes are contra ndash indicated in the POP Repair
ULTRA- LIGHT POLYPROPYLENE
bull Physiologically compatible 19 gsm1
bull Ultra lightweightbull Lowest weight available for pelvic restoration
bull 18 millimeter macropores1
ndash Consistent size throughout the mesh
bull 100 micron interstitial Smartporestrade 1ndash Simultaneously encourages both collagen growth and
bacteria fighting propertiesbull Fibroblasts will enter holes that are 50 to 200 microns in size23
bull Macrophages and neutrophils will enter holes that are 50 to 120 microns in size23
bull Reduce inflammation1 Data on file2 Greca FH et at (2007) The influence of porosity on integration histology of two polypropylene meshes for the treatment of abdominal wall
defects in dogs Hernia (12) 45-493 Marois Y et all (2000) Biostability inflammatory response and healing characteristics flourpassivated polyester-knit mesh in the repair of
experimental abdominal hernias Artif Organs 24533-543
ULTRA ndash LIGHT CLINICAL EVIDENCE
SUMMARY
bull Rates of Erosion and Exposurebull Less than 1 erosion rate1
bull Anterior exposure rate 172
bull Posterior exposure rate 052
bull Greater tissue strength 3 months post-op ndash 71 more collagen growth3
bull Mature vaginal elastin decrease was not observed with Smartmesh4
bull Smartmesh did not induce a negative change in collagen metabolism5
bull Smartmesh had similar innervation density as sham 6
bull Low incidence of de novo dyspareunia71 Alinsod R et al (2008) Long term outcomes of vaginal pelvic floor repair using an ultra lightweight mesh AAGL (2008)2 Alinsod R Et al (2012) Durability and Complications of an Ultra Lightweight Transvaginal Mesh in the Treatment of Pelvic Organ Prolapse Presented at the 37th Annual Meeting of IUGA3 Greca FH et al (2007) The influence of porosity on the integration histology of two polypropylene meshes for the treatment of abdominal wall defects in dogs Hernia (12) 45-494 Moalli et al (2012) Mesh implantation negatively impacts vagina elastin metabolism Female Pelvic Medicine amp Reconstructive Surgery Vol 18 (Suppl 2)S258-9 SeptOct paper 235 Moalli et al (2012) Increasing mesh stiffness negatively impacts vaginal collagen metabolism Female Pelvic Medicine amp Reconstructive Surgery Vol 18 (Suppl 2)S258-9 SeptOct paper 246 Moalli et al (2012) The impact of mesh implantation on vaginal smooth muscle innervation Female Pelvic Medicine amp Reconstructive Surgery Vol 18 (Suppl 2)S258-9 SeptOct paper 257 Hawthorn R et al (2007) Use of ultra lightweight mesh in vaginal vault repairs to minimize complications A two centre observation study British International Congress of Obstetrics amp Gynaecology
PRE FORMED Y-MESH VS CUTTING MESH AND MAKING IT TO FIT PATIENTS
Pr Bruno DEVAL MD Geoffroy Saint-Hilaire ndash Clinic
Hotel ndashDieu de Paris
Paris V University
Mesh and operative handling
The shape and weight of the mesh can help us during
laparoscopic procedure
A large Y mesh is a good choice for vaginal vault shape
Better intra-operative manipulation and suturing
Lower mesh mass accommodates easy passage through narrow
laparoscopic ports
Use re-absorbable sutures on the vagina
bull Stitch erosions are reported
bull Folding and wrinkling can cause
erosions and dyspaurenia
Avoid folding and wrinkling the
mesh must be well stretched
DO WE NEED TO DISSECT POSTERIOR DOWN TO PERINEUM OR
IN WHICH PATIENTS THIS IS INDICATED
Pr Bruno DEVAL MD Geoffroy Saint-Hilaire ndash Clinic
Hotel ndashDieu de Paris
Paris V University
Fix the mesh on the posterior
vaginal wall and not on the
elevator ani muscle
bull To avoid dyschezia and chronic
pelvic pain
bull Sacrocolpopexy should only be performed by board certified eligible surgeons (ObGyn or Urology)
bull Knowledge surgical skills and experience in reconstructive pelvic surgery
FPMRS fellowship
CME documentation
Proctoring on 10 cases
gt 50 practice in reconstructive surgery
bull Outcomes and complications of should be monitored by annual internal audit
bull Informed consent should highlight
Alternatives to ASC including pessary
Complications of ASC
Complications of mesh
AUGS Guidelines on Sacrocolpopexy Privileges(March 2013)
Source wwwaugsorg
Conclusion
bull The technique and expertise are
fundamental
bull Laparoscopic colposacropexy can safely
be offered to women with symptomatic
POP
bull Conventional LSCP = Open Way =
robotic way
bull Conventional LSCP gt Vaginal Way
Vaginal Injury04
ndash Preacuteventionbull Ant Vaginal Length - 6 cm ( 4 ndash 75) Jayle et al Masson 1918
bull Post Vaginal Lenght- 9cm (65 ndash 115) Jayle et al Masson 1918
bull There is no difference between the anterior and posteriorvagina thickness
bull If the vagina is too thin ndash Plicature of the vagina
ndash Treatmentbull If Vagina Injury Suture of the vagina
bull There is no contra indication to fix the meshes
RISK OF URETERAL
INJURY lt 11000
ndash Preacutevention
bull Parietal Uretera
ndash Cross between right extern iliac artery and uterine artery
bull Visceral Uretera
ndash Behind the ligaments
ndash Under the bladder
ndash In contact with the bladder
ndash Treatment
bull Per-op
ndash Per-op Bleu carmin en IV
ndash Ureteacuteral Catheter
bull Post-op
ndash Uro-scanner
ndash JJ Ureteral
Bladder
Collection
Sagittal T2
Vagina
Uterus
Ureter ariving in urinoma
Axial T2
Coronale T2
Bladder Injury2
ndash Sub-peacuteritoneacuteal Bladder
bull Vertical Position ++
bull Close to the ant face of the vagina
bull There is NO space
ndash Preacutevention
bull Following the Ant- Face of the vagina
bull Maleable Retractor
ndash Treatment
bull Immeacutediat Suture
bull Mesh Indication
bull Bladder Catheterisation 5 days
Small and Large Bowel Injury
bull Occur when adhesiolysis has to be undertaken
bull Avoid distended bowel at surgery by 48 hours pre op bowel prep
bull Avoid nitrous oxide during surgery as it causes bowel distension
bull If small bowel injured
ndash Repair laparoscopically
ndash Mesh can still be placed
bull Antibiotic cover for 7 days post op
CONCLUSION 1
1 To open the peritoneum tigh-it
2 Dissection on the right side of the mid-sacral ligament
3 Repair carefuly the vessels and the Right ureter
4 Try to preserve the right hypogatsric nerve
5 Fix your needle 1 cm below the promontory
MESH SELECTIONPERTINENT MESH SCIENCEWHY USE A CERTAIN MESH
Pr Bruno DEVAL MD Geoffroy Saint-Hilaire ndash Clinic
Hotel ndashDieu de Paris
Paris V University
MESH STIFFNESS
bullIncreased fibrosis and deposits of unorganized collagen create an increased stiffness
bull (Klinge 1999)
bullStiffness has been linked to clinical complications-heavier stiffer meshes having higher complications
bull (Dietz 2003)
bullStiffer meshes showed decreases in smooth muscle collagen and structural proteins following implantation
bull (Moalli P AUGS 2011)
bullHeavier stiffer meshes showed a greater propensity for stress shielding which in turn could cause reoccurrences of prolapse
bull (Moalli P AUGS 2011)
IMPACT OF VAGINAL SYNTHETIC PROLAPSE MESHES ON THE MECHANICS
OF THE HOST TISSUE RESPONSE
Feola Andrew J 02 February 2012 Doctoral Dissertation University of Pittsburgh
ldquoImplantation of the stiffest mesh in the non human primate
resulted in an exhibition of a stress-shielding response
manifested by inferior biomechanical properties of the
abdominal and vaginal tissues
Less stiff meshes resulted in preservation of tissue
propertiesrdquo
Wolffrsquos Law ndash remodeling of bone in response to stress
MESH CHARACTERISTICS
Density - Filament size ndash Elasticity - Pore size
Surface area ndash Overall ldquomesh loadrdquo
Biomechanical engineers working with type-1
polypropylene have focused on reducing overall
ldquomesh loadrdquo while maintaining durability
bullOptimal tissue incorporation and collagen growthbullNo erosionbullNo palpable mesh to patient and her partnerbullVaginal elasticity
TO OBTAIN
So lighter is better
WHAT KIND OF MESH
bull To date polypropylene meshes are the best type on the market
bull Absorbable meshes do not work
bull There is an evidence to use Polypropylene vs polyesther
bull PTFE and NW meshes are contra ndash indicated in the POP Repair
ULTRA- LIGHT POLYPROPYLENE
bull Physiologically compatible 19 gsm1
bull Ultra lightweightbull Lowest weight available for pelvic restoration
bull 18 millimeter macropores1
ndash Consistent size throughout the mesh
bull 100 micron interstitial Smartporestrade 1ndash Simultaneously encourages both collagen growth and
bacteria fighting propertiesbull Fibroblasts will enter holes that are 50 to 200 microns in size23
bull Macrophages and neutrophils will enter holes that are 50 to 120 microns in size23
bull Reduce inflammation1 Data on file2 Greca FH et at (2007) The influence of porosity on integration histology of two polypropylene meshes for the treatment of abdominal wall
defects in dogs Hernia (12) 45-493 Marois Y et all (2000) Biostability inflammatory response and healing characteristics flourpassivated polyester-knit mesh in the repair of
experimental abdominal hernias Artif Organs 24533-543
ULTRA ndash LIGHT CLINICAL EVIDENCE
SUMMARY
bull Rates of Erosion and Exposurebull Less than 1 erosion rate1
bull Anterior exposure rate 172
bull Posterior exposure rate 052
bull Greater tissue strength 3 months post-op ndash 71 more collagen growth3
bull Mature vaginal elastin decrease was not observed with Smartmesh4
bull Smartmesh did not induce a negative change in collagen metabolism5
bull Smartmesh had similar innervation density as sham 6
bull Low incidence of de novo dyspareunia71 Alinsod R et al (2008) Long term outcomes of vaginal pelvic floor repair using an ultra lightweight mesh AAGL (2008)2 Alinsod R Et al (2012) Durability and Complications of an Ultra Lightweight Transvaginal Mesh in the Treatment of Pelvic Organ Prolapse Presented at the 37th Annual Meeting of IUGA3 Greca FH et al (2007) The influence of porosity on the integration histology of two polypropylene meshes for the treatment of abdominal wall defects in dogs Hernia (12) 45-494 Moalli et al (2012) Mesh implantation negatively impacts vagina elastin metabolism Female Pelvic Medicine amp Reconstructive Surgery Vol 18 (Suppl 2)S258-9 SeptOct paper 235 Moalli et al (2012) Increasing mesh stiffness negatively impacts vaginal collagen metabolism Female Pelvic Medicine amp Reconstructive Surgery Vol 18 (Suppl 2)S258-9 SeptOct paper 246 Moalli et al (2012) The impact of mesh implantation on vaginal smooth muscle innervation Female Pelvic Medicine amp Reconstructive Surgery Vol 18 (Suppl 2)S258-9 SeptOct paper 257 Hawthorn R et al (2007) Use of ultra lightweight mesh in vaginal vault repairs to minimize complications A two centre observation study British International Congress of Obstetrics amp Gynaecology
PRE FORMED Y-MESH VS CUTTING MESH AND MAKING IT TO FIT PATIENTS
Pr Bruno DEVAL MD Geoffroy Saint-Hilaire ndash Clinic
Hotel ndashDieu de Paris
Paris V University
Mesh and operative handling
The shape and weight of the mesh can help us during
laparoscopic procedure
A large Y mesh is a good choice for vaginal vault shape
Better intra-operative manipulation and suturing
Lower mesh mass accommodates easy passage through narrow
laparoscopic ports
Use re-absorbable sutures on the vagina
bull Stitch erosions are reported
bull Folding and wrinkling can cause
erosions and dyspaurenia
Avoid folding and wrinkling the
mesh must be well stretched
DO WE NEED TO DISSECT POSTERIOR DOWN TO PERINEUM OR
IN WHICH PATIENTS THIS IS INDICATED
Pr Bruno DEVAL MD Geoffroy Saint-Hilaire ndash Clinic
Hotel ndashDieu de Paris
Paris V University
Fix the mesh on the posterior
vaginal wall and not on the
elevator ani muscle
bull To avoid dyschezia and chronic
pelvic pain
bull Sacrocolpopexy should only be performed by board certified eligible surgeons (ObGyn or Urology)
bull Knowledge surgical skills and experience in reconstructive pelvic surgery
FPMRS fellowship
CME documentation
Proctoring on 10 cases
gt 50 practice in reconstructive surgery
bull Outcomes and complications of should be monitored by annual internal audit
bull Informed consent should highlight
Alternatives to ASC including pessary
Complications of ASC
Complications of mesh
AUGS Guidelines on Sacrocolpopexy Privileges(March 2013)
Source wwwaugsorg
Conclusion
bull The technique and expertise are
fundamental
bull Laparoscopic colposacropexy can safely
be offered to women with symptomatic
POP
bull Conventional LSCP = Open Way =
robotic way
bull Conventional LSCP gt Vaginal Way
RISK OF URETERAL
INJURY lt 11000
ndash Preacutevention
bull Parietal Uretera
ndash Cross between right extern iliac artery and uterine artery
bull Visceral Uretera
ndash Behind the ligaments
ndash Under the bladder
ndash In contact with the bladder
ndash Treatment
bull Per-op
ndash Per-op Bleu carmin en IV
ndash Ureteacuteral Catheter
bull Post-op
ndash Uro-scanner
ndash JJ Ureteral
Bladder
Collection
Sagittal T2
Vagina
Uterus
Ureter ariving in urinoma
Axial T2
Coronale T2
Bladder Injury2
ndash Sub-peacuteritoneacuteal Bladder
bull Vertical Position ++
bull Close to the ant face of the vagina
bull There is NO space
ndash Preacutevention
bull Following the Ant- Face of the vagina
bull Maleable Retractor
ndash Treatment
bull Immeacutediat Suture
bull Mesh Indication
bull Bladder Catheterisation 5 days
Small and Large Bowel Injury
bull Occur when adhesiolysis has to be undertaken
bull Avoid distended bowel at surgery by 48 hours pre op bowel prep
bull Avoid nitrous oxide during surgery as it causes bowel distension
bull If small bowel injured
ndash Repair laparoscopically
ndash Mesh can still be placed
bull Antibiotic cover for 7 days post op
CONCLUSION 1
1 To open the peritoneum tigh-it
2 Dissection on the right side of the mid-sacral ligament
3 Repair carefuly the vessels and the Right ureter
4 Try to preserve the right hypogatsric nerve
5 Fix your needle 1 cm below the promontory
MESH SELECTIONPERTINENT MESH SCIENCEWHY USE A CERTAIN MESH
Pr Bruno DEVAL MD Geoffroy Saint-Hilaire ndash Clinic
Hotel ndashDieu de Paris
Paris V University
MESH STIFFNESS
bullIncreased fibrosis and deposits of unorganized collagen create an increased stiffness
bull (Klinge 1999)
bullStiffness has been linked to clinical complications-heavier stiffer meshes having higher complications
bull (Dietz 2003)
bullStiffer meshes showed decreases in smooth muscle collagen and structural proteins following implantation
bull (Moalli P AUGS 2011)
bullHeavier stiffer meshes showed a greater propensity for stress shielding which in turn could cause reoccurrences of prolapse
bull (Moalli P AUGS 2011)
IMPACT OF VAGINAL SYNTHETIC PROLAPSE MESHES ON THE MECHANICS
OF THE HOST TISSUE RESPONSE
Feola Andrew J 02 February 2012 Doctoral Dissertation University of Pittsburgh
ldquoImplantation of the stiffest mesh in the non human primate
resulted in an exhibition of a stress-shielding response
manifested by inferior biomechanical properties of the
abdominal and vaginal tissues
Less stiff meshes resulted in preservation of tissue
propertiesrdquo
Wolffrsquos Law ndash remodeling of bone in response to stress
MESH CHARACTERISTICS
Density - Filament size ndash Elasticity - Pore size
Surface area ndash Overall ldquomesh loadrdquo
Biomechanical engineers working with type-1
polypropylene have focused on reducing overall
ldquomesh loadrdquo while maintaining durability
bullOptimal tissue incorporation and collagen growthbullNo erosionbullNo palpable mesh to patient and her partnerbullVaginal elasticity
TO OBTAIN
So lighter is better
WHAT KIND OF MESH
bull To date polypropylene meshes are the best type on the market
bull Absorbable meshes do not work
bull There is an evidence to use Polypropylene vs polyesther
bull PTFE and NW meshes are contra ndash indicated in the POP Repair
ULTRA- LIGHT POLYPROPYLENE
bull Physiologically compatible 19 gsm1
bull Ultra lightweightbull Lowest weight available for pelvic restoration
bull 18 millimeter macropores1
ndash Consistent size throughout the mesh
bull 100 micron interstitial Smartporestrade 1ndash Simultaneously encourages both collagen growth and
bacteria fighting propertiesbull Fibroblasts will enter holes that are 50 to 200 microns in size23
bull Macrophages and neutrophils will enter holes that are 50 to 120 microns in size23
bull Reduce inflammation1 Data on file2 Greca FH et at (2007) The influence of porosity on integration histology of two polypropylene meshes for the treatment of abdominal wall
defects in dogs Hernia (12) 45-493 Marois Y et all (2000) Biostability inflammatory response and healing characteristics flourpassivated polyester-knit mesh in the repair of
experimental abdominal hernias Artif Organs 24533-543
ULTRA ndash LIGHT CLINICAL EVIDENCE
SUMMARY
bull Rates of Erosion and Exposurebull Less than 1 erosion rate1
bull Anterior exposure rate 172
bull Posterior exposure rate 052
bull Greater tissue strength 3 months post-op ndash 71 more collagen growth3
bull Mature vaginal elastin decrease was not observed with Smartmesh4
bull Smartmesh did not induce a negative change in collagen metabolism5
bull Smartmesh had similar innervation density as sham 6
bull Low incidence of de novo dyspareunia71 Alinsod R et al (2008) Long term outcomes of vaginal pelvic floor repair using an ultra lightweight mesh AAGL (2008)2 Alinsod R Et al (2012) Durability and Complications of an Ultra Lightweight Transvaginal Mesh in the Treatment of Pelvic Organ Prolapse Presented at the 37th Annual Meeting of IUGA3 Greca FH et al (2007) The influence of porosity on the integration histology of two polypropylene meshes for the treatment of abdominal wall defects in dogs Hernia (12) 45-494 Moalli et al (2012) Mesh implantation negatively impacts vagina elastin metabolism Female Pelvic Medicine amp Reconstructive Surgery Vol 18 (Suppl 2)S258-9 SeptOct paper 235 Moalli et al (2012) Increasing mesh stiffness negatively impacts vaginal collagen metabolism Female Pelvic Medicine amp Reconstructive Surgery Vol 18 (Suppl 2)S258-9 SeptOct paper 246 Moalli et al (2012) The impact of mesh implantation on vaginal smooth muscle innervation Female Pelvic Medicine amp Reconstructive Surgery Vol 18 (Suppl 2)S258-9 SeptOct paper 257 Hawthorn R et al (2007) Use of ultra lightweight mesh in vaginal vault repairs to minimize complications A two centre observation study British International Congress of Obstetrics amp Gynaecology
PRE FORMED Y-MESH VS CUTTING MESH AND MAKING IT TO FIT PATIENTS
Pr Bruno DEVAL MD Geoffroy Saint-Hilaire ndash Clinic
Hotel ndashDieu de Paris
Paris V University
Mesh and operative handling
The shape and weight of the mesh can help us during
laparoscopic procedure
A large Y mesh is a good choice for vaginal vault shape
Better intra-operative manipulation and suturing
Lower mesh mass accommodates easy passage through narrow
laparoscopic ports
Use re-absorbable sutures on the vagina
bull Stitch erosions are reported
bull Folding and wrinkling can cause
erosions and dyspaurenia
Avoid folding and wrinkling the
mesh must be well stretched
DO WE NEED TO DISSECT POSTERIOR DOWN TO PERINEUM OR
IN WHICH PATIENTS THIS IS INDICATED
Pr Bruno DEVAL MD Geoffroy Saint-Hilaire ndash Clinic
Hotel ndashDieu de Paris
Paris V University
Fix the mesh on the posterior
vaginal wall and not on the
elevator ani muscle
bull To avoid dyschezia and chronic
pelvic pain
bull Sacrocolpopexy should only be performed by board certified eligible surgeons (ObGyn or Urology)
bull Knowledge surgical skills and experience in reconstructive pelvic surgery
FPMRS fellowship
CME documentation
Proctoring on 10 cases
gt 50 practice in reconstructive surgery
bull Outcomes and complications of should be monitored by annual internal audit
bull Informed consent should highlight
Alternatives to ASC including pessary
Complications of ASC
Complications of mesh
AUGS Guidelines on Sacrocolpopexy Privileges(March 2013)
Source wwwaugsorg
Conclusion
bull The technique and expertise are
fundamental
bull Laparoscopic colposacropexy can safely
be offered to women with symptomatic
POP
bull Conventional LSCP = Open Way =
robotic way
bull Conventional LSCP gt Vaginal Way
Bladder
Collection
Sagittal T2
Vagina
Uterus
Ureter ariving in urinoma
Axial T2
Coronale T2
Bladder Injury2
ndash Sub-peacuteritoneacuteal Bladder
bull Vertical Position ++
bull Close to the ant face of the vagina
bull There is NO space
ndash Preacutevention
bull Following the Ant- Face of the vagina
bull Maleable Retractor
ndash Treatment
bull Immeacutediat Suture
bull Mesh Indication
bull Bladder Catheterisation 5 days
Small and Large Bowel Injury
bull Occur when adhesiolysis has to be undertaken
bull Avoid distended bowel at surgery by 48 hours pre op bowel prep
bull Avoid nitrous oxide during surgery as it causes bowel distension
bull If small bowel injured
ndash Repair laparoscopically
ndash Mesh can still be placed
bull Antibiotic cover for 7 days post op
CONCLUSION 1
1 To open the peritoneum tigh-it
2 Dissection on the right side of the mid-sacral ligament
3 Repair carefuly the vessels and the Right ureter
4 Try to preserve the right hypogatsric nerve
5 Fix your needle 1 cm below the promontory
MESH SELECTIONPERTINENT MESH SCIENCEWHY USE A CERTAIN MESH
Pr Bruno DEVAL MD Geoffroy Saint-Hilaire ndash Clinic
Hotel ndashDieu de Paris
Paris V University
MESH STIFFNESS
bullIncreased fibrosis and deposits of unorganized collagen create an increased stiffness
bull (Klinge 1999)
bullStiffness has been linked to clinical complications-heavier stiffer meshes having higher complications
bull (Dietz 2003)
bullStiffer meshes showed decreases in smooth muscle collagen and structural proteins following implantation
bull (Moalli P AUGS 2011)
bullHeavier stiffer meshes showed a greater propensity for stress shielding which in turn could cause reoccurrences of prolapse
bull (Moalli P AUGS 2011)
IMPACT OF VAGINAL SYNTHETIC PROLAPSE MESHES ON THE MECHANICS
OF THE HOST TISSUE RESPONSE
Feola Andrew J 02 February 2012 Doctoral Dissertation University of Pittsburgh
ldquoImplantation of the stiffest mesh in the non human primate
resulted in an exhibition of a stress-shielding response
manifested by inferior biomechanical properties of the
abdominal and vaginal tissues
Less stiff meshes resulted in preservation of tissue
propertiesrdquo
Wolffrsquos Law ndash remodeling of bone in response to stress
MESH CHARACTERISTICS
Density - Filament size ndash Elasticity - Pore size
Surface area ndash Overall ldquomesh loadrdquo
Biomechanical engineers working with type-1
polypropylene have focused on reducing overall
ldquomesh loadrdquo while maintaining durability
bullOptimal tissue incorporation and collagen growthbullNo erosionbullNo palpable mesh to patient and her partnerbullVaginal elasticity
TO OBTAIN
So lighter is better
WHAT KIND OF MESH
bull To date polypropylene meshes are the best type on the market
bull Absorbable meshes do not work
bull There is an evidence to use Polypropylene vs polyesther
bull PTFE and NW meshes are contra ndash indicated in the POP Repair
ULTRA- LIGHT POLYPROPYLENE
bull Physiologically compatible 19 gsm1
bull Ultra lightweightbull Lowest weight available for pelvic restoration
bull 18 millimeter macropores1
ndash Consistent size throughout the mesh
bull 100 micron interstitial Smartporestrade 1ndash Simultaneously encourages both collagen growth and
bacteria fighting propertiesbull Fibroblasts will enter holes that are 50 to 200 microns in size23
bull Macrophages and neutrophils will enter holes that are 50 to 120 microns in size23
bull Reduce inflammation1 Data on file2 Greca FH et at (2007) The influence of porosity on integration histology of two polypropylene meshes for the treatment of abdominal wall
defects in dogs Hernia (12) 45-493 Marois Y et all (2000) Biostability inflammatory response and healing characteristics flourpassivated polyester-knit mesh in the repair of
experimental abdominal hernias Artif Organs 24533-543
ULTRA ndash LIGHT CLINICAL EVIDENCE
SUMMARY
bull Rates of Erosion and Exposurebull Less than 1 erosion rate1
bull Anterior exposure rate 172
bull Posterior exposure rate 052
bull Greater tissue strength 3 months post-op ndash 71 more collagen growth3
bull Mature vaginal elastin decrease was not observed with Smartmesh4
bull Smartmesh did not induce a negative change in collagen metabolism5
bull Smartmesh had similar innervation density as sham 6
bull Low incidence of de novo dyspareunia71 Alinsod R et al (2008) Long term outcomes of vaginal pelvic floor repair using an ultra lightweight mesh AAGL (2008)2 Alinsod R Et al (2012) Durability and Complications of an Ultra Lightweight Transvaginal Mesh in the Treatment of Pelvic Organ Prolapse Presented at the 37th Annual Meeting of IUGA3 Greca FH et al (2007) The influence of porosity on the integration histology of two polypropylene meshes for the treatment of abdominal wall defects in dogs Hernia (12) 45-494 Moalli et al (2012) Mesh implantation negatively impacts vagina elastin metabolism Female Pelvic Medicine amp Reconstructive Surgery Vol 18 (Suppl 2)S258-9 SeptOct paper 235 Moalli et al (2012) Increasing mesh stiffness negatively impacts vaginal collagen metabolism Female Pelvic Medicine amp Reconstructive Surgery Vol 18 (Suppl 2)S258-9 SeptOct paper 246 Moalli et al (2012) The impact of mesh implantation on vaginal smooth muscle innervation Female Pelvic Medicine amp Reconstructive Surgery Vol 18 (Suppl 2)S258-9 SeptOct paper 257 Hawthorn R et al (2007) Use of ultra lightweight mesh in vaginal vault repairs to minimize complications A two centre observation study British International Congress of Obstetrics amp Gynaecology
PRE FORMED Y-MESH VS CUTTING MESH AND MAKING IT TO FIT PATIENTS
Pr Bruno DEVAL MD Geoffroy Saint-Hilaire ndash Clinic
Hotel ndashDieu de Paris
Paris V University
Mesh and operative handling
The shape and weight of the mesh can help us during
laparoscopic procedure
A large Y mesh is a good choice for vaginal vault shape
Better intra-operative manipulation and suturing
Lower mesh mass accommodates easy passage through narrow
laparoscopic ports
Use re-absorbable sutures on the vagina
bull Stitch erosions are reported
bull Folding and wrinkling can cause
erosions and dyspaurenia
Avoid folding and wrinkling the
mesh must be well stretched
DO WE NEED TO DISSECT POSTERIOR DOWN TO PERINEUM OR
IN WHICH PATIENTS THIS IS INDICATED
Pr Bruno DEVAL MD Geoffroy Saint-Hilaire ndash Clinic
Hotel ndashDieu de Paris
Paris V University
Fix the mesh on the posterior
vaginal wall and not on the
elevator ani muscle
bull To avoid dyschezia and chronic
pelvic pain
bull Sacrocolpopexy should only be performed by board certified eligible surgeons (ObGyn or Urology)
bull Knowledge surgical skills and experience in reconstructive pelvic surgery
FPMRS fellowship
CME documentation
Proctoring on 10 cases
gt 50 practice in reconstructive surgery
bull Outcomes and complications of should be monitored by annual internal audit
bull Informed consent should highlight
Alternatives to ASC including pessary
Complications of ASC
Complications of mesh
AUGS Guidelines on Sacrocolpopexy Privileges(March 2013)
Source wwwaugsorg
Conclusion
bull The technique and expertise are
fundamental
bull Laparoscopic colposacropexy can safely
be offered to women with symptomatic
POP
bull Conventional LSCP = Open Way =
robotic way
bull Conventional LSCP gt Vaginal Way
Ureter ariving in urinoma
Axial T2
Coronale T2
Bladder Injury2
ndash Sub-peacuteritoneacuteal Bladder
bull Vertical Position ++
bull Close to the ant face of the vagina
bull There is NO space
ndash Preacutevention
bull Following the Ant- Face of the vagina
bull Maleable Retractor
ndash Treatment
bull Immeacutediat Suture
bull Mesh Indication
bull Bladder Catheterisation 5 days
Small and Large Bowel Injury
bull Occur when adhesiolysis has to be undertaken
bull Avoid distended bowel at surgery by 48 hours pre op bowel prep
bull Avoid nitrous oxide during surgery as it causes bowel distension
bull If small bowel injured
ndash Repair laparoscopically
ndash Mesh can still be placed
bull Antibiotic cover for 7 days post op
CONCLUSION 1
1 To open the peritoneum tigh-it
2 Dissection on the right side of the mid-sacral ligament
3 Repair carefuly the vessels and the Right ureter
4 Try to preserve the right hypogatsric nerve
5 Fix your needle 1 cm below the promontory
MESH SELECTIONPERTINENT MESH SCIENCEWHY USE A CERTAIN MESH
Pr Bruno DEVAL MD Geoffroy Saint-Hilaire ndash Clinic
Hotel ndashDieu de Paris
Paris V University
MESH STIFFNESS
bullIncreased fibrosis and deposits of unorganized collagen create an increased stiffness
bull (Klinge 1999)
bullStiffness has been linked to clinical complications-heavier stiffer meshes having higher complications
bull (Dietz 2003)
bullStiffer meshes showed decreases in smooth muscle collagen and structural proteins following implantation
bull (Moalli P AUGS 2011)
bullHeavier stiffer meshes showed a greater propensity for stress shielding which in turn could cause reoccurrences of prolapse
bull (Moalli P AUGS 2011)
IMPACT OF VAGINAL SYNTHETIC PROLAPSE MESHES ON THE MECHANICS
OF THE HOST TISSUE RESPONSE
Feola Andrew J 02 February 2012 Doctoral Dissertation University of Pittsburgh
ldquoImplantation of the stiffest mesh in the non human primate
resulted in an exhibition of a stress-shielding response
manifested by inferior biomechanical properties of the
abdominal and vaginal tissues
Less stiff meshes resulted in preservation of tissue
propertiesrdquo
Wolffrsquos Law ndash remodeling of bone in response to stress
MESH CHARACTERISTICS
Density - Filament size ndash Elasticity - Pore size
Surface area ndash Overall ldquomesh loadrdquo
Biomechanical engineers working with type-1
polypropylene have focused on reducing overall
ldquomesh loadrdquo while maintaining durability
bullOptimal tissue incorporation and collagen growthbullNo erosionbullNo palpable mesh to patient and her partnerbullVaginal elasticity
TO OBTAIN
So lighter is better
WHAT KIND OF MESH
bull To date polypropylene meshes are the best type on the market
bull Absorbable meshes do not work
bull There is an evidence to use Polypropylene vs polyesther
bull PTFE and NW meshes are contra ndash indicated in the POP Repair
ULTRA- LIGHT POLYPROPYLENE
bull Physiologically compatible 19 gsm1
bull Ultra lightweightbull Lowest weight available for pelvic restoration
bull 18 millimeter macropores1
ndash Consistent size throughout the mesh
bull 100 micron interstitial Smartporestrade 1ndash Simultaneously encourages both collagen growth and
bacteria fighting propertiesbull Fibroblasts will enter holes that are 50 to 200 microns in size23
bull Macrophages and neutrophils will enter holes that are 50 to 120 microns in size23
bull Reduce inflammation1 Data on file2 Greca FH et at (2007) The influence of porosity on integration histology of two polypropylene meshes for the treatment of abdominal wall
defects in dogs Hernia (12) 45-493 Marois Y et all (2000) Biostability inflammatory response and healing characteristics flourpassivated polyester-knit mesh in the repair of
experimental abdominal hernias Artif Organs 24533-543
ULTRA ndash LIGHT CLINICAL EVIDENCE
SUMMARY
bull Rates of Erosion and Exposurebull Less than 1 erosion rate1
bull Anterior exposure rate 172
bull Posterior exposure rate 052
bull Greater tissue strength 3 months post-op ndash 71 more collagen growth3
bull Mature vaginal elastin decrease was not observed with Smartmesh4
bull Smartmesh did not induce a negative change in collagen metabolism5
bull Smartmesh had similar innervation density as sham 6
bull Low incidence of de novo dyspareunia71 Alinsod R et al (2008) Long term outcomes of vaginal pelvic floor repair using an ultra lightweight mesh AAGL (2008)2 Alinsod R Et al (2012) Durability and Complications of an Ultra Lightweight Transvaginal Mesh in the Treatment of Pelvic Organ Prolapse Presented at the 37th Annual Meeting of IUGA3 Greca FH et al (2007) The influence of porosity on the integration histology of two polypropylene meshes for the treatment of abdominal wall defects in dogs Hernia (12) 45-494 Moalli et al (2012) Mesh implantation negatively impacts vagina elastin metabolism Female Pelvic Medicine amp Reconstructive Surgery Vol 18 (Suppl 2)S258-9 SeptOct paper 235 Moalli et al (2012) Increasing mesh stiffness negatively impacts vaginal collagen metabolism Female Pelvic Medicine amp Reconstructive Surgery Vol 18 (Suppl 2)S258-9 SeptOct paper 246 Moalli et al (2012) The impact of mesh implantation on vaginal smooth muscle innervation Female Pelvic Medicine amp Reconstructive Surgery Vol 18 (Suppl 2)S258-9 SeptOct paper 257 Hawthorn R et al (2007) Use of ultra lightweight mesh in vaginal vault repairs to minimize complications A two centre observation study British International Congress of Obstetrics amp Gynaecology
PRE FORMED Y-MESH VS CUTTING MESH AND MAKING IT TO FIT PATIENTS
Pr Bruno DEVAL MD Geoffroy Saint-Hilaire ndash Clinic
Hotel ndashDieu de Paris
Paris V University
Mesh and operative handling
The shape and weight of the mesh can help us during
laparoscopic procedure
A large Y mesh is a good choice for vaginal vault shape
Better intra-operative manipulation and suturing
Lower mesh mass accommodates easy passage through narrow
laparoscopic ports
Use re-absorbable sutures on the vagina
bull Stitch erosions are reported
bull Folding and wrinkling can cause
erosions and dyspaurenia
Avoid folding and wrinkling the
mesh must be well stretched
DO WE NEED TO DISSECT POSTERIOR DOWN TO PERINEUM OR
IN WHICH PATIENTS THIS IS INDICATED
Pr Bruno DEVAL MD Geoffroy Saint-Hilaire ndash Clinic
Hotel ndashDieu de Paris
Paris V University
Fix the mesh on the posterior
vaginal wall and not on the
elevator ani muscle
bull To avoid dyschezia and chronic
pelvic pain
bull Sacrocolpopexy should only be performed by board certified eligible surgeons (ObGyn or Urology)
bull Knowledge surgical skills and experience in reconstructive pelvic surgery
FPMRS fellowship
CME documentation
Proctoring on 10 cases
gt 50 practice in reconstructive surgery
bull Outcomes and complications of should be monitored by annual internal audit
bull Informed consent should highlight
Alternatives to ASC including pessary
Complications of ASC
Complications of mesh
AUGS Guidelines on Sacrocolpopexy Privileges(March 2013)
Source wwwaugsorg
Conclusion
bull The technique and expertise are
fundamental
bull Laparoscopic colposacropexy can safely
be offered to women with symptomatic
POP
bull Conventional LSCP = Open Way =
robotic way
bull Conventional LSCP gt Vaginal Way
Bladder Injury2
ndash Sub-peacuteritoneacuteal Bladder
bull Vertical Position ++
bull Close to the ant face of the vagina
bull There is NO space
ndash Preacutevention
bull Following the Ant- Face of the vagina
bull Maleable Retractor
ndash Treatment
bull Immeacutediat Suture
bull Mesh Indication
bull Bladder Catheterisation 5 days
Small and Large Bowel Injury
bull Occur when adhesiolysis has to be undertaken
bull Avoid distended bowel at surgery by 48 hours pre op bowel prep
bull Avoid nitrous oxide during surgery as it causes bowel distension
bull If small bowel injured
ndash Repair laparoscopically
ndash Mesh can still be placed
bull Antibiotic cover for 7 days post op
CONCLUSION 1
1 To open the peritoneum tigh-it
2 Dissection on the right side of the mid-sacral ligament
3 Repair carefuly the vessels and the Right ureter
4 Try to preserve the right hypogatsric nerve
5 Fix your needle 1 cm below the promontory
MESH SELECTIONPERTINENT MESH SCIENCEWHY USE A CERTAIN MESH
Pr Bruno DEVAL MD Geoffroy Saint-Hilaire ndash Clinic
Hotel ndashDieu de Paris
Paris V University
MESH STIFFNESS
bullIncreased fibrosis and deposits of unorganized collagen create an increased stiffness
bull (Klinge 1999)
bullStiffness has been linked to clinical complications-heavier stiffer meshes having higher complications
bull (Dietz 2003)
bullStiffer meshes showed decreases in smooth muscle collagen and structural proteins following implantation
bull (Moalli P AUGS 2011)
bullHeavier stiffer meshes showed a greater propensity for stress shielding which in turn could cause reoccurrences of prolapse
bull (Moalli P AUGS 2011)
IMPACT OF VAGINAL SYNTHETIC PROLAPSE MESHES ON THE MECHANICS
OF THE HOST TISSUE RESPONSE
Feola Andrew J 02 February 2012 Doctoral Dissertation University of Pittsburgh
ldquoImplantation of the stiffest mesh in the non human primate
resulted in an exhibition of a stress-shielding response
manifested by inferior biomechanical properties of the
abdominal and vaginal tissues
Less stiff meshes resulted in preservation of tissue
propertiesrdquo
Wolffrsquos Law ndash remodeling of bone in response to stress
MESH CHARACTERISTICS
Density - Filament size ndash Elasticity - Pore size
Surface area ndash Overall ldquomesh loadrdquo
Biomechanical engineers working with type-1
polypropylene have focused on reducing overall
ldquomesh loadrdquo while maintaining durability
bullOptimal tissue incorporation and collagen growthbullNo erosionbullNo palpable mesh to patient and her partnerbullVaginal elasticity
TO OBTAIN
So lighter is better
WHAT KIND OF MESH
bull To date polypropylene meshes are the best type on the market
bull Absorbable meshes do not work
bull There is an evidence to use Polypropylene vs polyesther
bull PTFE and NW meshes are contra ndash indicated in the POP Repair
ULTRA- LIGHT POLYPROPYLENE
bull Physiologically compatible 19 gsm1
bull Ultra lightweightbull Lowest weight available for pelvic restoration
bull 18 millimeter macropores1
ndash Consistent size throughout the mesh
bull 100 micron interstitial Smartporestrade 1ndash Simultaneously encourages both collagen growth and
bacteria fighting propertiesbull Fibroblasts will enter holes that are 50 to 200 microns in size23
bull Macrophages and neutrophils will enter holes that are 50 to 120 microns in size23
bull Reduce inflammation1 Data on file2 Greca FH et at (2007) The influence of porosity on integration histology of two polypropylene meshes for the treatment of abdominal wall
defects in dogs Hernia (12) 45-493 Marois Y et all (2000) Biostability inflammatory response and healing characteristics flourpassivated polyester-knit mesh in the repair of
experimental abdominal hernias Artif Organs 24533-543
ULTRA ndash LIGHT CLINICAL EVIDENCE
SUMMARY
bull Rates of Erosion and Exposurebull Less than 1 erosion rate1
bull Anterior exposure rate 172
bull Posterior exposure rate 052
bull Greater tissue strength 3 months post-op ndash 71 more collagen growth3
bull Mature vaginal elastin decrease was not observed with Smartmesh4
bull Smartmesh did not induce a negative change in collagen metabolism5
bull Smartmesh had similar innervation density as sham 6
bull Low incidence of de novo dyspareunia71 Alinsod R et al (2008) Long term outcomes of vaginal pelvic floor repair using an ultra lightweight mesh AAGL (2008)2 Alinsod R Et al (2012) Durability and Complications of an Ultra Lightweight Transvaginal Mesh in the Treatment of Pelvic Organ Prolapse Presented at the 37th Annual Meeting of IUGA3 Greca FH et al (2007) The influence of porosity on the integration histology of two polypropylene meshes for the treatment of abdominal wall defects in dogs Hernia (12) 45-494 Moalli et al (2012) Mesh implantation negatively impacts vagina elastin metabolism Female Pelvic Medicine amp Reconstructive Surgery Vol 18 (Suppl 2)S258-9 SeptOct paper 235 Moalli et al (2012) Increasing mesh stiffness negatively impacts vaginal collagen metabolism Female Pelvic Medicine amp Reconstructive Surgery Vol 18 (Suppl 2)S258-9 SeptOct paper 246 Moalli et al (2012) The impact of mesh implantation on vaginal smooth muscle innervation Female Pelvic Medicine amp Reconstructive Surgery Vol 18 (Suppl 2)S258-9 SeptOct paper 257 Hawthorn R et al (2007) Use of ultra lightweight mesh in vaginal vault repairs to minimize complications A two centre observation study British International Congress of Obstetrics amp Gynaecology
PRE FORMED Y-MESH VS CUTTING MESH AND MAKING IT TO FIT PATIENTS
Pr Bruno DEVAL MD Geoffroy Saint-Hilaire ndash Clinic
Hotel ndashDieu de Paris
Paris V University
Mesh and operative handling
The shape and weight of the mesh can help us during
laparoscopic procedure
A large Y mesh is a good choice for vaginal vault shape
Better intra-operative manipulation and suturing
Lower mesh mass accommodates easy passage through narrow
laparoscopic ports
Use re-absorbable sutures on the vagina
bull Stitch erosions are reported
bull Folding and wrinkling can cause
erosions and dyspaurenia
Avoid folding and wrinkling the
mesh must be well stretched
DO WE NEED TO DISSECT POSTERIOR DOWN TO PERINEUM OR
IN WHICH PATIENTS THIS IS INDICATED
Pr Bruno DEVAL MD Geoffroy Saint-Hilaire ndash Clinic
Hotel ndashDieu de Paris
Paris V University
Fix the mesh on the posterior
vaginal wall and not on the
elevator ani muscle
bull To avoid dyschezia and chronic
pelvic pain
bull Sacrocolpopexy should only be performed by board certified eligible surgeons (ObGyn or Urology)
bull Knowledge surgical skills and experience in reconstructive pelvic surgery
FPMRS fellowship
CME documentation
Proctoring on 10 cases
gt 50 practice in reconstructive surgery
bull Outcomes and complications of should be monitored by annual internal audit
bull Informed consent should highlight
Alternatives to ASC including pessary
Complications of ASC
Complications of mesh
AUGS Guidelines on Sacrocolpopexy Privileges(March 2013)
Source wwwaugsorg
Conclusion
bull The technique and expertise are
fundamental
bull Laparoscopic colposacropexy can safely
be offered to women with symptomatic
POP
bull Conventional LSCP = Open Way =
robotic way
bull Conventional LSCP gt Vaginal Way
Small and Large Bowel Injury
bull Occur when adhesiolysis has to be undertaken
bull Avoid distended bowel at surgery by 48 hours pre op bowel prep
bull Avoid nitrous oxide during surgery as it causes bowel distension
bull If small bowel injured
ndash Repair laparoscopically
ndash Mesh can still be placed
bull Antibiotic cover for 7 days post op
CONCLUSION 1
1 To open the peritoneum tigh-it
2 Dissection on the right side of the mid-sacral ligament
3 Repair carefuly the vessels and the Right ureter
4 Try to preserve the right hypogatsric nerve
5 Fix your needle 1 cm below the promontory
MESH SELECTIONPERTINENT MESH SCIENCEWHY USE A CERTAIN MESH
Pr Bruno DEVAL MD Geoffroy Saint-Hilaire ndash Clinic
Hotel ndashDieu de Paris
Paris V University
MESH STIFFNESS
bullIncreased fibrosis and deposits of unorganized collagen create an increased stiffness
bull (Klinge 1999)
bullStiffness has been linked to clinical complications-heavier stiffer meshes having higher complications
bull (Dietz 2003)
bullStiffer meshes showed decreases in smooth muscle collagen and structural proteins following implantation
bull (Moalli P AUGS 2011)
bullHeavier stiffer meshes showed a greater propensity for stress shielding which in turn could cause reoccurrences of prolapse
bull (Moalli P AUGS 2011)
IMPACT OF VAGINAL SYNTHETIC PROLAPSE MESHES ON THE MECHANICS
OF THE HOST TISSUE RESPONSE
Feola Andrew J 02 February 2012 Doctoral Dissertation University of Pittsburgh
ldquoImplantation of the stiffest mesh in the non human primate
resulted in an exhibition of a stress-shielding response
manifested by inferior biomechanical properties of the
abdominal and vaginal tissues
Less stiff meshes resulted in preservation of tissue
propertiesrdquo
Wolffrsquos Law ndash remodeling of bone in response to stress
MESH CHARACTERISTICS
Density - Filament size ndash Elasticity - Pore size
Surface area ndash Overall ldquomesh loadrdquo
Biomechanical engineers working with type-1
polypropylene have focused on reducing overall
ldquomesh loadrdquo while maintaining durability
bullOptimal tissue incorporation and collagen growthbullNo erosionbullNo palpable mesh to patient and her partnerbullVaginal elasticity
TO OBTAIN
So lighter is better
WHAT KIND OF MESH
bull To date polypropylene meshes are the best type on the market
bull Absorbable meshes do not work
bull There is an evidence to use Polypropylene vs polyesther
bull PTFE and NW meshes are contra ndash indicated in the POP Repair
ULTRA- LIGHT POLYPROPYLENE
bull Physiologically compatible 19 gsm1
bull Ultra lightweightbull Lowest weight available for pelvic restoration
bull 18 millimeter macropores1
ndash Consistent size throughout the mesh
bull 100 micron interstitial Smartporestrade 1ndash Simultaneously encourages both collagen growth and
bacteria fighting propertiesbull Fibroblasts will enter holes that are 50 to 200 microns in size23
bull Macrophages and neutrophils will enter holes that are 50 to 120 microns in size23
bull Reduce inflammation1 Data on file2 Greca FH et at (2007) The influence of porosity on integration histology of two polypropylene meshes for the treatment of abdominal wall
defects in dogs Hernia (12) 45-493 Marois Y et all (2000) Biostability inflammatory response and healing characteristics flourpassivated polyester-knit mesh in the repair of
experimental abdominal hernias Artif Organs 24533-543
ULTRA ndash LIGHT CLINICAL EVIDENCE
SUMMARY
bull Rates of Erosion and Exposurebull Less than 1 erosion rate1
bull Anterior exposure rate 172
bull Posterior exposure rate 052
bull Greater tissue strength 3 months post-op ndash 71 more collagen growth3
bull Mature vaginal elastin decrease was not observed with Smartmesh4
bull Smartmesh did not induce a negative change in collagen metabolism5
bull Smartmesh had similar innervation density as sham 6
bull Low incidence of de novo dyspareunia71 Alinsod R et al (2008) Long term outcomes of vaginal pelvic floor repair using an ultra lightweight mesh AAGL (2008)2 Alinsod R Et al (2012) Durability and Complications of an Ultra Lightweight Transvaginal Mesh in the Treatment of Pelvic Organ Prolapse Presented at the 37th Annual Meeting of IUGA3 Greca FH et al (2007) The influence of porosity on the integration histology of two polypropylene meshes for the treatment of abdominal wall defects in dogs Hernia (12) 45-494 Moalli et al (2012) Mesh implantation negatively impacts vagina elastin metabolism Female Pelvic Medicine amp Reconstructive Surgery Vol 18 (Suppl 2)S258-9 SeptOct paper 235 Moalli et al (2012) Increasing mesh stiffness negatively impacts vaginal collagen metabolism Female Pelvic Medicine amp Reconstructive Surgery Vol 18 (Suppl 2)S258-9 SeptOct paper 246 Moalli et al (2012) The impact of mesh implantation on vaginal smooth muscle innervation Female Pelvic Medicine amp Reconstructive Surgery Vol 18 (Suppl 2)S258-9 SeptOct paper 257 Hawthorn R et al (2007) Use of ultra lightweight mesh in vaginal vault repairs to minimize complications A two centre observation study British International Congress of Obstetrics amp Gynaecology
PRE FORMED Y-MESH VS CUTTING MESH AND MAKING IT TO FIT PATIENTS
Pr Bruno DEVAL MD Geoffroy Saint-Hilaire ndash Clinic
Hotel ndashDieu de Paris
Paris V University
Mesh and operative handling
The shape and weight of the mesh can help us during
laparoscopic procedure
A large Y mesh is a good choice for vaginal vault shape
Better intra-operative manipulation and suturing
Lower mesh mass accommodates easy passage through narrow
laparoscopic ports
Use re-absorbable sutures on the vagina
bull Stitch erosions are reported
bull Folding and wrinkling can cause
erosions and dyspaurenia
Avoid folding and wrinkling the
mesh must be well stretched
DO WE NEED TO DISSECT POSTERIOR DOWN TO PERINEUM OR
IN WHICH PATIENTS THIS IS INDICATED
Pr Bruno DEVAL MD Geoffroy Saint-Hilaire ndash Clinic
Hotel ndashDieu de Paris
Paris V University
Fix the mesh on the posterior
vaginal wall and not on the
elevator ani muscle
bull To avoid dyschezia and chronic
pelvic pain
bull Sacrocolpopexy should only be performed by board certified eligible surgeons (ObGyn or Urology)
bull Knowledge surgical skills and experience in reconstructive pelvic surgery
FPMRS fellowship
CME documentation
Proctoring on 10 cases
gt 50 practice in reconstructive surgery
bull Outcomes and complications of should be monitored by annual internal audit
bull Informed consent should highlight
Alternatives to ASC including pessary
Complications of ASC
Complications of mesh
AUGS Guidelines on Sacrocolpopexy Privileges(March 2013)
Source wwwaugsorg
Conclusion
bull The technique and expertise are
fundamental
bull Laparoscopic colposacropexy can safely
be offered to women with symptomatic
POP
bull Conventional LSCP = Open Way =
robotic way
bull Conventional LSCP gt Vaginal Way
CONCLUSION 1
1 To open the peritoneum tigh-it
2 Dissection on the right side of the mid-sacral ligament
3 Repair carefuly the vessels and the Right ureter
4 Try to preserve the right hypogatsric nerve
5 Fix your needle 1 cm below the promontory
MESH SELECTIONPERTINENT MESH SCIENCEWHY USE A CERTAIN MESH
Pr Bruno DEVAL MD Geoffroy Saint-Hilaire ndash Clinic
Hotel ndashDieu de Paris
Paris V University
MESH STIFFNESS
bullIncreased fibrosis and deposits of unorganized collagen create an increased stiffness
bull (Klinge 1999)
bullStiffness has been linked to clinical complications-heavier stiffer meshes having higher complications
bull (Dietz 2003)
bullStiffer meshes showed decreases in smooth muscle collagen and structural proteins following implantation
bull (Moalli P AUGS 2011)
bullHeavier stiffer meshes showed a greater propensity for stress shielding which in turn could cause reoccurrences of prolapse
bull (Moalli P AUGS 2011)
IMPACT OF VAGINAL SYNTHETIC PROLAPSE MESHES ON THE MECHANICS
OF THE HOST TISSUE RESPONSE
Feola Andrew J 02 February 2012 Doctoral Dissertation University of Pittsburgh
ldquoImplantation of the stiffest mesh in the non human primate
resulted in an exhibition of a stress-shielding response
manifested by inferior biomechanical properties of the
abdominal and vaginal tissues
Less stiff meshes resulted in preservation of tissue
propertiesrdquo
Wolffrsquos Law ndash remodeling of bone in response to stress
MESH CHARACTERISTICS
Density - Filament size ndash Elasticity - Pore size
Surface area ndash Overall ldquomesh loadrdquo
Biomechanical engineers working with type-1
polypropylene have focused on reducing overall
ldquomesh loadrdquo while maintaining durability
bullOptimal tissue incorporation and collagen growthbullNo erosionbullNo palpable mesh to patient and her partnerbullVaginal elasticity
TO OBTAIN
So lighter is better
WHAT KIND OF MESH
bull To date polypropylene meshes are the best type on the market
bull Absorbable meshes do not work
bull There is an evidence to use Polypropylene vs polyesther
bull PTFE and NW meshes are contra ndash indicated in the POP Repair
ULTRA- LIGHT POLYPROPYLENE
bull Physiologically compatible 19 gsm1
bull Ultra lightweightbull Lowest weight available for pelvic restoration
bull 18 millimeter macropores1
ndash Consistent size throughout the mesh
bull 100 micron interstitial Smartporestrade 1ndash Simultaneously encourages both collagen growth and
bacteria fighting propertiesbull Fibroblasts will enter holes that are 50 to 200 microns in size23
bull Macrophages and neutrophils will enter holes that are 50 to 120 microns in size23
bull Reduce inflammation1 Data on file2 Greca FH et at (2007) The influence of porosity on integration histology of two polypropylene meshes for the treatment of abdominal wall
defects in dogs Hernia (12) 45-493 Marois Y et all (2000) Biostability inflammatory response and healing characteristics flourpassivated polyester-knit mesh in the repair of
experimental abdominal hernias Artif Organs 24533-543
ULTRA ndash LIGHT CLINICAL EVIDENCE
SUMMARY
bull Rates of Erosion and Exposurebull Less than 1 erosion rate1
bull Anterior exposure rate 172
bull Posterior exposure rate 052
bull Greater tissue strength 3 months post-op ndash 71 more collagen growth3
bull Mature vaginal elastin decrease was not observed with Smartmesh4
bull Smartmesh did not induce a negative change in collagen metabolism5
bull Smartmesh had similar innervation density as sham 6
bull Low incidence of de novo dyspareunia71 Alinsod R et al (2008) Long term outcomes of vaginal pelvic floor repair using an ultra lightweight mesh AAGL (2008)2 Alinsod R Et al (2012) Durability and Complications of an Ultra Lightweight Transvaginal Mesh in the Treatment of Pelvic Organ Prolapse Presented at the 37th Annual Meeting of IUGA3 Greca FH et al (2007) The influence of porosity on the integration histology of two polypropylene meshes for the treatment of abdominal wall defects in dogs Hernia (12) 45-494 Moalli et al (2012) Mesh implantation negatively impacts vagina elastin metabolism Female Pelvic Medicine amp Reconstructive Surgery Vol 18 (Suppl 2)S258-9 SeptOct paper 235 Moalli et al (2012) Increasing mesh stiffness negatively impacts vaginal collagen metabolism Female Pelvic Medicine amp Reconstructive Surgery Vol 18 (Suppl 2)S258-9 SeptOct paper 246 Moalli et al (2012) The impact of mesh implantation on vaginal smooth muscle innervation Female Pelvic Medicine amp Reconstructive Surgery Vol 18 (Suppl 2)S258-9 SeptOct paper 257 Hawthorn R et al (2007) Use of ultra lightweight mesh in vaginal vault repairs to minimize complications A two centre observation study British International Congress of Obstetrics amp Gynaecology
PRE FORMED Y-MESH VS CUTTING MESH AND MAKING IT TO FIT PATIENTS
Pr Bruno DEVAL MD Geoffroy Saint-Hilaire ndash Clinic
Hotel ndashDieu de Paris
Paris V University
Mesh and operative handling
The shape and weight of the mesh can help us during
laparoscopic procedure
A large Y mesh is a good choice for vaginal vault shape
Better intra-operative manipulation and suturing
Lower mesh mass accommodates easy passage through narrow
laparoscopic ports
Use re-absorbable sutures on the vagina
bull Stitch erosions are reported
bull Folding and wrinkling can cause
erosions and dyspaurenia
Avoid folding and wrinkling the
mesh must be well stretched
DO WE NEED TO DISSECT POSTERIOR DOWN TO PERINEUM OR
IN WHICH PATIENTS THIS IS INDICATED
Pr Bruno DEVAL MD Geoffroy Saint-Hilaire ndash Clinic
Hotel ndashDieu de Paris
Paris V University
Fix the mesh on the posterior
vaginal wall and not on the
elevator ani muscle
bull To avoid dyschezia and chronic
pelvic pain
bull Sacrocolpopexy should only be performed by board certified eligible surgeons (ObGyn or Urology)
bull Knowledge surgical skills and experience in reconstructive pelvic surgery
FPMRS fellowship
CME documentation
Proctoring on 10 cases
gt 50 practice in reconstructive surgery
bull Outcomes and complications of should be monitored by annual internal audit
bull Informed consent should highlight
Alternatives to ASC including pessary
Complications of ASC
Complications of mesh
AUGS Guidelines on Sacrocolpopexy Privileges(March 2013)
Source wwwaugsorg
Conclusion
bull The technique and expertise are
fundamental
bull Laparoscopic colposacropexy can safely
be offered to women with symptomatic
POP
bull Conventional LSCP = Open Way =
robotic way
bull Conventional LSCP gt Vaginal Way
MESH SELECTIONPERTINENT MESH SCIENCEWHY USE A CERTAIN MESH
Pr Bruno DEVAL MD Geoffroy Saint-Hilaire ndash Clinic
Hotel ndashDieu de Paris
Paris V University
MESH STIFFNESS
bullIncreased fibrosis and deposits of unorganized collagen create an increased stiffness
bull (Klinge 1999)
bullStiffness has been linked to clinical complications-heavier stiffer meshes having higher complications
bull (Dietz 2003)
bullStiffer meshes showed decreases in smooth muscle collagen and structural proteins following implantation
bull (Moalli P AUGS 2011)
bullHeavier stiffer meshes showed a greater propensity for stress shielding which in turn could cause reoccurrences of prolapse
bull (Moalli P AUGS 2011)
IMPACT OF VAGINAL SYNTHETIC PROLAPSE MESHES ON THE MECHANICS
OF THE HOST TISSUE RESPONSE
Feola Andrew J 02 February 2012 Doctoral Dissertation University of Pittsburgh
ldquoImplantation of the stiffest mesh in the non human primate
resulted in an exhibition of a stress-shielding response
manifested by inferior biomechanical properties of the
abdominal and vaginal tissues
Less stiff meshes resulted in preservation of tissue
propertiesrdquo
Wolffrsquos Law ndash remodeling of bone in response to stress
MESH CHARACTERISTICS
Density - Filament size ndash Elasticity - Pore size
Surface area ndash Overall ldquomesh loadrdquo
Biomechanical engineers working with type-1
polypropylene have focused on reducing overall
ldquomesh loadrdquo while maintaining durability
bullOptimal tissue incorporation and collagen growthbullNo erosionbullNo palpable mesh to patient and her partnerbullVaginal elasticity
TO OBTAIN
So lighter is better
WHAT KIND OF MESH
bull To date polypropylene meshes are the best type on the market
bull Absorbable meshes do not work
bull There is an evidence to use Polypropylene vs polyesther
bull PTFE and NW meshes are contra ndash indicated in the POP Repair
ULTRA- LIGHT POLYPROPYLENE
bull Physiologically compatible 19 gsm1
bull Ultra lightweightbull Lowest weight available for pelvic restoration
bull 18 millimeter macropores1
ndash Consistent size throughout the mesh
bull 100 micron interstitial Smartporestrade 1ndash Simultaneously encourages both collagen growth and
bacteria fighting propertiesbull Fibroblasts will enter holes that are 50 to 200 microns in size23
bull Macrophages and neutrophils will enter holes that are 50 to 120 microns in size23
bull Reduce inflammation1 Data on file2 Greca FH et at (2007) The influence of porosity on integration histology of two polypropylene meshes for the treatment of abdominal wall
defects in dogs Hernia (12) 45-493 Marois Y et all (2000) Biostability inflammatory response and healing characteristics flourpassivated polyester-knit mesh in the repair of
experimental abdominal hernias Artif Organs 24533-543
ULTRA ndash LIGHT CLINICAL EVIDENCE
SUMMARY
bull Rates of Erosion and Exposurebull Less than 1 erosion rate1
bull Anterior exposure rate 172
bull Posterior exposure rate 052
bull Greater tissue strength 3 months post-op ndash 71 more collagen growth3
bull Mature vaginal elastin decrease was not observed with Smartmesh4
bull Smartmesh did not induce a negative change in collagen metabolism5
bull Smartmesh had similar innervation density as sham 6
bull Low incidence of de novo dyspareunia71 Alinsod R et al (2008) Long term outcomes of vaginal pelvic floor repair using an ultra lightweight mesh AAGL (2008)2 Alinsod R Et al (2012) Durability and Complications of an Ultra Lightweight Transvaginal Mesh in the Treatment of Pelvic Organ Prolapse Presented at the 37th Annual Meeting of IUGA3 Greca FH et al (2007) The influence of porosity on the integration histology of two polypropylene meshes for the treatment of abdominal wall defects in dogs Hernia (12) 45-494 Moalli et al (2012) Mesh implantation negatively impacts vagina elastin metabolism Female Pelvic Medicine amp Reconstructive Surgery Vol 18 (Suppl 2)S258-9 SeptOct paper 235 Moalli et al (2012) Increasing mesh stiffness negatively impacts vaginal collagen metabolism Female Pelvic Medicine amp Reconstructive Surgery Vol 18 (Suppl 2)S258-9 SeptOct paper 246 Moalli et al (2012) The impact of mesh implantation on vaginal smooth muscle innervation Female Pelvic Medicine amp Reconstructive Surgery Vol 18 (Suppl 2)S258-9 SeptOct paper 257 Hawthorn R et al (2007) Use of ultra lightweight mesh in vaginal vault repairs to minimize complications A two centre observation study British International Congress of Obstetrics amp Gynaecology
PRE FORMED Y-MESH VS CUTTING MESH AND MAKING IT TO FIT PATIENTS
Pr Bruno DEVAL MD Geoffroy Saint-Hilaire ndash Clinic
Hotel ndashDieu de Paris
Paris V University
Mesh and operative handling
The shape and weight of the mesh can help us during
laparoscopic procedure
A large Y mesh is a good choice for vaginal vault shape
Better intra-operative manipulation and suturing
Lower mesh mass accommodates easy passage through narrow
laparoscopic ports
Use re-absorbable sutures on the vagina
bull Stitch erosions are reported
bull Folding and wrinkling can cause
erosions and dyspaurenia
Avoid folding and wrinkling the
mesh must be well stretched
DO WE NEED TO DISSECT POSTERIOR DOWN TO PERINEUM OR
IN WHICH PATIENTS THIS IS INDICATED
Pr Bruno DEVAL MD Geoffroy Saint-Hilaire ndash Clinic
Hotel ndashDieu de Paris
Paris V University
Fix the mesh on the posterior
vaginal wall and not on the
elevator ani muscle
bull To avoid dyschezia and chronic
pelvic pain
bull Sacrocolpopexy should only be performed by board certified eligible surgeons (ObGyn or Urology)
bull Knowledge surgical skills and experience in reconstructive pelvic surgery
FPMRS fellowship
CME documentation
Proctoring on 10 cases
gt 50 practice in reconstructive surgery
bull Outcomes and complications of should be monitored by annual internal audit
bull Informed consent should highlight
Alternatives to ASC including pessary
Complications of ASC
Complications of mesh
AUGS Guidelines on Sacrocolpopexy Privileges(March 2013)
Source wwwaugsorg
Conclusion
bull The technique and expertise are
fundamental
bull Laparoscopic colposacropexy can safely
be offered to women with symptomatic
POP
bull Conventional LSCP = Open Way =
robotic way
bull Conventional LSCP gt Vaginal Way
MESH STIFFNESS
bullIncreased fibrosis and deposits of unorganized collagen create an increased stiffness
bull (Klinge 1999)
bullStiffness has been linked to clinical complications-heavier stiffer meshes having higher complications
bull (Dietz 2003)
bullStiffer meshes showed decreases in smooth muscle collagen and structural proteins following implantation
bull (Moalli P AUGS 2011)
bullHeavier stiffer meshes showed a greater propensity for stress shielding which in turn could cause reoccurrences of prolapse
bull (Moalli P AUGS 2011)
IMPACT OF VAGINAL SYNTHETIC PROLAPSE MESHES ON THE MECHANICS
OF THE HOST TISSUE RESPONSE
Feola Andrew J 02 February 2012 Doctoral Dissertation University of Pittsburgh
ldquoImplantation of the stiffest mesh in the non human primate
resulted in an exhibition of a stress-shielding response
manifested by inferior biomechanical properties of the
abdominal and vaginal tissues
Less stiff meshes resulted in preservation of tissue
propertiesrdquo
Wolffrsquos Law ndash remodeling of bone in response to stress
MESH CHARACTERISTICS
Density - Filament size ndash Elasticity - Pore size
Surface area ndash Overall ldquomesh loadrdquo
Biomechanical engineers working with type-1
polypropylene have focused on reducing overall
ldquomesh loadrdquo while maintaining durability
bullOptimal tissue incorporation and collagen growthbullNo erosionbullNo palpable mesh to patient and her partnerbullVaginal elasticity
TO OBTAIN
So lighter is better
WHAT KIND OF MESH
bull To date polypropylene meshes are the best type on the market
bull Absorbable meshes do not work
bull There is an evidence to use Polypropylene vs polyesther
bull PTFE and NW meshes are contra ndash indicated in the POP Repair
ULTRA- LIGHT POLYPROPYLENE
bull Physiologically compatible 19 gsm1
bull Ultra lightweightbull Lowest weight available for pelvic restoration
bull 18 millimeter macropores1
ndash Consistent size throughout the mesh
bull 100 micron interstitial Smartporestrade 1ndash Simultaneously encourages both collagen growth and
bacteria fighting propertiesbull Fibroblasts will enter holes that are 50 to 200 microns in size23
bull Macrophages and neutrophils will enter holes that are 50 to 120 microns in size23
bull Reduce inflammation1 Data on file2 Greca FH et at (2007) The influence of porosity on integration histology of two polypropylene meshes for the treatment of abdominal wall
defects in dogs Hernia (12) 45-493 Marois Y et all (2000) Biostability inflammatory response and healing characteristics flourpassivated polyester-knit mesh in the repair of
experimental abdominal hernias Artif Organs 24533-543
ULTRA ndash LIGHT CLINICAL EVIDENCE
SUMMARY
bull Rates of Erosion and Exposurebull Less than 1 erosion rate1
bull Anterior exposure rate 172
bull Posterior exposure rate 052
bull Greater tissue strength 3 months post-op ndash 71 more collagen growth3
bull Mature vaginal elastin decrease was not observed with Smartmesh4
bull Smartmesh did not induce a negative change in collagen metabolism5
bull Smartmesh had similar innervation density as sham 6
bull Low incidence of de novo dyspareunia71 Alinsod R et al (2008) Long term outcomes of vaginal pelvic floor repair using an ultra lightweight mesh AAGL (2008)2 Alinsod R Et al (2012) Durability and Complications of an Ultra Lightweight Transvaginal Mesh in the Treatment of Pelvic Organ Prolapse Presented at the 37th Annual Meeting of IUGA3 Greca FH et al (2007) The influence of porosity on the integration histology of two polypropylene meshes for the treatment of abdominal wall defects in dogs Hernia (12) 45-494 Moalli et al (2012) Mesh implantation negatively impacts vagina elastin metabolism Female Pelvic Medicine amp Reconstructive Surgery Vol 18 (Suppl 2)S258-9 SeptOct paper 235 Moalli et al (2012) Increasing mesh stiffness negatively impacts vaginal collagen metabolism Female Pelvic Medicine amp Reconstructive Surgery Vol 18 (Suppl 2)S258-9 SeptOct paper 246 Moalli et al (2012) The impact of mesh implantation on vaginal smooth muscle innervation Female Pelvic Medicine amp Reconstructive Surgery Vol 18 (Suppl 2)S258-9 SeptOct paper 257 Hawthorn R et al (2007) Use of ultra lightweight mesh in vaginal vault repairs to minimize complications A two centre observation study British International Congress of Obstetrics amp Gynaecology
PRE FORMED Y-MESH VS CUTTING MESH AND MAKING IT TO FIT PATIENTS
Pr Bruno DEVAL MD Geoffroy Saint-Hilaire ndash Clinic
Hotel ndashDieu de Paris
Paris V University
Mesh and operative handling
The shape and weight of the mesh can help us during
laparoscopic procedure
A large Y mesh is a good choice for vaginal vault shape
Better intra-operative manipulation and suturing
Lower mesh mass accommodates easy passage through narrow
laparoscopic ports
Use re-absorbable sutures on the vagina
bull Stitch erosions are reported
bull Folding and wrinkling can cause
erosions and dyspaurenia
Avoid folding and wrinkling the
mesh must be well stretched
DO WE NEED TO DISSECT POSTERIOR DOWN TO PERINEUM OR
IN WHICH PATIENTS THIS IS INDICATED
Pr Bruno DEVAL MD Geoffroy Saint-Hilaire ndash Clinic
Hotel ndashDieu de Paris
Paris V University
Fix the mesh on the posterior
vaginal wall and not on the
elevator ani muscle
bull To avoid dyschezia and chronic
pelvic pain
bull Sacrocolpopexy should only be performed by board certified eligible surgeons (ObGyn or Urology)
bull Knowledge surgical skills and experience in reconstructive pelvic surgery
FPMRS fellowship
CME documentation
Proctoring on 10 cases
gt 50 practice in reconstructive surgery
bull Outcomes and complications of should be monitored by annual internal audit
bull Informed consent should highlight
Alternatives to ASC including pessary
Complications of ASC
Complications of mesh
AUGS Guidelines on Sacrocolpopexy Privileges(March 2013)
Source wwwaugsorg
Conclusion
bull The technique and expertise are
fundamental
bull Laparoscopic colposacropexy can safely
be offered to women with symptomatic
POP
bull Conventional LSCP = Open Way =
robotic way
bull Conventional LSCP gt Vaginal Way
IMPACT OF VAGINAL SYNTHETIC PROLAPSE MESHES ON THE MECHANICS
OF THE HOST TISSUE RESPONSE
Feola Andrew J 02 February 2012 Doctoral Dissertation University of Pittsburgh
ldquoImplantation of the stiffest mesh in the non human primate
resulted in an exhibition of a stress-shielding response
manifested by inferior biomechanical properties of the
abdominal and vaginal tissues
Less stiff meshes resulted in preservation of tissue
propertiesrdquo
Wolffrsquos Law ndash remodeling of bone in response to stress
MESH CHARACTERISTICS
Density - Filament size ndash Elasticity - Pore size
Surface area ndash Overall ldquomesh loadrdquo
Biomechanical engineers working with type-1
polypropylene have focused on reducing overall
ldquomesh loadrdquo while maintaining durability
bullOptimal tissue incorporation and collagen growthbullNo erosionbullNo palpable mesh to patient and her partnerbullVaginal elasticity
TO OBTAIN
So lighter is better
WHAT KIND OF MESH
bull To date polypropylene meshes are the best type on the market
bull Absorbable meshes do not work
bull There is an evidence to use Polypropylene vs polyesther
bull PTFE and NW meshes are contra ndash indicated in the POP Repair
ULTRA- LIGHT POLYPROPYLENE
bull Physiologically compatible 19 gsm1
bull Ultra lightweightbull Lowest weight available for pelvic restoration
bull 18 millimeter macropores1
ndash Consistent size throughout the mesh
bull 100 micron interstitial Smartporestrade 1ndash Simultaneously encourages both collagen growth and
bacteria fighting propertiesbull Fibroblasts will enter holes that are 50 to 200 microns in size23
bull Macrophages and neutrophils will enter holes that are 50 to 120 microns in size23
bull Reduce inflammation1 Data on file2 Greca FH et at (2007) The influence of porosity on integration histology of two polypropylene meshes for the treatment of abdominal wall
defects in dogs Hernia (12) 45-493 Marois Y et all (2000) Biostability inflammatory response and healing characteristics flourpassivated polyester-knit mesh in the repair of
experimental abdominal hernias Artif Organs 24533-543
ULTRA ndash LIGHT CLINICAL EVIDENCE
SUMMARY
bull Rates of Erosion and Exposurebull Less than 1 erosion rate1
bull Anterior exposure rate 172
bull Posterior exposure rate 052
bull Greater tissue strength 3 months post-op ndash 71 more collagen growth3
bull Mature vaginal elastin decrease was not observed with Smartmesh4
bull Smartmesh did not induce a negative change in collagen metabolism5
bull Smartmesh had similar innervation density as sham 6
bull Low incidence of de novo dyspareunia71 Alinsod R et al (2008) Long term outcomes of vaginal pelvic floor repair using an ultra lightweight mesh AAGL (2008)2 Alinsod R Et al (2012) Durability and Complications of an Ultra Lightweight Transvaginal Mesh in the Treatment of Pelvic Organ Prolapse Presented at the 37th Annual Meeting of IUGA3 Greca FH et al (2007) The influence of porosity on the integration histology of two polypropylene meshes for the treatment of abdominal wall defects in dogs Hernia (12) 45-494 Moalli et al (2012) Mesh implantation negatively impacts vagina elastin metabolism Female Pelvic Medicine amp Reconstructive Surgery Vol 18 (Suppl 2)S258-9 SeptOct paper 235 Moalli et al (2012) Increasing mesh stiffness negatively impacts vaginal collagen metabolism Female Pelvic Medicine amp Reconstructive Surgery Vol 18 (Suppl 2)S258-9 SeptOct paper 246 Moalli et al (2012) The impact of mesh implantation on vaginal smooth muscle innervation Female Pelvic Medicine amp Reconstructive Surgery Vol 18 (Suppl 2)S258-9 SeptOct paper 257 Hawthorn R et al (2007) Use of ultra lightweight mesh in vaginal vault repairs to minimize complications A two centre observation study British International Congress of Obstetrics amp Gynaecology
PRE FORMED Y-MESH VS CUTTING MESH AND MAKING IT TO FIT PATIENTS
Pr Bruno DEVAL MD Geoffroy Saint-Hilaire ndash Clinic
Hotel ndashDieu de Paris
Paris V University
Mesh and operative handling
The shape and weight of the mesh can help us during
laparoscopic procedure
A large Y mesh is a good choice for vaginal vault shape
Better intra-operative manipulation and suturing
Lower mesh mass accommodates easy passage through narrow
laparoscopic ports
Use re-absorbable sutures on the vagina
bull Stitch erosions are reported
bull Folding and wrinkling can cause
erosions and dyspaurenia
Avoid folding and wrinkling the
mesh must be well stretched
DO WE NEED TO DISSECT POSTERIOR DOWN TO PERINEUM OR
IN WHICH PATIENTS THIS IS INDICATED
Pr Bruno DEVAL MD Geoffroy Saint-Hilaire ndash Clinic
Hotel ndashDieu de Paris
Paris V University
Fix the mesh on the posterior
vaginal wall and not on the
elevator ani muscle
bull To avoid dyschezia and chronic
pelvic pain
bull Sacrocolpopexy should only be performed by board certified eligible surgeons (ObGyn or Urology)
bull Knowledge surgical skills and experience in reconstructive pelvic surgery
FPMRS fellowship
CME documentation
Proctoring on 10 cases
gt 50 practice in reconstructive surgery
bull Outcomes and complications of should be monitored by annual internal audit
bull Informed consent should highlight
Alternatives to ASC including pessary
Complications of ASC
Complications of mesh
AUGS Guidelines on Sacrocolpopexy Privileges(March 2013)
Source wwwaugsorg
Conclusion
bull The technique and expertise are
fundamental
bull Laparoscopic colposacropexy can safely
be offered to women with symptomatic
POP
bull Conventional LSCP = Open Way =
robotic way
bull Conventional LSCP gt Vaginal Way
MESH CHARACTERISTICS
Density - Filament size ndash Elasticity - Pore size
Surface area ndash Overall ldquomesh loadrdquo
Biomechanical engineers working with type-1
polypropylene have focused on reducing overall
ldquomesh loadrdquo while maintaining durability
bullOptimal tissue incorporation and collagen growthbullNo erosionbullNo palpable mesh to patient and her partnerbullVaginal elasticity
TO OBTAIN
So lighter is better
WHAT KIND OF MESH
bull To date polypropylene meshes are the best type on the market
bull Absorbable meshes do not work
bull There is an evidence to use Polypropylene vs polyesther
bull PTFE and NW meshes are contra ndash indicated in the POP Repair
ULTRA- LIGHT POLYPROPYLENE
bull Physiologically compatible 19 gsm1
bull Ultra lightweightbull Lowest weight available for pelvic restoration
bull 18 millimeter macropores1
ndash Consistent size throughout the mesh
bull 100 micron interstitial Smartporestrade 1ndash Simultaneously encourages both collagen growth and
bacteria fighting propertiesbull Fibroblasts will enter holes that are 50 to 200 microns in size23
bull Macrophages and neutrophils will enter holes that are 50 to 120 microns in size23
bull Reduce inflammation1 Data on file2 Greca FH et at (2007) The influence of porosity on integration histology of two polypropylene meshes for the treatment of abdominal wall
defects in dogs Hernia (12) 45-493 Marois Y et all (2000) Biostability inflammatory response and healing characteristics flourpassivated polyester-knit mesh in the repair of
experimental abdominal hernias Artif Organs 24533-543
ULTRA ndash LIGHT CLINICAL EVIDENCE
SUMMARY
bull Rates of Erosion and Exposurebull Less than 1 erosion rate1
bull Anterior exposure rate 172
bull Posterior exposure rate 052
bull Greater tissue strength 3 months post-op ndash 71 more collagen growth3
bull Mature vaginal elastin decrease was not observed with Smartmesh4
bull Smartmesh did not induce a negative change in collagen metabolism5
bull Smartmesh had similar innervation density as sham 6
bull Low incidence of de novo dyspareunia71 Alinsod R et al (2008) Long term outcomes of vaginal pelvic floor repair using an ultra lightweight mesh AAGL (2008)2 Alinsod R Et al (2012) Durability and Complications of an Ultra Lightweight Transvaginal Mesh in the Treatment of Pelvic Organ Prolapse Presented at the 37th Annual Meeting of IUGA3 Greca FH et al (2007) The influence of porosity on the integration histology of two polypropylene meshes for the treatment of abdominal wall defects in dogs Hernia (12) 45-494 Moalli et al (2012) Mesh implantation negatively impacts vagina elastin metabolism Female Pelvic Medicine amp Reconstructive Surgery Vol 18 (Suppl 2)S258-9 SeptOct paper 235 Moalli et al (2012) Increasing mesh stiffness negatively impacts vaginal collagen metabolism Female Pelvic Medicine amp Reconstructive Surgery Vol 18 (Suppl 2)S258-9 SeptOct paper 246 Moalli et al (2012) The impact of mesh implantation on vaginal smooth muscle innervation Female Pelvic Medicine amp Reconstructive Surgery Vol 18 (Suppl 2)S258-9 SeptOct paper 257 Hawthorn R et al (2007) Use of ultra lightweight mesh in vaginal vault repairs to minimize complications A two centre observation study British International Congress of Obstetrics amp Gynaecology
PRE FORMED Y-MESH VS CUTTING MESH AND MAKING IT TO FIT PATIENTS
Pr Bruno DEVAL MD Geoffroy Saint-Hilaire ndash Clinic
Hotel ndashDieu de Paris
Paris V University
Mesh and operative handling
The shape and weight of the mesh can help us during
laparoscopic procedure
A large Y mesh is a good choice for vaginal vault shape
Better intra-operative manipulation and suturing
Lower mesh mass accommodates easy passage through narrow
laparoscopic ports
Use re-absorbable sutures on the vagina
bull Stitch erosions are reported
bull Folding and wrinkling can cause
erosions and dyspaurenia
Avoid folding and wrinkling the
mesh must be well stretched
DO WE NEED TO DISSECT POSTERIOR DOWN TO PERINEUM OR
IN WHICH PATIENTS THIS IS INDICATED
Pr Bruno DEVAL MD Geoffroy Saint-Hilaire ndash Clinic
Hotel ndashDieu de Paris
Paris V University
Fix the mesh on the posterior
vaginal wall and not on the
elevator ani muscle
bull To avoid dyschezia and chronic
pelvic pain
bull Sacrocolpopexy should only be performed by board certified eligible surgeons (ObGyn or Urology)
bull Knowledge surgical skills and experience in reconstructive pelvic surgery
FPMRS fellowship
CME documentation
Proctoring on 10 cases
gt 50 practice in reconstructive surgery
bull Outcomes and complications of should be monitored by annual internal audit
bull Informed consent should highlight
Alternatives to ASC including pessary
Complications of ASC
Complications of mesh
AUGS Guidelines on Sacrocolpopexy Privileges(March 2013)
Source wwwaugsorg
Conclusion
bull The technique and expertise are
fundamental
bull Laparoscopic colposacropexy can safely
be offered to women with symptomatic
POP
bull Conventional LSCP = Open Way =
robotic way
bull Conventional LSCP gt Vaginal Way
WHAT KIND OF MESH
bull To date polypropylene meshes are the best type on the market
bull Absorbable meshes do not work
bull There is an evidence to use Polypropylene vs polyesther
bull PTFE and NW meshes are contra ndash indicated in the POP Repair
ULTRA- LIGHT POLYPROPYLENE
bull Physiologically compatible 19 gsm1
bull Ultra lightweightbull Lowest weight available for pelvic restoration
bull 18 millimeter macropores1
ndash Consistent size throughout the mesh
bull 100 micron interstitial Smartporestrade 1ndash Simultaneously encourages both collagen growth and
bacteria fighting propertiesbull Fibroblasts will enter holes that are 50 to 200 microns in size23
bull Macrophages and neutrophils will enter holes that are 50 to 120 microns in size23
bull Reduce inflammation1 Data on file2 Greca FH et at (2007) The influence of porosity on integration histology of two polypropylene meshes for the treatment of abdominal wall
defects in dogs Hernia (12) 45-493 Marois Y et all (2000) Biostability inflammatory response and healing characteristics flourpassivated polyester-knit mesh in the repair of
experimental abdominal hernias Artif Organs 24533-543
ULTRA ndash LIGHT CLINICAL EVIDENCE
SUMMARY
bull Rates of Erosion and Exposurebull Less than 1 erosion rate1
bull Anterior exposure rate 172
bull Posterior exposure rate 052
bull Greater tissue strength 3 months post-op ndash 71 more collagen growth3
bull Mature vaginal elastin decrease was not observed with Smartmesh4
bull Smartmesh did not induce a negative change in collagen metabolism5
bull Smartmesh had similar innervation density as sham 6
bull Low incidence of de novo dyspareunia71 Alinsod R et al (2008) Long term outcomes of vaginal pelvic floor repair using an ultra lightweight mesh AAGL (2008)2 Alinsod R Et al (2012) Durability and Complications of an Ultra Lightweight Transvaginal Mesh in the Treatment of Pelvic Organ Prolapse Presented at the 37th Annual Meeting of IUGA3 Greca FH et al (2007) The influence of porosity on the integration histology of two polypropylene meshes for the treatment of abdominal wall defects in dogs Hernia (12) 45-494 Moalli et al (2012) Mesh implantation negatively impacts vagina elastin metabolism Female Pelvic Medicine amp Reconstructive Surgery Vol 18 (Suppl 2)S258-9 SeptOct paper 235 Moalli et al (2012) Increasing mesh stiffness negatively impacts vaginal collagen metabolism Female Pelvic Medicine amp Reconstructive Surgery Vol 18 (Suppl 2)S258-9 SeptOct paper 246 Moalli et al (2012) The impact of mesh implantation on vaginal smooth muscle innervation Female Pelvic Medicine amp Reconstructive Surgery Vol 18 (Suppl 2)S258-9 SeptOct paper 257 Hawthorn R et al (2007) Use of ultra lightweight mesh in vaginal vault repairs to minimize complications A two centre observation study British International Congress of Obstetrics amp Gynaecology
PRE FORMED Y-MESH VS CUTTING MESH AND MAKING IT TO FIT PATIENTS
Pr Bruno DEVAL MD Geoffroy Saint-Hilaire ndash Clinic
Hotel ndashDieu de Paris
Paris V University
Mesh and operative handling
The shape and weight of the mesh can help us during
laparoscopic procedure
A large Y mesh is a good choice for vaginal vault shape
Better intra-operative manipulation and suturing
Lower mesh mass accommodates easy passage through narrow
laparoscopic ports
Use re-absorbable sutures on the vagina
bull Stitch erosions are reported
bull Folding and wrinkling can cause
erosions and dyspaurenia
Avoid folding and wrinkling the
mesh must be well stretched
DO WE NEED TO DISSECT POSTERIOR DOWN TO PERINEUM OR
IN WHICH PATIENTS THIS IS INDICATED
Pr Bruno DEVAL MD Geoffroy Saint-Hilaire ndash Clinic
Hotel ndashDieu de Paris
Paris V University
Fix the mesh on the posterior
vaginal wall and not on the
elevator ani muscle
bull To avoid dyschezia and chronic
pelvic pain
bull Sacrocolpopexy should only be performed by board certified eligible surgeons (ObGyn or Urology)
bull Knowledge surgical skills and experience in reconstructive pelvic surgery
FPMRS fellowship
CME documentation
Proctoring on 10 cases
gt 50 practice in reconstructive surgery
bull Outcomes and complications of should be monitored by annual internal audit
bull Informed consent should highlight
Alternatives to ASC including pessary
Complications of ASC
Complications of mesh
AUGS Guidelines on Sacrocolpopexy Privileges(March 2013)
Source wwwaugsorg
Conclusion
bull The technique and expertise are
fundamental
bull Laparoscopic colposacropexy can safely
be offered to women with symptomatic
POP
bull Conventional LSCP = Open Way =
robotic way
bull Conventional LSCP gt Vaginal Way
ULTRA- LIGHT POLYPROPYLENE
bull Physiologically compatible 19 gsm1
bull Ultra lightweightbull Lowest weight available for pelvic restoration
bull 18 millimeter macropores1
ndash Consistent size throughout the mesh
bull 100 micron interstitial Smartporestrade 1ndash Simultaneously encourages both collagen growth and
bacteria fighting propertiesbull Fibroblasts will enter holes that are 50 to 200 microns in size23
bull Macrophages and neutrophils will enter holes that are 50 to 120 microns in size23
bull Reduce inflammation1 Data on file2 Greca FH et at (2007) The influence of porosity on integration histology of two polypropylene meshes for the treatment of abdominal wall
defects in dogs Hernia (12) 45-493 Marois Y et all (2000) Biostability inflammatory response and healing characteristics flourpassivated polyester-knit mesh in the repair of
experimental abdominal hernias Artif Organs 24533-543
ULTRA ndash LIGHT CLINICAL EVIDENCE
SUMMARY
bull Rates of Erosion and Exposurebull Less than 1 erosion rate1
bull Anterior exposure rate 172
bull Posterior exposure rate 052
bull Greater tissue strength 3 months post-op ndash 71 more collagen growth3
bull Mature vaginal elastin decrease was not observed with Smartmesh4
bull Smartmesh did not induce a negative change in collagen metabolism5
bull Smartmesh had similar innervation density as sham 6
bull Low incidence of de novo dyspareunia71 Alinsod R et al (2008) Long term outcomes of vaginal pelvic floor repair using an ultra lightweight mesh AAGL (2008)2 Alinsod R Et al (2012) Durability and Complications of an Ultra Lightweight Transvaginal Mesh in the Treatment of Pelvic Organ Prolapse Presented at the 37th Annual Meeting of IUGA3 Greca FH et al (2007) The influence of porosity on the integration histology of two polypropylene meshes for the treatment of abdominal wall defects in dogs Hernia (12) 45-494 Moalli et al (2012) Mesh implantation negatively impacts vagina elastin metabolism Female Pelvic Medicine amp Reconstructive Surgery Vol 18 (Suppl 2)S258-9 SeptOct paper 235 Moalli et al (2012) Increasing mesh stiffness negatively impacts vaginal collagen metabolism Female Pelvic Medicine amp Reconstructive Surgery Vol 18 (Suppl 2)S258-9 SeptOct paper 246 Moalli et al (2012) The impact of mesh implantation on vaginal smooth muscle innervation Female Pelvic Medicine amp Reconstructive Surgery Vol 18 (Suppl 2)S258-9 SeptOct paper 257 Hawthorn R et al (2007) Use of ultra lightweight mesh in vaginal vault repairs to minimize complications A two centre observation study British International Congress of Obstetrics amp Gynaecology
PRE FORMED Y-MESH VS CUTTING MESH AND MAKING IT TO FIT PATIENTS
Pr Bruno DEVAL MD Geoffroy Saint-Hilaire ndash Clinic
Hotel ndashDieu de Paris
Paris V University
Mesh and operative handling
The shape and weight of the mesh can help us during
laparoscopic procedure
A large Y mesh is a good choice for vaginal vault shape
Better intra-operative manipulation and suturing
Lower mesh mass accommodates easy passage through narrow
laparoscopic ports
Use re-absorbable sutures on the vagina
bull Stitch erosions are reported
bull Folding and wrinkling can cause
erosions and dyspaurenia
Avoid folding and wrinkling the
mesh must be well stretched
DO WE NEED TO DISSECT POSTERIOR DOWN TO PERINEUM OR
IN WHICH PATIENTS THIS IS INDICATED
Pr Bruno DEVAL MD Geoffroy Saint-Hilaire ndash Clinic
Hotel ndashDieu de Paris
Paris V University
Fix the mesh on the posterior
vaginal wall and not on the
elevator ani muscle
bull To avoid dyschezia and chronic
pelvic pain
bull Sacrocolpopexy should only be performed by board certified eligible surgeons (ObGyn or Urology)
bull Knowledge surgical skills and experience in reconstructive pelvic surgery
FPMRS fellowship
CME documentation
Proctoring on 10 cases
gt 50 practice in reconstructive surgery
bull Outcomes and complications of should be monitored by annual internal audit
bull Informed consent should highlight
Alternatives to ASC including pessary
Complications of ASC
Complications of mesh
AUGS Guidelines on Sacrocolpopexy Privileges(March 2013)
Source wwwaugsorg
Conclusion
bull The technique and expertise are
fundamental
bull Laparoscopic colposacropexy can safely
be offered to women with symptomatic
POP
bull Conventional LSCP = Open Way =
robotic way
bull Conventional LSCP gt Vaginal Way
ULTRA ndash LIGHT CLINICAL EVIDENCE
SUMMARY
bull Rates of Erosion and Exposurebull Less than 1 erosion rate1
bull Anterior exposure rate 172
bull Posterior exposure rate 052
bull Greater tissue strength 3 months post-op ndash 71 more collagen growth3
bull Mature vaginal elastin decrease was not observed with Smartmesh4
bull Smartmesh did not induce a negative change in collagen metabolism5
bull Smartmesh had similar innervation density as sham 6
bull Low incidence of de novo dyspareunia71 Alinsod R et al (2008) Long term outcomes of vaginal pelvic floor repair using an ultra lightweight mesh AAGL (2008)2 Alinsod R Et al (2012) Durability and Complications of an Ultra Lightweight Transvaginal Mesh in the Treatment of Pelvic Organ Prolapse Presented at the 37th Annual Meeting of IUGA3 Greca FH et al (2007) The influence of porosity on the integration histology of two polypropylene meshes for the treatment of abdominal wall defects in dogs Hernia (12) 45-494 Moalli et al (2012) Mesh implantation negatively impacts vagina elastin metabolism Female Pelvic Medicine amp Reconstructive Surgery Vol 18 (Suppl 2)S258-9 SeptOct paper 235 Moalli et al (2012) Increasing mesh stiffness negatively impacts vaginal collagen metabolism Female Pelvic Medicine amp Reconstructive Surgery Vol 18 (Suppl 2)S258-9 SeptOct paper 246 Moalli et al (2012) The impact of mesh implantation on vaginal smooth muscle innervation Female Pelvic Medicine amp Reconstructive Surgery Vol 18 (Suppl 2)S258-9 SeptOct paper 257 Hawthorn R et al (2007) Use of ultra lightweight mesh in vaginal vault repairs to minimize complications A two centre observation study British International Congress of Obstetrics amp Gynaecology
PRE FORMED Y-MESH VS CUTTING MESH AND MAKING IT TO FIT PATIENTS
Pr Bruno DEVAL MD Geoffroy Saint-Hilaire ndash Clinic
Hotel ndashDieu de Paris
Paris V University
Mesh and operative handling
The shape and weight of the mesh can help us during
laparoscopic procedure
A large Y mesh is a good choice for vaginal vault shape
Better intra-operative manipulation and suturing
Lower mesh mass accommodates easy passage through narrow
laparoscopic ports
Use re-absorbable sutures on the vagina
bull Stitch erosions are reported
bull Folding and wrinkling can cause
erosions and dyspaurenia
Avoid folding and wrinkling the
mesh must be well stretched
DO WE NEED TO DISSECT POSTERIOR DOWN TO PERINEUM OR
IN WHICH PATIENTS THIS IS INDICATED
Pr Bruno DEVAL MD Geoffroy Saint-Hilaire ndash Clinic
Hotel ndashDieu de Paris
Paris V University
Fix the mesh on the posterior
vaginal wall and not on the
elevator ani muscle
bull To avoid dyschezia and chronic
pelvic pain
bull Sacrocolpopexy should only be performed by board certified eligible surgeons (ObGyn or Urology)
bull Knowledge surgical skills and experience in reconstructive pelvic surgery
FPMRS fellowship
CME documentation
Proctoring on 10 cases
gt 50 practice in reconstructive surgery
bull Outcomes and complications of should be monitored by annual internal audit
bull Informed consent should highlight
Alternatives to ASC including pessary
Complications of ASC
Complications of mesh
AUGS Guidelines on Sacrocolpopexy Privileges(March 2013)
Source wwwaugsorg
Conclusion
bull The technique and expertise are
fundamental
bull Laparoscopic colposacropexy can safely
be offered to women with symptomatic
POP
bull Conventional LSCP = Open Way =
robotic way
bull Conventional LSCP gt Vaginal Way
PRE FORMED Y-MESH VS CUTTING MESH AND MAKING IT TO FIT PATIENTS
Pr Bruno DEVAL MD Geoffroy Saint-Hilaire ndash Clinic
Hotel ndashDieu de Paris
Paris V University
Mesh and operative handling
The shape and weight of the mesh can help us during
laparoscopic procedure
A large Y mesh is a good choice for vaginal vault shape
Better intra-operative manipulation and suturing
Lower mesh mass accommodates easy passage through narrow
laparoscopic ports
Use re-absorbable sutures on the vagina
bull Stitch erosions are reported
bull Folding and wrinkling can cause
erosions and dyspaurenia
Avoid folding and wrinkling the
mesh must be well stretched
DO WE NEED TO DISSECT POSTERIOR DOWN TO PERINEUM OR
IN WHICH PATIENTS THIS IS INDICATED
Pr Bruno DEVAL MD Geoffroy Saint-Hilaire ndash Clinic
Hotel ndashDieu de Paris
Paris V University
Fix the mesh on the posterior
vaginal wall and not on the
elevator ani muscle
bull To avoid dyschezia and chronic
pelvic pain
bull Sacrocolpopexy should only be performed by board certified eligible surgeons (ObGyn or Urology)
bull Knowledge surgical skills and experience in reconstructive pelvic surgery
FPMRS fellowship
CME documentation
Proctoring on 10 cases
gt 50 practice in reconstructive surgery
bull Outcomes and complications of should be monitored by annual internal audit
bull Informed consent should highlight
Alternatives to ASC including pessary
Complications of ASC
Complications of mesh
AUGS Guidelines on Sacrocolpopexy Privileges(March 2013)
Source wwwaugsorg
Conclusion
bull The technique and expertise are
fundamental
bull Laparoscopic colposacropexy can safely
be offered to women with symptomatic
POP
bull Conventional LSCP = Open Way =
robotic way
bull Conventional LSCP gt Vaginal Way
Mesh and operative handling
The shape and weight of the mesh can help us during
laparoscopic procedure
A large Y mesh is a good choice for vaginal vault shape
Better intra-operative manipulation and suturing
Lower mesh mass accommodates easy passage through narrow
laparoscopic ports
Use re-absorbable sutures on the vagina
bull Stitch erosions are reported
bull Folding and wrinkling can cause
erosions and dyspaurenia
Avoid folding and wrinkling the
mesh must be well stretched
DO WE NEED TO DISSECT POSTERIOR DOWN TO PERINEUM OR
IN WHICH PATIENTS THIS IS INDICATED
Pr Bruno DEVAL MD Geoffroy Saint-Hilaire ndash Clinic
Hotel ndashDieu de Paris
Paris V University
Fix the mesh on the posterior
vaginal wall and not on the
elevator ani muscle
bull To avoid dyschezia and chronic
pelvic pain
bull Sacrocolpopexy should only be performed by board certified eligible surgeons (ObGyn or Urology)
bull Knowledge surgical skills and experience in reconstructive pelvic surgery
FPMRS fellowship
CME documentation
Proctoring on 10 cases
gt 50 practice in reconstructive surgery
bull Outcomes and complications of should be monitored by annual internal audit
bull Informed consent should highlight
Alternatives to ASC including pessary
Complications of ASC
Complications of mesh
AUGS Guidelines on Sacrocolpopexy Privileges(March 2013)
Source wwwaugsorg
Conclusion
bull The technique and expertise are
fundamental
bull Laparoscopic colposacropexy can safely
be offered to women with symptomatic
POP
bull Conventional LSCP = Open Way =
robotic way
bull Conventional LSCP gt Vaginal Way
Use re-absorbable sutures on the vagina
bull Stitch erosions are reported
bull Folding and wrinkling can cause
erosions and dyspaurenia
Avoid folding and wrinkling the
mesh must be well stretched
DO WE NEED TO DISSECT POSTERIOR DOWN TO PERINEUM OR
IN WHICH PATIENTS THIS IS INDICATED
Pr Bruno DEVAL MD Geoffroy Saint-Hilaire ndash Clinic
Hotel ndashDieu de Paris
Paris V University
Fix the mesh on the posterior
vaginal wall and not on the
elevator ani muscle
bull To avoid dyschezia and chronic
pelvic pain
bull Sacrocolpopexy should only be performed by board certified eligible surgeons (ObGyn or Urology)
bull Knowledge surgical skills and experience in reconstructive pelvic surgery
FPMRS fellowship
CME documentation
Proctoring on 10 cases
gt 50 practice in reconstructive surgery
bull Outcomes and complications of should be monitored by annual internal audit
bull Informed consent should highlight
Alternatives to ASC including pessary
Complications of ASC
Complications of mesh
AUGS Guidelines on Sacrocolpopexy Privileges(March 2013)
Source wwwaugsorg
Conclusion
bull The technique and expertise are
fundamental
bull Laparoscopic colposacropexy can safely
be offered to women with symptomatic
POP
bull Conventional LSCP = Open Way =
robotic way
bull Conventional LSCP gt Vaginal Way
DO WE NEED TO DISSECT POSTERIOR DOWN TO PERINEUM OR
IN WHICH PATIENTS THIS IS INDICATED
Pr Bruno DEVAL MD Geoffroy Saint-Hilaire ndash Clinic
Hotel ndashDieu de Paris
Paris V University
Fix the mesh on the posterior
vaginal wall and not on the
elevator ani muscle
bull To avoid dyschezia and chronic
pelvic pain
bull Sacrocolpopexy should only be performed by board certified eligible surgeons (ObGyn or Urology)
bull Knowledge surgical skills and experience in reconstructive pelvic surgery
FPMRS fellowship
CME documentation
Proctoring on 10 cases
gt 50 practice in reconstructive surgery
bull Outcomes and complications of should be monitored by annual internal audit
bull Informed consent should highlight
Alternatives to ASC including pessary
Complications of ASC
Complications of mesh
AUGS Guidelines on Sacrocolpopexy Privileges(March 2013)
Source wwwaugsorg
Conclusion
bull The technique and expertise are
fundamental
bull Laparoscopic colposacropexy can safely
be offered to women with symptomatic
POP
bull Conventional LSCP = Open Way =
robotic way
bull Conventional LSCP gt Vaginal Way
Fix the mesh on the posterior
vaginal wall and not on the
elevator ani muscle
bull To avoid dyschezia and chronic
pelvic pain
bull Sacrocolpopexy should only be performed by board certified eligible surgeons (ObGyn or Urology)
bull Knowledge surgical skills and experience in reconstructive pelvic surgery
FPMRS fellowship
CME documentation
Proctoring on 10 cases
gt 50 practice in reconstructive surgery
bull Outcomes and complications of should be monitored by annual internal audit
bull Informed consent should highlight
Alternatives to ASC including pessary
Complications of ASC
Complications of mesh
AUGS Guidelines on Sacrocolpopexy Privileges(March 2013)
Source wwwaugsorg
Conclusion
bull The technique and expertise are
fundamental
bull Laparoscopic colposacropexy can safely
be offered to women with symptomatic
POP
bull Conventional LSCP = Open Way =
robotic way
bull Conventional LSCP gt Vaginal Way
bull Sacrocolpopexy should only be performed by board certified eligible surgeons (ObGyn or Urology)
bull Knowledge surgical skills and experience in reconstructive pelvic surgery
FPMRS fellowship
CME documentation
Proctoring on 10 cases
gt 50 practice in reconstructive surgery
bull Outcomes and complications of should be monitored by annual internal audit
bull Informed consent should highlight
Alternatives to ASC including pessary
Complications of ASC
Complications of mesh
AUGS Guidelines on Sacrocolpopexy Privileges(March 2013)
Source wwwaugsorg
Conclusion
bull The technique and expertise are
fundamental
bull Laparoscopic colposacropexy can safely
be offered to women with symptomatic
POP
bull Conventional LSCP = Open Way =
robotic way
bull Conventional LSCP gt Vaginal Way
Conclusion
bull The technique and expertise are
fundamental
bull Laparoscopic colposacropexy can safely
be offered to women with symptomatic
POP
bull Conventional LSCP = Open Way =
robotic way
bull Conventional LSCP gt Vaginal Way