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Managing Posterior Vaginal Wall Prolapse
Patients with pelvic organ prolapse present with a variety of symptoms and anatomical findings. In the case of posterior vaginal wall prolapse, one must first determine what part of the patient's support mechanism has failed. It is important to decide in the clinical examination whether her prolapse is related to a loss of apical support, a weakness in the distal vaginal wall, a separation or weakness in the perineal body, or some combination of these support failures.
Like anterior wall prolapse, loss of apical support can lead to prolapse of the upper and mid vagina. Elevating the top of the vagina with a ring forceps or Kelly clamp to a more physiologically normal position in the office or operating room can determine the role of apical failure in the posterior wall prolapse. Once that determination is made, the surgeon then can decide on the type of repair the patient requires.
Occasionally, if the clinical examination does not match the patient's symptoms, radiologic studies such as a defecography can help identify the support defects.
If the prolapse stems predominantly from a loss of apical support, treatment can be addressed through one of several procedures, from a sacral colpopexy to a uterosacral suspension or a sacrospinous vaginal vault suspension. If the prolapse involves a more traditional type of rectocele, where there is loss of support in the distal vaginal wall, one must decide what type of repair—site specific or standard posterior colporrhaphy—will result in the best anatomic and functional outcomes.
Finally, weakness in the perineal body or perineocele is determined by palpating the thickness and integrity of the perineal body on rectal exam.
Equally important to the anatomic considerations and prior to any surgery, the patient's symptoms as well as her current and future sexual function should be addressed. Women with posterior compartment prolapse frequently have symptoms related to bowel dysfunction, including straining, incomplete bowel emptying, painful bowel movements, and fecal incontinence. The extent or severity of symptoms is not necessarily related to the severity of prolapse, and frequently her bowel function is most dependent on upper GI function and the type and frequency of her stool.
Studies have generally shown that most bowel symptoms—particularly straining and incomplete emptying—are resolved or improved with posterior wall repair. In some cases, surgical treatment may not necessarily correct bowel dysfunction, and occasionally it may contribute to bowel dysfunction.
Before surgical therapy, it is critical to understand which symptoms are bothering the patient, if they are related to the physical findings, and if surgical correction of the anatomy will improve her symptoms. Each patient should be appropriately counseled about the possible impact of prolapse surgery on both bowel and sexual function. Depending on the aggressiveness of the repair, approximately 15% of patients may experience some discomfort with intercourse after a colpoperineorrhaphy. Not plicating the levators can decrease but not totally alleviate this risk (Obstet. Gynecol. 2004;104:1403-21).ht
Traditional Repair Yields Best Outcomes
The approach to rectocele repair has evolved over the years, but the literature still suggests that a more traditional type of repair, with side-to-side plication and the use of delayed absorbable suture yields the best results with the least morbidity.
This surgical technique generally involves a two-layer repair, with minimal trimming of some of the vaginal wall and closure of the vaginal mucosa with an interrupted or running polyglactin suture.
Authors of a 2007 Cochrane Review of the Surgical Management of Pelvic Organ Prolapse in Women reported that for posterior vaginal wall prolapse, the vaginal approach was associated with a lower rate of recurrent rectocele and/or enterocele compared with the transanal approach (relative risk 0.24), a type of rectocele repair performed commonly performed by colorectal surgeons. However, data on the effect of surgery on bowel symptoms and the use of polyglactin mesh inlay or porcine small intestine graft inlay on the risk of recurrent rectocele were insufficient for meta-analysis. There also were no randomized trials using permanent mesh for rectocele repairs, either as an inlay or as a “suspension kit” (Cochrane Database Syst. Rev. 2007;3:CD004014).h
In one well-conducted, randomized controlled study, the traditional posterior colporrhaphy was found to have a lower failure rate compared with the site-specific repair alone, or a site-specific repair with the addition of a porcine small intestine submucosa graft for rectoceles. Symptomatically, if the anatomical repair was successful, there were no significant differences between the posterior colporrhaphy, site-specific repair, or site-specific repair augmented with porcine small intestine submucosa in terms of perioperative and postoperative morbidity, functional outcomes, quality of life, and bowel and sexual function (Am. J. Obstet. Gynecol. 2006;195:1762-71).
Currently there is little evidence to support the use of absorbable or permanent mesh in the posterior wall. Case series of mesh inlays or mesh kits without native tissue controls are still needed to determine the risks and benefits of these procedures. The caution is to not consider the posterior vaginal wall as a mirror image of the anterior vaginal wall. While one type of graft may improve the surgical cure for cystoceles, it may not add any benefit for rectocele repairs.
Additionally, stiffness in the posterior vaginal wall can lead to dyspareunia and defecation disorders, primarily fecal urgency and fecal incontinence. If the rectum is not expandable because the posterior vaginal wall is stiff and nonpliable, the patient feels a constant urge to defecate, and if she has poor anal sphincter function, a noncompliant rectal reservoir can lead to fecal or flatal loss.
In my practice, when a patient complains of splinting or incomplete evacuation, I suspect a distal rectocele and a deficient perineal body. Perineal body defects are often found in patients who have an enlarged vaginal introitus or a history of straining or prior episiotomy, for instance, and addressing these defects is a key part of posterior wall repair that is too often neglected.
When a perineorrhaphy is performed, the bulbocavernosus muscles must be identified and plicated in the midline with care so as not to narrow the introitus so significantly that coital activity would be impaired. Caudad to the bulbocavernosus muscles, mobilization of the lateral tissues will enable plication of the medial portions of the puboperineus muscles. This compensatory repair will help bulk and strengthen the perineal body.
I use 3-0 prolonged, delayed, absorbable sutures, in one or two layers. This step increases the length and thickness of the perineal body and can also increase the functional length of the posterior vaginal wall.
Technique for Traditional Colporrhaphy
As described by Dr. B.H. Goff and later Dr. David Nichols, the traditional posterior colporrhaphy involves opening the posterior vaginal wall epithelium in the midline and dissecting laterally and superiorly, then plicating the posterior vaginal wall muscularis—or rectovaginal septum, as the endopelvic fascia is termed—in the midline. The excess of the epithelium is then trimmed and brought back together in the midline.
With the Goff method, the rectovaginal septum is not dissected “off” the posterior vaginal wall. In contrast, with the Bullard modification, the rectovaginal septum is dissected off the posterior vaginal wall. This mobilizes the connective tissue layer to the lateral sidewalls and allows a separate layer to be plicated between the vagina and rectum.
I prefer this technique for two reasons. First, it allows one to decrease the size of a dilated rectal ampulla by inverting the dilated rectal wall into the rectal lumen similar to a transrectal rectocele repair. Also with this method, any “ridge” created is directed posterior for less dyspareunia. The levator muscles should never be plicated, unless an obliterative procedure is being performed, because of the impact on sexual function.
To begin, two Allis clamps are placed on the hymen at approximately the 5 o'clock and 7 o'clock positions. The position of these clamps should be modified, however, depending on the size of the genital hiatus, so that three finger breaths can be easily admitted to ensure enough room for sexual intercourse. As patients age, this becomes increasingly important as the incidence of erectile dysfunction in male partners precludes penetration in a very narrow genital hiatus.
Since rectocele repair is usually done after other apical or anterior wall compartment defects are corrected (rectoceles are rarely isolated problems, and high rectoceles are usually associated with apical defects or enteroceles), it is important to appreciate that the introitus may tighten during the healing process.
Once the Allis clamps are placed on the hymenal ring, with a finger placed in the rectum, the surgeon must identify the extent of the weakness in the vaginal wall. This is accomplished by a thorough examination of the vagina with palpation between the finger and thumb. For example, with a finger in the rectum, palpate transrectally the thickness of the perineal body. This will enable you to determine if the bulbocavernosus muscles are separated or retracted, generally from childbirth or chronic straining or constipation, and will give you an assessment of the perineal body integrity.
Further, by elevating the vaginal wall rectally, the point of weakness and placement of the apical limit of the repair can be determined. At that point, another Allis clamp is then placed accordingly in the vagina to mark the top of the repair.
Once you have determined the size of your dissection, use a dilute vasopressin solution to infiltrate underneath the posterior vaginal wall along the dissection margins (we use vasopressin 20 U in 50 cc of normal saline). An incision along those margins is made with a knife through the mucosa. Metzenbaum scissors or a knife can then be used to excise the vaginal mucosa.
I prefer to keep a finger in the rectum at all times. This helps prevent inadvertent placement of a stitch in the rectum. I generally grasp the edges of the incision with Allis clamps and mobilize the “rectovaginal septum” off the posterior vaginal wall.
Prolonged delayed absorbable sutures are used to plicate the fibromuscularis tissue in the midline in a side-to-side fashion. I generally use a 2-0 polydioxanone (PDS) absorbable suture on a CT-2 needle, oplaced in interrupted horizontal mattress stitches to the level of the hymen. I try to create a ridge of tissue that is directed posterior toward the rectum.
If the rectal ampulla is enlarged, it will often invert as the dense connective tissue is plicated, thus reducing the size of the rectum. Depending on the size of the rectocele and how high I have gone with the rectocele repair, I place two to eight stitches.
Generally, before placing those sutures, I will place a stitch using a 3-0 Vicryl suture at the apex of the incision so that once I finish the deep layer I can easily run a 3-0 Vicryl suture interlocking with about every third stitch to the level of the hymen. I have found interlocking every few stitches prevents shortening of the wall.
When applicable, the perineal body must be addressed next. With the extent of the deficiency taken into account, I mobilize and dissect the mucosa with Metzenbaum scissors so that I can identify or at least attempt to palpate the ends of the retracted bulbocavernosus muscles.
I will grasp these muscles with an Allis clamp and place a horizontal mattress of stitch using a 2-0 PDS suture on a CT-2 needle. The assistant frequently will assist by grabbing the needle with a tonsil clamp. A finger in the rectum can also help stabilize the needle.
Depending on the tissue, I will place one or two layers at this point. I will then close with the 3-0 Vicryl suture that I'd placed above and held, with a deep layer down and a subcuticular layer back up, with the knot just inside of the hymenal ring, similar to an episiotomy closure.
Although not glamorous, repair of a posterior wall defect can often be life changing for a patient. The ability to have bowel movements without manual manipulation, wear a tampon, or just regain confidence as a consequence of improved body image is invaluable.
Often, at the end of a long reconstructive case, the relative importance of a good colpoperineorrhaphy can be hard to appreciate. Yet, for the completion of pelvic floor function and anatomical outcomes, it is often a necessity.
Seventy-five to 95% of women will have good anatomical outcomes with this type of repair with similar improvements in splinting for defecation.
Allis clamps are placed on the hymen at approximately the 5 o'clock and 7 o'clock positions. Clamps are adjusted to desired introital size. Figure 2: Mobilize the “rectovaginal septum” off the posterior vaginal wall. Figure 3: Plicate the fibromuscularis tissue in the midline in a side-to-side fashion. Figure 4: A tonsil clamp is used to invert the enlarged rectal ampulla as the dense connective tissue is plicated. Figure 5: Mobilize and dissect the mucosa of the perineal body to identify or at least attempt to palpate the ends of the retracted bulbocavernosus muscles. Figure 6: Grasp the retracted bulbocavernosus muscles, and place a horizontal mattress stitch. Figure 7: Close the repair with Vicryl suture that was placed above and held, with a deep layer down and a subcuticular layer back up, with the knot just inside of the hymenal ring.
Source Photos courtesy Dr. Dee E. Fenner
Revisiting Symptomatic Rectocele Repair
Concerns have been raised about the use of mesh and subsequent erosion in rectocele repair via posterior colporrhaphy, although many still advocate the use of mesh. Furthermore, it has been noted in several studies that vaginal surgery augmented by mesh did not result in significantly less recurrent prolapse than traditional colporrhaphy. Given this issue, it is pertinent to revisit posterior colporrhaphy and perineorrhaphy for rectocele repair without mesh augmentation.
Approximately 200,000 women undergo surgery for pelvic prolapse each year in the United States. According to the Department of Health and Human Services' Administration on Aging, three-quarters of women with prolapse have a rectocele. It has now been nearly a century since approaches to the posterior compartment to treat symptomatic rectoceles were first described. Through much of this time period, posterior colporrhaphy and perineorrhaphy have proven to be the gold standard. By plicating the posterior vaginal muscularis or medial aspect of the levator ani muscles in the midline, and when prudent performing a perineorrhaphy, cure rates of 76%-96% have been noted.
In this Master Class in Gynecologic Surgery, I have asked Dr. Dee E. Fenner, Harold A. Furlong Professor of Women's Health and director of gynecology at the University of Michigan, Ann Arbor, to discuss the technique of posterior colporrhaphy and perineorrhaphy. Dr. Fenner's current research includes mechanisms of vaginal wall support failure; she is a nationally known expert in urogynecology and travels throughout the country as an invited lecturer. It is an honor to have Dr. Fenner's recommendations on this very pertinent topic.
Patients with pelvic organ prolapse present with a variety of symptoms and anatomical findings. In the case of posterior vaginal wall prolapse, one must first determine what part of the patient's support mechanism has failed. It is important to decide in the clinical examination whether her prolapse is related to a loss of apical support, a weakness in the distal vaginal wall, a separation or weakness in the perineal body, or some combination of these support failures.
Like anterior wall prolapse, loss of apical support can lead to prolapse of the upper and mid vagina. Elevating the top of the vagina with a ring forceps or Kelly clamp to a more physiologically normal position in the office or operating room can determine the role of apical failure in the posterior wall prolapse. Once that determination is made, the surgeon then can decide on the type of repair the patient requires.
Occasionally, if the clinical examination does not match the patient's symptoms, radiologic studies such as a defecography can help identify the support defects.
If the prolapse stems predominantly from a loss of apical support, treatment can be addressed through one of several procedures, from a sacral colpopexy to a uterosacral suspension or a sacrospinous vaginal vault suspension. If the prolapse involves a more traditional type of rectocele, where there is loss of support in the distal vaginal wall, one must decide what type of repair—site specific or standard posterior colporrhaphy—will result in the best anatomic and functional outcomes.
Finally, weakness in the perineal body or perineocele is determined by palpating the thickness and integrity of the perineal body on rectal exam.
Equally important to the anatomic considerations and prior to any surgery, the patient's symptoms as well as her current and future sexual function should be addressed. Women with posterior compartment prolapse frequently have symptoms related to bowel dysfunction, including straining, incomplete bowel emptying, painful bowel movements, and fecal incontinence. The extent or severity of symptoms is not necessarily related to the severity of prolapse, and frequently her bowel function is most dependent on upper GI function and the type and frequency of her stool.
Studies have generally shown that most bowel symptoms—particularly straining and incomplete emptying—are resolved or improved with posterior wall repair. In some cases, surgical treatment may not necessarily correct bowel dysfunction, and occasionally it may contribute to bowel dysfunction.
Before surgical therapy, it is critical to understand which symptoms are bothering the patient, if they are related to the physical findings, and if surgical correction of the anatomy will improve her symptoms. Each patient should be appropriately counseled about the possible impact of prolapse surgery on both bowel and sexual function. Depending on the aggressiveness of the repair, approximately 15% of patients may experience some discomfort with intercourse after a colpoperineorrhaphy. Not plicating the levators can decrease but not totally alleviate this risk (Obstet. Gynecol. 2004;104:1403-21).ht
Traditional Repair Yields Best Outcomes
The approach to rectocele repair has evolved over the years, but the literature still suggests that a more traditional type of repair, with side-to-side plication and the use of delayed absorbable suture yields the best results with the least morbidity.
This surgical technique generally involves a two-layer repair, with minimal trimming of some of the vaginal wall and closure of the vaginal mucosa with an interrupted or running polyglactin suture.
Authors of a 2007 Cochrane Review of the Surgical Management of Pelvic Organ Prolapse in Women reported that for posterior vaginal wall prolapse, the vaginal approach was associated with a lower rate of recurrent rectocele and/or enterocele compared with the transanal approach (relative risk 0.24), a type of rectocele repair performed commonly performed by colorectal surgeons. However, data on the effect of surgery on bowel symptoms and the use of polyglactin mesh inlay or porcine small intestine graft inlay on the risk of recurrent rectocele were insufficient for meta-analysis. There also were no randomized trials using permanent mesh for rectocele repairs, either as an inlay or as a “suspension kit” (Cochrane Database Syst. Rev. 2007;3:CD004014).h
In one well-conducted, randomized controlled study, the traditional posterior colporrhaphy was found to have a lower failure rate compared with the site-specific repair alone, or a site-specific repair with the addition of a porcine small intestine submucosa graft for rectoceles. Symptomatically, if the anatomical repair was successful, there were no significant differences between the posterior colporrhaphy, site-specific repair, or site-specific repair augmented with porcine small intestine submucosa in terms of perioperative and postoperative morbidity, functional outcomes, quality of life, and bowel and sexual function (Am. J. Obstet. Gynecol. 2006;195:1762-71).
Currently there is little evidence to support the use of absorbable or permanent mesh in the posterior wall. Case series of mesh inlays or mesh kits without native tissue controls are still needed to determine the risks and benefits of these procedures. The caution is to not consider the posterior vaginal wall as a mirror image of the anterior vaginal wall. While one type of graft may improve the surgical cure for cystoceles, it may not add any benefit for rectocele repairs.
Additionally, stiffness in the posterior vaginal wall can lead to dyspareunia and defecation disorders, primarily fecal urgency and fecal incontinence. If the rectum is not expandable because the posterior vaginal wall is stiff and nonpliable, the patient feels a constant urge to defecate, and if she has poor anal sphincter function, a noncompliant rectal reservoir can lead to fecal or flatal loss.
In my practice, when a patient complains of splinting or incomplete evacuation, I suspect a distal rectocele and a deficient perineal body. Perineal body defects are often found in patients who have an enlarged vaginal introitus or a history of straining or prior episiotomy, for instance, and addressing these defects is a key part of posterior wall repair that is too often neglected.
When a perineorrhaphy is performed, the bulbocavernosus muscles must be identified and plicated in the midline with care so as not to narrow the introitus so significantly that coital activity would be impaired. Caudad to the bulbocavernosus muscles, mobilization of the lateral tissues will enable plication of the medial portions of the puboperineus muscles. This compensatory repair will help bulk and strengthen the perineal body.
I use 3-0 prolonged, delayed, absorbable sutures, in one or two layers. This step increases the length and thickness of the perineal body and can also increase the functional length of the posterior vaginal wall.
Technique for Traditional Colporrhaphy
As described by Dr. B.H. Goff and later Dr. David Nichols, the traditional posterior colporrhaphy involves opening the posterior vaginal wall epithelium in the midline and dissecting laterally and superiorly, then plicating the posterior vaginal wall muscularis—or rectovaginal septum, as the endopelvic fascia is termed—in the midline. The excess of the epithelium is then trimmed and brought back together in the midline.
With the Goff method, the rectovaginal septum is not dissected “off” the posterior vaginal wall. In contrast, with the Bullard modification, the rectovaginal septum is dissected off the posterior vaginal wall. This mobilizes the connective tissue layer to the lateral sidewalls and allows a separate layer to be plicated between the vagina and rectum.
I prefer this technique for two reasons. First, it allows one to decrease the size of a dilated rectal ampulla by inverting the dilated rectal wall into the rectal lumen similar to a transrectal rectocele repair. Also with this method, any “ridge” created is directed posterior for less dyspareunia. The levator muscles should never be plicated, unless an obliterative procedure is being performed, because of the impact on sexual function.
To begin, two Allis clamps are placed on the hymen at approximately the 5 o'clock and 7 o'clock positions. The position of these clamps should be modified, however, depending on the size of the genital hiatus, so that three finger breaths can be easily admitted to ensure enough room for sexual intercourse. As patients age, this becomes increasingly important as the incidence of erectile dysfunction in male partners precludes penetration in a very narrow genital hiatus.
Since rectocele repair is usually done after other apical or anterior wall compartment defects are corrected (rectoceles are rarely isolated problems, and high rectoceles are usually associated with apical defects or enteroceles), it is important to appreciate that the introitus may tighten during the healing process.
Once the Allis clamps are placed on the hymenal ring, with a finger placed in the rectum, the surgeon must identify the extent of the weakness in the vaginal wall. This is accomplished by a thorough examination of the vagina with palpation between the finger and thumb. For example, with a finger in the rectum, palpate transrectally the thickness of the perineal body. This will enable you to determine if the bulbocavernosus muscles are separated or retracted, generally from childbirth or chronic straining or constipation, and will give you an assessment of the perineal body integrity.
Further, by elevating the vaginal wall rectally, the point of weakness and placement of the apical limit of the repair can be determined. At that point, another Allis clamp is then placed accordingly in the vagina to mark the top of the repair.
Once you have determined the size of your dissection, use a dilute vasopressin solution to infiltrate underneath the posterior vaginal wall along the dissection margins (we use vasopressin 20 U in 50 cc of normal saline). An incision along those margins is made with a knife through the mucosa. Metzenbaum scissors or a knife can then be used to excise the vaginal mucosa.
I prefer to keep a finger in the rectum at all times. This helps prevent inadvertent placement of a stitch in the rectum. I generally grasp the edges of the incision with Allis clamps and mobilize the “rectovaginal septum” off the posterior vaginal wall.
Prolonged delayed absorbable sutures are used to plicate the fibromuscularis tissue in the midline in a side-to-side fashion. I generally use a 2-0 polydioxanone (PDS) absorbable suture on a CT-2 needle, oplaced in interrupted horizontal mattress stitches to the level of the hymen. I try to create a ridge of tissue that is directed posterior toward the rectum.
If the rectal ampulla is enlarged, it will often invert as the dense connective tissue is plicated, thus reducing the size of the rectum. Depending on the size of the rectocele and how high I have gone with the rectocele repair, I place two to eight stitches.
Generally, before placing those sutures, I will place a stitch using a 3-0 Vicryl suture at the apex of the incision so that once I finish the deep layer I can easily run a 3-0 Vicryl suture interlocking with about every third stitch to the level of the hymen. I have found interlocking every few stitches prevents shortening of the wall.
When applicable, the perineal body must be addressed next. With the extent of the deficiency taken into account, I mobilize and dissect the mucosa with Metzenbaum scissors so that I can identify or at least attempt to palpate the ends of the retracted bulbocavernosus muscles.
I will grasp these muscles with an Allis clamp and place a horizontal mattress of stitch using a 2-0 PDS suture on a CT-2 needle. The assistant frequently will assist by grabbing the needle with a tonsil clamp. A finger in the rectum can also help stabilize the needle.
Depending on the tissue, I will place one or two layers at this point. I will then close with the 3-0 Vicryl suture that I'd placed above and held, with a deep layer down and a subcuticular layer back up, with the knot just inside of the hymenal ring, similar to an episiotomy closure.
Although not glamorous, repair of a posterior wall defect can often be life changing for a patient. The ability to have bowel movements without manual manipulation, wear a tampon, or just regain confidence as a consequence of improved body image is invaluable.
Often, at the end of a long reconstructive case, the relative importance of a good colpoperineorrhaphy can be hard to appreciate. Yet, for the completion of pelvic floor function and anatomical outcomes, it is often a necessity.
Seventy-five to 95% of women will have good anatomical outcomes with this type of repair with similar improvements in splinting for defecation.
Allis clamps are placed on the hymen at approximately the 5 o'clock and 7 o'clock positions. Clamps are adjusted to desired introital size. Figure 2: Mobilize the “rectovaginal septum” off the posterior vaginal wall. Figure 3: Plicate the fibromuscularis tissue in the midline in a side-to-side fashion. Figure 4: A tonsil clamp is used to invert the enlarged rectal ampulla as the dense connective tissue is plicated. Figure 5: Mobilize and dissect the mucosa of the perineal body to identify or at least attempt to palpate the ends of the retracted bulbocavernosus muscles. Figure 6: Grasp the retracted bulbocavernosus muscles, and place a horizontal mattress stitch. Figure 7: Close the repair with Vicryl suture that was placed above and held, with a deep layer down and a subcuticular layer back up, with the knot just inside of the hymenal ring.
Source Photos courtesy Dr. Dee E. Fenner
Revisiting Symptomatic Rectocele Repair
Concerns have been raised about the use of mesh and subsequent erosion in rectocele repair via posterior colporrhaphy, although many still advocate the use of mesh. Furthermore, it has been noted in several studies that vaginal surgery augmented by mesh did not result in significantly less recurrent prolapse than traditional colporrhaphy. Given this issue, it is pertinent to revisit posterior colporrhaphy and perineorrhaphy for rectocele repair without mesh augmentation.
Approximately 200,000 women undergo surgery for pelvic prolapse each year in the United States. According to the Department of Health and Human Services' Administration on Aging, three-quarters of women with prolapse have a rectocele. It has now been nearly a century since approaches to the posterior compartment to treat symptomatic rectoceles were first described. Through much of this time period, posterior colporrhaphy and perineorrhaphy have proven to be the gold standard. By plicating the posterior vaginal muscularis or medial aspect of the levator ani muscles in the midline, and when prudent performing a perineorrhaphy, cure rates of 76%-96% have been noted.
In this Master Class in Gynecologic Surgery, I have asked Dr. Dee E. Fenner, Harold A. Furlong Professor of Women's Health and director of gynecology at the University of Michigan, Ann Arbor, to discuss the technique of posterior colporrhaphy and perineorrhaphy. Dr. Fenner's current research includes mechanisms of vaginal wall support failure; she is a nationally known expert in urogynecology and travels throughout the country as an invited lecturer. It is an honor to have Dr. Fenner's recommendations on this very pertinent topic.
Patients with pelvic organ prolapse present with a variety of symptoms and anatomical findings. In the case of posterior vaginal wall prolapse, one must first determine what part of the patient's support mechanism has failed. It is important to decide in the clinical examination whether her prolapse is related to a loss of apical support, a weakness in the distal vaginal wall, a separation or weakness in the perineal body, or some combination of these support failures.
Like anterior wall prolapse, loss of apical support can lead to prolapse of the upper and mid vagina. Elevating the top of the vagina with a ring forceps or Kelly clamp to a more physiologically normal position in the office or operating room can determine the role of apical failure in the posterior wall prolapse. Once that determination is made, the surgeon then can decide on the type of repair the patient requires.
Occasionally, if the clinical examination does not match the patient's symptoms, radiologic studies such as a defecography can help identify the support defects.
If the prolapse stems predominantly from a loss of apical support, treatment can be addressed through one of several procedures, from a sacral colpopexy to a uterosacral suspension or a sacrospinous vaginal vault suspension. If the prolapse involves a more traditional type of rectocele, where there is loss of support in the distal vaginal wall, one must decide what type of repair—site specific or standard posterior colporrhaphy—will result in the best anatomic and functional outcomes.
Finally, weakness in the perineal body or perineocele is determined by palpating the thickness and integrity of the perineal body on rectal exam.
Equally important to the anatomic considerations and prior to any surgery, the patient's symptoms as well as her current and future sexual function should be addressed. Women with posterior compartment prolapse frequently have symptoms related to bowel dysfunction, including straining, incomplete bowel emptying, painful bowel movements, and fecal incontinence. The extent or severity of symptoms is not necessarily related to the severity of prolapse, and frequently her bowel function is most dependent on upper GI function and the type and frequency of her stool.
Studies have generally shown that most bowel symptoms—particularly straining and incomplete emptying—are resolved or improved with posterior wall repair. In some cases, surgical treatment may not necessarily correct bowel dysfunction, and occasionally it may contribute to bowel dysfunction.
Before surgical therapy, it is critical to understand which symptoms are bothering the patient, if they are related to the physical findings, and if surgical correction of the anatomy will improve her symptoms. Each patient should be appropriately counseled about the possible impact of prolapse surgery on both bowel and sexual function. Depending on the aggressiveness of the repair, approximately 15% of patients may experience some discomfort with intercourse after a colpoperineorrhaphy. Not plicating the levators can decrease but not totally alleviate this risk (Obstet. Gynecol. 2004;104:1403-21).ht
Traditional Repair Yields Best Outcomes
The approach to rectocele repair has evolved over the years, but the literature still suggests that a more traditional type of repair, with side-to-side plication and the use of delayed absorbable suture yields the best results with the least morbidity.
This surgical technique generally involves a two-layer repair, with minimal trimming of some of the vaginal wall and closure of the vaginal mucosa with an interrupted or running polyglactin suture.
Authors of a 2007 Cochrane Review of the Surgical Management of Pelvic Organ Prolapse in Women reported that for posterior vaginal wall prolapse, the vaginal approach was associated with a lower rate of recurrent rectocele and/or enterocele compared with the transanal approach (relative risk 0.24), a type of rectocele repair performed commonly performed by colorectal surgeons. However, data on the effect of surgery on bowel symptoms and the use of polyglactin mesh inlay or porcine small intestine graft inlay on the risk of recurrent rectocele were insufficient for meta-analysis. There also were no randomized trials using permanent mesh for rectocele repairs, either as an inlay or as a “suspension kit” (Cochrane Database Syst. Rev. 2007;3:CD004014).h
In one well-conducted, randomized controlled study, the traditional posterior colporrhaphy was found to have a lower failure rate compared with the site-specific repair alone, or a site-specific repair with the addition of a porcine small intestine submucosa graft for rectoceles. Symptomatically, if the anatomical repair was successful, there were no significant differences between the posterior colporrhaphy, site-specific repair, or site-specific repair augmented with porcine small intestine submucosa in terms of perioperative and postoperative morbidity, functional outcomes, quality of life, and bowel and sexual function (Am. J. Obstet. Gynecol. 2006;195:1762-71).
Currently there is little evidence to support the use of absorbable or permanent mesh in the posterior wall. Case series of mesh inlays or mesh kits without native tissue controls are still needed to determine the risks and benefits of these procedures. The caution is to not consider the posterior vaginal wall as a mirror image of the anterior vaginal wall. While one type of graft may improve the surgical cure for cystoceles, it may not add any benefit for rectocele repairs.
Additionally, stiffness in the posterior vaginal wall can lead to dyspareunia and defecation disorders, primarily fecal urgency and fecal incontinence. If the rectum is not expandable because the posterior vaginal wall is stiff and nonpliable, the patient feels a constant urge to defecate, and if she has poor anal sphincter function, a noncompliant rectal reservoir can lead to fecal or flatal loss.
In my practice, when a patient complains of splinting or incomplete evacuation, I suspect a distal rectocele and a deficient perineal body. Perineal body defects are often found in patients who have an enlarged vaginal introitus or a history of straining or prior episiotomy, for instance, and addressing these defects is a key part of posterior wall repair that is too often neglected.
When a perineorrhaphy is performed, the bulbocavernosus muscles must be identified and plicated in the midline with care so as not to narrow the introitus so significantly that coital activity would be impaired. Caudad to the bulbocavernosus muscles, mobilization of the lateral tissues will enable plication of the medial portions of the puboperineus muscles. This compensatory repair will help bulk and strengthen the perineal body.
I use 3-0 prolonged, delayed, absorbable sutures, in one or two layers. This step increases the length and thickness of the perineal body and can also increase the functional length of the posterior vaginal wall.
Technique for Traditional Colporrhaphy
As described by Dr. B.H. Goff and later Dr. David Nichols, the traditional posterior colporrhaphy involves opening the posterior vaginal wall epithelium in the midline and dissecting laterally and superiorly, then plicating the posterior vaginal wall muscularis—or rectovaginal septum, as the endopelvic fascia is termed—in the midline. The excess of the epithelium is then trimmed and brought back together in the midline.
With the Goff method, the rectovaginal septum is not dissected “off” the posterior vaginal wall. In contrast, with the Bullard modification, the rectovaginal septum is dissected off the posterior vaginal wall. This mobilizes the connective tissue layer to the lateral sidewalls and allows a separate layer to be plicated between the vagina and rectum.
I prefer this technique for two reasons. First, it allows one to decrease the size of a dilated rectal ampulla by inverting the dilated rectal wall into the rectal lumen similar to a transrectal rectocele repair. Also with this method, any “ridge” created is directed posterior for less dyspareunia. The levator muscles should never be plicated, unless an obliterative procedure is being performed, because of the impact on sexual function.
To begin, two Allis clamps are placed on the hymen at approximately the 5 o'clock and 7 o'clock positions. The position of these clamps should be modified, however, depending on the size of the genital hiatus, so that three finger breaths can be easily admitted to ensure enough room for sexual intercourse. As patients age, this becomes increasingly important as the incidence of erectile dysfunction in male partners precludes penetration in a very narrow genital hiatus.
Since rectocele repair is usually done after other apical or anterior wall compartment defects are corrected (rectoceles are rarely isolated problems, and high rectoceles are usually associated with apical defects or enteroceles), it is important to appreciate that the introitus may tighten during the healing process.
Once the Allis clamps are placed on the hymenal ring, with a finger placed in the rectum, the surgeon must identify the extent of the weakness in the vaginal wall. This is accomplished by a thorough examination of the vagina with palpation between the finger and thumb. For example, with a finger in the rectum, palpate transrectally the thickness of the perineal body. This will enable you to determine if the bulbocavernosus muscles are separated or retracted, generally from childbirth or chronic straining or constipation, and will give you an assessment of the perineal body integrity.
Further, by elevating the vaginal wall rectally, the point of weakness and placement of the apical limit of the repair can be determined. At that point, another Allis clamp is then placed accordingly in the vagina to mark the top of the repair.
Once you have determined the size of your dissection, use a dilute vasopressin solution to infiltrate underneath the posterior vaginal wall along the dissection margins (we use vasopressin 20 U in 50 cc of normal saline). An incision along those margins is made with a knife through the mucosa. Metzenbaum scissors or a knife can then be used to excise the vaginal mucosa.
I prefer to keep a finger in the rectum at all times. This helps prevent inadvertent placement of a stitch in the rectum. I generally grasp the edges of the incision with Allis clamps and mobilize the “rectovaginal septum” off the posterior vaginal wall.
Prolonged delayed absorbable sutures are used to plicate the fibromuscularis tissue in the midline in a side-to-side fashion. I generally use a 2-0 polydioxanone (PDS) absorbable suture on a CT-2 needle, oplaced in interrupted horizontal mattress stitches to the level of the hymen. I try to create a ridge of tissue that is directed posterior toward the rectum.
If the rectal ampulla is enlarged, it will often invert as the dense connective tissue is plicated, thus reducing the size of the rectum. Depending on the size of the rectocele and how high I have gone with the rectocele repair, I place two to eight stitches.
Generally, before placing those sutures, I will place a stitch using a 3-0 Vicryl suture at the apex of the incision so that once I finish the deep layer I can easily run a 3-0 Vicryl suture interlocking with about every third stitch to the level of the hymen. I have found interlocking every few stitches prevents shortening of the wall.
When applicable, the perineal body must be addressed next. With the extent of the deficiency taken into account, I mobilize and dissect the mucosa with Metzenbaum scissors so that I can identify or at least attempt to palpate the ends of the retracted bulbocavernosus muscles.
I will grasp these muscles with an Allis clamp and place a horizontal mattress of stitch using a 2-0 PDS suture on a CT-2 needle. The assistant frequently will assist by grabbing the needle with a tonsil clamp. A finger in the rectum can also help stabilize the needle.
Depending on the tissue, I will place one or two layers at this point. I will then close with the 3-0 Vicryl suture that I'd placed above and held, with a deep layer down and a subcuticular layer back up, with the knot just inside of the hymenal ring, similar to an episiotomy closure.
Although not glamorous, repair of a posterior wall defect can often be life changing for a patient. The ability to have bowel movements without manual manipulation, wear a tampon, or just regain confidence as a consequence of improved body image is invaluable.
Often, at the end of a long reconstructive case, the relative importance of a good colpoperineorrhaphy can be hard to appreciate. Yet, for the completion of pelvic floor function and anatomical outcomes, it is often a necessity.
Seventy-five to 95% of women will have good anatomical outcomes with this type of repair with similar improvements in splinting for defecation.
Allis clamps are placed on the hymen at approximately the 5 o'clock and 7 o'clock positions. Clamps are adjusted to desired introital size. Figure 2: Mobilize the “rectovaginal septum” off the posterior vaginal wall. Figure 3: Plicate the fibromuscularis tissue in the midline in a side-to-side fashion. Figure 4: A tonsil clamp is used to invert the enlarged rectal ampulla as the dense connective tissue is plicated. Figure 5: Mobilize and dissect the mucosa of the perineal body to identify or at least attempt to palpate the ends of the retracted bulbocavernosus muscles. Figure 6: Grasp the retracted bulbocavernosus muscles, and place a horizontal mattress stitch. Figure 7: Close the repair with Vicryl suture that was placed above and held, with a deep layer down and a subcuticular layer back up, with the knot just inside of the hymenal ring.
Source Photos courtesy Dr. Dee E. Fenner
Revisiting Symptomatic Rectocele Repair
Concerns have been raised about the use of mesh and subsequent erosion in rectocele repair via posterior colporrhaphy, although many still advocate the use of mesh. Furthermore, it has been noted in several studies that vaginal surgery augmented by mesh did not result in significantly less recurrent prolapse than traditional colporrhaphy. Given this issue, it is pertinent to revisit posterior colporrhaphy and perineorrhaphy for rectocele repair without mesh augmentation.
Approximately 200,000 women undergo surgery for pelvic prolapse each year in the United States. According to the Department of Health and Human Services' Administration on Aging, three-quarters of women with prolapse have a rectocele. It has now been nearly a century since approaches to the posterior compartment to treat symptomatic rectoceles were first described. Through much of this time period, posterior colporrhaphy and perineorrhaphy have proven to be the gold standard. By plicating the posterior vaginal muscularis or medial aspect of the levator ani muscles in the midline, and when prudent performing a perineorrhaphy, cure rates of 76%-96% have been noted.
In this Master Class in Gynecologic Surgery, I have asked Dr. Dee E. Fenner, Harold A. Furlong Professor of Women's Health and director of gynecology at the University of Michigan, Ann Arbor, to discuss the technique of posterior colporrhaphy and perineorrhaphy. Dr. Fenner's current research includes mechanisms of vaginal wall support failure; she is a nationally known expert in urogynecology and travels throughout the country as an invited lecturer. It is an honor to have Dr. Fenner's recommendations on this very pertinent topic.
Laparoscopic Single-Site Hysterectomies
For more than 20 years now, surgeons have been exploring minimally invasive techniques to decrease the complications of traditional abdominal hysterectomy.
Although two-thirds of all hysterectomies in the United States still are performed through a large abdominal incision, we know that minimally invasive hysterectomy provides women with a faster recovery, less pain, a quicker return to normal activities, and fewer complications.
Gynecologic surgeons who have embraced laparoscopy for patients who are not candidates for a vaginal hysterectomy have improved their laparoscopic skills notably over the last 10-15 years. The laparoscopic techniques themselves, however, have remained relatively unchanged since laparoscopic hysterectomy became an option.
From my standpoint as a minimally invasive gynecologic surgeon, I view conventional laparoscopic hysterectomy as a wonderful option for women who do not qualify for a vaginal approach. But on the flip side, I see further progress to be made since the surgery still requires several small incisions and ports, each of which increases the potential morbidity from bleeding, nerve injuries, or port-site hernias and hematomas, and each of which diminishes the cosmetic outcome that many women desire.
This next frontier for women needing hysterectomy—the next logical step in the development of minimally invasive surgery—may have recently arrived. It is a new laparoscopic approach, most commonly called single-incision laparoscopy or laparoendoscopic single-site surgery (LESS), that involves a single umbilical incision and the use of one special port through which three to four traditional or slightly modified hand instruments can be passed.
Numerous terms have been used over the years to describe single-incision laparoscopic surgery, from keyhole surgery to transumbilical endoscopic surgery to embryonic natural orifice transluminal endoscopic surgery. Just recently, a multispecialty, industry-sponsored consortium published a white paper/consensus statement saying that the term laparoendoscopic single-site surgery “most accurately conveys the broad philosophical and practical aspects of the field” (Surg. Endosc. 2009 Dec. 9;doi:10.1007/s00464-009-0688-8).
While LESS will likely be the term used most often in print, I still often use the term “single-incision laparoscopic surgery” in my discussions with patients.
Urologists are among the specialists who have reported a significant increase in the use of LESS in the past several years; successes for partial nephrectomy, pyeloplasty, renal biopsy, and numerous other procedures have been described.
In gynecologic surgery, we are building on this experience. We have a unique advantage, though, in that we have access to the uterus through the vagina. Using a uterine manipulator gives us an extra hand, in essence making a single-incision approach much easier for us than it is for other specialists.
My initial experience and that of other gynecologic surgeons suggests that single-incision laparoscopy is feasible and well tolerated and leaves no visible physical scar. Depending on the specific anatomy of each patient's umbilicus, we can often hide the incision completely in its natural creases. And just as—if not more—importantly, we may further reduce the potential morbidity associated with the use of multiple laparoscopic trocars.
History and Instrumentation
Laparoscopic hysterectomy using a single umbilical puncture was first reported by Dr. Marco A. Pelosi and Dr. Marco A. Pelosi III in 1991 (N.J. Med. 1991;88:721-6).hThe instrumentation they used for their laparoscopic-assisted vaginal hysterectomies was primitive, compared with the currently available ports, instruments, and optics, however, and the technique did not catch on. Single-incision total laparoscopic hysterectomy as we know it today really came about in 2007, when Dr. Homero Rivas, a general surgeon who was performing single-incision laparoscopic cholecystectomy at the University of Texas Southwestern Medical Center at Dallas, traveled to Mexico where his brother is a gynecologist. There, with his brother's guidance, Dr. Rivas successfully performed a hysterectomy using single-incision laparoscopy.
Single-incision laparoscopy was really taking off in general surgery and urology at about this time. Many minimally invasive surgeons saw it as a bridge to an experimental approach called natural orifice transluminal endoscopic surgery (NOTES), which uses natural orifices for access to the abdominal viscera and which might, they believed, represent the ultimate approach to minimally invasive surgery.
Single-incision laparoscopy rapidly became more than a bridge to NOTES, however. It came into its own, surpassing NOTES as a technique with lasting and broad acceptance—and one without the limitations or surgical difficulties of NOTES. Nephrectomies, splenectomies, appendectomies, and a host of other procedures were performed using single-incision laparoscopy.
Like Dr. Rivas and other general and gynecologic surgeons who began using the technique several years ago, I began my experience with single-incision total laparoscopic hysterectomy utilizing articulating surgical equipment that had been around for years. (I started using the technique in 2008.) In the past few years, laparoscopic equipment has been modified and refined in ways that have made the technique even easier and achievable by more surgeons. Articulating laparoscopic graspers, endoshears, and graspers all are commercially available.
I believe that single-incision laparoscopic hysterectomy is easiest when articulating instruments and a flexible-tip scope are used, although some surgeons are using higher-angled scopes (30 or 45 degrees) and prototype instruments that are angled rather than having the capability to articulate. (An array of bent laparoscopic instrumentation should be commercially available early this year.)
The goal, of course, is to avoid the crowding or clashing of instruments—commonly called “sword fighting”—that can come with inserting several instruments through a single port and at a single trajectory. As with any laparoscopic surgery, one needs appropriate triangulation in order to have enough intracorporeal working space with access to the tissue.
I have used a specialized 5-mm Olympus flexible scope with a reticulating camera tip. With its hysteroscopelike controls, the instrument can flex to angles greater than 90 degrees in any direction. By flexing the camera tip, I can increase my working space and deflect the camera out of the operative field to prevent my hands and instruments from clashing.
To effectively use an articulating instrument such as a grasper, I find it is best to work “across” the patient. For work on the right side, this means inserting the articulating instrument through the left cannula on the port. The instrument will cross the pelvis and articulate back toward the midline. The straight vessel-sealing device is then placed through the remaining cannula.
A wider array of articulating laparoscopes and instruments should soon be available. Most, if not all, major manufacturers of laparoscopic equipment now have divisions on single-incision laparoscopy. (In December, the Millennium Research Group, a medical technology market research group, predicted that more than 20% of all laparoscopic procedures will be done through a single-port approach by 2014.)
Four companies currently market multichannel ports that can be inserted into the base of the umbilicus. The differences in the ports are subtle, and one's choice is a matter of personal preference.
The two Food and Drug Administration–approved multichannel ports that are most commonly used today are the SILS port by Covidien, and the TriPort now distributed by Olympus. Each consists of a retractor component that is placed through the fascia and individual valves or ports where laparoscopic instruments and scopes can be inserted simultaneously. Each of these multichannel ports has three inlet ports—one that holds a 12-mm instrument and two for 5-mm instruments.
Like the other instrumentation available for single-incision laparoscopy, the multichannel ports are in their infancy. All are in their first generation and are being revised by their manufacturers. The first of the second-generation ports should become available early this year.
Technique and Surgical Pearls
Overall, there is not much difference between the LESS approach and conventional laparoscopy, and the new approach should be performed in a manner that is similar to the conventional laparoscopic technique with which one is most familiar.
Entering the abdomen is performed in the traditional open laparoscopy technique described by Hassan. Although standard single-channel ports generally require a 5- to 10-mm incision (or a 15-mmincision for the Hassan entry technique), the multichannel ports used for single-incision laparoscopy require a slightly larger incision. I generally recommend a 20- to 25-mm incision.
In patients with a deeper umbilicus, I make a midline incision through the base of the umbilicus. In thinner patients with a flat umbilicus, I use a semicircular incision around the base of the umbilicus. In either case, making the incision in keeping with the natural folds of the umbilicus enables one to minimize or eliminate any visible scar in the abdomen.
With the TriPort, the inner ring is loaded into the transducer, and inserted into the fascial incision by advancing a lever with one's thumb. The plastic is repeatedly pulled up and the ring is advanced until it is firmly in place against the patient's abdomen. The port is then clamped into place so that it sits snugly against the inner abdominal peritoneum.
In obese patients, I recommend suturing the peritoneum to the fascia to prevent the inner ring from slipping into the preperitoneal space as the case progresses.
In patients for whom I use a semicircular incision, the fascial opening can be extended bilaterally to facilitate easy placement of either the SILS port or the TriPort by using S hooks to expand the incision.
To insert the SILS port, the port is grasped with a Kelly clamp and placed into the fascia so that it sits flat on the abdominal surface with the inner ring inside the peritoneal cavity. Individual cannulas are then placed in the holes of the SILS port.
The camera (a flexible-tip camera in this case) is inserted into the port, and the tip flexed, to assess the abdomen and pelvis. One can achieve the best, unobstructed views of the pelvis—and avoid instrument clashing—when the camera tip is placed toward the anterior abdominal wall and deviated downward toward the pelvis. As the surgery proceeds, one can obtain excellent views by simply adjusting the flexible-tip camera.
In a total laparoscopic hysterectomy, I have found that it is easier to begin with the primary surgeon standing near the patient's left shoulder to address the left side first. The uterine manipulator will deflect the uterus cephalad and toward the operator, placing the right utero-ovarian ligaments under tension.
With use of the reticulating grasper, the utero-ovarian ligament is elevated, which provides easy access for a straight vessel-sealing device. At this point the camera is best positioned providing views from the right lower quadrant looking anteriorly. (This is accomplished by lowering the camera toward the patient's chest and deflecting the camera tip inferiorly and medially.)
A vessel-sealing device of your choice can then be used to cross-clamp, seal, and transect the utero-ovarian, round, and broad ligaments. The bladder flap can be developed with either a hook cautery, scissors, or a vessel-sealing device. Often, the small vaginal branches of the uterine vessels will become compressed across the top of the manipulator cuff—be sure to use the vessel-sealing device to control this.
For the colpotomy, I generally use the monopolar hook with 40- to 50-W pure cutting. The disposable hook electrode is advantageous for LESS because it can be bent. By moving the flexible-tip camera, one can adequately visualize the entire colpotomy. I also use the uterine manipulator to advantage—applying upward pressure usually provides adequate views of all the cervical-vaginal attachments.
Once the uterus is detached, it generally can be delivered vaginally. When necessary, morcellation can be accomplished either vaginally (with or without a mechanical morcellator) or with a morcellator placed through the port in the umbilicus.
Suturing presents the biggest challenges. Even those who have mastered suturing in conventional laparoscopy will face a learning curve. The vaginal cuff can be closed intracorporeally using one conventional needle driver and one reticulating grasper, but it can also be facilitated with a commercial suturing device and extracorporeal knot tying. (This latter option may be advisable during the learning curve.)
When extracorporeal knot tying is used, be careful to prevent the suture from getting wrapped around the other instruments, especially if using the TriPort.
A few more tips to shorten the learning curve with single-incision laparoscopic hysterectomy:
▸ Don't hesitate to “pexy” the ovaries, epiploica, uterus, etc., when necessary.
▸ Lubricate instruments frequently.
▸ Complete one side before moving on to the other side. Anything you can do to minimize instrument changes will improve efficiency and eliminate the need to reposition the camera and instruments. When switching sides, maintain the same instrument configuration.
▸ The camera in the vertical position with upward flexion at the tip provides an excellent view of the posterior uterus and cul de sac.
▸ The camera in the horizontal position with downward flexion at the tip provides excellent views of the anterior uterus and bladder flap, and is preferable for viewing the broad ligaments.
Experience and Outcomes
Since June 2008, I have done more than 90 hysterectomies and 20 other surgeries using the LESS technique. Data from a 5-month period in 2008, involving 22 patients who had LESS surgery (19 of whom had a hysterectomy), show that patients used narcotic pain medications for an average of 2.5 days and any analgesic medication for an average of 5 days. Their length of stay averaged approximately 11.5 hours, and they returned to work after an average of 3.5 days. The average uterine weight was 324 g, and weight was as high as 1,600 g.
Blood loss averaged 50 mL, and the median operative time was 171 minutes. Surgical time was directly related to body mass index and uterine weight, and estimated blood loss increased with increasing uterine weight. Prior laparotomy and the presence of severe adhesions did not affect the length of surgery.
I encountered no intraoperative complications or conversions, although in one patient, morcellation of the 1,600-g uterus was carried out through an additional 15-mm suprapubic incision.
The complications I encountered in this initial group of 22 patients were vaginal bleeding on day 6 in one patient and a suture granuloma 3 weeks postop in another. A third patient had a tubo-ovarian abscess 11 days after surgery; she had a history of sexually transmitted diseases and substance abuse.
These outcomes may be a little better than those of standard laparoscopic surgery—they are at least comparable—and the cosmetic results are certainly superior. It may be difficult to demonstrate statistically significant differences in pain and recovery, at least in smaller populations of patients. I am in the process of doing a comparative study of conventional laparoscopy and LESS, but a larger series will be needed to quantify many of the intraoperative and postoperative benefits.
Laparoscopic surgeons have been driven to learn and offer the technique to reduce the minimal but not insignificant risk of complications associated with each incision. Why would I put four incisions in my patient when I can complete the procedure through just one?
For work on the right side, the articulating instrument is placed through the left cannula on the multichannel port.
Source Courtesy Dr. Kevin J. Stepp
Surgical pearl: The gynecologic surgeon can achieve unobstructed views of the pelvis by adjusting the tip of the flexible-tip camera.
A reticulating grasper (left) can be used to elevate the utero-ovarian ligament in order to provide access for a straight vessel-sealing device (right).
Source Images courtesy Dr. Kevin J. Stepp
'Minimal' Minimally Invasive Surgery
So, is it time for an old dog to learn a new trick? That's exactly what I thought to myself as I attended a program on laparoscopic single-site surgery during the annual meeting of the AAGL.
After performing operative laparoscopy for more than a quarter of a century, I questioned whether I was truly ready to convert my midumbilical “closed” technique to a larger infraumbilical “open” technique. At the end of the day, I pondered, are 5-mm lateral incisions really not cosmetic? Once in the abdominal cavity, could I really retrain myself to use articulating instrumentation? Does single-port surgery offer the same triangulation of instrumentation as conventional laparoscopic surgery, or for that matter, robotic-assisted surgery?
As you read this latest edition of the Master Class in Gynecologic Surgery, authored by an excellent young physician, Dr. Kevin J. Stepp, I am sure you will contemplate issues similar to these. Nevertheless, this truly is exciting, thought-provoking technology that is “all the buzz” in minimally invasive surgery.
Dr. Stepp is assistant professor of reproductive biology at Case Western Reserve University, Cleveland. He is the program director for the new urogynecology and minimally invasive surgery fellowship at MetroHealth Medical Center in Cleveland. Dr. Stepp also serves as the director of gynecologic surgical education for the MetroHealth/Cleveland Clinic obstetrics and gynecology residency program. In 2009, he performed the world's first single-surgeon, single-incision robotic-assisted laparoscopic hysterectomy.
For more than 20 years now, surgeons have been exploring minimally invasive techniques to decrease the complications of traditional abdominal hysterectomy.
Although two-thirds of all hysterectomies in the United States still are performed through a large abdominal incision, we know that minimally invasive hysterectomy provides women with a faster recovery, less pain, a quicker return to normal activities, and fewer complications.
Gynecologic surgeons who have embraced laparoscopy for patients who are not candidates for a vaginal hysterectomy have improved their laparoscopic skills notably over the last 10-15 years. The laparoscopic techniques themselves, however, have remained relatively unchanged since laparoscopic hysterectomy became an option.
From my standpoint as a minimally invasive gynecologic surgeon, I view conventional laparoscopic hysterectomy as a wonderful option for women who do not qualify for a vaginal approach. But on the flip side, I see further progress to be made since the surgery still requires several small incisions and ports, each of which increases the potential morbidity from bleeding, nerve injuries, or port-site hernias and hematomas, and each of which diminishes the cosmetic outcome that many women desire.
This next frontier for women needing hysterectomy—the next logical step in the development of minimally invasive surgery—may have recently arrived. It is a new laparoscopic approach, most commonly called single-incision laparoscopy or laparoendoscopic single-site surgery (LESS), that involves a single umbilical incision and the use of one special port through which three to four traditional or slightly modified hand instruments can be passed.
Numerous terms have been used over the years to describe single-incision laparoscopic surgery, from keyhole surgery to transumbilical endoscopic surgery to embryonic natural orifice transluminal endoscopic surgery. Just recently, a multispecialty, industry-sponsored consortium published a white paper/consensus statement saying that the term laparoendoscopic single-site surgery “most accurately conveys the broad philosophical and practical aspects of the field” (Surg. Endosc. 2009 Dec. 9;doi:10.1007/s00464-009-0688-8).
While LESS will likely be the term used most often in print, I still often use the term “single-incision laparoscopic surgery” in my discussions with patients.
Urologists are among the specialists who have reported a significant increase in the use of LESS in the past several years; successes for partial nephrectomy, pyeloplasty, renal biopsy, and numerous other procedures have been described.
In gynecologic surgery, we are building on this experience. We have a unique advantage, though, in that we have access to the uterus through the vagina. Using a uterine manipulator gives us an extra hand, in essence making a single-incision approach much easier for us than it is for other specialists.
My initial experience and that of other gynecologic surgeons suggests that single-incision laparoscopy is feasible and well tolerated and leaves no visible physical scar. Depending on the specific anatomy of each patient's umbilicus, we can often hide the incision completely in its natural creases. And just as—if not more—importantly, we may further reduce the potential morbidity associated with the use of multiple laparoscopic trocars.
History and Instrumentation
Laparoscopic hysterectomy using a single umbilical puncture was first reported by Dr. Marco A. Pelosi and Dr. Marco A. Pelosi III in 1991 (N.J. Med. 1991;88:721-6).hThe instrumentation they used for their laparoscopic-assisted vaginal hysterectomies was primitive, compared with the currently available ports, instruments, and optics, however, and the technique did not catch on. Single-incision total laparoscopic hysterectomy as we know it today really came about in 2007, when Dr. Homero Rivas, a general surgeon who was performing single-incision laparoscopic cholecystectomy at the University of Texas Southwestern Medical Center at Dallas, traveled to Mexico where his brother is a gynecologist. There, with his brother's guidance, Dr. Rivas successfully performed a hysterectomy using single-incision laparoscopy.
Single-incision laparoscopy was really taking off in general surgery and urology at about this time. Many minimally invasive surgeons saw it as a bridge to an experimental approach called natural orifice transluminal endoscopic surgery (NOTES), which uses natural orifices for access to the abdominal viscera and which might, they believed, represent the ultimate approach to minimally invasive surgery.
Single-incision laparoscopy rapidly became more than a bridge to NOTES, however. It came into its own, surpassing NOTES as a technique with lasting and broad acceptance—and one without the limitations or surgical difficulties of NOTES. Nephrectomies, splenectomies, appendectomies, and a host of other procedures were performed using single-incision laparoscopy.
Like Dr. Rivas and other general and gynecologic surgeons who began using the technique several years ago, I began my experience with single-incision total laparoscopic hysterectomy utilizing articulating surgical equipment that had been around for years. (I started using the technique in 2008.) In the past few years, laparoscopic equipment has been modified and refined in ways that have made the technique even easier and achievable by more surgeons. Articulating laparoscopic graspers, endoshears, and graspers all are commercially available.
I believe that single-incision laparoscopic hysterectomy is easiest when articulating instruments and a flexible-tip scope are used, although some surgeons are using higher-angled scopes (30 or 45 degrees) and prototype instruments that are angled rather than having the capability to articulate. (An array of bent laparoscopic instrumentation should be commercially available early this year.)
The goal, of course, is to avoid the crowding or clashing of instruments—commonly called “sword fighting”—that can come with inserting several instruments through a single port and at a single trajectory. As with any laparoscopic surgery, one needs appropriate triangulation in order to have enough intracorporeal working space with access to the tissue.
I have used a specialized 5-mm Olympus flexible scope with a reticulating camera tip. With its hysteroscopelike controls, the instrument can flex to angles greater than 90 degrees in any direction. By flexing the camera tip, I can increase my working space and deflect the camera out of the operative field to prevent my hands and instruments from clashing.
To effectively use an articulating instrument such as a grasper, I find it is best to work “across” the patient. For work on the right side, this means inserting the articulating instrument through the left cannula on the port. The instrument will cross the pelvis and articulate back toward the midline. The straight vessel-sealing device is then placed through the remaining cannula.
A wider array of articulating laparoscopes and instruments should soon be available. Most, if not all, major manufacturers of laparoscopic equipment now have divisions on single-incision laparoscopy. (In December, the Millennium Research Group, a medical technology market research group, predicted that more than 20% of all laparoscopic procedures will be done through a single-port approach by 2014.)
Four companies currently market multichannel ports that can be inserted into the base of the umbilicus. The differences in the ports are subtle, and one's choice is a matter of personal preference.
The two Food and Drug Administration–approved multichannel ports that are most commonly used today are the SILS port by Covidien, and the TriPort now distributed by Olympus. Each consists of a retractor component that is placed through the fascia and individual valves or ports where laparoscopic instruments and scopes can be inserted simultaneously. Each of these multichannel ports has three inlet ports—one that holds a 12-mm instrument and two for 5-mm instruments.
Like the other instrumentation available for single-incision laparoscopy, the multichannel ports are in their infancy. All are in their first generation and are being revised by their manufacturers. The first of the second-generation ports should become available early this year.
Technique and Surgical Pearls
Overall, there is not much difference between the LESS approach and conventional laparoscopy, and the new approach should be performed in a manner that is similar to the conventional laparoscopic technique with which one is most familiar.
Entering the abdomen is performed in the traditional open laparoscopy technique described by Hassan. Although standard single-channel ports generally require a 5- to 10-mm incision (or a 15-mmincision for the Hassan entry technique), the multichannel ports used for single-incision laparoscopy require a slightly larger incision. I generally recommend a 20- to 25-mm incision.
In patients with a deeper umbilicus, I make a midline incision through the base of the umbilicus. In thinner patients with a flat umbilicus, I use a semicircular incision around the base of the umbilicus. In either case, making the incision in keeping with the natural folds of the umbilicus enables one to minimize or eliminate any visible scar in the abdomen.
With the TriPort, the inner ring is loaded into the transducer, and inserted into the fascial incision by advancing a lever with one's thumb. The plastic is repeatedly pulled up and the ring is advanced until it is firmly in place against the patient's abdomen. The port is then clamped into place so that it sits snugly against the inner abdominal peritoneum.
In obese patients, I recommend suturing the peritoneum to the fascia to prevent the inner ring from slipping into the preperitoneal space as the case progresses.
In patients for whom I use a semicircular incision, the fascial opening can be extended bilaterally to facilitate easy placement of either the SILS port or the TriPort by using S hooks to expand the incision.
To insert the SILS port, the port is grasped with a Kelly clamp and placed into the fascia so that it sits flat on the abdominal surface with the inner ring inside the peritoneal cavity. Individual cannulas are then placed in the holes of the SILS port.
The camera (a flexible-tip camera in this case) is inserted into the port, and the tip flexed, to assess the abdomen and pelvis. One can achieve the best, unobstructed views of the pelvis—and avoid instrument clashing—when the camera tip is placed toward the anterior abdominal wall and deviated downward toward the pelvis. As the surgery proceeds, one can obtain excellent views by simply adjusting the flexible-tip camera.
In a total laparoscopic hysterectomy, I have found that it is easier to begin with the primary surgeon standing near the patient's left shoulder to address the left side first. The uterine manipulator will deflect the uterus cephalad and toward the operator, placing the right utero-ovarian ligaments under tension.
With use of the reticulating grasper, the utero-ovarian ligament is elevated, which provides easy access for a straight vessel-sealing device. At this point the camera is best positioned providing views from the right lower quadrant looking anteriorly. (This is accomplished by lowering the camera toward the patient's chest and deflecting the camera tip inferiorly and medially.)
A vessel-sealing device of your choice can then be used to cross-clamp, seal, and transect the utero-ovarian, round, and broad ligaments. The bladder flap can be developed with either a hook cautery, scissors, or a vessel-sealing device. Often, the small vaginal branches of the uterine vessels will become compressed across the top of the manipulator cuff—be sure to use the vessel-sealing device to control this.
For the colpotomy, I generally use the monopolar hook with 40- to 50-W pure cutting. The disposable hook electrode is advantageous for LESS because it can be bent. By moving the flexible-tip camera, one can adequately visualize the entire colpotomy. I also use the uterine manipulator to advantage—applying upward pressure usually provides adequate views of all the cervical-vaginal attachments.
Once the uterus is detached, it generally can be delivered vaginally. When necessary, morcellation can be accomplished either vaginally (with or without a mechanical morcellator) or with a morcellator placed through the port in the umbilicus.
Suturing presents the biggest challenges. Even those who have mastered suturing in conventional laparoscopy will face a learning curve. The vaginal cuff can be closed intracorporeally using one conventional needle driver and one reticulating grasper, but it can also be facilitated with a commercial suturing device and extracorporeal knot tying. (This latter option may be advisable during the learning curve.)
When extracorporeal knot tying is used, be careful to prevent the suture from getting wrapped around the other instruments, especially if using the TriPort.
A few more tips to shorten the learning curve with single-incision laparoscopic hysterectomy:
▸ Don't hesitate to “pexy” the ovaries, epiploica, uterus, etc., when necessary.
▸ Lubricate instruments frequently.
▸ Complete one side before moving on to the other side. Anything you can do to minimize instrument changes will improve efficiency and eliminate the need to reposition the camera and instruments. When switching sides, maintain the same instrument configuration.
▸ The camera in the vertical position with upward flexion at the tip provides an excellent view of the posterior uterus and cul de sac.
▸ The camera in the horizontal position with downward flexion at the tip provides excellent views of the anterior uterus and bladder flap, and is preferable for viewing the broad ligaments.
Experience and Outcomes
Since June 2008, I have done more than 90 hysterectomies and 20 other surgeries using the LESS technique. Data from a 5-month period in 2008, involving 22 patients who had LESS surgery (19 of whom had a hysterectomy), show that patients used narcotic pain medications for an average of 2.5 days and any analgesic medication for an average of 5 days. Their length of stay averaged approximately 11.5 hours, and they returned to work after an average of 3.5 days. The average uterine weight was 324 g, and weight was as high as 1,600 g.
Blood loss averaged 50 mL, and the median operative time was 171 minutes. Surgical time was directly related to body mass index and uterine weight, and estimated blood loss increased with increasing uterine weight. Prior laparotomy and the presence of severe adhesions did not affect the length of surgery.
I encountered no intraoperative complications or conversions, although in one patient, morcellation of the 1,600-g uterus was carried out through an additional 15-mm suprapubic incision.
The complications I encountered in this initial group of 22 patients were vaginal bleeding on day 6 in one patient and a suture granuloma 3 weeks postop in another. A third patient had a tubo-ovarian abscess 11 days after surgery; she had a history of sexually transmitted diseases and substance abuse.
These outcomes may be a little better than those of standard laparoscopic surgery—they are at least comparable—and the cosmetic results are certainly superior. It may be difficult to demonstrate statistically significant differences in pain and recovery, at least in smaller populations of patients. I am in the process of doing a comparative study of conventional laparoscopy and LESS, but a larger series will be needed to quantify many of the intraoperative and postoperative benefits.
Laparoscopic surgeons have been driven to learn and offer the technique to reduce the minimal but not insignificant risk of complications associated with each incision. Why would I put four incisions in my patient when I can complete the procedure through just one?
For work on the right side, the articulating instrument is placed through the left cannula on the multichannel port.
Source Courtesy Dr. Kevin J. Stepp
Surgical pearl: The gynecologic surgeon can achieve unobstructed views of the pelvis by adjusting the tip of the flexible-tip camera.
A reticulating grasper (left) can be used to elevate the utero-ovarian ligament in order to provide access for a straight vessel-sealing device (right).
Source Images courtesy Dr. Kevin J. Stepp
'Minimal' Minimally Invasive Surgery
So, is it time for an old dog to learn a new trick? That's exactly what I thought to myself as I attended a program on laparoscopic single-site surgery during the annual meeting of the AAGL.
After performing operative laparoscopy for more than a quarter of a century, I questioned whether I was truly ready to convert my midumbilical “closed” technique to a larger infraumbilical “open” technique. At the end of the day, I pondered, are 5-mm lateral incisions really not cosmetic? Once in the abdominal cavity, could I really retrain myself to use articulating instrumentation? Does single-port surgery offer the same triangulation of instrumentation as conventional laparoscopic surgery, or for that matter, robotic-assisted surgery?
As you read this latest edition of the Master Class in Gynecologic Surgery, authored by an excellent young physician, Dr. Kevin J. Stepp, I am sure you will contemplate issues similar to these. Nevertheless, this truly is exciting, thought-provoking technology that is “all the buzz” in minimally invasive surgery.
Dr. Stepp is assistant professor of reproductive biology at Case Western Reserve University, Cleveland. He is the program director for the new urogynecology and minimally invasive surgery fellowship at MetroHealth Medical Center in Cleveland. Dr. Stepp also serves as the director of gynecologic surgical education for the MetroHealth/Cleveland Clinic obstetrics and gynecology residency program. In 2009, he performed the world's first single-surgeon, single-incision robotic-assisted laparoscopic hysterectomy.
For more than 20 years now, surgeons have been exploring minimally invasive techniques to decrease the complications of traditional abdominal hysterectomy.
Although two-thirds of all hysterectomies in the United States still are performed through a large abdominal incision, we know that minimally invasive hysterectomy provides women with a faster recovery, less pain, a quicker return to normal activities, and fewer complications.
Gynecologic surgeons who have embraced laparoscopy for patients who are not candidates for a vaginal hysterectomy have improved their laparoscopic skills notably over the last 10-15 years. The laparoscopic techniques themselves, however, have remained relatively unchanged since laparoscopic hysterectomy became an option.
From my standpoint as a minimally invasive gynecologic surgeon, I view conventional laparoscopic hysterectomy as a wonderful option for women who do not qualify for a vaginal approach. But on the flip side, I see further progress to be made since the surgery still requires several small incisions and ports, each of which increases the potential morbidity from bleeding, nerve injuries, or port-site hernias and hematomas, and each of which diminishes the cosmetic outcome that many women desire.
This next frontier for women needing hysterectomy—the next logical step in the development of minimally invasive surgery—may have recently arrived. It is a new laparoscopic approach, most commonly called single-incision laparoscopy or laparoendoscopic single-site surgery (LESS), that involves a single umbilical incision and the use of one special port through which three to four traditional or slightly modified hand instruments can be passed.
Numerous terms have been used over the years to describe single-incision laparoscopic surgery, from keyhole surgery to transumbilical endoscopic surgery to embryonic natural orifice transluminal endoscopic surgery. Just recently, a multispecialty, industry-sponsored consortium published a white paper/consensus statement saying that the term laparoendoscopic single-site surgery “most accurately conveys the broad philosophical and practical aspects of the field” (Surg. Endosc. 2009 Dec. 9;doi:10.1007/s00464-009-0688-8).
While LESS will likely be the term used most often in print, I still often use the term “single-incision laparoscopic surgery” in my discussions with patients.
Urologists are among the specialists who have reported a significant increase in the use of LESS in the past several years; successes for partial nephrectomy, pyeloplasty, renal biopsy, and numerous other procedures have been described.
In gynecologic surgery, we are building on this experience. We have a unique advantage, though, in that we have access to the uterus through the vagina. Using a uterine manipulator gives us an extra hand, in essence making a single-incision approach much easier for us than it is for other specialists.
My initial experience and that of other gynecologic surgeons suggests that single-incision laparoscopy is feasible and well tolerated and leaves no visible physical scar. Depending on the specific anatomy of each patient's umbilicus, we can often hide the incision completely in its natural creases. And just as—if not more—importantly, we may further reduce the potential morbidity associated with the use of multiple laparoscopic trocars.
History and Instrumentation
Laparoscopic hysterectomy using a single umbilical puncture was first reported by Dr. Marco A. Pelosi and Dr. Marco A. Pelosi III in 1991 (N.J. Med. 1991;88:721-6).hThe instrumentation they used for their laparoscopic-assisted vaginal hysterectomies was primitive, compared with the currently available ports, instruments, and optics, however, and the technique did not catch on. Single-incision total laparoscopic hysterectomy as we know it today really came about in 2007, when Dr. Homero Rivas, a general surgeon who was performing single-incision laparoscopic cholecystectomy at the University of Texas Southwestern Medical Center at Dallas, traveled to Mexico where his brother is a gynecologist. There, with his brother's guidance, Dr. Rivas successfully performed a hysterectomy using single-incision laparoscopy.
Single-incision laparoscopy was really taking off in general surgery and urology at about this time. Many minimally invasive surgeons saw it as a bridge to an experimental approach called natural orifice transluminal endoscopic surgery (NOTES), which uses natural orifices for access to the abdominal viscera and which might, they believed, represent the ultimate approach to minimally invasive surgery.
Single-incision laparoscopy rapidly became more than a bridge to NOTES, however. It came into its own, surpassing NOTES as a technique with lasting and broad acceptance—and one without the limitations or surgical difficulties of NOTES. Nephrectomies, splenectomies, appendectomies, and a host of other procedures were performed using single-incision laparoscopy.
Like Dr. Rivas and other general and gynecologic surgeons who began using the technique several years ago, I began my experience with single-incision total laparoscopic hysterectomy utilizing articulating surgical equipment that had been around for years. (I started using the technique in 2008.) In the past few years, laparoscopic equipment has been modified and refined in ways that have made the technique even easier and achievable by more surgeons. Articulating laparoscopic graspers, endoshears, and graspers all are commercially available.
I believe that single-incision laparoscopic hysterectomy is easiest when articulating instruments and a flexible-tip scope are used, although some surgeons are using higher-angled scopes (30 or 45 degrees) and prototype instruments that are angled rather than having the capability to articulate. (An array of bent laparoscopic instrumentation should be commercially available early this year.)
The goal, of course, is to avoid the crowding or clashing of instruments—commonly called “sword fighting”—that can come with inserting several instruments through a single port and at a single trajectory. As with any laparoscopic surgery, one needs appropriate triangulation in order to have enough intracorporeal working space with access to the tissue.
I have used a specialized 5-mm Olympus flexible scope with a reticulating camera tip. With its hysteroscopelike controls, the instrument can flex to angles greater than 90 degrees in any direction. By flexing the camera tip, I can increase my working space and deflect the camera out of the operative field to prevent my hands and instruments from clashing.
To effectively use an articulating instrument such as a grasper, I find it is best to work “across” the patient. For work on the right side, this means inserting the articulating instrument through the left cannula on the port. The instrument will cross the pelvis and articulate back toward the midline. The straight vessel-sealing device is then placed through the remaining cannula.
A wider array of articulating laparoscopes and instruments should soon be available. Most, if not all, major manufacturers of laparoscopic equipment now have divisions on single-incision laparoscopy. (In December, the Millennium Research Group, a medical technology market research group, predicted that more than 20% of all laparoscopic procedures will be done through a single-port approach by 2014.)
Four companies currently market multichannel ports that can be inserted into the base of the umbilicus. The differences in the ports are subtle, and one's choice is a matter of personal preference.
The two Food and Drug Administration–approved multichannel ports that are most commonly used today are the SILS port by Covidien, and the TriPort now distributed by Olympus. Each consists of a retractor component that is placed through the fascia and individual valves or ports where laparoscopic instruments and scopes can be inserted simultaneously. Each of these multichannel ports has three inlet ports—one that holds a 12-mm instrument and two for 5-mm instruments.
Like the other instrumentation available for single-incision laparoscopy, the multichannel ports are in their infancy. All are in their first generation and are being revised by their manufacturers. The first of the second-generation ports should become available early this year.
Technique and Surgical Pearls
Overall, there is not much difference between the LESS approach and conventional laparoscopy, and the new approach should be performed in a manner that is similar to the conventional laparoscopic technique with which one is most familiar.
Entering the abdomen is performed in the traditional open laparoscopy technique described by Hassan. Although standard single-channel ports generally require a 5- to 10-mm incision (or a 15-mmincision for the Hassan entry technique), the multichannel ports used for single-incision laparoscopy require a slightly larger incision. I generally recommend a 20- to 25-mm incision.
In patients with a deeper umbilicus, I make a midline incision through the base of the umbilicus. In thinner patients with a flat umbilicus, I use a semicircular incision around the base of the umbilicus. In either case, making the incision in keeping with the natural folds of the umbilicus enables one to minimize or eliminate any visible scar in the abdomen.
With the TriPort, the inner ring is loaded into the transducer, and inserted into the fascial incision by advancing a lever with one's thumb. The plastic is repeatedly pulled up and the ring is advanced until it is firmly in place against the patient's abdomen. The port is then clamped into place so that it sits snugly against the inner abdominal peritoneum.
In obese patients, I recommend suturing the peritoneum to the fascia to prevent the inner ring from slipping into the preperitoneal space as the case progresses.
In patients for whom I use a semicircular incision, the fascial opening can be extended bilaterally to facilitate easy placement of either the SILS port or the TriPort by using S hooks to expand the incision.
To insert the SILS port, the port is grasped with a Kelly clamp and placed into the fascia so that it sits flat on the abdominal surface with the inner ring inside the peritoneal cavity. Individual cannulas are then placed in the holes of the SILS port.
The camera (a flexible-tip camera in this case) is inserted into the port, and the tip flexed, to assess the abdomen and pelvis. One can achieve the best, unobstructed views of the pelvis—and avoid instrument clashing—when the camera tip is placed toward the anterior abdominal wall and deviated downward toward the pelvis. As the surgery proceeds, one can obtain excellent views by simply adjusting the flexible-tip camera.
In a total laparoscopic hysterectomy, I have found that it is easier to begin with the primary surgeon standing near the patient's left shoulder to address the left side first. The uterine manipulator will deflect the uterus cephalad and toward the operator, placing the right utero-ovarian ligaments under tension.
With use of the reticulating grasper, the utero-ovarian ligament is elevated, which provides easy access for a straight vessel-sealing device. At this point the camera is best positioned providing views from the right lower quadrant looking anteriorly. (This is accomplished by lowering the camera toward the patient's chest and deflecting the camera tip inferiorly and medially.)
A vessel-sealing device of your choice can then be used to cross-clamp, seal, and transect the utero-ovarian, round, and broad ligaments. The bladder flap can be developed with either a hook cautery, scissors, or a vessel-sealing device. Often, the small vaginal branches of the uterine vessels will become compressed across the top of the manipulator cuff—be sure to use the vessel-sealing device to control this.
For the colpotomy, I generally use the monopolar hook with 40- to 50-W pure cutting. The disposable hook electrode is advantageous for LESS because it can be bent. By moving the flexible-tip camera, one can adequately visualize the entire colpotomy. I also use the uterine manipulator to advantage—applying upward pressure usually provides adequate views of all the cervical-vaginal attachments.
Once the uterus is detached, it generally can be delivered vaginally. When necessary, morcellation can be accomplished either vaginally (with or without a mechanical morcellator) or with a morcellator placed through the port in the umbilicus.
Suturing presents the biggest challenges. Even those who have mastered suturing in conventional laparoscopy will face a learning curve. The vaginal cuff can be closed intracorporeally using one conventional needle driver and one reticulating grasper, but it can also be facilitated with a commercial suturing device and extracorporeal knot tying. (This latter option may be advisable during the learning curve.)
When extracorporeal knot tying is used, be careful to prevent the suture from getting wrapped around the other instruments, especially if using the TriPort.
A few more tips to shorten the learning curve with single-incision laparoscopic hysterectomy:
▸ Don't hesitate to “pexy” the ovaries, epiploica, uterus, etc., when necessary.
▸ Lubricate instruments frequently.
▸ Complete one side before moving on to the other side. Anything you can do to minimize instrument changes will improve efficiency and eliminate the need to reposition the camera and instruments. When switching sides, maintain the same instrument configuration.
▸ The camera in the vertical position with upward flexion at the tip provides an excellent view of the posterior uterus and cul de sac.
▸ The camera in the horizontal position with downward flexion at the tip provides excellent views of the anterior uterus and bladder flap, and is preferable for viewing the broad ligaments.
Experience and Outcomes
Since June 2008, I have done more than 90 hysterectomies and 20 other surgeries using the LESS technique. Data from a 5-month period in 2008, involving 22 patients who had LESS surgery (19 of whom had a hysterectomy), show that patients used narcotic pain medications for an average of 2.5 days and any analgesic medication for an average of 5 days. Their length of stay averaged approximately 11.5 hours, and they returned to work after an average of 3.5 days. The average uterine weight was 324 g, and weight was as high as 1,600 g.
Blood loss averaged 50 mL, and the median operative time was 171 minutes. Surgical time was directly related to body mass index and uterine weight, and estimated blood loss increased with increasing uterine weight. Prior laparotomy and the presence of severe adhesions did not affect the length of surgery.
I encountered no intraoperative complications or conversions, although in one patient, morcellation of the 1,600-g uterus was carried out through an additional 15-mm suprapubic incision.
The complications I encountered in this initial group of 22 patients were vaginal bleeding on day 6 in one patient and a suture granuloma 3 weeks postop in another. A third patient had a tubo-ovarian abscess 11 days after surgery; she had a history of sexually transmitted diseases and substance abuse.
These outcomes may be a little better than those of standard laparoscopic surgery—they are at least comparable—and the cosmetic results are certainly superior. It may be difficult to demonstrate statistically significant differences in pain and recovery, at least in smaller populations of patients. I am in the process of doing a comparative study of conventional laparoscopy and LESS, but a larger series will be needed to quantify many of the intraoperative and postoperative benefits.
Laparoscopic surgeons have been driven to learn and offer the technique to reduce the minimal but not insignificant risk of complications associated with each incision. Why would I put four incisions in my patient when I can complete the procedure through just one?
For work on the right side, the articulating instrument is placed through the left cannula on the multichannel port.
Source Courtesy Dr. Kevin J. Stepp
Surgical pearl: The gynecologic surgeon can achieve unobstructed views of the pelvis by adjusting the tip of the flexible-tip camera.
A reticulating grasper (left) can be used to elevate the utero-ovarian ligament in order to provide access for a straight vessel-sealing device (right).
Source Images courtesy Dr. Kevin J. Stepp
'Minimal' Minimally Invasive Surgery
So, is it time for an old dog to learn a new trick? That's exactly what I thought to myself as I attended a program on laparoscopic single-site surgery during the annual meeting of the AAGL.
After performing operative laparoscopy for more than a quarter of a century, I questioned whether I was truly ready to convert my midumbilical “closed” technique to a larger infraumbilical “open” technique. At the end of the day, I pondered, are 5-mm lateral incisions really not cosmetic? Once in the abdominal cavity, could I really retrain myself to use articulating instrumentation? Does single-port surgery offer the same triangulation of instrumentation as conventional laparoscopic surgery, or for that matter, robotic-assisted surgery?
As you read this latest edition of the Master Class in Gynecologic Surgery, authored by an excellent young physician, Dr. Kevin J. Stepp, I am sure you will contemplate issues similar to these. Nevertheless, this truly is exciting, thought-provoking technology that is “all the buzz” in minimally invasive surgery.
Dr. Stepp is assistant professor of reproductive biology at Case Western Reserve University, Cleveland. He is the program director for the new urogynecology and minimally invasive surgery fellowship at MetroHealth Medical Center in Cleveland. Dr. Stepp also serves as the director of gynecologic surgical education for the MetroHealth/Cleveland Clinic obstetrics and gynecology residency program. In 2009, he performed the world's first single-surgeon, single-incision robotic-assisted laparoscopic hysterectomy.
Vaginoscopy in Practice
Gynecologic surgeons are getting good reimbursement rates for office hysteroscopy, and patients appreciate the convenience of having hysteroscopic evaluations done more quickly and comfortably in an office with which they are familiar.
As commitments to office-based surgery expand, it seems logical and important for physicians to become familiar with—and consider adopting—a less-invasive approach to hysteroscopy. The vaginoscopic technique for hysteroscopy—sometimes referred to as a no-touch approach—avoids the use of a vaginal speculum and cervical tenaculum. It is an easier and quicker procedure for the surgeon, provides equally good visualization, and most importantly is even more tolerable for patients than the traditional approach that utilizes instrumentation.
Without placing a speculum in the vagina, grasping the cervix with a tenaculum, or injecting a paracervical block, I have seen a significant decrease in discomfort among my patients. I use minimal premedication and rarely use any local anesthetic. In addition to diagnosing and evaluating the uterine cavity, I can perform minor therapeutic and operative procedures such as removing polyps, lysing adhesions, obtaining biopsies, removing lost intrauterine devices, and occluding the tubes using the Essure sterilization system.
With patients tolerating the procedure even more than they would a traditional hysteroscopy, we have the opportunity to increase the possible applications of hysteroscopy, to do more during the procedure, and to advance hysteroscopy even further as a successful in-office procedure that is part and parcel of our diagnostic and therapeutic armamentarium.
Key Studies
Vaginoscopy has been described in the literature as far back as the 1950s and continues to be used for diagnosing vaginal endometriosis, pelvic floor mesh erosions, vaginal fistulas, and cervical pathology, for example, as well as excising vaginal lesions or longitudinal vaginal septums. It has also been utilized in the pediatric/adolescent population for visualizing and removing foreign bodies, and for evaluating pelvic trauma, abnormal bleeding, and infection.
Dr. Stefano Bettocchi and Dr. Luigi Selvaggi in Italy were the first, however, to describe the utilization of a vaginoscopic approach to office hysteroscopy for evaluating the endocervical canal and uterine cavity in addition to the vagina and external cervical os. In a paper published in 1997 in the Journal of the American Association of Gynecologic Laparoscopists (4:255–8), they described various approaches they took to improve patient tolerance during the 1,200 diagnostic hysteroscopies they performed between 1992 and 1996.
The first 49 procedures were done using the speculum and tenaculum but without local anesthesia. The investigators saw high rates of discomfort (53%), moderate pain (25%), and severe pain (20%), as well as two cases of serious vagal reactions.
They then began using local anesthetic (mepivacaine 2%) but found that, while it helped some of the women, many of them continued to have discomfort or pain. In the next 169 cases, 69% had discomfort or mild pain, 11% had moderate pain, and 8% had severe pain resulting in suspension of the procedure (again, including two women who had vagal reactions requiring medical assistance).
Dr. Bettocchi and Dr. Selvaggi then decided to use the speculum to visualize the cervix but not place the tenaculum. They did not use any anesthesia with this group of 308 women. Their patients' pain levels started decreasing quite a bit, with 66% of these patients reporting no complaints. Cases of severe pain disappeared completely.
They then took it a step further to deal with the remaining causes of pain (32% had reported mild pain and 2% had reported moderate pain) and utilized the vaginoscopic approach. In these last 680 procedures—in unselected patients, both multiparas and nulliparas—the patients had a 96% no-discomfort rate. By not using the speculum and tenaculum to expose and grasp the cervix, the investigators nearly eliminated patient discomfort while still performing effective hysteroscopy.
Since this landmark report, several teams that have adopted a vaginoscopic approach to hysteroscopy have reported good results, and at least two teams among those I reviewed in the literature have conducted randomized prospective studies.
Dr. M. Sharma and his team in London randomized 120 women to undergo either traditional hysteroscopy or vaginoscopic hysteroscopy (60 women in each group)—with a further breakdown into the use of a 2.9-mm and a 4-mm hysteroscope. The investigators reported an overall success rate of 99%. They used the need for local anesthesia as a primary outcome measure. Although they reported lower requirements with the vaginoscopic approach using the narrower hysteroscope, they found that overall, there was no significant difference in the use of local anesthesia among the groups. There also were no statistically significant differences in pain scores between the two techniques.
The main difference for this team lay in the length of the procedure. Hysteroscopy and biopsy times were significantly shorter (more than 25% faster) with the vaginoscopic technique—a difference that Dr. Sharma and his colleagues said is important for patients who are anxious about the procedure (BJOG 2005;112:963–7).
In the other randomized study, in contrast, Dr. O. Garbin and his colleagues in France found that patients had significantly less pain with the vaginoscopic approach. Their randomization of 200 patients to conventional and 200 patients to vaginoscopic hysteroscopy—with no use of either anesthesia or premedication in either group—showed no differences in the quality, success, or duration of the exam but significant differences in patients' ratings of pain on a visual analog scale. Two cases of vasovagal syncope occurred in the group with traditional hysteroscopy.
Cervical passage was easier overall with vaginoscopic hysteroscopy, Dr. Garbin and his team reported, though the differences were not significant (Hum. Reprod. 2006;21:2996–3000). All of their procedures were performed using rigid single-flow hysteroscopes with an external sheath diameter of 3.5 mm.
The two randomized studies were quite different, and it's possible that Dr. Sharma's study lacked sufficient power. Certainly, it was more complicated with its use of two different hysteroscopes and the frequent use of anesthesia. Interestingly, Dr. Garbin and his colleagues addressed the issue of pelvic infection and pointed out that their procedures began with disinfection—something that was not mentioned in either Dr. Bettocchi's or Dr. Sharma's reports but is a practice that we do routinely.
All told, what I've taken away from the literature thus far is that the vaginoscopic approach to hysteroscopy is superior in terms of patient tolerance and can be quicker—without any impairment in cervical passage or visual quality.
In Practice
I first prep the vagina and the cervix with a small-diameter swab dipped in Betadine (povidone-iodine), or an alternative if the patient has an allergy to iodine. I use normal saline as a distention medium, so each patient is positioned on an under-buttocks drape to catch fluid. A 1,000-cc normal saline bag inserted in a pressure bag is hung on a tall IV pole with standard IV tubing.
I tell patients in preprocedure counseling that the use of saline and distention of the uterine walls usually causes some cramping but that ibuprofen or Celebrex (celecoxib) can minimize this cramping. I show them the diameter of the hysteroscope, which often helps alleviate any anxiety. In rare cases, if a patient is very anxious and worried about her tolerance for the procedure, or if the procedure is expected to be unusually long, I will prescribe Valium (diazepam). Usually such patients are young and have never experienced a gynecologic procedure before. In practice, however, I have almost never needed to use any local anesthetic.
I do premedicate patients—especially nulliparous patients and postmenopausal patients with stenotic cervices—with Cytotec (misoprostol) to facilitate an easier entry of the hysteroscope into the cervix.
I use a 3-mm single-flow rigid hysteroscope for diagnostic purposes and can quickly add the operative sheath, making the hysteroscope a 5-mm operative rigid hysteroscope, when I need to perform a minor procedure. If I anticipate performing a procedure, I will directly enter with the 5-mm hysteroscope. I prefer using the Bettocchi hysteroscope system (Karl Storz Endoscopy-America Inc.) because of its oblong shape that, when rotated horizontally with the light cord, easily slips into the slit-shaped external cervical os.
Rigid hysteroscopes have a camera lens angle of 0–30 degrees. I most often use scopes with a 30-degree angle to optimize visualization with minimal manipulation. With this angle, the hysteroscope can be brought to the midline of the uterine cavity and simply rotated about 90 degrees to the left or right with the light cord without much movement of the hysteroscope to visualize the cornu.
In contrast, visualizing the cornu with a 0-degree scope would require manipulation of the entire hysteroscope, potentially increasing patient discomfort. A 12-degree scope offers similar advantages to the 30-degree scope, and either one can be chosen based on physician familiarity and preference.
After placing the hysteroscope into the lower vagina, I guide it into the posterior fornix of the vagina so that I know I'm at the end of the vaginal canal. Then, I slowly pull back while observing anteriorly and visualizing the external cervical os. I then introduce the hysteroscope through the cervical os, and based on an understanding of the anatomy and the scope's angled view, I guide the hysteroscope through the endocervical canal and into the uterus. If I am not getting good distention of the vaginal walls, I will gently pinch the labia together to minimize fluid leakage.
Insertion of the hysteroscope without a tenaculum requires a great deal of dexterity and comfort with the instrument. The surgeon needs to understand the correlation between what is seen on the screen and the exact position of the hysteroscope so that the instrument does not rub against the cervix or the uterine tissue and cause trauma and pain.
With an angled hysteroscope, the image displayed on the screen reflects what is actually above the tip of the instrument. If the opening to the cervical os looks like it's straight ahead, for instance, it is actually above the direction in which the scope is being guided, and the scope must therefore be angled to enter the canal. Understanding the correlation and being comfortable with this 12- or 30-degree fore-oblique view takes some practice, as does visualizing the cervix correctly when pulling back from the posterior fornix. For most gynecologic surgeons, the necessary skills and comfort levels fall into place after just a few vaginoscopic procedures.
I have not found any difference in difficulty based on the axis of the uterus. I fact, I have found that utilizing a vaginal speculum in conjunction with a cervical tenaculum to straighten the uterine axis has limited my hysteroscope manipulation for extreme ante- or retroversion, increasing patient discomfort.
Just as with traditional hysteroscopy, operative hysteroscopy is possible right after or even at the same time as a diagnostic hysteroscopy performed with a vaginoscopic approach. The gynecologic surgeon can remove polyps that are visualized during a diagnostic procedure, for instance; perform adhesiolysis for Asherman's syndrome and tubular cannulation for blocked proximal tubal obstruction; retrieve lost IUDs; and perform tubal occlusion using the Essure system. My most recent tubal occlusion procedure took less than 5 minutes from start to finish, and the patient drove herself home within 15 minutes after completion of the procedure.
I do nothing differently when performing an operative hysteroscopy utilizing the vaginoscopic approach than I would using the traditional approach, except for not using the speculum and tenaculum.
I recommend fluid monitoring when performing operative hysteroscopy especially. I generally monitor fluid outflow in my practice, with a nurse checking fluid levels and monitoring the deficit while I explain to the patient what I am doing and visualizing. Because diagnostic procedures are fairly short, the likelihood of fluid intravasation at high volumes is low, however.
Vaginoscopy can be extremely helpful for evaluating patients who are morbidly obese and for whom standard office instruments are not adequately sized for visualization of the cervix. I recently tried to obtain a Pap smear and do an endometrial biopsy in a patient who was morbidly obese and had a large fibroid uterus, but with conventional methods I was unable to do so using our instruments. I brought the patient to the operating room to use larger instruments, but even these were insufficient. I finally performed the Pap smear successfully by palpating the cervix and os, and used vaginoscopy to visualize the entire cervix. I then continued with the hysteroscopy and endometrial biopsy.
After the diagnostic—and sometimes operative—procedure, our nurses will check patients' vital signs and ensure that they are feeling well and are ambulatory. Most of the time, patients leave the office within 15 minutes or so, happy to have had their procedure done in the office as opposed to the hospital.
Vaginoscopy also has been shown to be effective, fast, and easy for managing gynecologic problems in pediatric and adolescent patients. In a report published in 2000, Dr. Abraham Golan and his colleagues in Israel reported that they were able to complete the procedure successfully in 22 patients aged 3–16 years who were evaluated for vulvovaginitis, vaginal trauma, bleeding, or genital malformation (J. Am. Assoc. Gynecol. Laparosc. 2000;7:526–8). Gynecologic surgeons who build skills and experience with the vaginoscopic approach to hysteroscopy could also serve the pediatric/adolescent community well.
The hysteroscope is guided into the posterior vaginal fornix.
Source IMAGES COURTESY DR. AARATHI CHOLKERI-SINGH
Then it is pulled back while the external cervical os is visualized anteriorly.
Then the scope is guided through the endocervical canal.
Vaginoscopy's Approach to Hysteroscopy
Over the past several years, the number of office-based gynecologic surgical procedures has skyrocketed. Factors cited in this trend toward in-office surgery are better reimbursement, greater efficiency for both patient and physician, as well as the ability to provide a familiar environment for the patient. Both diagnostic as well as operative hysteroscopy are two such procedures that easily can be converted to the office setting.
A common concern from the inception of in-office surgery is patient comfort. With the use of anesthetic agents, convalescence both in the office setting as well as at home may be extended. Furthermore, the cost of the procedure will be increased, thus affecting overall reimbursement. Finally, most gynecologists are uncomfortable providing even conscious sedation for their patient in the office. Thus, the key to successful transition to surgery in an office setting would be to modify the procedures to minimize pain. Vaginoscopy allows such an approach to both diagnostic and operative hysteroscopy.
I am especially pleased that my associate, Dr. Aarathi Cholkeri-Singh, has agreed to write this edition of the Master Class in Gynecologic Surgery on vaginoscopy. After completing her residency at Advocate Lutheran General Hospital, a large teaching hospital in a Northern suburb of Chicago, Dr. Cholkeri-Singh went on to complete an AAGL/American Society for Reproductive Medicine Fellowship in minimally invasive gynecologic surgery at Harvard Medical School and Brown University hospital affiliates. It was during her training that Dr. Cholkeri-Singh gained experience with in-office vaginoscopy under the watchful eye of noted hysteroscopic guru Dr. Keith Isaacson.
Now the associate director of minimally invasive gynecologic surgery at Advocate Lutheran General Hospital, Dr. Cholkeri-Singh's practice is concentrated on minimally invasive gynecologic surgery and office gynecology. She will be a featured speaker at the AAGL's 38th Global Congress of Minimally Invasive Gynecology this month in Orlando.
Gynecologic surgeons are getting good reimbursement rates for office hysteroscopy, and patients appreciate the convenience of having hysteroscopic evaluations done more quickly and comfortably in an office with which they are familiar.
As commitments to office-based surgery expand, it seems logical and important for physicians to become familiar with—and consider adopting—a less-invasive approach to hysteroscopy. The vaginoscopic technique for hysteroscopy—sometimes referred to as a no-touch approach—avoids the use of a vaginal speculum and cervical tenaculum. It is an easier and quicker procedure for the surgeon, provides equally good visualization, and most importantly is even more tolerable for patients than the traditional approach that utilizes instrumentation.
Without placing a speculum in the vagina, grasping the cervix with a tenaculum, or injecting a paracervical block, I have seen a significant decrease in discomfort among my patients. I use minimal premedication and rarely use any local anesthetic. In addition to diagnosing and evaluating the uterine cavity, I can perform minor therapeutic and operative procedures such as removing polyps, lysing adhesions, obtaining biopsies, removing lost intrauterine devices, and occluding the tubes using the Essure sterilization system.
With patients tolerating the procedure even more than they would a traditional hysteroscopy, we have the opportunity to increase the possible applications of hysteroscopy, to do more during the procedure, and to advance hysteroscopy even further as a successful in-office procedure that is part and parcel of our diagnostic and therapeutic armamentarium.
Key Studies
Vaginoscopy has been described in the literature as far back as the 1950s and continues to be used for diagnosing vaginal endometriosis, pelvic floor mesh erosions, vaginal fistulas, and cervical pathology, for example, as well as excising vaginal lesions or longitudinal vaginal septums. It has also been utilized in the pediatric/adolescent population for visualizing and removing foreign bodies, and for evaluating pelvic trauma, abnormal bleeding, and infection.
Dr. Stefano Bettocchi and Dr. Luigi Selvaggi in Italy were the first, however, to describe the utilization of a vaginoscopic approach to office hysteroscopy for evaluating the endocervical canal and uterine cavity in addition to the vagina and external cervical os. In a paper published in 1997 in the Journal of the American Association of Gynecologic Laparoscopists (4:255–8), they described various approaches they took to improve patient tolerance during the 1,200 diagnostic hysteroscopies they performed between 1992 and 1996.
The first 49 procedures were done using the speculum and tenaculum but without local anesthesia. The investigators saw high rates of discomfort (53%), moderate pain (25%), and severe pain (20%), as well as two cases of serious vagal reactions.
They then began using local anesthetic (mepivacaine 2%) but found that, while it helped some of the women, many of them continued to have discomfort or pain. In the next 169 cases, 69% had discomfort or mild pain, 11% had moderate pain, and 8% had severe pain resulting in suspension of the procedure (again, including two women who had vagal reactions requiring medical assistance).
Dr. Bettocchi and Dr. Selvaggi then decided to use the speculum to visualize the cervix but not place the tenaculum. They did not use any anesthesia with this group of 308 women. Their patients' pain levels started decreasing quite a bit, with 66% of these patients reporting no complaints. Cases of severe pain disappeared completely.
They then took it a step further to deal with the remaining causes of pain (32% had reported mild pain and 2% had reported moderate pain) and utilized the vaginoscopic approach. In these last 680 procedures—in unselected patients, both multiparas and nulliparas—the patients had a 96% no-discomfort rate. By not using the speculum and tenaculum to expose and grasp the cervix, the investigators nearly eliminated patient discomfort while still performing effective hysteroscopy.
Since this landmark report, several teams that have adopted a vaginoscopic approach to hysteroscopy have reported good results, and at least two teams among those I reviewed in the literature have conducted randomized prospective studies.
Dr. M. Sharma and his team in London randomized 120 women to undergo either traditional hysteroscopy or vaginoscopic hysteroscopy (60 women in each group)—with a further breakdown into the use of a 2.9-mm and a 4-mm hysteroscope. The investigators reported an overall success rate of 99%. They used the need for local anesthesia as a primary outcome measure. Although they reported lower requirements with the vaginoscopic approach using the narrower hysteroscope, they found that overall, there was no significant difference in the use of local anesthesia among the groups. There also were no statistically significant differences in pain scores between the two techniques.
The main difference for this team lay in the length of the procedure. Hysteroscopy and biopsy times were significantly shorter (more than 25% faster) with the vaginoscopic technique—a difference that Dr. Sharma and his colleagues said is important for patients who are anxious about the procedure (BJOG 2005;112:963–7).
In the other randomized study, in contrast, Dr. O. Garbin and his colleagues in France found that patients had significantly less pain with the vaginoscopic approach. Their randomization of 200 patients to conventional and 200 patients to vaginoscopic hysteroscopy—with no use of either anesthesia or premedication in either group—showed no differences in the quality, success, or duration of the exam but significant differences in patients' ratings of pain on a visual analog scale. Two cases of vasovagal syncope occurred in the group with traditional hysteroscopy.
Cervical passage was easier overall with vaginoscopic hysteroscopy, Dr. Garbin and his team reported, though the differences were not significant (Hum. Reprod. 2006;21:2996–3000). All of their procedures were performed using rigid single-flow hysteroscopes with an external sheath diameter of 3.5 mm.
The two randomized studies were quite different, and it's possible that Dr. Sharma's study lacked sufficient power. Certainly, it was more complicated with its use of two different hysteroscopes and the frequent use of anesthesia. Interestingly, Dr. Garbin and his colleagues addressed the issue of pelvic infection and pointed out that their procedures began with disinfection—something that was not mentioned in either Dr. Bettocchi's or Dr. Sharma's reports but is a practice that we do routinely.
All told, what I've taken away from the literature thus far is that the vaginoscopic approach to hysteroscopy is superior in terms of patient tolerance and can be quicker—without any impairment in cervical passage or visual quality.
In Practice
I first prep the vagina and the cervix with a small-diameter swab dipped in Betadine (povidone-iodine), or an alternative if the patient has an allergy to iodine. I use normal saline as a distention medium, so each patient is positioned on an under-buttocks drape to catch fluid. A 1,000-cc normal saline bag inserted in a pressure bag is hung on a tall IV pole with standard IV tubing.
I tell patients in preprocedure counseling that the use of saline and distention of the uterine walls usually causes some cramping but that ibuprofen or Celebrex (celecoxib) can minimize this cramping. I show them the diameter of the hysteroscope, which often helps alleviate any anxiety. In rare cases, if a patient is very anxious and worried about her tolerance for the procedure, or if the procedure is expected to be unusually long, I will prescribe Valium (diazepam). Usually such patients are young and have never experienced a gynecologic procedure before. In practice, however, I have almost never needed to use any local anesthetic.
I do premedicate patients—especially nulliparous patients and postmenopausal patients with stenotic cervices—with Cytotec (misoprostol) to facilitate an easier entry of the hysteroscope into the cervix.
I use a 3-mm single-flow rigid hysteroscope for diagnostic purposes and can quickly add the operative sheath, making the hysteroscope a 5-mm operative rigid hysteroscope, when I need to perform a minor procedure. If I anticipate performing a procedure, I will directly enter with the 5-mm hysteroscope. I prefer using the Bettocchi hysteroscope system (Karl Storz Endoscopy-America Inc.) because of its oblong shape that, when rotated horizontally with the light cord, easily slips into the slit-shaped external cervical os.
Rigid hysteroscopes have a camera lens angle of 0–30 degrees. I most often use scopes with a 30-degree angle to optimize visualization with minimal manipulation. With this angle, the hysteroscope can be brought to the midline of the uterine cavity and simply rotated about 90 degrees to the left or right with the light cord without much movement of the hysteroscope to visualize the cornu.
In contrast, visualizing the cornu with a 0-degree scope would require manipulation of the entire hysteroscope, potentially increasing patient discomfort. A 12-degree scope offers similar advantages to the 30-degree scope, and either one can be chosen based on physician familiarity and preference.
After placing the hysteroscope into the lower vagina, I guide it into the posterior fornix of the vagina so that I know I'm at the end of the vaginal canal. Then, I slowly pull back while observing anteriorly and visualizing the external cervical os. I then introduce the hysteroscope through the cervical os, and based on an understanding of the anatomy and the scope's angled view, I guide the hysteroscope through the endocervical canal and into the uterus. If I am not getting good distention of the vaginal walls, I will gently pinch the labia together to minimize fluid leakage.
Insertion of the hysteroscope without a tenaculum requires a great deal of dexterity and comfort with the instrument. The surgeon needs to understand the correlation between what is seen on the screen and the exact position of the hysteroscope so that the instrument does not rub against the cervix or the uterine tissue and cause trauma and pain.
With an angled hysteroscope, the image displayed on the screen reflects what is actually above the tip of the instrument. If the opening to the cervical os looks like it's straight ahead, for instance, it is actually above the direction in which the scope is being guided, and the scope must therefore be angled to enter the canal. Understanding the correlation and being comfortable with this 12- or 30-degree fore-oblique view takes some practice, as does visualizing the cervix correctly when pulling back from the posterior fornix. For most gynecologic surgeons, the necessary skills and comfort levels fall into place after just a few vaginoscopic procedures.
I have not found any difference in difficulty based on the axis of the uterus. I fact, I have found that utilizing a vaginal speculum in conjunction with a cervical tenaculum to straighten the uterine axis has limited my hysteroscope manipulation for extreme ante- or retroversion, increasing patient discomfort.
Just as with traditional hysteroscopy, operative hysteroscopy is possible right after or even at the same time as a diagnostic hysteroscopy performed with a vaginoscopic approach. The gynecologic surgeon can remove polyps that are visualized during a diagnostic procedure, for instance; perform adhesiolysis for Asherman's syndrome and tubular cannulation for blocked proximal tubal obstruction; retrieve lost IUDs; and perform tubal occlusion using the Essure system. My most recent tubal occlusion procedure took less than 5 minutes from start to finish, and the patient drove herself home within 15 minutes after completion of the procedure.
I do nothing differently when performing an operative hysteroscopy utilizing the vaginoscopic approach than I would using the traditional approach, except for not using the speculum and tenaculum.
I recommend fluid monitoring when performing operative hysteroscopy especially. I generally monitor fluid outflow in my practice, with a nurse checking fluid levels and monitoring the deficit while I explain to the patient what I am doing and visualizing. Because diagnostic procedures are fairly short, the likelihood of fluid intravasation at high volumes is low, however.
Vaginoscopy can be extremely helpful for evaluating patients who are morbidly obese and for whom standard office instruments are not adequately sized for visualization of the cervix. I recently tried to obtain a Pap smear and do an endometrial biopsy in a patient who was morbidly obese and had a large fibroid uterus, but with conventional methods I was unable to do so using our instruments. I brought the patient to the operating room to use larger instruments, but even these were insufficient. I finally performed the Pap smear successfully by palpating the cervix and os, and used vaginoscopy to visualize the entire cervix. I then continued with the hysteroscopy and endometrial biopsy.
After the diagnostic—and sometimes operative—procedure, our nurses will check patients' vital signs and ensure that they are feeling well and are ambulatory. Most of the time, patients leave the office within 15 minutes or so, happy to have had their procedure done in the office as opposed to the hospital.
Vaginoscopy also has been shown to be effective, fast, and easy for managing gynecologic problems in pediatric and adolescent patients. In a report published in 2000, Dr. Abraham Golan and his colleagues in Israel reported that they were able to complete the procedure successfully in 22 patients aged 3–16 years who were evaluated for vulvovaginitis, vaginal trauma, bleeding, or genital malformation (J. Am. Assoc. Gynecol. Laparosc. 2000;7:526–8). Gynecologic surgeons who build skills and experience with the vaginoscopic approach to hysteroscopy could also serve the pediatric/adolescent community well.
The hysteroscope is guided into the posterior vaginal fornix.
Source IMAGES COURTESY DR. AARATHI CHOLKERI-SINGH
Then it is pulled back while the external cervical os is visualized anteriorly.
Then the scope is guided through the endocervical canal.
Vaginoscopy's Approach to Hysteroscopy
Over the past several years, the number of office-based gynecologic surgical procedures has skyrocketed. Factors cited in this trend toward in-office surgery are better reimbursement, greater efficiency for both patient and physician, as well as the ability to provide a familiar environment for the patient. Both diagnostic as well as operative hysteroscopy are two such procedures that easily can be converted to the office setting.
A common concern from the inception of in-office surgery is patient comfort. With the use of anesthetic agents, convalescence both in the office setting as well as at home may be extended. Furthermore, the cost of the procedure will be increased, thus affecting overall reimbursement. Finally, most gynecologists are uncomfortable providing even conscious sedation for their patient in the office. Thus, the key to successful transition to surgery in an office setting would be to modify the procedures to minimize pain. Vaginoscopy allows such an approach to both diagnostic and operative hysteroscopy.
I am especially pleased that my associate, Dr. Aarathi Cholkeri-Singh, has agreed to write this edition of the Master Class in Gynecologic Surgery on vaginoscopy. After completing her residency at Advocate Lutheran General Hospital, a large teaching hospital in a Northern suburb of Chicago, Dr. Cholkeri-Singh went on to complete an AAGL/American Society for Reproductive Medicine Fellowship in minimally invasive gynecologic surgery at Harvard Medical School and Brown University hospital affiliates. It was during her training that Dr. Cholkeri-Singh gained experience with in-office vaginoscopy under the watchful eye of noted hysteroscopic guru Dr. Keith Isaacson.
Now the associate director of minimally invasive gynecologic surgery at Advocate Lutheran General Hospital, Dr. Cholkeri-Singh's practice is concentrated on minimally invasive gynecologic surgery and office gynecology. She will be a featured speaker at the AAGL's 38th Global Congress of Minimally Invasive Gynecology this month in Orlando.
Gynecologic surgeons are getting good reimbursement rates for office hysteroscopy, and patients appreciate the convenience of having hysteroscopic evaluations done more quickly and comfortably in an office with which they are familiar.
As commitments to office-based surgery expand, it seems logical and important for physicians to become familiar with—and consider adopting—a less-invasive approach to hysteroscopy. The vaginoscopic technique for hysteroscopy—sometimes referred to as a no-touch approach—avoids the use of a vaginal speculum and cervical tenaculum. It is an easier and quicker procedure for the surgeon, provides equally good visualization, and most importantly is even more tolerable for patients than the traditional approach that utilizes instrumentation.
Without placing a speculum in the vagina, grasping the cervix with a tenaculum, or injecting a paracervical block, I have seen a significant decrease in discomfort among my patients. I use minimal premedication and rarely use any local anesthetic. In addition to diagnosing and evaluating the uterine cavity, I can perform minor therapeutic and operative procedures such as removing polyps, lysing adhesions, obtaining biopsies, removing lost intrauterine devices, and occluding the tubes using the Essure sterilization system.
With patients tolerating the procedure even more than they would a traditional hysteroscopy, we have the opportunity to increase the possible applications of hysteroscopy, to do more during the procedure, and to advance hysteroscopy even further as a successful in-office procedure that is part and parcel of our diagnostic and therapeutic armamentarium.
Key Studies
Vaginoscopy has been described in the literature as far back as the 1950s and continues to be used for diagnosing vaginal endometriosis, pelvic floor mesh erosions, vaginal fistulas, and cervical pathology, for example, as well as excising vaginal lesions or longitudinal vaginal septums. It has also been utilized in the pediatric/adolescent population for visualizing and removing foreign bodies, and for evaluating pelvic trauma, abnormal bleeding, and infection.
Dr. Stefano Bettocchi and Dr. Luigi Selvaggi in Italy were the first, however, to describe the utilization of a vaginoscopic approach to office hysteroscopy for evaluating the endocervical canal and uterine cavity in addition to the vagina and external cervical os. In a paper published in 1997 in the Journal of the American Association of Gynecologic Laparoscopists (4:255–8), they described various approaches they took to improve patient tolerance during the 1,200 diagnostic hysteroscopies they performed between 1992 and 1996.
The first 49 procedures were done using the speculum and tenaculum but without local anesthesia. The investigators saw high rates of discomfort (53%), moderate pain (25%), and severe pain (20%), as well as two cases of serious vagal reactions.
They then began using local anesthetic (mepivacaine 2%) but found that, while it helped some of the women, many of them continued to have discomfort or pain. In the next 169 cases, 69% had discomfort or mild pain, 11% had moderate pain, and 8% had severe pain resulting in suspension of the procedure (again, including two women who had vagal reactions requiring medical assistance).
Dr. Bettocchi and Dr. Selvaggi then decided to use the speculum to visualize the cervix but not place the tenaculum. They did not use any anesthesia with this group of 308 women. Their patients' pain levels started decreasing quite a bit, with 66% of these patients reporting no complaints. Cases of severe pain disappeared completely.
They then took it a step further to deal with the remaining causes of pain (32% had reported mild pain and 2% had reported moderate pain) and utilized the vaginoscopic approach. In these last 680 procedures—in unselected patients, both multiparas and nulliparas—the patients had a 96% no-discomfort rate. By not using the speculum and tenaculum to expose and grasp the cervix, the investigators nearly eliminated patient discomfort while still performing effective hysteroscopy.
Since this landmark report, several teams that have adopted a vaginoscopic approach to hysteroscopy have reported good results, and at least two teams among those I reviewed in the literature have conducted randomized prospective studies.
Dr. M. Sharma and his team in London randomized 120 women to undergo either traditional hysteroscopy or vaginoscopic hysteroscopy (60 women in each group)—with a further breakdown into the use of a 2.9-mm and a 4-mm hysteroscope. The investigators reported an overall success rate of 99%. They used the need for local anesthesia as a primary outcome measure. Although they reported lower requirements with the vaginoscopic approach using the narrower hysteroscope, they found that overall, there was no significant difference in the use of local anesthesia among the groups. There also were no statistically significant differences in pain scores between the two techniques.
The main difference for this team lay in the length of the procedure. Hysteroscopy and biopsy times were significantly shorter (more than 25% faster) with the vaginoscopic technique—a difference that Dr. Sharma and his colleagues said is important for patients who are anxious about the procedure (BJOG 2005;112:963–7).
In the other randomized study, in contrast, Dr. O. Garbin and his colleagues in France found that patients had significantly less pain with the vaginoscopic approach. Their randomization of 200 patients to conventional and 200 patients to vaginoscopic hysteroscopy—with no use of either anesthesia or premedication in either group—showed no differences in the quality, success, or duration of the exam but significant differences in patients' ratings of pain on a visual analog scale. Two cases of vasovagal syncope occurred in the group with traditional hysteroscopy.
Cervical passage was easier overall with vaginoscopic hysteroscopy, Dr. Garbin and his team reported, though the differences were not significant (Hum. Reprod. 2006;21:2996–3000). All of their procedures were performed using rigid single-flow hysteroscopes with an external sheath diameter of 3.5 mm.
The two randomized studies were quite different, and it's possible that Dr. Sharma's study lacked sufficient power. Certainly, it was more complicated with its use of two different hysteroscopes and the frequent use of anesthesia. Interestingly, Dr. Garbin and his colleagues addressed the issue of pelvic infection and pointed out that their procedures began with disinfection—something that was not mentioned in either Dr. Bettocchi's or Dr. Sharma's reports but is a practice that we do routinely.
All told, what I've taken away from the literature thus far is that the vaginoscopic approach to hysteroscopy is superior in terms of patient tolerance and can be quicker—without any impairment in cervical passage or visual quality.
In Practice
I first prep the vagina and the cervix with a small-diameter swab dipped in Betadine (povidone-iodine), or an alternative if the patient has an allergy to iodine. I use normal saline as a distention medium, so each patient is positioned on an under-buttocks drape to catch fluid. A 1,000-cc normal saline bag inserted in a pressure bag is hung on a tall IV pole with standard IV tubing.
I tell patients in preprocedure counseling that the use of saline and distention of the uterine walls usually causes some cramping but that ibuprofen or Celebrex (celecoxib) can minimize this cramping. I show them the diameter of the hysteroscope, which often helps alleviate any anxiety. In rare cases, if a patient is very anxious and worried about her tolerance for the procedure, or if the procedure is expected to be unusually long, I will prescribe Valium (diazepam). Usually such patients are young and have never experienced a gynecologic procedure before. In practice, however, I have almost never needed to use any local anesthetic.
I do premedicate patients—especially nulliparous patients and postmenopausal patients with stenotic cervices—with Cytotec (misoprostol) to facilitate an easier entry of the hysteroscope into the cervix.
I use a 3-mm single-flow rigid hysteroscope for diagnostic purposes and can quickly add the operative sheath, making the hysteroscope a 5-mm operative rigid hysteroscope, when I need to perform a minor procedure. If I anticipate performing a procedure, I will directly enter with the 5-mm hysteroscope. I prefer using the Bettocchi hysteroscope system (Karl Storz Endoscopy-America Inc.) because of its oblong shape that, when rotated horizontally with the light cord, easily slips into the slit-shaped external cervical os.
Rigid hysteroscopes have a camera lens angle of 0–30 degrees. I most often use scopes with a 30-degree angle to optimize visualization with minimal manipulation. With this angle, the hysteroscope can be brought to the midline of the uterine cavity and simply rotated about 90 degrees to the left or right with the light cord without much movement of the hysteroscope to visualize the cornu.
In contrast, visualizing the cornu with a 0-degree scope would require manipulation of the entire hysteroscope, potentially increasing patient discomfort. A 12-degree scope offers similar advantages to the 30-degree scope, and either one can be chosen based on physician familiarity and preference.
After placing the hysteroscope into the lower vagina, I guide it into the posterior fornix of the vagina so that I know I'm at the end of the vaginal canal. Then, I slowly pull back while observing anteriorly and visualizing the external cervical os. I then introduce the hysteroscope through the cervical os, and based on an understanding of the anatomy and the scope's angled view, I guide the hysteroscope through the endocervical canal and into the uterus. If I am not getting good distention of the vaginal walls, I will gently pinch the labia together to minimize fluid leakage.
Insertion of the hysteroscope without a tenaculum requires a great deal of dexterity and comfort with the instrument. The surgeon needs to understand the correlation between what is seen on the screen and the exact position of the hysteroscope so that the instrument does not rub against the cervix or the uterine tissue and cause trauma and pain.
With an angled hysteroscope, the image displayed on the screen reflects what is actually above the tip of the instrument. If the opening to the cervical os looks like it's straight ahead, for instance, it is actually above the direction in which the scope is being guided, and the scope must therefore be angled to enter the canal. Understanding the correlation and being comfortable with this 12- or 30-degree fore-oblique view takes some practice, as does visualizing the cervix correctly when pulling back from the posterior fornix. For most gynecologic surgeons, the necessary skills and comfort levels fall into place after just a few vaginoscopic procedures.
I have not found any difference in difficulty based on the axis of the uterus. I fact, I have found that utilizing a vaginal speculum in conjunction with a cervical tenaculum to straighten the uterine axis has limited my hysteroscope manipulation for extreme ante- or retroversion, increasing patient discomfort.
Just as with traditional hysteroscopy, operative hysteroscopy is possible right after or even at the same time as a diagnostic hysteroscopy performed with a vaginoscopic approach. The gynecologic surgeon can remove polyps that are visualized during a diagnostic procedure, for instance; perform adhesiolysis for Asherman's syndrome and tubular cannulation for blocked proximal tubal obstruction; retrieve lost IUDs; and perform tubal occlusion using the Essure system. My most recent tubal occlusion procedure took less than 5 minutes from start to finish, and the patient drove herself home within 15 minutes after completion of the procedure.
I do nothing differently when performing an operative hysteroscopy utilizing the vaginoscopic approach than I would using the traditional approach, except for not using the speculum and tenaculum.
I recommend fluid monitoring when performing operative hysteroscopy especially. I generally monitor fluid outflow in my practice, with a nurse checking fluid levels and monitoring the deficit while I explain to the patient what I am doing and visualizing. Because diagnostic procedures are fairly short, the likelihood of fluid intravasation at high volumes is low, however.
Vaginoscopy can be extremely helpful for evaluating patients who are morbidly obese and for whom standard office instruments are not adequately sized for visualization of the cervix. I recently tried to obtain a Pap smear and do an endometrial biopsy in a patient who was morbidly obese and had a large fibroid uterus, but with conventional methods I was unable to do so using our instruments. I brought the patient to the operating room to use larger instruments, but even these were insufficient. I finally performed the Pap smear successfully by palpating the cervix and os, and used vaginoscopy to visualize the entire cervix. I then continued with the hysteroscopy and endometrial biopsy.
After the diagnostic—and sometimes operative—procedure, our nurses will check patients' vital signs and ensure that they are feeling well and are ambulatory. Most of the time, patients leave the office within 15 minutes or so, happy to have had their procedure done in the office as opposed to the hospital.
Vaginoscopy also has been shown to be effective, fast, and easy for managing gynecologic problems in pediatric and adolescent patients. In a report published in 2000, Dr. Abraham Golan and his colleagues in Israel reported that they were able to complete the procedure successfully in 22 patients aged 3–16 years who were evaluated for vulvovaginitis, vaginal trauma, bleeding, or genital malformation (J. Am. Assoc. Gynecol. Laparosc. 2000;7:526–8). Gynecologic surgeons who build skills and experience with the vaginoscopic approach to hysteroscopy could also serve the pediatric/adolescent community well.
The hysteroscope is guided into the posterior vaginal fornix.
Source IMAGES COURTESY DR. AARATHI CHOLKERI-SINGH
Then it is pulled back while the external cervical os is visualized anteriorly.
Then the scope is guided through the endocervical canal.
Vaginoscopy's Approach to Hysteroscopy
Over the past several years, the number of office-based gynecologic surgical procedures has skyrocketed. Factors cited in this trend toward in-office surgery are better reimbursement, greater efficiency for both patient and physician, as well as the ability to provide a familiar environment for the patient. Both diagnostic as well as operative hysteroscopy are two such procedures that easily can be converted to the office setting.
A common concern from the inception of in-office surgery is patient comfort. With the use of anesthetic agents, convalescence both in the office setting as well as at home may be extended. Furthermore, the cost of the procedure will be increased, thus affecting overall reimbursement. Finally, most gynecologists are uncomfortable providing even conscious sedation for their patient in the office. Thus, the key to successful transition to surgery in an office setting would be to modify the procedures to minimize pain. Vaginoscopy allows such an approach to both diagnostic and operative hysteroscopy.
I am especially pleased that my associate, Dr. Aarathi Cholkeri-Singh, has agreed to write this edition of the Master Class in Gynecologic Surgery on vaginoscopy. After completing her residency at Advocate Lutheran General Hospital, a large teaching hospital in a Northern suburb of Chicago, Dr. Cholkeri-Singh went on to complete an AAGL/American Society for Reproductive Medicine Fellowship in minimally invasive gynecologic surgery at Harvard Medical School and Brown University hospital affiliates. It was during her training that Dr. Cholkeri-Singh gained experience with in-office vaginoscopy under the watchful eye of noted hysteroscopic guru Dr. Keith Isaacson.
Now the associate director of minimally invasive gynecologic surgery at Advocate Lutheran General Hospital, Dr. Cholkeri-Singh's practice is concentrated on minimally invasive gynecologic surgery and office gynecology. She will be a featured speaker at the AAGL's 38th Global Congress of Minimally Invasive Gynecology this month in Orlando.
Potential Pitfalls in Pregnant Patients
Operative laparoscopy during pregnancy has been part of the growing field of minimally invasive surgery for more than 2 decades. As efforts during the 1980s to develop laparoscopic techniques unfolded, pregnant women were on the radar screen; one of the first textbooks of minimally invasive surgery, published in the 1980s, for instance, featured a chapter on laparoscopy in pregnancy.
A report on more than 150 patients undergoing laparoscopic appendectomy, including 6 pregnant patients, was published in 1990 (Surg. Endosc. 1990;4:100–2). The first laparoscopic cholecystectomy during pregnancy was reported in 1991 (Obstet. Gynecol. 1991;78[pt. 2]:958–9).
Through the 1990s, as technology improved and laparoscopy assumed a prominent place in gynecologic practice, and as general surgeons acquired more skill in laparoscopy, it became increasingly apparent that pregnant patients with appendicitis, cholecystitis, and other complications—both nonobstetric problems and problems of a more obstetric and gynecologic nature—were among the patients for whom laparoscopic surgery is often the treatment of choice.
Experience with the laparoscopic approach in pregnant patients increased, and anesthesiologists, surgeons, and obstetricians learned more about the effects of excessive intraabdominal pressure, other anesthesia-related problems, and the importance of prophylaxis for deep vein thromboses, among other issues.
Today, we can tell pregnant patients that laparoscopic surgery is a safe option. Data have shown that the second trimester is generally the safest time to intervene, and that most complications—when they do occur—seem to be related to the underlying disorder rather than the surgery per se. Overall, the complication rate for laparoscopic surgery during pregnancy is similar to that in the nonpregnant state.
It is important that we are aware of and knowledgeable about the unique presentation of certain problems during pregnancy, such as acute appendicitis and cholecystitis, and that we are ready to call upon a general surgeon with advanced minimally invasive skills.
Problems Requiring Surgery
Up to 2% of pregnancies are complicated by a surgical problem.
By far the most common surgical condition during pregnancy is acute appendicitis; its incidence is 0.5–1 per 1,000 pregnancies. Other surgical emergencies in pregnancy include acute cholecystitis (with an incidence of 5 per 10,000 pregnancies), intestinal obstruction, persistent ovarian cysts larger than 6 cm, and ovarian torsion and other adnexal problems. (The incidence of adnexal torsion is 1 in 5,000, and the incidence of any adnexal problem complicating pregnancy is 1 per 500–600 pregnancies.)
With the advent of assisted reproductive technologies, the incidence of heterotropic pregnancies is increasing, and growing numbers of successful laparoscopic surgeries for these pregnancies in hemodynamically unstable patients also are being reported. The extrauterine pregnancy can be addressed via salpingostomy or salpingectomy depending on the intraoperative findings. Minimal disturbance of the uterus and intrauterine gestation is the goal of intraoperative management.
The approach to laparoscopic surgery for these patients must take into account the physiological changes of pregnancy, including a 45% increase in plasma volume and a 10%-20% increase in cardiac volume, as well as increased oxygen consumption, decreased functional residual volume, and a theoretical predisposition to thromboembolic complications.
We must also be aware that the Trendelenburg position increases intrathoracic pressure, impairing venous return and accentuating the change in functional residual capacity. We may not, therefore, be able to achieve as steep a Trendelenburg position in pregnancy as in the nonpregnant state.
Because we are dealing with two passengers on these surgical journeys, we also must ensure that we not disturb the uteroplacental blood flow and oxygenation—that is, we must prevent fetal asphyxia and preterm labor—and that we are cognizant of the potential teratogenic effects of analgesics and other medications.
Medications and Assessment
Medications that have been recommended related to surgical intervention during pregnancy include indomethacin supplementation 25–50 mg preoperatively and a second dose 12 hours later. Unfortunately, however, there is a paucity of prospective data to support any one specific recommendation.
Progesterone supplementation—through a vaginal supplement of 25–100 mg postop for up to 7 days—has also been advocated after the procedure. Again, there are no well-designed studies to provide a firm basis for medication support.
Data from studies in ovariectomized rats supports the subcutaneous use of 3 mg of progesterone plus 200 ng of estradiol benzoate for 10–19 days with monitoring of serum progesterone levels (J. Reprod. Fertil. 1990;90:63–70).
Diagnostic procedures utilizing radiation should be limited to 5–10 rad during the first 25 weeks of gestation. Beyond that dosage, chromosomal mutations and neurologic abnormalities become concerns, as does the theoretical increased risk of childhood leukemia and other hematologic cancers.
Assessment CT scans generally are an appropriate test during pregnancy because the amount of radiation is relatively low—from 2 to 4 rad for a single study. MR imaging is appropriate, of course, as it does not involve ionizing radiation. Potentially concerning is the use of a contrast agent with CT or MR imaging. Gadolinium is commonly used in pregnancy; the use of this or other contrast agents should be discussed by the obstetrician and radiologist.
The second trimester is generally the safest time to intervene because there is a higher incidence of preterm labor in the third trimester and spontaneous abortion during the first trimester. The incidence of miscarriage after surgery in the second trimester is 5.6%, compared with 12% in the first trimester.
Ideally, pre-, intra-, and postoperative management should be planned through multispecialty discussion involving anesthesiologists, general surgeons, and gynecologic surgeons.
Preanesthetic medications include benzodiazepines (for example, midazolam) and/or opioids (such as Fentanyl administered intravenously). Intravenous induction agents include propofol, barbiturates, ketamine, and etomidate (Arch. Gynecol. Obstet. 2007;276:201–9). Neuromuscular blocking medications include succinylcholine, vecuronium, or atracurium complemented by the administration of nitrous oxide.
Operative Management
Patient positioning during surgery is critical. The pregnant patient should be placed in the left lateral decubitus position, with her right hip elevated, to minimize interference with venous return. She must also undergo a more gradual, careful change to the Trendelenburg position than a nonpregnant patient would, and even more gradual reverse Trendelenburg positional changes.
Intraoperative monitoring should include measurement of vital signs, oxygen saturation, and end-tidal CO2 level, and observation of uterine activity. Intraabdominal pressure generally should be in the range of 12–15 mm Hg. Ideally, lower-extremity pneumatic compression devices should be utilized.
Careful monitoring for signs of preterm labor is also important. Fetal heart rate monitoring can provide useful data, both preoperatively and postoperatively. The use of tocolytic agents is certainly indicated when there are signs of preterm labor, but there is minimal support among experts for routine prophylactic tocolysis in the second trimester. Depending on the clinical circumstance, at 24 weeks' gestation, tocolysis can be considered.
Experts have debated for years the gestational age at which the uterus limits laparoscopic access to the abdominal cavity, and there still is no consensus.
Controversy continues over the use of the open laparoscopic technique versus the use of the Veress needle traditional technique (closed), especially in the left upper quadrant. Researchers are also investigating the use of gasless laparoscopy during pregnancy.
The vast majority of gynecologic and general surgeons who perform laparoscopic surgery in pregnant patients lean toward an open laparoscopic technique, but the closed and gasless techniques are also acceptable. I favor the primary use of an open approach with the Hasson cannula. This often provides better overall control with regard to entrance into the peritoneal cavity.
Clinicians who opt to use a Veress needle are certainly focused on an acceptable alternative to introduction of CO2 into the peritoneal cavity. The decision-making process is primarily a reflection of the gynecologic surgeon's training and level of comfort.
We should strive to avoid placing any instruments near the cervix. A sponge on a stick can provide an element of uterine manipulation in an atraumatic manner.
Secondary trocar placement must take into account the size of the uterus, with secondary trocar sleeves placed above the umbilicus and away from the uterus. Careful planning of where ports should be placed is a wise idea prior to making the skin incision. Inferior epigastric vessels should be identified to include superficial branches.
Direct visualization of trocar entrance into the abdominal cavity is of paramount importance and should be documented in the record accordingly.
Prompt Diagnosis
Associated morbidity makes a prompt diagnosis of acute appendicitis or cholecystitis critical. As obstetricians we should be well versed in the various symptoms and clinical presentation of these problems in pregnant patients. We must have a high index of suspicion and be ready to engage a general surgeon colleague early on.
A diagnosis of appendicitis can all too easily be delayed because of the displacement of the appendix by the gravid uterus and the normal physiological leukocytosis of pregnancy. The consequences of delay, however, are significant: The incidence of fetal loss is as high as 35% when the appendix ruptures, compared with 1.5% with uncomplicated appendicitis.
The appendix changes location during gestation, rising progressively above the McBurney point. At 8 or 9 months, the appendix can essentially be as high as the top of the uterine fundus. As an inflamed appendix drifts away from the abdominal wall, the signs of peritoneal irritation are often minimized; fewer than half of pregnant patients, in fact, have peritoneal signs.
During the first trimester, the pain is primarily in the area of the McBurney point, and sometimes in the pelvic area. In the second trimester, the pain is associated with the displacement of the appendix, with the point of maximal tenderness frequently above the iliac crest. In the third trimester, pain and tenderness may be localized to the right costal margin. Irrespective of the trimester, patients often have right lateral rectal tenderness.
The pain of appendicitis must be differentiated from the pain of uterine origin. The latter often can be alleviated by providing adequate hydration and placing the patient in the decubitus position. Both Alder's sign (fixed tenderness) and Bryan's sign (tenderness in the right lateral position) can help with this differentiation.
Acute cholecystitis often presents initially with biliary colic associated with nausea and vomiting. When the common bile duct is obstructed by a stone, pain persists and often radiates to the subscapular area, right flank, or shoulder. Patients typically have right subcostal tenderness associated with fever.
Ultrasonography is usually effective for diagnosing the presence of stones or dilatation of the common bile duct. Technetium-99m-iminodiacetic acid scans of the gallbladder can be used in pregnancy with minimal risk of radiation exposure.
Whenever possible, first-trimester patients with cholecystitis should be treated conservatively until the second trimester. Any patient who does not improve with medical management, however, should undergo laparoscopic surgery regardless of the gestational age of the fetus.
With adnexal cysts, it is generally acceptable to provide expectant management if the enlargement is less than 6 cm. There is evidence that 80%-90% of these enlargements will resolve spontaneously.
Again, it is of paramount importance that the obstetrician/gynecologist is cognizant of the anatomic and physiological changes associated with pregnancy. The option of a minimally invasive approach is often appropriate and timely in the management of nonobstetric emergencies during pregnancy.
Source ELSEVIER GLOBAL MEDICAL NEWS
Laparoscopic Surgery During Pregnancy
In a large multisurgeon survey published by the Society of Laparoendoscopic Surgeons, 1.2% of the 16,329 surgeon members said they performed laparoscopic procedures in pregnancy. The most common of the 413 laparoscopic procedures performed in pregnancy by these 192 surgeons appeared to be cholecystectomies, adnexal procedures, and appendectomies (J. Reprod. Med. 1997;42:33–8).
In an excellent review article (Obstet. Gynecol. Surv. 2001;56:50–9), Dr. Mohammad Fatum and Dr. Nathan Rojansky from Hadassah Ein-Kerem Medical Center and the Hebrew University Medical School, Jerusalem, noted the following major advantages of laparoscopic surgery during pregnancy:
▸ Small abdominal incisions resulting in rapid postoperative recovery and early mobilization, thus minimizing the increased risk of thromboembolism associated with pregnancy.
▸ Early return of gastrointestinal activity because of less manipulation of the bowel during surgery, which may result in fewer postoperative adhesions and intestinal obstruction.
▸ Smaller scars.
▸ Fewer incisional hernias.
▸ A reduced rate of fetal depression because of decreased pain and less narcotic use.
▸ Shorter hospitalization time and a prompt return to regular life.
I am pleased that Dr. Joseph S. Sanfilippo agreed to author this edition of the Master Class in Gynecologic Surgery on laparoscopic surgery during pregnancy.
A 1973 Chicago Medical School graduate, Dr. Sanfilippo was honored with a Distinguished Alumnus Award in 1990. He completed his fellowship in reproductive endocrinology and infertility at the University of Louisville (Ky.) School of Medicine and later gained his MBA degree at Chatham College in Pittsburgh.
Currently, Dr. Sanfilippo is professor of obstetrics, gynecology, and reproductive sciences; vice chairman of reproductive sciences; and director of reproductive endocrinology and infertility at Magee-Womens Hospital, Pittsburgh.
He has been a prolific researcher and author, particularly in the areas of surgery, reproductive medicine, and adolescent gynecology.
He also is considered an expert in laparoscopic surgery in pregnancy and has contributed to literature in this area as well.
Laparoscopic Cholecystectomy
▸ The overall complication rate for this procedure has been reported to be 0.75% in the literature.
▸ The highest incidence of fetal loss associated with laparoscopic cholecystectomy is in the first trimester, and the highest incidence of premature labor is in the third trimester.
▸ Elective abortion is not recommended, even with an intraoperative cholangiogram.
▸ Extrahepatic biliary obstruction due to gallstones can be managed laparoscopically.
Source: Dr. Sanfilippo
Operative laparoscopy during pregnancy has been part of the growing field of minimally invasive surgery for more than 2 decades. As efforts during the 1980s to develop laparoscopic techniques unfolded, pregnant women were on the radar screen; one of the first textbooks of minimally invasive surgery, published in the 1980s, for instance, featured a chapter on laparoscopy in pregnancy.
A report on more than 150 patients undergoing laparoscopic appendectomy, including 6 pregnant patients, was published in 1990 (Surg. Endosc. 1990;4:100–2). The first laparoscopic cholecystectomy during pregnancy was reported in 1991 (Obstet. Gynecol. 1991;78[pt. 2]:958–9).
Through the 1990s, as technology improved and laparoscopy assumed a prominent place in gynecologic practice, and as general surgeons acquired more skill in laparoscopy, it became increasingly apparent that pregnant patients with appendicitis, cholecystitis, and other complications—both nonobstetric problems and problems of a more obstetric and gynecologic nature—were among the patients for whom laparoscopic surgery is often the treatment of choice.
Experience with the laparoscopic approach in pregnant patients increased, and anesthesiologists, surgeons, and obstetricians learned more about the effects of excessive intraabdominal pressure, other anesthesia-related problems, and the importance of prophylaxis for deep vein thromboses, among other issues.
Today, we can tell pregnant patients that laparoscopic surgery is a safe option. Data have shown that the second trimester is generally the safest time to intervene, and that most complications—when they do occur—seem to be related to the underlying disorder rather than the surgery per se. Overall, the complication rate for laparoscopic surgery during pregnancy is similar to that in the nonpregnant state.
It is important that we are aware of and knowledgeable about the unique presentation of certain problems during pregnancy, such as acute appendicitis and cholecystitis, and that we are ready to call upon a general surgeon with advanced minimally invasive skills.
Problems Requiring Surgery
Up to 2% of pregnancies are complicated by a surgical problem.
By far the most common surgical condition during pregnancy is acute appendicitis; its incidence is 0.5–1 per 1,000 pregnancies. Other surgical emergencies in pregnancy include acute cholecystitis (with an incidence of 5 per 10,000 pregnancies), intestinal obstruction, persistent ovarian cysts larger than 6 cm, and ovarian torsion and other adnexal problems. (The incidence of adnexal torsion is 1 in 5,000, and the incidence of any adnexal problem complicating pregnancy is 1 per 500–600 pregnancies.)
With the advent of assisted reproductive technologies, the incidence of heterotropic pregnancies is increasing, and growing numbers of successful laparoscopic surgeries for these pregnancies in hemodynamically unstable patients also are being reported. The extrauterine pregnancy can be addressed via salpingostomy or salpingectomy depending on the intraoperative findings. Minimal disturbance of the uterus and intrauterine gestation is the goal of intraoperative management.
The approach to laparoscopic surgery for these patients must take into account the physiological changes of pregnancy, including a 45% increase in plasma volume and a 10%-20% increase in cardiac volume, as well as increased oxygen consumption, decreased functional residual volume, and a theoretical predisposition to thromboembolic complications.
We must also be aware that the Trendelenburg position increases intrathoracic pressure, impairing venous return and accentuating the change in functional residual capacity. We may not, therefore, be able to achieve as steep a Trendelenburg position in pregnancy as in the nonpregnant state.
Because we are dealing with two passengers on these surgical journeys, we also must ensure that we not disturb the uteroplacental blood flow and oxygenation—that is, we must prevent fetal asphyxia and preterm labor—and that we are cognizant of the potential teratogenic effects of analgesics and other medications.
Medications and Assessment
Medications that have been recommended related to surgical intervention during pregnancy include indomethacin supplementation 25–50 mg preoperatively and a second dose 12 hours later. Unfortunately, however, there is a paucity of prospective data to support any one specific recommendation.
Progesterone supplementation—through a vaginal supplement of 25–100 mg postop for up to 7 days—has also been advocated after the procedure. Again, there are no well-designed studies to provide a firm basis for medication support.
Data from studies in ovariectomized rats supports the subcutaneous use of 3 mg of progesterone plus 200 ng of estradiol benzoate for 10–19 days with monitoring of serum progesterone levels (J. Reprod. Fertil. 1990;90:63–70).
Diagnostic procedures utilizing radiation should be limited to 5–10 rad during the first 25 weeks of gestation. Beyond that dosage, chromosomal mutations and neurologic abnormalities become concerns, as does the theoretical increased risk of childhood leukemia and other hematologic cancers.
Assessment CT scans generally are an appropriate test during pregnancy because the amount of radiation is relatively low—from 2 to 4 rad for a single study. MR imaging is appropriate, of course, as it does not involve ionizing radiation. Potentially concerning is the use of a contrast agent with CT or MR imaging. Gadolinium is commonly used in pregnancy; the use of this or other contrast agents should be discussed by the obstetrician and radiologist.
The second trimester is generally the safest time to intervene because there is a higher incidence of preterm labor in the third trimester and spontaneous abortion during the first trimester. The incidence of miscarriage after surgery in the second trimester is 5.6%, compared with 12% in the first trimester.
Ideally, pre-, intra-, and postoperative management should be planned through multispecialty discussion involving anesthesiologists, general surgeons, and gynecologic surgeons.
Preanesthetic medications include benzodiazepines (for example, midazolam) and/or opioids (such as Fentanyl administered intravenously). Intravenous induction agents include propofol, barbiturates, ketamine, and etomidate (Arch. Gynecol. Obstet. 2007;276:201–9). Neuromuscular blocking medications include succinylcholine, vecuronium, or atracurium complemented by the administration of nitrous oxide.
Operative Management
Patient positioning during surgery is critical. The pregnant patient should be placed in the left lateral decubitus position, with her right hip elevated, to minimize interference with venous return. She must also undergo a more gradual, careful change to the Trendelenburg position than a nonpregnant patient would, and even more gradual reverse Trendelenburg positional changes.
Intraoperative monitoring should include measurement of vital signs, oxygen saturation, and end-tidal CO2 level, and observation of uterine activity. Intraabdominal pressure generally should be in the range of 12–15 mm Hg. Ideally, lower-extremity pneumatic compression devices should be utilized.
Careful monitoring for signs of preterm labor is also important. Fetal heart rate monitoring can provide useful data, both preoperatively and postoperatively. The use of tocolytic agents is certainly indicated when there are signs of preterm labor, but there is minimal support among experts for routine prophylactic tocolysis in the second trimester. Depending on the clinical circumstance, at 24 weeks' gestation, tocolysis can be considered.
Experts have debated for years the gestational age at which the uterus limits laparoscopic access to the abdominal cavity, and there still is no consensus.
Controversy continues over the use of the open laparoscopic technique versus the use of the Veress needle traditional technique (closed), especially in the left upper quadrant. Researchers are also investigating the use of gasless laparoscopy during pregnancy.
The vast majority of gynecologic and general surgeons who perform laparoscopic surgery in pregnant patients lean toward an open laparoscopic technique, but the closed and gasless techniques are also acceptable. I favor the primary use of an open approach with the Hasson cannula. This often provides better overall control with regard to entrance into the peritoneal cavity.
Clinicians who opt to use a Veress needle are certainly focused on an acceptable alternative to introduction of CO2 into the peritoneal cavity. The decision-making process is primarily a reflection of the gynecologic surgeon's training and level of comfort.
We should strive to avoid placing any instruments near the cervix. A sponge on a stick can provide an element of uterine manipulation in an atraumatic manner.
Secondary trocar placement must take into account the size of the uterus, with secondary trocar sleeves placed above the umbilicus and away from the uterus. Careful planning of where ports should be placed is a wise idea prior to making the skin incision. Inferior epigastric vessels should be identified to include superficial branches.
Direct visualization of trocar entrance into the abdominal cavity is of paramount importance and should be documented in the record accordingly.
Prompt Diagnosis
Associated morbidity makes a prompt diagnosis of acute appendicitis or cholecystitis critical. As obstetricians we should be well versed in the various symptoms and clinical presentation of these problems in pregnant patients. We must have a high index of suspicion and be ready to engage a general surgeon colleague early on.
A diagnosis of appendicitis can all too easily be delayed because of the displacement of the appendix by the gravid uterus and the normal physiological leukocytosis of pregnancy. The consequences of delay, however, are significant: The incidence of fetal loss is as high as 35% when the appendix ruptures, compared with 1.5% with uncomplicated appendicitis.
The appendix changes location during gestation, rising progressively above the McBurney point. At 8 or 9 months, the appendix can essentially be as high as the top of the uterine fundus. As an inflamed appendix drifts away from the abdominal wall, the signs of peritoneal irritation are often minimized; fewer than half of pregnant patients, in fact, have peritoneal signs.
During the first trimester, the pain is primarily in the area of the McBurney point, and sometimes in the pelvic area. In the second trimester, the pain is associated with the displacement of the appendix, with the point of maximal tenderness frequently above the iliac crest. In the third trimester, pain and tenderness may be localized to the right costal margin. Irrespective of the trimester, patients often have right lateral rectal tenderness.
The pain of appendicitis must be differentiated from the pain of uterine origin. The latter often can be alleviated by providing adequate hydration and placing the patient in the decubitus position. Both Alder's sign (fixed tenderness) and Bryan's sign (tenderness in the right lateral position) can help with this differentiation.
Acute cholecystitis often presents initially with biliary colic associated with nausea and vomiting. When the common bile duct is obstructed by a stone, pain persists and often radiates to the subscapular area, right flank, or shoulder. Patients typically have right subcostal tenderness associated with fever.
Ultrasonography is usually effective for diagnosing the presence of stones or dilatation of the common bile duct. Technetium-99m-iminodiacetic acid scans of the gallbladder can be used in pregnancy with minimal risk of radiation exposure.
Whenever possible, first-trimester patients with cholecystitis should be treated conservatively until the second trimester. Any patient who does not improve with medical management, however, should undergo laparoscopic surgery regardless of the gestational age of the fetus.
With adnexal cysts, it is generally acceptable to provide expectant management if the enlargement is less than 6 cm. There is evidence that 80%-90% of these enlargements will resolve spontaneously.
Again, it is of paramount importance that the obstetrician/gynecologist is cognizant of the anatomic and physiological changes associated with pregnancy. The option of a minimally invasive approach is often appropriate and timely in the management of nonobstetric emergencies during pregnancy.
Source ELSEVIER GLOBAL MEDICAL NEWS
Laparoscopic Surgery During Pregnancy
In a large multisurgeon survey published by the Society of Laparoendoscopic Surgeons, 1.2% of the 16,329 surgeon members said they performed laparoscopic procedures in pregnancy. The most common of the 413 laparoscopic procedures performed in pregnancy by these 192 surgeons appeared to be cholecystectomies, adnexal procedures, and appendectomies (J. Reprod. Med. 1997;42:33–8).
In an excellent review article (Obstet. Gynecol. Surv. 2001;56:50–9), Dr. Mohammad Fatum and Dr. Nathan Rojansky from Hadassah Ein-Kerem Medical Center and the Hebrew University Medical School, Jerusalem, noted the following major advantages of laparoscopic surgery during pregnancy:
▸ Small abdominal incisions resulting in rapid postoperative recovery and early mobilization, thus minimizing the increased risk of thromboembolism associated with pregnancy.
▸ Early return of gastrointestinal activity because of less manipulation of the bowel during surgery, which may result in fewer postoperative adhesions and intestinal obstruction.
▸ Smaller scars.
▸ Fewer incisional hernias.
▸ A reduced rate of fetal depression because of decreased pain and less narcotic use.
▸ Shorter hospitalization time and a prompt return to regular life.
I am pleased that Dr. Joseph S. Sanfilippo agreed to author this edition of the Master Class in Gynecologic Surgery on laparoscopic surgery during pregnancy.
A 1973 Chicago Medical School graduate, Dr. Sanfilippo was honored with a Distinguished Alumnus Award in 1990. He completed his fellowship in reproductive endocrinology and infertility at the University of Louisville (Ky.) School of Medicine and later gained his MBA degree at Chatham College in Pittsburgh.
Currently, Dr. Sanfilippo is professor of obstetrics, gynecology, and reproductive sciences; vice chairman of reproductive sciences; and director of reproductive endocrinology and infertility at Magee-Womens Hospital, Pittsburgh.
He has been a prolific researcher and author, particularly in the areas of surgery, reproductive medicine, and adolescent gynecology.
He also is considered an expert in laparoscopic surgery in pregnancy and has contributed to literature in this area as well.
Laparoscopic Cholecystectomy
▸ The overall complication rate for this procedure has been reported to be 0.75% in the literature.
▸ The highest incidence of fetal loss associated with laparoscopic cholecystectomy is in the first trimester, and the highest incidence of premature labor is in the third trimester.
▸ Elective abortion is not recommended, even with an intraoperative cholangiogram.
▸ Extrahepatic biliary obstruction due to gallstones can be managed laparoscopically.
Source: Dr. Sanfilippo
Operative laparoscopy during pregnancy has been part of the growing field of minimally invasive surgery for more than 2 decades. As efforts during the 1980s to develop laparoscopic techniques unfolded, pregnant women were on the radar screen; one of the first textbooks of minimally invasive surgery, published in the 1980s, for instance, featured a chapter on laparoscopy in pregnancy.
A report on more than 150 patients undergoing laparoscopic appendectomy, including 6 pregnant patients, was published in 1990 (Surg. Endosc. 1990;4:100–2). The first laparoscopic cholecystectomy during pregnancy was reported in 1991 (Obstet. Gynecol. 1991;78[pt. 2]:958–9).
Through the 1990s, as technology improved and laparoscopy assumed a prominent place in gynecologic practice, and as general surgeons acquired more skill in laparoscopy, it became increasingly apparent that pregnant patients with appendicitis, cholecystitis, and other complications—both nonobstetric problems and problems of a more obstetric and gynecologic nature—were among the patients for whom laparoscopic surgery is often the treatment of choice.
Experience with the laparoscopic approach in pregnant patients increased, and anesthesiologists, surgeons, and obstetricians learned more about the effects of excessive intraabdominal pressure, other anesthesia-related problems, and the importance of prophylaxis for deep vein thromboses, among other issues.
Today, we can tell pregnant patients that laparoscopic surgery is a safe option. Data have shown that the second trimester is generally the safest time to intervene, and that most complications—when they do occur—seem to be related to the underlying disorder rather than the surgery per se. Overall, the complication rate for laparoscopic surgery during pregnancy is similar to that in the nonpregnant state.
It is important that we are aware of and knowledgeable about the unique presentation of certain problems during pregnancy, such as acute appendicitis and cholecystitis, and that we are ready to call upon a general surgeon with advanced minimally invasive skills.
Problems Requiring Surgery
Up to 2% of pregnancies are complicated by a surgical problem.
By far the most common surgical condition during pregnancy is acute appendicitis; its incidence is 0.5–1 per 1,000 pregnancies. Other surgical emergencies in pregnancy include acute cholecystitis (with an incidence of 5 per 10,000 pregnancies), intestinal obstruction, persistent ovarian cysts larger than 6 cm, and ovarian torsion and other adnexal problems. (The incidence of adnexal torsion is 1 in 5,000, and the incidence of any adnexal problem complicating pregnancy is 1 per 500–600 pregnancies.)
With the advent of assisted reproductive technologies, the incidence of heterotropic pregnancies is increasing, and growing numbers of successful laparoscopic surgeries for these pregnancies in hemodynamically unstable patients also are being reported. The extrauterine pregnancy can be addressed via salpingostomy or salpingectomy depending on the intraoperative findings. Minimal disturbance of the uterus and intrauterine gestation is the goal of intraoperative management.
The approach to laparoscopic surgery for these patients must take into account the physiological changes of pregnancy, including a 45% increase in plasma volume and a 10%-20% increase in cardiac volume, as well as increased oxygen consumption, decreased functional residual volume, and a theoretical predisposition to thromboembolic complications.
We must also be aware that the Trendelenburg position increases intrathoracic pressure, impairing venous return and accentuating the change in functional residual capacity. We may not, therefore, be able to achieve as steep a Trendelenburg position in pregnancy as in the nonpregnant state.
Because we are dealing with two passengers on these surgical journeys, we also must ensure that we not disturb the uteroplacental blood flow and oxygenation—that is, we must prevent fetal asphyxia and preterm labor—and that we are cognizant of the potential teratogenic effects of analgesics and other medications.
Medications and Assessment
Medications that have been recommended related to surgical intervention during pregnancy include indomethacin supplementation 25–50 mg preoperatively and a second dose 12 hours later. Unfortunately, however, there is a paucity of prospective data to support any one specific recommendation.
Progesterone supplementation—through a vaginal supplement of 25–100 mg postop for up to 7 days—has also been advocated after the procedure. Again, there are no well-designed studies to provide a firm basis for medication support.
Data from studies in ovariectomized rats supports the subcutaneous use of 3 mg of progesterone plus 200 ng of estradiol benzoate for 10–19 days with monitoring of serum progesterone levels (J. Reprod. Fertil. 1990;90:63–70).
Diagnostic procedures utilizing radiation should be limited to 5–10 rad during the first 25 weeks of gestation. Beyond that dosage, chromosomal mutations and neurologic abnormalities become concerns, as does the theoretical increased risk of childhood leukemia and other hematologic cancers.
Assessment CT scans generally are an appropriate test during pregnancy because the amount of radiation is relatively low—from 2 to 4 rad for a single study. MR imaging is appropriate, of course, as it does not involve ionizing radiation. Potentially concerning is the use of a contrast agent with CT or MR imaging. Gadolinium is commonly used in pregnancy; the use of this or other contrast agents should be discussed by the obstetrician and radiologist.
The second trimester is generally the safest time to intervene because there is a higher incidence of preterm labor in the third trimester and spontaneous abortion during the first trimester. The incidence of miscarriage after surgery in the second trimester is 5.6%, compared with 12% in the first trimester.
Ideally, pre-, intra-, and postoperative management should be planned through multispecialty discussion involving anesthesiologists, general surgeons, and gynecologic surgeons.
Preanesthetic medications include benzodiazepines (for example, midazolam) and/or opioids (such as Fentanyl administered intravenously). Intravenous induction agents include propofol, barbiturates, ketamine, and etomidate (Arch. Gynecol. Obstet. 2007;276:201–9). Neuromuscular blocking medications include succinylcholine, vecuronium, or atracurium complemented by the administration of nitrous oxide.
Operative Management
Patient positioning during surgery is critical. The pregnant patient should be placed in the left lateral decubitus position, with her right hip elevated, to minimize interference with venous return. She must also undergo a more gradual, careful change to the Trendelenburg position than a nonpregnant patient would, and even more gradual reverse Trendelenburg positional changes.
Intraoperative monitoring should include measurement of vital signs, oxygen saturation, and end-tidal CO2 level, and observation of uterine activity. Intraabdominal pressure generally should be in the range of 12–15 mm Hg. Ideally, lower-extremity pneumatic compression devices should be utilized.
Careful monitoring for signs of preterm labor is also important. Fetal heart rate monitoring can provide useful data, both preoperatively and postoperatively. The use of tocolytic agents is certainly indicated when there are signs of preterm labor, but there is minimal support among experts for routine prophylactic tocolysis in the second trimester. Depending on the clinical circumstance, at 24 weeks' gestation, tocolysis can be considered.
Experts have debated for years the gestational age at which the uterus limits laparoscopic access to the abdominal cavity, and there still is no consensus.
Controversy continues over the use of the open laparoscopic technique versus the use of the Veress needle traditional technique (closed), especially in the left upper quadrant. Researchers are also investigating the use of gasless laparoscopy during pregnancy.
The vast majority of gynecologic and general surgeons who perform laparoscopic surgery in pregnant patients lean toward an open laparoscopic technique, but the closed and gasless techniques are also acceptable. I favor the primary use of an open approach with the Hasson cannula. This often provides better overall control with regard to entrance into the peritoneal cavity.
Clinicians who opt to use a Veress needle are certainly focused on an acceptable alternative to introduction of CO2 into the peritoneal cavity. The decision-making process is primarily a reflection of the gynecologic surgeon's training and level of comfort.
We should strive to avoid placing any instruments near the cervix. A sponge on a stick can provide an element of uterine manipulation in an atraumatic manner.
Secondary trocar placement must take into account the size of the uterus, with secondary trocar sleeves placed above the umbilicus and away from the uterus. Careful planning of where ports should be placed is a wise idea prior to making the skin incision. Inferior epigastric vessels should be identified to include superficial branches.
Direct visualization of trocar entrance into the abdominal cavity is of paramount importance and should be documented in the record accordingly.
Prompt Diagnosis
Associated morbidity makes a prompt diagnosis of acute appendicitis or cholecystitis critical. As obstetricians we should be well versed in the various symptoms and clinical presentation of these problems in pregnant patients. We must have a high index of suspicion and be ready to engage a general surgeon colleague early on.
A diagnosis of appendicitis can all too easily be delayed because of the displacement of the appendix by the gravid uterus and the normal physiological leukocytosis of pregnancy. The consequences of delay, however, are significant: The incidence of fetal loss is as high as 35% when the appendix ruptures, compared with 1.5% with uncomplicated appendicitis.
The appendix changes location during gestation, rising progressively above the McBurney point. At 8 or 9 months, the appendix can essentially be as high as the top of the uterine fundus. As an inflamed appendix drifts away from the abdominal wall, the signs of peritoneal irritation are often minimized; fewer than half of pregnant patients, in fact, have peritoneal signs.
During the first trimester, the pain is primarily in the area of the McBurney point, and sometimes in the pelvic area. In the second trimester, the pain is associated with the displacement of the appendix, with the point of maximal tenderness frequently above the iliac crest. In the third trimester, pain and tenderness may be localized to the right costal margin. Irrespective of the trimester, patients often have right lateral rectal tenderness.
The pain of appendicitis must be differentiated from the pain of uterine origin. The latter often can be alleviated by providing adequate hydration and placing the patient in the decubitus position. Both Alder's sign (fixed tenderness) and Bryan's sign (tenderness in the right lateral position) can help with this differentiation.
Acute cholecystitis often presents initially with biliary colic associated with nausea and vomiting. When the common bile duct is obstructed by a stone, pain persists and often radiates to the subscapular area, right flank, or shoulder. Patients typically have right subcostal tenderness associated with fever.
Ultrasonography is usually effective for diagnosing the presence of stones or dilatation of the common bile duct. Technetium-99m-iminodiacetic acid scans of the gallbladder can be used in pregnancy with minimal risk of radiation exposure.
Whenever possible, first-trimester patients with cholecystitis should be treated conservatively until the second trimester. Any patient who does not improve with medical management, however, should undergo laparoscopic surgery regardless of the gestational age of the fetus.
With adnexal cysts, it is generally acceptable to provide expectant management if the enlargement is less than 6 cm. There is evidence that 80%-90% of these enlargements will resolve spontaneously.
Again, it is of paramount importance that the obstetrician/gynecologist is cognizant of the anatomic and physiological changes associated with pregnancy. The option of a minimally invasive approach is often appropriate and timely in the management of nonobstetric emergencies during pregnancy.
Source ELSEVIER GLOBAL MEDICAL NEWS
Laparoscopic Surgery During Pregnancy
In a large multisurgeon survey published by the Society of Laparoendoscopic Surgeons, 1.2% of the 16,329 surgeon members said they performed laparoscopic procedures in pregnancy. The most common of the 413 laparoscopic procedures performed in pregnancy by these 192 surgeons appeared to be cholecystectomies, adnexal procedures, and appendectomies (J. Reprod. Med. 1997;42:33–8).
In an excellent review article (Obstet. Gynecol. Surv. 2001;56:50–9), Dr. Mohammad Fatum and Dr. Nathan Rojansky from Hadassah Ein-Kerem Medical Center and the Hebrew University Medical School, Jerusalem, noted the following major advantages of laparoscopic surgery during pregnancy:
▸ Small abdominal incisions resulting in rapid postoperative recovery and early mobilization, thus minimizing the increased risk of thromboembolism associated with pregnancy.
▸ Early return of gastrointestinal activity because of less manipulation of the bowel during surgery, which may result in fewer postoperative adhesions and intestinal obstruction.
▸ Smaller scars.
▸ Fewer incisional hernias.
▸ A reduced rate of fetal depression because of decreased pain and less narcotic use.
▸ Shorter hospitalization time and a prompt return to regular life.
I am pleased that Dr. Joseph S. Sanfilippo agreed to author this edition of the Master Class in Gynecologic Surgery on laparoscopic surgery during pregnancy.
A 1973 Chicago Medical School graduate, Dr. Sanfilippo was honored with a Distinguished Alumnus Award in 1990. He completed his fellowship in reproductive endocrinology and infertility at the University of Louisville (Ky.) School of Medicine and later gained his MBA degree at Chatham College in Pittsburgh.
Currently, Dr. Sanfilippo is professor of obstetrics, gynecology, and reproductive sciences; vice chairman of reproductive sciences; and director of reproductive endocrinology and infertility at Magee-Womens Hospital, Pittsburgh.
He has been a prolific researcher and author, particularly in the areas of surgery, reproductive medicine, and adolescent gynecology.
He also is considered an expert in laparoscopic surgery in pregnancy and has contributed to literature in this area as well.
Laparoscopic Cholecystectomy
▸ The overall complication rate for this procedure has been reported to be 0.75% in the literature.
▸ The highest incidence of fetal loss associated with laparoscopic cholecystectomy is in the first trimester, and the highest incidence of premature labor is in the third trimester.
▸ Elective abortion is not recommended, even with an intraoperative cholangiogram.
▸ Extrahepatic biliary obstruction due to gallstones can be managed laparoscopically.
Source: Dr. Sanfilippo
Interval Cervicoisthmic Cerclage: Its Time Has Come
For more than a decade, the capacity to perform cervicoisthmic cerclage by laparoscopy has provided a minimally invasive alternative for some women to the often-complicated traditional abdominal approach that was first reported in 1965.
With a laparoscopic cerclage performed by 12 weeks' gestation, patients for whom conventional vaginal cerclage has failed or is not possible have had successful deliveries without the extended midline incision, considerable hospital stays, or significant risks to the mother and fetus that are associated with the conventional abdominal approach.
Laparoscopic cerclage is a highly innovative procedure that has offered hope and delivered good outcomes. Still, one has to ask, are we really achieving all we can for our patients?
Does it not make sense to intervene earlier—before pregnancy—in certain high-risk women with anatomically altered or deficient cervices and/or with previous failures of conventional vaginal cerclages for cervical incompetence?
The notion of “interval cerclage” as opposed to interventional or “rescue” cerclage is an idea whose time has come. There are significant numbers of women who would substantially benefit from the insertion of a cervicoisthmic cerclage in the nonpregnant state—when the surgeon is not constrained by the contents, size, or fragility of the gravid uterus or challenged by the marked pelvic vascularity and other physiological changes of pregnancy.
The pregnant women who have undergone laparoscopic cervicoisthmic cerclage under our care have experienced failures of conventional vaginal cerclages, and many have suffered repeated second-trimester losses.
These high-stakes cases involving patients who are desperate for a successful pregnancy have led us to believe that one failure is enough—or, in the cases of patients who have other clear risk factors such as anatomically altered cervices, that one failure is too many.
As we move further into the era of reproductive technology and extended reproductive years, pregnancies are increasingly high-stakes experiences with a limited number of assisted cycles. Women do not have time to spare and do not want to take risks. Older women seeking to have a child not only are more likely to have had in vitro fertilization and other fertility treatments, they also are more likely to have had a loop electrosurgical excision procedure (LEEP), cone biopsy, or other procedure that has been associated with cervical incompetence. Many of these women are possible candidates for interval cerclage.
This type of cerclage requires a new thought process—a new mind-set—as well as new and creative collaboration between skilled laparoscopic surgeons and the perinatologists who are following and counseling these patients.
By working in teams, with the perinatologist cultivating a relationship with an experienced laparoscopic surgeon, specialists can work together to bring the option of interval cerclage into discussions with patients who have poor obstetric histories due to cervical incompetence or serious risk factors associated with poor pregnancy outcomes, and then see the procedure through when it is deemed worthwhile and desirable.
In our experience, once we met each other and became aware of each other's interests and expertise, it seemed only natural to collaborate and offer these patients interval laparoscopic cerclage.
The Benefits
Ironically, we have shifted in the last 5–10 years from early-pregnancy cerclage based largely on history toward cerclage that is performed based on ultrasound measurement of cervical length during pregnancy. Cervical change rarely occurs before 12–14 weeks' gestation, which means that by the time of “discovery” of a short cervical length, cerclage is all the more difficult and risky to perform.
The advantages to an interval approach to cerclage are numerous: The surgeon does not have to contend with the burden of an intrauterine pregnancy associated with the increased pelvic vascularity of pregnancy (up to 25% of the maternal circulation moves through the pelvis at this time) or the increased uterine size, which can be constraining, particularly for a laparoscopic approach.
Beyond 12–14 weeks, in fact, it becomes almost impossible with a laparoscopic approach to gently manipulate the uterus to see both the front and back of the lower uterine segment. Avoiding interventions close to the gravid uterus, of course, is always desirable. And with an interval cerclage, healing is typically completed by the time pregnancy occurs.
For a surgeon with advanced laparoscopic experience, the laparoscopic approach to a cervicoisthmic cerclage is generally much easier and safer than a “true” transvaginal cervicoisthmic cerclage.
Some experienced surgeons—though very few—have performed classical cervicoisthmic cerclage transvaginally during early pregnancy in the belief that a higher cerclage placement is more effective than a lower one. When the stitch is placed high at the level of the cervicoisthmic junction—or even higher—and above the level of the cardinal ligaments, the stitch is less likely to slip down along the cervix. It is supported from underneath by the cardinal ligaments.
The normal cervix can be anatomically represented by the letter Y. Then imagine it becoming the letter V, and then the letter U. This is the type of change that an incompetent cervix undergoes. If we can prevent, as much as possible, the formation of the V, then these changes are less likely to occur.
Although there is no scientific evidence, per se, to support this “higher is better” belief, it makes intrinsic sense, and there are data to suggest better outcomes with this higher stitch placement. Our experience shows that the vast majority of patients with previous failed cerclages had the conventional vaginal procedure, a simple Mersilene purse-string stitch placed low in the cervical stroma, not approximating the internal os where deformities typically are.
The problem is that transvaginal insertion of a cervical suture high at the level of the cervicoisthmic junction is complex and fraught with the risk of complications because the high stitch placement involves mobilizing and climbing up under the bladder, in close proximity to the vasculature of the uterus. Some surgeons have had success, but in general, what needs to be done exceeds the skills and experience of most.
In patients who are pregnant, traditional abdominal cervicoisthmic cerclage—the other alternative—has been associated with severe complications, such as hemorrhage and pregnancy loss. (Our sense is that few of these surgeries are performed because the stakes are so high and the risks so real.) Patients who are not pregnant still face an extended midline incision and a considerable hospital stay.
With laparoscopy, we can achieve the higher is better principle less invasively with more ease and superior precision. Compared with the vaginal or laparotomic approach, the laparoscopic method provides less trauma to the gravid uterus and unparalleled visual and mechanical access to the key anatomical structures either incorporated or potentially injured during cervicoisthmic cerclage. Placing the stitch precisely at the correct level is the most important element of this procedure.
Moreover, laparoscopic placement of the tape may reduce the recognized incidence of postoperative chorioamnionitis by removing the presence of a foreign body in the vagina. A first-trimester loss can usually be evacuated using conventional techniques, while elimination of more-advanced gestations can be simply facilitated by removing the stitch laparoscopically.
Whereas patients undergoing laparoscopic cervicoisthmic cerclage still must have a laparotomy at the end, because the cerclage is a permanent suture and necessitates delivery by cesarean section, morbidity and mortality risks are cut in half compared with patients undergoing two traditional abdominal surgeries.
Success rates after cervical cerclage are high, up to 87%. The interpretation of outcome is complex, however, because of the conflicting indications for treatment and differing timing of the procedure (before or during pregnancy). Quality research comparing approaches in patients with high-risk indications has been difficult to conduct as well, in part because patients who have had recurrent pregnancy failures are reluctant to participate in such studies.
Much of the available data, moreover, is confounded by a multiplicity of high-risk factors and variables related to recurrent pregnancy loss.
Dr. Brill's Technique
Patients are placed in a modified dorsal lithotomy position, and a No. 12 Foley catheter is inserted for bladder drainage. When the patient is pregnant, I perform an assiduous pelvic exam to assess for advanced cervical dilation.
In gravid patients, the largest cervical cup from a disassembled KOH colpotomizer is used to laparoscopically delineate the vaginal fornices and atraumatically manipulate the cervix and lower uterine segment by using two ring forceps secured opposite one another to the outer ring.
Fetal heart tones are documented before the laparoscopic procedure is initiated. The risk of incidental trauma to the gravid uterus is minimized by using open laparoscopy to attain peritoneal access.
The intra-abdominal pressure is strictly limited to 12 mm Hg, and all patients are placed in a maximally tolerated Trendelenburg position. I then determine the feasibility of the procedure based on an assessment of anatomical access and ready mobility of the gravid uterus.
Two 5-mm midquadrant ports are placed under direct vision, each lateral to the respective epigastric arteries and slightly below the level of the umbilicus. A 10-mm port is carefully introduced in the midline, one to two finger breadths above the pubic ramus.
The vesicouterine peritoneum is dissected transversely using either a monopolar spatula electrode or the 5-mm curved Harmonic shears. The uterus is mobilized using the pericervical cup and a 5-mm blunt probe.
The bladder is then minimally dissected off the lower uterine segment to reveal native pubocervical fascia and the course of the uterine vessels. With a combination of blunt and sharp dissection, an adequate surgical window is created medial to each set of uterine vessels at the level of the isthmus (
A 5-mm Mersilene tape is prepared by removing the attached curved needles, and the suture is then introduced into the posterior pelvis through the 10-mm suprapubic port. A 10-mm right-angle forceps through the suprapubic port is used to grasp and position the ligature around the lower uterine segment at the level of the isthmus by first piercing through the surgical windows in an anterior-to-posterior direction to then grasp and withdraw each end of the suture back into the vesicouterine space.
Care must be taken to confirm that the tape is flatly applied to the posterior lower uterine segment. The suture is then tied intracorporeally on the pubocervical fascia with at least five knots (
Whenever possible the vesicouterine peritoneal defect is closed with a running suture and tied extracorporeally. A vaginal exam is then performed to ensure that the suture ligature is above the level of the vaginal fornices. Fetal heart tones are once again documented.
In nongravid patients, a conventional uterine elevator is used for uterine manipulation. Conventional closed laparoscopic techniques are used for peritoneal access. Lower-quadrant trocar sites are lateral to the inferior epigastric vessels and usually at the level of the anterior superior iliac spines.
Whereas I employ the same dissection and suture ligature techniques used during the early cases of interval cerclage, more recently I have employed the classical technique using the two attached 48-mm needles to direct the Mersilene tape through the broad ligament just medial to the uterine vessels at the level of the isthmus.
After dissection of the anterior lower uterine segment to mobilize the bladder and to expose the uterine vessels, the uterus is anteverted and windows are created in the posterior broad ligament to expose the course of the uterine vessels.
The large needles still attached to the tape are introduced into the abdomen through one of the exposed lateral trocar sites by successively grasping each end of the suture several centimeters from the swedge point and then directing the needles through the abdominal wall and then into the peritoneal cavity under direct vision. Using the uterine elevator to retroflex the uterus and then expose the anterior lower uterine segment, I drive each needle medial to the uterine vessels perpendicularly to exit posteriorly as the uterus is simultaneously anteflexed to expose the broad ligament windows (
Once tightened around the lower uterine segment at the level of the isthmus, the tape ends are cut to release the needles, which are then extracted through the open suprapubic port site by reversing the maneuver used for their introduction. Care must be taken to confirm that the tape is flatly applied to the anterior lower uterine segment. The ligature ends are then tied together posteriorly by intracorporeal knot tying and are not peritonealized (
Cervical Cerclage
Cervical cerclage involves the placement of sutures, wires, or synthetic tape to mechanically increase the tensile strength of the cervix. The procedure is done either electively or emergently (rescue) to reduce the risk of cervical insufficiency and the resultant second-trimester recurrent pregnancy loss.
After reviewing the 2006 article in the American Journal of Obstetrics and Gynecology by Dr. Roberto Romero and his associates, the subsequent letter to the editors by Sietske M. Althuisius, Ph.D., and Pieter Hummel, Ph.D., and the author's reply, debate still lingers about whether credit should be given to Lazare Rivière, in his 1655 article published in Latin, for the first description of cervical insufficiency. By 1678, A. Cole, N. Culpepper, and W. Rowland described this entity in their book “Practice of Physick”:“The second fault in women which hindered conception is when the seed is not retained or the orifice of the womb is so slack that it cannot rightly contract itself to keep in the seed; which is chiefly caused by abortion or hard labor and childbirth, whereby the fibers of the womb are broken in pieces one from another and the inner orifice of the womb overmuch slackened.”
Three hundred years later, in an 1865 letter to the editor of the Lancet, G.T. Gream described a patient who had previously undergone cervical surgery “as a cure for dysmenorrhea and sterility.” Gream wrote: “She had arrived at about the fourth month of pregnancy; telling me—without, however, attributing her pregnancy to the operation—that the uterus had 6 years before been operated upon; and so complete had been the division of the cervix that the finger could readily be introduced into the uterine cavity, and the membranes of the ovum could be touched, as they can be sometimes during the last days of gestation. … According to prognostications, abortion resulted but a few weeks afterwards, from the inability of the uterus to retain its contents.”
V.N. Shirodkar, professor of midwifery and gynecology at Grant Medical College in Bombay, India, is credited with the introduction of cervical cerclage into modern obstetric practice in 1955. The need was based on his finding that “some women abort[ed] repeatedly between the fourth and seventh month and no amount of rest and treatment with hormones seemed to help them in retaining the product of conception.” This was immediately followed by Ian McDonald's report from the Royal Melbourne Hospital on his cerclage experience in 70 patients in 1957.
In this edition of Master Class in Gynecologic Surgery, I have asked Dr. Andrew I. Brill, director of minimally invasive gynecology, reparative pelvic surgery, and training at the California Pacific Medical Center, San Francisco, and former president of the AAGL, as well as Dr. Michael Katz, clinical professor of obstetrics, gynecology, and reproductive sciences, University of California, San Francisco, and chief of perinatal services at California Pacific Medical Center, to discuss interval cervicoisthmic cerclage, with an emphasis on a laparoscopic approach.
Dr. Brill coauthored the first report on a laparoscopic preconceptional cervicoisthmic cerclage in a woman with repeated midtrimester cervical cerclage failure for the Journal of Minimally Invasive Gynecology. Despite being an experienced vaginal surgeon and having extensive experience in classical transvaginal cervicoisthmic cerclage, upon observing Dr. Brill's laparoscopic technique, Dr. Katz became familiar with the benefits of this approach. It is our intent that after reading this edition of the Master Class in Gynecologic Surgery, you will, too.
Dr. Brill's Experience
Over the last 5 years, I have performed laparoscopic cervicoisthmic cerclage under general anesthesia in 23 patients who had documented histories consistent with cervical incompetence.
There have been 18 successful deliveries (at a mean gestational age of 36.6 weeks) with a fetal salvage rate of 78% (18/23), compared with 7.3% (6/82) during all of the patients' previous intrauterine pregnancies. In 12 of the 23 cases (52%), the cerclage was performed preconceptionally as an interval procedure. In the remaining 11, cerclage was performed during early pregnancy (at a mean gestational age of 12 weeks). Three of the cases were ultimately completed laparotomically—two secondary to pelvic adhesions and the other secondary to bleeding. In the 11 pregnant patients, only two losses occurred intraoperatively—one secondary to advanced cervical dilation and one for undetermined reasons 10 days postoperatively.
For more than a decade, the capacity to perform cervicoisthmic cerclage by laparoscopy has provided a minimally invasive alternative for some women to the often-complicated traditional abdominal approach that was first reported in 1965.
With a laparoscopic cerclage performed by 12 weeks' gestation, patients for whom conventional vaginal cerclage has failed or is not possible have had successful deliveries without the extended midline incision, considerable hospital stays, or significant risks to the mother and fetus that are associated with the conventional abdominal approach.
Laparoscopic cerclage is a highly innovative procedure that has offered hope and delivered good outcomes. Still, one has to ask, are we really achieving all we can for our patients?
Does it not make sense to intervene earlier—before pregnancy—in certain high-risk women with anatomically altered or deficient cervices and/or with previous failures of conventional vaginal cerclages for cervical incompetence?
The notion of “interval cerclage” as opposed to interventional or “rescue” cerclage is an idea whose time has come. There are significant numbers of women who would substantially benefit from the insertion of a cervicoisthmic cerclage in the nonpregnant state—when the surgeon is not constrained by the contents, size, or fragility of the gravid uterus or challenged by the marked pelvic vascularity and other physiological changes of pregnancy.
The pregnant women who have undergone laparoscopic cervicoisthmic cerclage under our care have experienced failures of conventional vaginal cerclages, and many have suffered repeated second-trimester losses.
These high-stakes cases involving patients who are desperate for a successful pregnancy have led us to believe that one failure is enough—or, in the cases of patients who have other clear risk factors such as anatomically altered cervices, that one failure is too many.
As we move further into the era of reproductive technology and extended reproductive years, pregnancies are increasingly high-stakes experiences with a limited number of assisted cycles. Women do not have time to spare and do not want to take risks. Older women seeking to have a child not only are more likely to have had in vitro fertilization and other fertility treatments, they also are more likely to have had a loop electrosurgical excision procedure (LEEP), cone biopsy, or other procedure that has been associated with cervical incompetence. Many of these women are possible candidates for interval cerclage.
This type of cerclage requires a new thought process—a new mind-set—as well as new and creative collaboration between skilled laparoscopic surgeons and the perinatologists who are following and counseling these patients.
By working in teams, with the perinatologist cultivating a relationship with an experienced laparoscopic surgeon, specialists can work together to bring the option of interval cerclage into discussions with patients who have poor obstetric histories due to cervical incompetence or serious risk factors associated with poor pregnancy outcomes, and then see the procedure through when it is deemed worthwhile and desirable.
In our experience, once we met each other and became aware of each other's interests and expertise, it seemed only natural to collaborate and offer these patients interval laparoscopic cerclage.
The Benefits
Ironically, we have shifted in the last 5–10 years from early-pregnancy cerclage based largely on history toward cerclage that is performed based on ultrasound measurement of cervical length during pregnancy. Cervical change rarely occurs before 12–14 weeks' gestation, which means that by the time of “discovery” of a short cervical length, cerclage is all the more difficult and risky to perform.
The advantages to an interval approach to cerclage are numerous: The surgeon does not have to contend with the burden of an intrauterine pregnancy associated with the increased pelvic vascularity of pregnancy (up to 25% of the maternal circulation moves through the pelvis at this time) or the increased uterine size, which can be constraining, particularly for a laparoscopic approach.
Beyond 12–14 weeks, in fact, it becomes almost impossible with a laparoscopic approach to gently manipulate the uterus to see both the front and back of the lower uterine segment. Avoiding interventions close to the gravid uterus, of course, is always desirable. And with an interval cerclage, healing is typically completed by the time pregnancy occurs.
For a surgeon with advanced laparoscopic experience, the laparoscopic approach to a cervicoisthmic cerclage is generally much easier and safer than a “true” transvaginal cervicoisthmic cerclage.
Some experienced surgeons—though very few—have performed classical cervicoisthmic cerclage transvaginally during early pregnancy in the belief that a higher cerclage placement is more effective than a lower one. When the stitch is placed high at the level of the cervicoisthmic junction—or even higher—and above the level of the cardinal ligaments, the stitch is less likely to slip down along the cervix. It is supported from underneath by the cardinal ligaments.
The normal cervix can be anatomically represented by the letter Y. Then imagine it becoming the letter V, and then the letter U. This is the type of change that an incompetent cervix undergoes. If we can prevent, as much as possible, the formation of the V, then these changes are less likely to occur.
Although there is no scientific evidence, per se, to support this “higher is better” belief, it makes intrinsic sense, and there are data to suggest better outcomes with this higher stitch placement. Our experience shows that the vast majority of patients with previous failed cerclages had the conventional vaginal procedure, a simple Mersilene purse-string stitch placed low in the cervical stroma, not approximating the internal os where deformities typically are.
The problem is that transvaginal insertion of a cervical suture high at the level of the cervicoisthmic junction is complex and fraught with the risk of complications because the high stitch placement involves mobilizing and climbing up under the bladder, in close proximity to the vasculature of the uterus. Some surgeons have had success, but in general, what needs to be done exceeds the skills and experience of most.
In patients who are pregnant, traditional abdominal cervicoisthmic cerclage—the other alternative—has been associated with severe complications, such as hemorrhage and pregnancy loss. (Our sense is that few of these surgeries are performed because the stakes are so high and the risks so real.) Patients who are not pregnant still face an extended midline incision and a considerable hospital stay.
With laparoscopy, we can achieve the higher is better principle less invasively with more ease and superior precision. Compared with the vaginal or laparotomic approach, the laparoscopic method provides less trauma to the gravid uterus and unparalleled visual and mechanical access to the key anatomical structures either incorporated or potentially injured during cervicoisthmic cerclage. Placing the stitch precisely at the correct level is the most important element of this procedure.
Moreover, laparoscopic placement of the tape may reduce the recognized incidence of postoperative chorioamnionitis by removing the presence of a foreign body in the vagina. A first-trimester loss can usually be evacuated using conventional techniques, while elimination of more-advanced gestations can be simply facilitated by removing the stitch laparoscopically.
Whereas patients undergoing laparoscopic cervicoisthmic cerclage still must have a laparotomy at the end, because the cerclage is a permanent suture and necessitates delivery by cesarean section, morbidity and mortality risks are cut in half compared with patients undergoing two traditional abdominal surgeries.
Success rates after cervical cerclage are high, up to 87%. The interpretation of outcome is complex, however, because of the conflicting indications for treatment and differing timing of the procedure (before or during pregnancy). Quality research comparing approaches in patients with high-risk indications has been difficult to conduct as well, in part because patients who have had recurrent pregnancy failures are reluctant to participate in such studies.
Much of the available data, moreover, is confounded by a multiplicity of high-risk factors and variables related to recurrent pregnancy loss.
Dr. Brill's Technique
Patients are placed in a modified dorsal lithotomy position, and a No. 12 Foley catheter is inserted for bladder drainage. When the patient is pregnant, I perform an assiduous pelvic exam to assess for advanced cervical dilation.
In gravid patients, the largest cervical cup from a disassembled KOH colpotomizer is used to laparoscopically delineate the vaginal fornices and atraumatically manipulate the cervix and lower uterine segment by using two ring forceps secured opposite one another to the outer ring.
Fetal heart tones are documented before the laparoscopic procedure is initiated. The risk of incidental trauma to the gravid uterus is minimized by using open laparoscopy to attain peritoneal access.
The intra-abdominal pressure is strictly limited to 12 mm Hg, and all patients are placed in a maximally tolerated Trendelenburg position. I then determine the feasibility of the procedure based on an assessment of anatomical access and ready mobility of the gravid uterus.
Two 5-mm midquadrant ports are placed under direct vision, each lateral to the respective epigastric arteries and slightly below the level of the umbilicus. A 10-mm port is carefully introduced in the midline, one to two finger breadths above the pubic ramus.
The vesicouterine peritoneum is dissected transversely using either a monopolar spatula electrode or the 5-mm curved Harmonic shears. The uterus is mobilized using the pericervical cup and a 5-mm blunt probe.
The bladder is then minimally dissected off the lower uterine segment to reveal native pubocervical fascia and the course of the uterine vessels. With a combination of blunt and sharp dissection, an adequate surgical window is created medial to each set of uterine vessels at the level of the isthmus (
A 5-mm Mersilene tape is prepared by removing the attached curved needles, and the suture is then introduced into the posterior pelvis through the 10-mm suprapubic port. A 10-mm right-angle forceps through the suprapubic port is used to grasp and position the ligature around the lower uterine segment at the level of the isthmus by first piercing through the surgical windows in an anterior-to-posterior direction to then grasp and withdraw each end of the suture back into the vesicouterine space.
Care must be taken to confirm that the tape is flatly applied to the posterior lower uterine segment. The suture is then tied intracorporeally on the pubocervical fascia with at least five knots (
Whenever possible the vesicouterine peritoneal defect is closed with a running suture and tied extracorporeally. A vaginal exam is then performed to ensure that the suture ligature is above the level of the vaginal fornices. Fetal heart tones are once again documented.
In nongravid patients, a conventional uterine elevator is used for uterine manipulation. Conventional closed laparoscopic techniques are used for peritoneal access. Lower-quadrant trocar sites are lateral to the inferior epigastric vessels and usually at the level of the anterior superior iliac spines.
Whereas I employ the same dissection and suture ligature techniques used during the early cases of interval cerclage, more recently I have employed the classical technique using the two attached 48-mm needles to direct the Mersilene tape through the broad ligament just medial to the uterine vessels at the level of the isthmus.
After dissection of the anterior lower uterine segment to mobilize the bladder and to expose the uterine vessels, the uterus is anteverted and windows are created in the posterior broad ligament to expose the course of the uterine vessels.
The large needles still attached to the tape are introduced into the abdomen through one of the exposed lateral trocar sites by successively grasping each end of the suture several centimeters from the swedge point and then directing the needles through the abdominal wall and then into the peritoneal cavity under direct vision. Using the uterine elevator to retroflex the uterus and then expose the anterior lower uterine segment, I drive each needle medial to the uterine vessels perpendicularly to exit posteriorly as the uterus is simultaneously anteflexed to expose the broad ligament windows (
Once tightened around the lower uterine segment at the level of the isthmus, the tape ends are cut to release the needles, which are then extracted through the open suprapubic port site by reversing the maneuver used for their introduction. Care must be taken to confirm that the tape is flatly applied to the anterior lower uterine segment. The ligature ends are then tied together posteriorly by intracorporeal knot tying and are not peritonealized (
Cervical Cerclage
Cervical cerclage involves the placement of sutures, wires, or synthetic tape to mechanically increase the tensile strength of the cervix. The procedure is done either electively or emergently (rescue) to reduce the risk of cervical insufficiency and the resultant second-trimester recurrent pregnancy loss.
After reviewing the 2006 article in the American Journal of Obstetrics and Gynecology by Dr. Roberto Romero and his associates, the subsequent letter to the editors by Sietske M. Althuisius, Ph.D., and Pieter Hummel, Ph.D., and the author's reply, debate still lingers about whether credit should be given to Lazare Rivière, in his 1655 article published in Latin, for the first description of cervical insufficiency. By 1678, A. Cole, N. Culpepper, and W. Rowland described this entity in their book “Practice of Physick”:“The second fault in women which hindered conception is when the seed is not retained or the orifice of the womb is so slack that it cannot rightly contract itself to keep in the seed; which is chiefly caused by abortion or hard labor and childbirth, whereby the fibers of the womb are broken in pieces one from another and the inner orifice of the womb overmuch slackened.”
Three hundred years later, in an 1865 letter to the editor of the Lancet, G.T. Gream described a patient who had previously undergone cervical surgery “as a cure for dysmenorrhea and sterility.” Gream wrote: “She had arrived at about the fourth month of pregnancy; telling me—without, however, attributing her pregnancy to the operation—that the uterus had 6 years before been operated upon; and so complete had been the division of the cervix that the finger could readily be introduced into the uterine cavity, and the membranes of the ovum could be touched, as they can be sometimes during the last days of gestation. … According to prognostications, abortion resulted but a few weeks afterwards, from the inability of the uterus to retain its contents.”
V.N. Shirodkar, professor of midwifery and gynecology at Grant Medical College in Bombay, India, is credited with the introduction of cervical cerclage into modern obstetric practice in 1955. The need was based on his finding that “some women abort[ed] repeatedly between the fourth and seventh month and no amount of rest and treatment with hormones seemed to help them in retaining the product of conception.” This was immediately followed by Ian McDonald's report from the Royal Melbourne Hospital on his cerclage experience in 70 patients in 1957.
In this edition of Master Class in Gynecologic Surgery, I have asked Dr. Andrew I. Brill, director of minimally invasive gynecology, reparative pelvic surgery, and training at the California Pacific Medical Center, San Francisco, and former president of the AAGL, as well as Dr. Michael Katz, clinical professor of obstetrics, gynecology, and reproductive sciences, University of California, San Francisco, and chief of perinatal services at California Pacific Medical Center, to discuss interval cervicoisthmic cerclage, with an emphasis on a laparoscopic approach.
Dr. Brill coauthored the first report on a laparoscopic preconceptional cervicoisthmic cerclage in a woman with repeated midtrimester cervical cerclage failure for the Journal of Minimally Invasive Gynecology. Despite being an experienced vaginal surgeon and having extensive experience in classical transvaginal cervicoisthmic cerclage, upon observing Dr. Brill's laparoscopic technique, Dr. Katz became familiar with the benefits of this approach. It is our intent that after reading this edition of the Master Class in Gynecologic Surgery, you will, too.
Dr. Brill's Experience
Over the last 5 years, I have performed laparoscopic cervicoisthmic cerclage under general anesthesia in 23 patients who had documented histories consistent with cervical incompetence.
There have been 18 successful deliveries (at a mean gestational age of 36.6 weeks) with a fetal salvage rate of 78% (18/23), compared with 7.3% (6/82) during all of the patients' previous intrauterine pregnancies. In 12 of the 23 cases (52%), the cerclage was performed preconceptionally as an interval procedure. In the remaining 11, cerclage was performed during early pregnancy (at a mean gestational age of 12 weeks). Three of the cases were ultimately completed laparotomically—two secondary to pelvic adhesions and the other secondary to bleeding. In the 11 pregnant patients, only two losses occurred intraoperatively—one secondary to advanced cervical dilation and one for undetermined reasons 10 days postoperatively.
For more than a decade, the capacity to perform cervicoisthmic cerclage by laparoscopy has provided a minimally invasive alternative for some women to the often-complicated traditional abdominal approach that was first reported in 1965.
With a laparoscopic cerclage performed by 12 weeks' gestation, patients for whom conventional vaginal cerclage has failed or is not possible have had successful deliveries without the extended midline incision, considerable hospital stays, or significant risks to the mother and fetus that are associated with the conventional abdominal approach.
Laparoscopic cerclage is a highly innovative procedure that has offered hope and delivered good outcomes. Still, one has to ask, are we really achieving all we can for our patients?
Does it not make sense to intervene earlier—before pregnancy—in certain high-risk women with anatomically altered or deficient cervices and/or with previous failures of conventional vaginal cerclages for cervical incompetence?
The notion of “interval cerclage” as opposed to interventional or “rescue” cerclage is an idea whose time has come. There are significant numbers of women who would substantially benefit from the insertion of a cervicoisthmic cerclage in the nonpregnant state—when the surgeon is not constrained by the contents, size, or fragility of the gravid uterus or challenged by the marked pelvic vascularity and other physiological changes of pregnancy.
The pregnant women who have undergone laparoscopic cervicoisthmic cerclage under our care have experienced failures of conventional vaginal cerclages, and many have suffered repeated second-trimester losses.
These high-stakes cases involving patients who are desperate for a successful pregnancy have led us to believe that one failure is enough—or, in the cases of patients who have other clear risk factors such as anatomically altered cervices, that one failure is too many.
As we move further into the era of reproductive technology and extended reproductive years, pregnancies are increasingly high-stakes experiences with a limited number of assisted cycles. Women do not have time to spare and do not want to take risks. Older women seeking to have a child not only are more likely to have had in vitro fertilization and other fertility treatments, they also are more likely to have had a loop electrosurgical excision procedure (LEEP), cone biopsy, or other procedure that has been associated with cervical incompetence. Many of these women are possible candidates for interval cerclage.
This type of cerclage requires a new thought process—a new mind-set—as well as new and creative collaboration between skilled laparoscopic surgeons and the perinatologists who are following and counseling these patients.
By working in teams, with the perinatologist cultivating a relationship with an experienced laparoscopic surgeon, specialists can work together to bring the option of interval cerclage into discussions with patients who have poor obstetric histories due to cervical incompetence or serious risk factors associated with poor pregnancy outcomes, and then see the procedure through when it is deemed worthwhile and desirable.
In our experience, once we met each other and became aware of each other's interests and expertise, it seemed only natural to collaborate and offer these patients interval laparoscopic cerclage.
The Benefits
Ironically, we have shifted in the last 5–10 years from early-pregnancy cerclage based largely on history toward cerclage that is performed based on ultrasound measurement of cervical length during pregnancy. Cervical change rarely occurs before 12–14 weeks' gestation, which means that by the time of “discovery” of a short cervical length, cerclage is all the more difficult and risky to perform.
The advantages to an interval approach to cerclage are numerous: The surgeon does not have to contend with the burden of an intrauterine pregnancy associated with the increased pelvic vascularity of pregnancy (up to 25% of the maternal circulation moves through the pelvis at this time) or the increased uterine size, which can be constraining, particularly for a laparoscopic approach.
Beyond 12–14 weeks, in fact, it becomes almost impossible with a laparoscopic approach to gently manipulate the uterus to see both the front and back of the lower uterine segment. Avoiding interventions close to the gravid uterus, of course, is always desirable. And with an interval cerclage, healing is typically completed by the time pregnancy occurs.
For a surgeon with advanced laparoscopic experience, the laparoscopic approach to a cervicoisthmic cerclage is generally much easier and safer than a “true” transvaginal cervicoisthmic cerclage.
Some experienced surgeons—though very few—have performed classical cervicoisthmic cerclage transvaginally during early pregnancy in the belief that a higher cerclage placement is more effective than a lower one. When the stitch is placed high at the level of the cervicoisthmic junction—or even higher—and above the level of the cardinal ligaments, the stitch is less likely to slip down along the cervix. It is supported from underneath by the cardinal ligaments.
The normal cervix can be anatomically represented by the letter Y. Then imagine it becoming the letter V, and then the letter U. This is the type of change that an incompetent cervix undergoes. If we can prevent, as much as possible, the formation of the V, then these changes are less likely to occur.
Although there is no scientific evidence, per se, to support this “higher is better” belief, it makes intrinsic sense, and there are data to suggest better outcomes with this higher stitch placement. Our experience shows that the vast majority of patients with previous failed cerclages had the conventional vaginal procedure, a simple Mersilene purse-string stitch placed low in the cervical stroma, not approximating the internal os where deformities typically are.
The problem is that transvaginal insertion of a cervical suture high at the level of the cervicoisthmic junction is complex and fraught with the risk of complications because the high stitch placement involves mobilizing and climbing up under the bladder, in close proximity to the vasculature of the uterus. Some surgeons have had success, but in general, what needs to be done exceeds the skills and experience of most.
In patients who are pregnant, traditional abdominal cervicoisthmic cerclage—the other alternative—has been associated with severe complications, such as hemorrhage and pregnancy loss. (Our sense is that few of these surgeries are performed because the stakes are so high and the risks so real.) Patients who are not pregnant still face an extended midline incision and a considerable hospital stay.
With laparoscopy, we can achieve the higher is better principle less invasively with more ease and superior precision. Compared with the vaginal or laparotomic approach, the laparoscopic method provides less trauma to the gravid uterus and unparalleled visual and mechanical access to the key anatomical structures either incorporated or potentially injured during cervicoisthmic cerclage. Placing the stitch precisely at the correct level is the most important element of this procedure.
Moreover, laparoscopic placement of the tape may reduce the recognized incidence of postoperative chorioamnionitis by removing the presence of a foreign body in the vagina. A first-trimester loss can usually be evacuated using conventional techniques, while elimination of more-advanced gestations can be simply facilitated by removing the stitch laparoscopically.
Whereas patients undergoing laparoscopic cervicoisthmic cerclage still must have a laparotomy at the end, because the cerclage is a permanent suture and necessitates delivery by cesarean section, morbidity and mortality risks are cut in half compared with patients undergoing two traditional abdominal surgeries.
Success rates after cervical cerclage are high, up to 87%. The interpretation of outcome is complex, however, because of the conflicting indications for treatment and differing timing of the procedure (before or during pregnancy). Quality research comparing approaches in patients with high-risk indications has been difficult to conduct as well, in part because patients who have had recurrent pregnancy failures are reluctant to participate in such studies.
Much of the available data, moreover, is confounded by a multiplicity of high-risk factors and variables related to recurrent pregnancy loss.
Dr. Brill's Technique
Patients are placed in a modified dorsal lithotomy position, and a No. 12 Foley catheter is inserted for bladder drainage. When the patient is pregnant, I perform an assiduous pelvic exam to assess for advanced cervical dilation.
In gravid patients, the largest cervical cup from a disassembled KOH colpotomizer is used to laparoscopically delineate the vaginal fornices and atraumatically manipulate the cervix and lower uterine segment by using two ring forceps secured opposite one another to the outer ring.
Fetal heart tones are documented before the laparoscopic procedure is initiated. The risk of incidental trauma to the gravid uterus is minimized by using open laparoscopy to attain peritoneal access.
The intra-abdominal pressure is strictly limited to 12 mm Hg, and all patients are placed in a maximally tolerated Trendelenburg position. I then determine the feasibility of the procedure based on an assessment of anatomical access and ready mobility of the gravid uterus.
Two 5-mm midquadrant ports are placed under direct vision, each lateral to the respective epigastric arteries and slightly below the level of the umbilicus. A 10-mm port is carefully introduced in the midline, one to two finger breadths above the pubic ramus.
The vesicouterine peritoneum is dissected transversely using either a monopolar spatula electrode or the 5-mm curved Harmonic shears. The uterus is mobilized using the pericervical cup and a 5-mm blunt probe.
The bladder is then minimally dissected off the lower uterine segment to reveal native pubocervical fascia and the course of the uterine vessels. With a combination of blunt and sharp dissection, an adequate surgical window is created medial to each set of uterine vessels at the level of the isthmus (
A 5-mm Mersilene tape is prepared by removing the attached curved needles, and the suture is then introduced into the posterior pelvis through the 10-mm suprapubic port. A 10-mm right-angle forceps through the suprapubic port is used to grasp and position the ligature around the lower uterine segment at the level of the isthmus by first piercing through the surgical windows in an anterior-to-posterior direction to then grasp and withdraw each end of the suture back into the vesicouterine space.
Care must be taken to confirm that the tape is flatly applied to the posterior lower uterine segment. The suture is then tied intracorporeally on the pubocervical fascia with at least five knots (
Whenever possible the vesicouterine peritoneal defect is closed with a running suture and tied extracorporeally. A vaginal exam is then performed to ensure that the suture ligature is above the level of the vaginal fornices. Fetal heart tones are once again documented.
In nongravid patients, a conventional uterine elevator is used for uterine manipulation. Conventional closed laparoscopic techniques are used for peritoneal access. Lower-quadrant trocar sites are lateral to the inferior epigastric vessels and usually at the level of the anterior superior iliac spines.
Whereas I employ the same dissection and suture ligature techniques used during the early cases of interval cerclage, more recently I have employed the classical technique using the two attached 48-mm needles to direct the Mersilene tape through the broad ligament just medial to the uterine vessels at the level of the isthmus.
After dissection of the anterior lower uterine segment to mobilize the bladder and to expose the uterine vessels, the uterus is anteverted and windows are created in the posterior broad ligament to expose the course of the uterine vessels.
The large needles still attached to the tape are introduced into the abdomen through one of the exposed lateral trocar sites by successively grasping each end of the suture several centimeters from the swedge point and then directing the needles through the abdominal wall and then into the peritoneal cavity under direct vision. Using the uterine elevator to retroflex the uterus and then expose the anterior lower uterine segment, I drive each needle medial to the uterine vessels perpendicularly to exit posteriorly as the uterus is simultaneously anteflexed to expose the broad ligament windows (
Once tightened around the lower uterine segment at the level of the isthmus, the tape ends are cut to release the needles, which are then extracted through the open suprapubic port site by reversing the maneuver used for their introduction. Care must be taken to confirm that the tape is flatly applied to the anterior lower uterine segment. The ligature ends are then tied together posteriorly by intracorporeal knot tying and are not peritonealized (
Cervical Cerclage
Cervical cerclage involves the placement of sutures, wires, or synthetic tape to mechanically increase the tensile strength of the cervix. The procedure is done either electively or emergently (rescue) to reduce the risk of cervical insufficiency and the resultant second-trimester recurrent pregnancy loss.
After reviewing the 2006 article in the American Journal of Obstetrics and Gynecology by Dr. Roberto Romero and his associates, the subsequent letter to the editors by Sietske M. Althuisius, Ph.D., and Pieter Hummel, Ph.D., and the author's reply, debate still lingers about whether credit should be given to Lazare Rivière, in his 1655 article published in Latin, for the first description of cervical insufficiency. By 1678, A. Cole, N. Culpepper, and W. Rowland described this entity in their book “Practice of Physick”:“The second fault in women which hindered conception is when the seed is not retained or the orifice of the womb is so slack that it cannot rightly contract itself to keep in the seed; which is chiefly caused by abortion or hard labor and childbirth, whereby the fibers of the womb are broken in pieces one from another and the inner orifice of the womb overmuch slackened.”
Three hundred years later, in an 1865 letter to the editor of the Lancet, G.T. Gream described a patient who had previously undergone cervical surgery “as a cure for dysmenorrhea and sterility.” Gream wrote: “She had arrived at about the fourth month of pregnancy; telling me—without, however, attributing her pregnancy to the operation—that the uterus had 6 years before been operated upon; and so complete had been the division of the cervix that the finger could readily be introduced into the uterine cavity, and the membranes of the ovum could be touched, as they can be sometimes during the last days of gestation. … According to prognostications, abortion resulted but a few weeks afterwards, from the inability of the uterus to retain its contents.”
V.N. Shirodkar, professor of midwifery and gynecology at Grant Medical College in Bombay, India, is credited with the introduction of cervical cerclage into modern obstetric practice in 1955. The need was based on his finding that “some women abort[ed] repeatedly between the fourth and seventh month and no amount of rest and treatment with hormones seemed to help them in retaining the product of conception.” This was immediately followed by Ian McDonald's report from the Royal Melbourne Hospital on his cerclage experience in 70 patients in 1957.
In this edition of Master Class in Gynecologic Surgery, I have asked Dr. Andrew I. Brill, director of minimally invasive gynecology, reparative pelvic surgery, and training at the California Pacific Medical Center, San Francisco, and former president of the AAGL, as well as Dr. Michael Katz, clinical professor of obstetrics, gynecology, and reproductive sciences, University of California, San Francisco, and chief of perinatal services at California Pacific Medical Center, to discuss interval cervicoisthmic cerclage, with an emphasis on a laparoscopic approach.
Dr. Brill coauthored the first report on a laparoscopic preconceptional cervicoisthmic cerclage in a woman with repeated midtrimester cervical cerclage failure for the Journal of Minimally Invasive Gynecology. Despite being an experienced vaginal surgeon and having extensive experience in classical transvaginal cervicoisthmic cerclage, upon observing Dr. Brill's laparoscopic technique, Dr. Katz became familiar with the benefits of this approach. It is our intent that after reading this edition of the Master Class in Gynecologic Surgery, you will, too.
Dr. Brill's Experience
Over the last 5 years, I have performed laparoscopic cervicoisthmic cerclage under general anesthesia in 23 patients who had documented histories consistent with cervical incompetence.
There have been 18 successful deliveries (at a mean gestational age of 36.6 weeks) with a fetal salvage rate of 78% (18/23), compared with 7.3% (6/82) during all of the patients' previous intrauterine pregnancies. In 12 of the 23 cases (52%), the cerclage was performed preconceptionally as an interval procedure. In the remaining 11, cerclage was performed during early pregnancy (at a mean gestational age of 12 weeks). Three of the cases were ultimately completed laparotomically—two secondary to pelvic adhesions and the other secondary to bleeding. In the 11 pregnant patients, only two losses occurred intraoperatively—one secondary to advanced cervical dilation and one for undetermined reasons 10 days postoperatively.
Fad or Future?
As credited to the Ebers papyrus, prolapse was first described in 1500 B.C. Hippocrates described several methods in the treatment of prolapse, including suspending the patient upside down. Another technique championed by Hippocrates included irrigation of the displaced uterus with wine. Once the uterus was reduced, the position was maintained with a pomegranate “pessary.”
Just after the birth of Christ, Soranus of Ephesus placed perfumes at the patient's head and foul-smelling substances near the prolapsed portion of the uterus to draw the uterus cephalad.
Needless to say, great advancements have occurred since antiquity in the treatment of pelvic organ prolapse.
Most recently, the use of nonabsorbable polypropylene mesh has become increasingly popular. The latest permutation of this technique is the use of a total pelvic floor repair kit.
I have asked Dr. Dennis P. Miller to discuss the use of total pelvic floor repair kits.
Dr. Miller currently serves as the medical director of urogynecology at Wheaton Franciscan Medical Group, Milwaukee. Since 1995, he has proctored hundreds of surgeons in urogynecologic surgery, including laparoscopic and minimally invasive vaginal approaches to incontinence and prolapse.
Currently, Dr. Miller serves on the American Urogynecologic Society Presidential Task Force on graft procedures as well as the International Urogynecologic Association's graft outcomes committee.
Enjoy reading Dr. Miller's excellent article, which is the latest addition in the Master Class in Gynecologic Surgery.
As credited to the Ebers papyrus, prolapse was first described in 1500 B.C. Hippocrates described several methods in the treatment of prolapse, including suspending the patient upside down. Another technique championed by Hippocrates included irrigation of the displaced uterus with wine. Once the uterus was reduced, the position was maintained with a pomegranate “pessary.”
Just after the birth of Christ, Soranus of Ephesus placed perfumes at the patient's head and foul-smelling substances near the prolapsed portion of the uterus to draw the uterus cephalad.
Needless to say, great advancements have occurred since antiquity in the treatment of pelvic organ prolapse.
Most recently, the use of nonabsorbable polypropylene mesh has become increasingly popular. The latest permutation of this technique is the use of a total pelvic floor repair kit.
I have asked Dr. Dennis P. Miller to discuss the use of total pelvic floor repair kits.
Dr. Miller currently serves as the medical director of urogynecology at Wheaton Franciscan Medical Group, Milwaukee. Since 1995, he has proctored hundreds of surgeons in urogynecologic surgery, including laparoscopic and minimally invasive vaginal approaches to incontinence and prolapse.
Currently, Dr. Miller serves on the American Urogynecologic Society Presidential Task Force on graft procedures as well as the International Urogynecologic Association's graft outcomes committee.
Enjoy reading Dr. Miller's excellent article, which is the latest addition in the Master Class in Gynecologic Surgery.
As credited to the Ebers papyrus, prolapse was first described in 1500 B.C. Hippocrates described several methods in the treatment of prolapse, including suspending the patient upside down. Another technique championed by Hippocrates included irrigation of the displaced uterus with wine. Once the uterus was reduced, the position was maintained with a pomegranate “pessary.”
Just after the birth of Christ, Soranus of Ephesus placed perfumes at the patient's head and foul-smelling substances near the prolapsed portion of the uterus to draw the uterus cephalad.
Needless to say, great advancements have occurred since antiquity in the treatment of pelvic organ prolapse.
Most recently, the use of nonabsorbable polypropylene mesh has become increasingly popular. The latest permutation of this technique is the use of a total pelvic floor repair kit.
I have asked Dr. Dennis P. Miller to discuss the use of total pelvic floor repair kits.
Dr. Miller currently serves as the medical director of urogynecology at Wheaton Franciscan Medical Group, Milwaukee. Since 1995, he has proctored hundreds of surgeons in urogynecologic surgery, including laparoscopic and minimally invasive vaginal approaches to incontinence and prolapse.
Currently, Dr. Miller serves on the American Urogynecologic Society Presidential Task Force on graft procedures as well as the International Urogynecologic Association's graft outcomes committee.
Enjoy reading Dr. Miller's excellent article, which is the latest addition in the Master Class in Gynecologic Surgery.
Pelvic Organ Prolapse Repair With Prolift
About one of every nine women in the United States will have surgery for a vaginal support defect (pelvic organ prolapse). Our armamentarium of surgical options for helping these patients now includes improved mesh designs and new synthetic mesh kits for transvaginal repair.
The development of synthetic mesh is important, as we have learned over the years that some women have visceral connective tissues (the connective tissues that support the vagina, bladder, and rectum) that are not strong enough to maintain a conventional surgical repair. We have learned, moreover, that surgical repairs utilizing the patient's native tissue too often do not last: Failure rates of 20%–50% have been reported.
Although it's still unclear what constitutes the “perfect mesh,” we have found that the use of a permanent, loosely woven polypropylene mesh can improve our operative results and significantly decrease the failure rates of our reparative vaginal surgery in women with vaginal support defects.
The failure of previous conventional reparative surgery for vaginal support defects is a clear indication for mesh. I operate on many patients who have recurrences of prolapse, and most of the time I use a permanent polypropylene mesh. For almost 4 years, I have been using the transvaginal Prolift systems for anterior, posterior, and total pelvic floor repair; other gynecologic surgeons favor different mesh kits that are currently available.
In October 2008, the Food and Drug Administration issued a Public Health Notification saying that it had received over 1,000 reports from surgical mesh manufacturers of complications associated with mesh devices that are used to repair pelvic organ prolapse and stress urinary incontinence. The warning lists the most frequent complications, such as erosion through vaginal epithelium, infection, pain, and urinary problems. However, the warning does not report which meshes were used—some meshes have been taken off the market—or provide a denominator of the number of total mesh placements.
The warning serves as a reminder of what gynecologic surgeons have advocated thus far: the need for significant experience in reparative vaginal surgery before using mesh implants. It is only in the last 10–15 years that gynecologic surgeons have acquired a detailed understanding of vaginal support anatomy, and of what happens to that anatomy to cause vaginal support defects.
To use mesh kits, the physician must both understand this anatomy and the variability in patients' connective tissues, and have experience in dissection techniques and the safe development of the proper dissection planes between the bladder and vagina, between the rectum and vagina, at the vaginal apex, and in the paravaginal and pararectal areas.
We must be able to dissect without causing undue bleeding or injury, and we must know how to minimize the exposure or erosion of mesh, which is usually through the vaginal wall. (Erosion of the mesh into the bladder or rectum is very rare.) Fortunately, we have access in the postgraduate arena to human cadaver courses that can give us valuable experience.
I have had very few complications in using mesh kits for pelvic floor repair, but I always tell patients that they have a 5% risk of infection, rejection of the mesh, or erosion or exposure of the mesh, as well as a 5%–10% chance of developing dyspareunia. I inform them, of course, that implantation of the mesh is permanent. And I always ask the patient to work with me in diagnosing or resolving any problem, complication, or unexpected outcome if it occurs.
Preparing for the Procedure
I use permanent polypropylene mesh for patients who have a recurring, symptomatic vaginal support defect. Even after the vagina is estrogenized, the vaginal wall in these patients is smooth and lacks the transverse ripples that are indicative, theoretically, of healthy connective tissue that could itself be used for repair.
The Prolift system that I use comprises precut nonabsorbable mesh implants (different precut implants for anterior, posterior, and total repairs) and a set of instruments (anatomical guides and retrieval devices with cannulas) to facilitate mesh placement.
The patient is placed in the dorsal lithotomy position, with her thighs at about 80 degrees to horizontal. She is not overly abducted, and her sacrum is well padded. I recommend using boot-type stirrups. A Foley catheter is inserted.
At 1 hour before anesthesia is administered, I give the patient a dose of prophylactic antibiotic. So far, I have not seen infection from mesh in any of the hundreds of Prolift procedures I've performed.
Anterior Prolapse Repair
The use of anatomical landmarks is critical to the mastery of dissection techniques.
For repair of an anterior vaginal prolapse (a cystocele), the two most important landmarks are the ischial spine and the junction of the inferior pubic ramus with the body of the pubic bone. This is because the “white line” of para-vaginal support goes from one of these points to the other. The anatomical orientation of the anterior vaginal wall must also be delineated. Overlying the lower third is the urethra, and overlying the middle third is the trigone of the bladder, an area of significant innervation. Overlying the upper third of the anterior vaginal wall is the bladder itself. The ureters travel across this upper third from lateral to medial, entering the bladder at the junction of the middle third and the upper third of the vagina.
A 3-cm anterior colpotomy incision is made in the upper third of the vagina. We stay away from the middle of the anterior vaginal wall so that innervation to the bladder is not disrupted, and so that the area underneath the urethra remains fresh for placement of a midurethral transvaginal tape, if needed.
The incision to the anterior vaginal wall should be a full-thickness incision that leaves the white, shiny pubo-cervical fascia on the back of the vaginal epithelium. Once you pass through this fascia, you are in the true vesicovaginal space, and the visceral fascia that surrounds the bladder can be seen.
A curved Mayo scissors, or your finger, can then be used to gently develop the lateral space between the bladder and the vaginal epithelium. There should be minimal bleeding. (If there is more than minimal bleeding, you're either in the wrong dissection plane or you're encountering significant scar tissue from your patient's previous surgery.)
Your goal is to work laterally, so that you can actually feel the tough parietal fascia that covers the obturator muscles.
When you feel the junction of the inferior pubic ramus with the body of the pubic bone—one of the two most important landmarks—you then can slide your finger along the obturator internus fascia right down to the ischial spine. That distance is only about 5–6 cm. By doing so on both sides, the bladder is mobilized away from the anterior vaginal epithelium, and the bladder and ureters are mobilized away from the pelvic side walls. Again, there should be minimal blood loss (no more than 50 cc).
The cannula-equipped curved metal guides must then be passed through the inner thighs. A first incision (no more than 5 mm) is made at the level of the urethra, about 1 cm lateral to the inferior pubic ramus, which you can palpate through the skin of the thigh. This is for the anteromedial, or superficial, passage. The second incision (of the same size) is made at 1 cm lateral and 2 cm posterior to the first mark. This is for the posterolateral, or deep, passage. I always work through the deep passage first. With its tip perpendicular to the skin, I push the cannula-equipped guide straight in until I feel the tip pop through the fascia lata. I then bring the handle of the guide up, so that the directional force is parallel to the fascial white line.
The goal in this deep passage is to pass the guide through the posterior aspect of the obturator membrane and through the obturator internus muscle so that the tip of the cannula is about 1 cm inferior (and a bit anterior) to the ischial spine as it pops through the muscle into the paravaginal space. My finger waits there to feel the tip pass through the fascia of the obturator internus muscle. I then feed a small dull curette into the paravaginal space with my finger and slip it over the cannula, and my assistant carefully removes the guide.
The retrieval device—a piece of long plastic tubing, in essence, with a loop at the end—can then be passed through the cannula. When I feel the loop come through, I entrap it against the end of the curette and pull both the loop and the retrieval device out of the vagina. (Some surgeons hook the loop with a finger, but I find the curette helpful.)
The superficial passage involves the same maneuvers, except this time I'm looking for the junction of the inferior pubic ramus with the body of the pubic bone. With my finger in the paravaginal space, I dissect any intervening tissue away from the fascia of the obturator internus muscle at this junction. I also ensure that the bladder is mobilized away from the central portion of the anterior vaginal epithelium, so that the proximal portion of the mesh—an apical flap—can be attached to the apex of the vagina. (This apical flap also helps repair the anterior enterocele that usually exists with the cystocele.)
When the dissection is complete, I have two cannulas in place on each side, each holding a retrieval device. To attach the mesh, I first place a delayed absorbable suture into the vesicovaginal space through the apex of the vagina, and attach the apical portion of the mesh onto the suture.
I then place each posterolateral, or deep, arm of the mesh by passing about 1 cm of the end of the arm through the loop of the retrieval device, and then pulling the loop back through the cannula. During these maneuvers, we must be sure that no tissue becomes caught in the mesh or the retrieval device loop. The superficial arms of the mesh are then similarly placed.
At this point, I remove the Foley catheter, inject about 300 cc of sterile water into the bladder, and use a 70-degree cystoscope to look through the urethra and into the bladder to confirm the absence of any mesh, perforation, or other injury to the bladder. I also check the functioning of the ureters, and check for any pathology in the bladder. I then empty the bladder and reinsert the Foley catheter before proceeding to finish the mesh placement.
The key to successful mesh placement—and a reduced risk of mesh erosion—lies in placing the mesh loosely in the vesico-vaginal space.
I try to ensure loose placement by lifting up the mesh as I'm removing the cannula so that I can feel the back of the pubic bone. During cannula removal, you can also ensure that the edge of the mesh is at least one finger's breadth away from the pelvic side wall.
Loose placement of the mesh is necessary because the mesh-scar tissue complex that forms will shrink by about 25%–30%. If the mesh is too tight, the risk of erosion and exposure of that mesh to the anterior vaginal wall will rise significantly. It may even appear (if you look into the vagina at the end of the procedure) as if the patient still has a first- or second-degree cystocele. This is fine. Your goal is to have an anterior vaginal wall that is well supported but not straight and tight.
I close the incisions using a running, interlocking Vicryl stitch. I also use vaginal packing for 24 hours, and I send the patient home after the packing and Foley catheter are removed.
The vaginal packing is another key feature of this procedure, as it helps to prevent hematoma formation, which can lead to mesh erosion. It also facilitates the adherence of the mesh to the back of the vaginal epithelium. From my experience, 24 hours is all that is needed.
Most of my patients have reported pain levels of about 3 out of 10, and some are fine with an NSAID. Some are given ketorolac (Toradol) for several days, and others who have more severe pain may be given a conventional narcotic. Patients are seen in the office 2 weeks later and are counseled to call earlier in the case of a high fever, increased vaginal bleeding other than spotting, or significant pain.
Some physicians send patients home with instructions to use vaginal dilators on a daily basis in order to keep the mesh as pliable as possible as it integrates into the scar tissue that forms, but we don't have any studies on the effects of such a recommendation.
Posterior Prolapse Repair
If you are looking at the posterior vaginal wall, the lower third of the vagina overlies the perineal body, and the upper two-thirds overlie the rectum. A full-thickness incision is made either vertically in the middle third of the posterior vaginal wall or transversely through the vaginal epithelium at the junction of the middle-third and lower-third of the vagina.
Using curved Mayo scissors or my finger, I mobilize the rectum away from the vaginal epithelium. I then slide my finger laterally until I feel the iliococcygeus muscle, at which point I gently dissect down until I feel the ischial spine. Any filmy tissue on the sacrospinous ligament should be wiped away medially from the ischial spine at this point.
I also mobilize the rectum away from the underside of the posterior vaginal wall to allow access to the apex of the vagina. Just as with the anterior surgery, all of this dissection should involve minimal blood loss (no more than 50 cc).
The 5-mm incisions for passage of the cannula-equipped guides are made through the skin of the buttocks at 3 cm lateral and 3 cm posterior to the anus. I like to have the patient's back parallel to the floor and to lower the table accordingly so the cannula-equipped guide can be pushed straight in and the tip advanced toward the underside of the sacrospinous ligament.
Again, anatomical landmarks provide significant guidance. As I push the cannula-equipped guide through the ischioanal fossa with one hand, my nondominant finger is on the ischial spine waiting to feel the tip. (If the tip cannot be felt, you can stop and drop the handle of the guide, which will bring the tip up to where it can be felt through the levator ani muscle.)
The goal is to bring the tip of the guide up through the sacrospinous ligament into the dissected rectovaginal space. We want to be sure the tip is at least 2 cm medial to the ischial spine and 1 cm above the lower edge of the sacrospinous ligament. This keeps us far enough away from the pudendal nerve and the internal pudendal artery and vein that travel right underneath the ischial spine along the side wall of the pelvis, and away from the interior gluteal artery nerve and vein that travel near the upper edge of the sacrospinous ligament.
The posterior mesh is positioned by using techniques similar to those of an anterior repair. Again, I find that a dull curette is helpful for capturing the retrieval device.
After the mesh arms are placed, I examine the rectum to make sure there isn't any mesh perforating into the rectum or injury to the rectum. And just as with the anterior repair, the mesh must be placed loosely in the rectovaginal space to minimize erosion.
I often trim a bit of the mesh at the distal end and then place that end in the rectovaginal space to ensure its proximity to the apex of the perineal body. Again, I close the incision with a running interlocking stitch and use vaginal packing for 24 hours. I also often perform a perineorrhaphy to repair the perineal body and help with vaginal support.
When I first started using the Prolift transvaginal mesh kits, my erosion rate (when the mesh could be seen or felt through the vagina) was about 4%. Now, it is about 1%.
The Prolift mesh kit contains loosely woven polypropylene mesh, cannulas, a metal guide, and blue retrieval devices. ©ETHICON, INC.
Vaginal support anatomy: The pubocervical fascia is fused with the anterior vaginal wall and attached to each uterosacral ligament. The bladder passively rests on this “hammock.” ©Elsevier, Clinical Gynecology, Churchill Livingstone 2006
The surgeon's blue-gloved finger is near the right ischial spine; the white cannula traverses the obturator internus muscle. ©ETHICON, INC.
The mesh is placed in the vesicovaginal space and the arms are anchored through the obturator membranes. ©ETHICON, INC.
Synthetic Mesh
In the United States from 2005 to 2007, a reported total of 994,890 surgeries—363,000 procedures for pelvic floor prolapse and 631,890 procedures for stress urinary incontinence—utilized synthetic mesh. The impetus for mesh usage was based on the fact that conventional pelvic floor prolapse repair has an estimated failure rate of 30%–50%.
In October 2008, a Public Health Notification was issued by the Food and Drug Administration regarding complications with the transvaginal placement of surgical mesh for pelvic floor prolapse and stress urinary incontinence. Over a 3-year period, the FDA has received more than 1,000 reports of serious mesh-related complications from nine manufacturers. The most frequent complications included erosion through vaginal epithelium, infection, pain, urinary problems, and recurrence. Additional complications were noted due to bowel, bladder, and blood vessel perforation. In some cases, vaginal scarring and erosion led to decreased quality of life.
Because of the concerns noted above, I believe it is essential to review the proper technique that is involved with synthetic mesh placement for pelvic floor prolapse.
I have asked Dr. Robert M. Rogers to author this Master Class in Gynecologic Surgery. Dr. Rogers currently is in private practice in Kalispell, Mont. Committed to teaching, he serves as the chairman of the education committee of the Society of Gynecologic Surgeons. Not only is Dr. Rogers well known for his surgical prowess, especially in pelvic floor prolapse, but he also has lectured and written extensively on pelvic floor anatomy.
This Master Class will be a lesson not only in pelvic prolapse surgery, but in pelvic anatomy as well.
About one of every nine women in the United States will have surgery for a vaginal support defect (pelvic organ prolapse). Our armamentarium of surgical options for helping these patients now includes improved mesh designs and new synthetic mesh kits for transvaginal repair.
The development of synthetic mesh is important, as we have learned over the years that some women have visceral connective tissues (the connective tissues that support the vagina, bladder, and rectum) that are not strong enough to maintain a conventional surgical repair. We have learned, moreover, that surgical repairs utilizing the patient's native tissue too often do not last: Failure rates of 20%–50% have been reported.
Although it's still unclear what constitutes the “perfect mesh,” we have found that the use of a permanent, loosely woven polypropylene mesh can improve our operative results and significantly decrease the failure rates of our reparative vaginal surgery in women with vaginal support defects.
The failure of previous conventional reparative surgery for vaginal support defects is a clear indication for mesh. I operate on many patients who have recurrences of prolapse, and most of the time I use a permanent polypropylene mesh. For almost 4 years, I have been using the transvaginal Prolift systems for anterior, posterior, and total pelvic floor repair; other gynecologic surgeons favor different mesh kits that are currently available.
In October 2008, the Food and Drug Administration issued a Public Health Notification saying that it had received over 1,000 reports from surgical mesh manufacturers of complications associated with mesh devices that are used to repair pelvic organ prolapse and stress urinary incontinence. The warning lists the most frequent complications, such as erosion through vaginal epithelium, infection, pain, and urinary problems. However, the warning does not report which meshes were used—some meshes have been taken off the market—or provide a denominator of the number of total mesh placements.
The warning serves as a reminder of what gynecologic surgeons have advocated thus far: the need for significant experience in reparative vaginal surgery before using mesh implants. It is only in the last 10–15 years that gynecologic surgeons have acquired a detailed understanding of vaginal support anatomy, and of what happens to that anatomy to cause vaginal support defects.
To use mesh kits, the physician must both understand this anatomy and the variability in patients' connective tissues, and have experience in dissection techniques and the safe development of the proper dissection planes between the bladder and vagina, between the rectum and vagina, at the vaginal apex, and in the paravaginal and pararectal areas.
We must be able to dissect without causing undue bleeding or injury, and we must know how to minimize the exposure or erosion of mesh, which is usually through the vaginal wall. (Erosion of the mesh into the bladder or rectum is very rare.) Fortunately, we have access in the postgraduate arena to human cadaver courses that can give us valuable experience.
I have had very few complications in using mesh kits for pelvic floor repair, but I always tell patients that they have a 5% risk of infection, rejection of the mesh, or erosion or exposure of the mesh, as well as a 5%–10% chance of developing dyspareunia. I inform them, of course, that implantation of the mesh is permanent. And I always ask the patient to work with me in diagnosing or resolving any problem, complication, or unexpected outcome if it occurs.
Preparing for the Procedure
I use permanent polypropylene mesh for patients who have a recurring, symptomatic vaginal support defect. Even after the vagina is estrogenized, the vaginal wall in these patients is smooth and lacks the transverse ripples that are indicative, theoretically, of healthy connective tissue that could itself be used for repair.
The Prolift system that I use comprises precut nonabsorbable mesh implants (different precut implants for anterior, posterior, and total repairs) and a set of instruments (anatomical guides and retrieval devices with cannulas) to facilitate mesh placement.
The patient is placed in the dorsal lithotomy position, with her thighs at about 80 degrees to horizontal. She is not overly abducted, and her sacrum is well padded. I recommend using boot-type stirrups. A Foley catheter is inserted.
At 1 hour before anesthesia is administered, I give the patient a dose of prophylactic antibiotic. So far, I have not seen infection from mesh in any of the hundreds of Prolift procedures I've performed.
Anterior Prolapse Repair
The use of anatomical landmarks is critical to the mastery of dissection techniques.
For repair of an anterior vaginal prolapse (a cystocele), the two most important landmarks are the ischial spine and the junction of the inferior pubic ramus with the body of the pubic bone. This is because the “white line” of para-vaginal support goes from one of these points to the other. The anatomical orientation of the anterior vaginal wall must also be delineated. Overlying the lower third is the urethra, and overlying the middle third is the trigone of the bladder, an area of significant innervation. Overlying the upper third of the anterior vaginal wall is the bladder itself. The ureters travel across this upper third from lateral to medial, entering the bladder at the junction of the middle third and the upper third of the vagina.
A 3-cm anterior colpotomy incision is made in the upper third of the vagina. We stay away from the middle of the anterior vaginal wall so that innervation to the bladder is not disrupted, and so that the area underneath the urethra remains fresh for placement of a midurethral transvaginal tape, if needed.
The incision to the anterior vaginal wall should be a full-thickness incision that leaves the white, shiny pubo-cervical fascia on the back of the vaginal epithelium. Once you pass through this fascia, you are in the true vesicovaginal space, and the visceral fascia that surrounds the bladder can be seen.
A curved Mayo scissors, or your finger, can then be used to gently develop the lateral space between the bladder and the vaginal epithelium. There should be minimal bleeding. (If there is more than minimal bleeding, you're either in the wrong dissection plane or you're encountering significant scar tissue from your patient's previous surgery.)
Your goal is to work laterally, so that you can actually feel the tough parietal fascia that covers the obturator muscles.
When you feel the junction of the inferior pubic ramus with the body of the pubic bone—one of the two most important landmarks—you then can slide your finger along the obturator internus fascia right down to the ischial spine. That distance is only about 5–6 cm. By doing so on both sides, the bladder is mobilized away from the anterior vaginal epithelium, and the bladder and ureters are mobilized away from the pelvic side walls. Again, there should be minimal blood loss (no more than 50 cc).
The cannula-equipped curved metal guides must then be passed through the inner thighs. A first incision (no more than 5 mm) is made at the level of the urethra, about 1 cm lateral to the inferior pubic ramus, which you can palpate through the skin of the thigh. This is for the anteromedial, or superficial, passage. The second incision (of the same size) is made at 1 cm lateral and 2 cm posterior to the first mark. This is for the posterolateral, or deep, passage. I always work through the deep passage first. With its tip perpendicular to the skin, I push the cannula-equipped guide straight in until I feel the tip pop through the fascia lata. I then bring the handle of the guide up, so that the directional force is parallel to the fascial white line.
The goal in this deep passage is to pass the guide through the posterior aspect of the obturator membrane and through the obturator internus muscle so that the tip of the cannula is about 1 cm inferior (and a bit anterior) to the ischial spine as it pops through the muscle into the paravaginal space. My finger waits there to feel the tip pass through the fascia of the obturator internus muscle. I then feed a small dull curette into the paravaginal space with my finger and slip it over the cannula, and my assistant carefully removes the guide.
The retrieval device—a piece of long plastic tubing, in essence, with a loop at the end—can then be passed through the cannula. When I feel the loop come through, I entrap it against the end of the curette and pull both the loop and the retrieval device out of the vagina. (Some surgeons hook the loop with a finger, but I find the curette helpful.)
The superficial passage involves the same maneuvers, except this time I'm looking for the junction of the inferior pubic ramus with the body of the pubic bone. With my finger in the paravaginal space, I dissect any intervening tissue away from the fascia of the obturator internus muscle at this junction. I also ensure that the bladder is mobilized away from the central portion of the anterior vaginal epithelium, so that the proximal portion of the mesh—an apical flap—can be attached to the apex of the vagina. (This apical flap also helps repair the anterior enterocele that usually exists with the cystocele.)
When the dissection is complete, I have two cannulas in place on each side, each holding a retrieval device. To attach the mesh, I first place a delayed absorbable suture into the vesicovaginal space through the apex of the vagina, and attach the apical portion of the mesh onto the suture.
I then place each posterolateral, or deep, arm of the mesh by passing about 1 cm of the end of the arm through the loop of the retrieval device, and then pulling the loop back through the cannula. During these maneuvers, we must be sure that no tissue becomes caught in the mesh or the retrieval device loop. The superficial arms of the mesh are then similarly placed.
At this point, I remove the Foley catheter, inject about 300 cc of sterile water into the bladder, and use a 70-degree cystoscope to look through the urethra and into the bladder to confirm the absence of any mesh, perforation, or other injury to the bladder. I also check the functioning of the ureters, and check for any pathology in the bladder. I then empty the bladder and reinsert the Foley catheter before proceeding to finish the mesh placement.
The key to successful mesh placement—and a reduced risk of mesh erosion—lies in placing the mesh loosely in the vesico-vaginal space.
I try to ensure loose placement by lifting up the mesh as I'm removing the cannula so that I can feel the back of the pubic bone. During cannula removal, you can also ensure that the edge of the mesh is at least one finger's breadth away from the pelvic side wall.
Loose placement of the mesh is necessary because the mesh-scar tissue complex that forms will shrink by about 25%–30%. If the mesh is too tight, the risk of erosion and exposure of that mesh to the anterior vaginal wall will rise significantly. It may even appear (if you look into the vagina at the end of the procedure) as if the patient still has a first- or second-degree cystocele. This is fine. Your goal is to have an anterior vaginal wall that is well supported but not straight and tight.
I close the incisions using a running, interlocking Vicryl stitch. I also use vaginal packing for 24 hours, and I send the patient home after the packing and Foley catheter are removed.
The vaginal packing is another key feature of this procedure, as it helps to prevent hematoma formation, which can lead to mesh erosion. It also facilitates the adherence of the mesh to the back of the vaginal epithelium. From my experience, 24 hours is all that is needed.
Most of my patients have reported pain levels of about 3 out of 10, and some are fine with an NSAID. Some are given ketorolac (Toradol) for several days, and others who have more severe pain may be given a conventional narcotic. Patients are seen in the office 2 weeks later and are counseled to call earlier in the case of a high fever, increased vaginal bleeding other than spotting, or significant pain.
Some physicians send patients home with instructions to use vaginal dilators on a daily basis in order to keep the mesh as pliable as possible as it integrates into the scar tissue that forms, but we don't have any studies on the effects of such a recommendation.
Posterior Prolapse Repair
If you are looking at the posterior vaginal wall, the lower third of the vagina overlies the perineal body, and the upper two-thirds overlie the rectum. A full-thickness incision is made either vertically in the middle third of the posterior vaginal wall or transversely through the vaginal epithelium at the junction of the middle-third and lower-third of the vagina.
Using curved Mayo scissors or my finger, I mobilize the rectum away from the vaginal epithelium. I then slide my finger laterally until I feel the iliococcygeus muscle, at which point I gently dissect down until I feel the ischial spine. Any filmy tissue on the sacrospinous ligament should be wiped away medially from the ischial spine at this point.
I also mobilize the rectum away from the underside of the posterior vaginal wall to allow access to the apex of the vagina. Just as with the anterior surgery, all of this dissection should involve minimal blood loss (no more than 50 cc).
The 5-mm incisions for passage of the cannula-equipped guides are made through the skin of the buttocks at 3 cm lateral and 3 cm posterior to the anus. I like to have the patient's back parallel to the floor and to lower the table accordingly so the cannula-equipped guide can be pushed straight in and the tip advanced toward the underside of the sacrospinous ligament.
Again, anatomical landmarks provide significant guidance. As I push the cannula-equipped guide through the ischioanal fossa with one hand, my nondominant finger is on the ischial spine waiting to feel the tip. (If the tip cannot be felt, you can stop and drop the handle of the guide, which will bring the tip up to where it can be felt through the levator ani muscle.)
The goal is to bring the tip of the guide up through the sacrospinous ligament into the dissected rectovaginal space. We want to be sure the tip is at least 2 cm medial to the ischial spine and 1 cm above the lower edge of the sacrospinous ligament. This keeps us far enough away from the pudendal nerve and the internal pudendal artery and vein that travel right underneath the ischial spine along the side wall of the pelvis, and away from the interior gluteal artery nerve and vein that travel near the upper edge of the sacrospinous ligament.
The posterior mesh is positioned by using techniques similar to those of an anterior repair. Again, I find that a dull curette is helpful for capturing the retrieval device.
After the mesh arms are placed, I examine the rectum to make sure there isn't any mesh perforating into the rectum or injury to the rectum. And just as with the anterior repair, the mesh must be placed loosely in the rectovaginal space to minimize erosion.
I often trim a bit of the mesh at the distal end and then place that end in the rectovaginal space to ensure its proximity to the apex of the perineal body. Again, I close the incision with a running interlocking stitch and use vaginal packing for 24 hours. I also often perform a perineorrhaphy to repair the perineal body and help with vaginal support.
When I first started using the Prolift transvaginal mesh kits, my erosion rate (when the mesh could be seen or felt through the vagina) was about 4%. Now, it is about 1%.
The Prolift mesh kit contains loosely woven polypropylene mesh, cannulas, a metal guide, and blue retrieval devices. ©ETHICON, INC.
Vaginal support anatomy: The pubocervical fascia is fused with the anterior vaginal wall and attached to each uterosacral ligament. The bladder passively rests on this “hammock.” ©Elsevier, Clinical Gynecology, Churchill Livingstone 2006
The surgeon's blue-gloved finger is near the right ischial spine; the white cannula traverses the obturator internus muscle. ©ETHICON, INC.
The mesh is placed in the vesicovaginal space and the arms are anchored through the obturator membranes. ©ETHICON, INC.
Synthetic Mesh
In the United States from 2005 to 2007, a reported total of 994,890 surgeries—363,000 procedures for pelvic floor prolapse and 631,890 procedures for stress urinary incontinence—utilized synthetic mesh. The impetus for mesh usage was based on the fact that conventional pelvic floor prolapse repair has an estimated failure rate of 30%–50%.
In October 2008, a Public Health Notification was issued by the Food and Drug Administration regarding complications with the transvaginal placement of surgical mesh for pelvic floor prolapse and stress urinary incontinence. Over a 3-year period, the FDA has received more than 1,000 reports of serious mesh-related complications from nine manufacturers. The most frequent complications included erosion through vaginal epithelium, infection, pain, urinary problems, and recurrence. Additional complications were noted due to bowel, bladder, and blood vessel perforation. In some cases, vaginal scarring and erosion led to decreased quality of life.
Because of the concerns noted above, I believe it is essential to review the proper technique that is involved with synthetic mesh placement for pelvic floor prolapse.
I have asked Dr. Robert M. Rogers to author this Master Class in Gynecologic Surgery. Dr. Rogers currently is in private practice in Kalispell, Mont. Committed to teaching, he serves as the chairman of the education committee of the Society of Gynecologic Surgeons. Not only is Dr. Rogers well known for his surgical prowess, especially in pelvic floor prolapse, but he also has lectured and written extensively on pelvic floor anatomy.
This Master Class will be a lesson not only in pelvic prolapse surgery, but in pelvic anatomy as well.
About one of every nine women in the United States will have surgery for a vaginal support defect (pelvic organ prolapse). Our armamentarium of surgical options for helping these patients now includes improved mesh designs and new synthetic mesh kits for transvaginal repair.
The development of synthetic mesh is important, as we have learned over the years that some women have visceral connective tissues (the connective tissues that support the vagina, bladder, and rectum) that are not strong enough to maintain a conventional surgical repair. We have learned, moreover, that surgical repairs utilizing the patient's native tissue too often do not last: Failure rates of 20%–50% have been reported.
Although it's still unclear what constitutes the “perfect mesh,” we have found that the use of a permanent, loosely woven polypropylene mesh can improve our operative results and significantly decrease the failure rates of our reparative vaginal surgery in women with vaginal support defects.
The failure of previous conventional reparative surgery for vaginal support defects is a clear indication for mesh. I operate on many patients who have recurrences of prolapse, and most of the time I use a permanent polypropylene mesh. For almost 4 years, I have been using the transvaginal Prolift systems for anterior, posterior, and total pelvic floor repair; other gynecologic surgeons favor different mesh kits that are currently available.
In October 2008, the Food and Drug Administration issued a Public Health Notification saying that it had received over 1,000 reports from surgical mesh manufacturers of complications associated with mesh devices that are used to repair pelvic organ prolapse and stress urinary incontinence. The warning lists the most frequent complications, such as erosion through vaginal epithelium, infection, pain, and urinary problems. However, the warning does not report which meshes were used—some meshes have been taken off the market—or provide a denominator of the number of total mesh placements.
The warning serves as a reminder of what gynecologic surgeons have advocated thus far: the need for significant experience in reparative vaginal surgery before using mesh implants. It is only in the last 10–15 years that gynecologic surgeons have acquired a detailed understanding of vaginal support anatomy, and of what happens to that anatomy to cause vaginal support defects.
To use mesh kits, the physician must both understand this anatomy and the variability in patients' connective tissues, and have experience in dissection techniques and the safe development of the proper dissection planes between the bladder and vagina, between the rectum and vagina, at the vaginal apex, and in the paravaginal and pararectal areas.
We must be able to dissect without causing undue bleeding or injury, and we must know how to minimize the exposure or erosion of mesh, which is usually through the vaginal wall. (Erosion of the mesh into the bladder or rectum is very rare.) Fortunately, we have access in the postgraduate arena to human cadaver courses that can give us valuable experience.
I have had very few complications in using mesh kits for pelvic floor repair, but I always tell patients that they have a 5% risk of infection, rejection of the mesh, or erosion or exposure of the mesh, as well as a 5%–10% chance of developing dyspareunia. I inform them, of course, that implantation of the mesh is permanent. And I always ask the patient to work with me in diagnosing or resolving any problem, complication, or unexpected outcome if it occurs.
Preparing for the Procedure
I use permanent polypropylene mesh for patients who have a recurring, symptomatic vaginal support defect. Even after the vagina is estrogenized, the vaginal wall in these patients is smooth and lacks the transverse ripples that are indicative, theoretically, of healthy connective tissue that could itself be used for repair.
The Prolift system that I use comprises precut nonabsorbable mesh implants (different precut implants for anterior, posterior, and total repairs) and a set of instruments (anatomical guides and retrieval devices with cannulas) to facilitate mesh placement.
The patient is placed in the dorsal lithotomy position, with her thighs at about 80 degrees to horizontal. She is not overly abducted, and her sacrum is well padded. I recommend using boot-type stirrups. A Foley catheter is inserted.
At 1 hour before anesthesia is administered, I give the patient a dose of prophylactic antibiotic. So far, I have not seen infection from mesh in any of the hundreds of Prolift procedures I've performed.
Anterior Prolapse Repair
The use of anatomical landmarks is critical to the mastery of dissection techniques.
For repair of an anterior vaginal prolapse (a cystocele), the two most important landmarks are the ischial spine and the junction of the inferior pubic ramus with the body of the pubic bone. This is because the “white line” of para-vaginal support goes from one of these points to the other. The anatomical orientation of the anterior vaginal wall must also be delineated. Overlying the lower third is the urethra, and overlying the middle third is the trigone of the bladder, an area of significant innervation. Overlying the upper third of the anterior vaginal wall is the bladder itself. The ureters travel across this upper third from lateral to medial, entering the bladder at the junction of the middle third and the upper third of the vagina.
A 3-cm anterior colpotomy incision is made in the upper third of the vagina. We stay away from the middle of the anterior vaginal wall so that innervation to the bladder is not disrupted, and so that the area underneath the urethra remains fresh for placement of a midurethral transvaginal tape, if needed.
The incision to the anterior vaginal wall should be a full-thickness incision that leaves the white, shiny pubo-cervical fascia on the back of the vaginal epithelium. Once you pass through this fascia, you are in the true vesicovaginal space, and the visceral fascia that surrounds the bladder can be seen.
A curved Mayo scissors, or your finger, can then be used to gently develop the lateral space between the bladder and the vaginal epithelium. There should be minimal bleeding. (If there is more than minimal bleeding, you're either in the wrong dissection plane or you're encountering significant scar tissue from your patient's previous surgery.)
Your goal is to work laterally, so that you can actually feel the tough parietal fascia that covers the obturator muscles.
When you feel the junction of the inferior pubic ramus with the body of the pubic bone—one of the two most important landmarks—you then can slide your finger along the obturator internus fascia right down to the ischial spine. That distance is only about 5–6 cm. By doing so on both sides, the bladder is mobilized away from the anterior vaginal epithelium, and the bladder and ureters are mobilized away from the pelvic side walls. Again, there should be minimal blood loss (no more than 50 cc).
The cannula-equipped curved metal guides must then be passed through the inner thighs. A first incision (no more than 5 mm) is made at the level of the urethra, about 1 cm lateral to the inferior pubic ramus, which you can palpate through the skin of the thigh. This is for the anteromedial, or superficial, passage. The second incision (of the same size) is made at 1 cm lateral and 2 cm posterior to the first mark. This is for the posterolateral, or deep, passage. I always work through the deep passage first. With its tip perpendicular to the skin, I push the cannula-equipped guide straight in until I feel the tip pop through the fascia lata. I then bring the handle of the guide up, so that the directional force is parallel to the fascial white line.
The goal in this deep passage is to pass the guide through the posterior aspect of the obturator membrane and through the obturator internus muscle so that the tip of the cannula is about 1 cm inferior (and a bit anterior) to the ischial spine as it pops through the muscle into the paravaginal space. My finger waits there to feel the tip pass through the fascia of the obturator internus muscle. I then feed a small dull curette into the paravaginal space with my finger and slip it over the cannula, and my assistant carefully removes the guide.
The retrieval device—a piece of long plastic tubing, in essence, with a loop at the end—can then be passed through the cannula. When I feel the loop come through, I entrap it against the end of the curette and pull both the loop and the retrieval device out of the vagina. (Some surgeons hook the loop with a finger, but I find the curette helpful.)
The superficial passage involves the same maneuvers, except this time I'm looking for the junction of the inferior pubic ramus with the body of the pubic bone. With my finger in the paravaginal space, I dissect any intervening tissue away from the fascia of the obturator internus muscle at this junction. I also ensure that the bladder is mobilized away from the central portion of the anterior vaginal epithelium, so that the proximal portion of the mesh—an apical flap—can be attached to the apex of the vagina. (This apical flap also helps repair the anterior enterocele that usually exists with the cystocele.)
When the dissection is complete, I have two cannulas in place on each side, each holding a retrieval device. To attach the mesh, I first place a delayed absorbable suture into the vesicovaginal space through the apex of the vagina, and attach the apical portion of the mesh onto the suture.
I then place each posterolateral, or deep, arm of the mesh by passing about 1 cm of the end of the arm through the loop of the retrieval device, and then pulling the loop back through the cannula. During these maneuvers, we must be sure that no tissue becomes caught in the mesh or the retrieval device loop. The superficial arms of the mesh are then similarly placed.
At this point, I remove the Foley catheter, inject about 300 cc of sterile water into the bladder, and use a 70-degree cystoscope to look through the urethra and into the bladder to confirm the absence of any mesh, perforation, or other injury to the bladder. I also check the functioning of the ureters, and check for any pathology in the bladder. I then empty the bladder and reinsert the Foley catheter before proceeding to finish the mesh placement.
The key to successful mesh placement—and a reduced risk of mesh erosion—lies in placing the mesh loosely in the vesico-vaginal space.
I try to ensure loose placement by lifting up the mesh as I'm removing the cannula so that I can feel the back of the pubic bone. During cannula removal, you can also ensure that the edge of the mesh is at least one finger's breadth away from the pelvic side wall.
Loose placement of the mesh is necessary because the mesh-scar tissue complex that forms will shrink by about 25%–30%. If the mesh is too tight, the risk of erosion and exposure of that mesh to the anterior vaginal wall will rise significantly. It may even appear (if you look into the vagina at the end of the procedure) as if the patient still has a first- or second-degree cystocele. This is fine. Your goal is to have an anterior vaginal wall that is well supported but not straight and tight.
I close the incisions using a running, interlocking Vicryl stitch. I also use vaginal packing for 24 hours, and I send the patient home after the packing and Foley catheter are removed.
The vaginal packing is another key feature of this procedure, as it helps to prevent hematoma formation, which can lead to mesh erosion. It also facilitates the adherence of the mesh to the back of the vaginal epithelium. From my experience, 24 hours is all that is needed.
Most of my patients have reported pain levels of about 3 out of 10, and some are fine with an NSAID. Some are given ketorolac (Toradol) for several days, and others who have more severe pain may be given a conventional narcotic. Patients are seen in the office 2 weeks later and are counseled to call earlier in the case of a high fever, increased vaginal bleeding other than spotting, or significant pain.
Some physicians send patients home with instructions to use vaginal dilators on a daily basis in order to keep the mesh as pliable as possible as it integrates into the scar tissue that forms, but we don't have any studies on the effects of such a recommendation.
Posterior Prolapse Repair
If you are looking at the posterior vaginal wall, the lower third of the vagina overlies the perineal body, and the upper two-thirds overlie the rectum. A full-thickness incision is made either vertically in the middle third of the posterior vaginal wall or transversely through the vaginal epithelium at the junction of the middle-third and lower-third of the vagina.
Using curved Mayo scissors or my finger, I mobilize the rectum away from the vaginal epithelium. I then slide my finger laterally until I feel the iliococcygeus muscle, at which point I gently dissect down until I feel the ischial spine. Any filmy tissue on the sacrospinous ligament should be wiped away medially from the ischial spine at this point.
I also mobilize the rectum away from the underside of the posterior vaginal wall to allow access to the apex of the vagina. Just as with the anterior surgery, all of this dissection should involve minimal blood loss (no more than 50 cc).
The 5-mm incisions for passage of the cannula-equipped guides are made through the skin of the buttocks at 3 cm lateral and 3 cm posterior to the anus. I like to have the patient's back parallel to the floor and to lower the table accordingly so the cannula-equipped guide can be pushed straight in and the tip advanced toward the underside of the sacrospinous ligament.
Again, anatomical landmarks provide significant guidance. As I push the cannula-equipped guide through the ischioanal fossa with one hand, my nondominant finger is on the ischial spine waiting to feel the tip. (If the tip cannot be felt, you can stop and drop the handle of the guide, which will bring the tip up to where it can be felt through the levator ani muscle.)
The goal is to bring the tip of the guide up through the sacrospinous ligament into the dissected rectovaginal space. We want to be sure the tip is at least 2 cm medial to the ischial spine and 1 cm above the lower edge of the sacrospinous ligament. This keeps us far enough away from the pudendal nerve and the internal pudendal artery and vein that travel right underneath the ischial spine along the side wall of the pelvis, and away from the interior gluteal artery nerve and vein that travel near the upper edge of the sacrospinous ligament.
The posterior mesh is positioned by using techniques similar to those of an anterior repair. Again, I find that a dull curette is helpful for capturing the retrieval device.
After the mesh arms are placed, I examine the rectum to make sure there isn't any mesh perforating into the rectum or injury to the rectum. And just as with the anterior repair, the mesh must be placed loosely in the rectovaginal space to minimize erosion.
I often trim a bit of the mesh at the distal end and then place that end in the rectovaginal space to ensure its proximity to the apex of the perineal body. Again, I close the incision with a running interlocking stitch and use vaginal packing for 24 hours. I also often perform a perineorrhaphy to repair the perineal body and help with vaginal support.
When I first started using the Prolift transvaginal mesh kits, my erosion rate (when the mesh could be seen or felt through the vagina) was about 4%. Now, it is about 1%.
The Prolift mesh kit contains loosely woven polypropylene mesh, cannulas, a metal guide, and blue retrieval devices. ©ETHICON, INC.
Vaginal support anatomy: The pubocervical fascia is fused with the anterior vaginal wall and attached to each uterosacral ligament. The bladder passively rests on this “hammock.” ©Elsevier, Clinical Gynecology, Churchill Livingstone 2006
The surgeon's blue-gloved finger is near the right ischial spine; the white cannula traverses the obturator internus muscle. ©ETHICON, INC.
The mesh is placed in the vesicovaginal space and the arms are anchored through the obturator membranes. ©ETHICON, INC.
Synthetic Mesh
In the United States from 2005 to 2007, a reported total of 994,890 surgeries—363,000 procedures for pelvic floor prolapse and 631,890 procedures for stress urinary incontinence—utilized synthetic mesh. The impetus for mesh usage was based on the fact that conventional pelvic floor prolapse repair has an estimated failure rate of 30%–50%.
In October 2008, a Public Health Notification was issued by the Food and Drug Administration regarding complications with the transvaginal placement of surgical mesh for pelvic floor prolapse and stress urinary incontinence. Over a 3-year period, the FDA has received more than 1,000 reports of serious mesh-related complications from nine manufacturers. The most frequent complications included erosion through vaginal epithelium, infection, pain, urinary problems, and recurrence. Additional complications were noted due to bowel, bladder, and blood vessel perforation. In some cases, vaginal scarring and erosion led to decreased quality of life.
Because of the concerns noted above, I believe it is essential to review the proper technique that is involved with synthetic mesh placement for pelvic floor prolapse.
I have asked Dr. Robert M. Rogers to author this Master Class in Gynecologic Surgery. Dr. Rogers currently is in private practice in Kalispell, Mont. Committed to teaching, he serves as the chairman of the education committee of the Society of Gynecologic Surgeons. Not only is Dr. Rogers well known for his surgical prowess, especially in pelvic floor prolapse, but he also has lectured and written extensively on pelvic floor anatomy.
This Master Class will be a lesson not only in pelvic prolapse surgery, but in pelvic anatomy as well.
Robotic Technology Overcomes Previous Limitations
The tepid response is due largely to conventional laparoscopy having significant drawbacks. In a standing position, surgeons use a flat, 2-D image and instruments that are long and nonarticulating. Motions are counterintuitive and the learning curve, consequently, is long.
With the robotic technology currently available, such limitations are largely overcome. Advantages of the technology include a 3-D view, an increase in instrument “wrist” mobility from four to seven degrees, and movements that are significantly more intuitive.
These improvements facilitate better vision, easier suturing, and more precise dissection of tissue around sensitive areas such as major blood vessels and the ureters. And because the surgeon sits at a console unit instead of in an awkward position at the operating table, surgeon fatigue is significantly reduced.
This merging of the advantages of laparotomy and laparoscopy—and the more precise gynecologic surgery that results—is changing lymphadenectomy just as it is other types of gynecologic surgery.
The first laparoscopic radical hysterectomy was performed in June 1986; however, until recently, fewer than 1,000 cases of laparoscopic radical hysterectomy with lymphadenectomy had been reported. Now, with the availability of the da Vinci robotic system, more and more gynecologic oncologists in both teaching and community hospitals are routinely performing this procedure and other lymphadenectomies in patients with endometrial, cervical, early ovarian, fallopian tube, and other gynecologic malignancies.
In fellowship training programs specifically, the application of the technology has increased the usage of laparoscopy in gynecologic oncology—with learning curves documented as being significantly shorter than the learning curves associated with conventional laparoscopy.
Pelvic Lymphadenectomy
In terms of patient selection, there are no more limitations to the use of the robotic approach than with conventional laparoscopy. Robotic lymph node dissection can be offered to all patients for whom laparoscopy is deemed appropriate. It is advantageous, in fact, for women who are obese since the robotic approach bypasses the fulcrum effect that is especially challenging in patients with a thick abdominal wall.
As with other robotic-assisted gynecologic procedures, robotic lymphadenectomy is performed using the da Vinci system, an integrated computer-based system consisting of three interactive robotic arms and a camera arm with a remote control console. The system is the only robotic device with FDA approval for use in gynecologic surgery at the present time.
For pelvic lymphadenectomy, with the patient under general endotracheal anesthesia, we place our primary robotic trocar (a 12-mm port) through the umbilicus for the laparoscope. Two 8-mm trocars are placed 8–10 cm bilaterally and 2–3 cm lower than the umbilicus. Such placement enables optimal movement of the robotic arms and minimizes the risk of collisions (
A 10- to 12-mm assistant port is then placed on one side (most often the right side) of the umbilicus (between the camera port and one of the 8-mm trocars, 1–2 cm high). Through this port, the assistant can introduce suture and instrumentation used for retraction and suction/irrigation, as well as remove specimens. We use the Harris-Kronner Uterine Manipulator-Injector (Humi) for our gynecologic cancer patients whenever possible. Although some physicians believe its use during either conventional or robotic-assisted laparoscopy may cause dissemination of the cancer, we have found this not to be the case.
In a series of cases in which we performed laparoscopic staging for both cervical and endometrial cancer using the manipulator and compared it with conventional staging through laparotomy, we found no compromise in recurrence or in the survival rate (Int. J. Gynecol. Cancer 2007:17;1075–82 and J. Minim. Invasive Gynecol. 2008:15;181–7).
Once the trocars are placed, the patient is placed in a steep Trendelenburg's position and the robotic tower is docked between the patient's legs. The surgeon sits at a console, and the assistant stands to the patient's left or right side. Occasionally, we use a second assistant—most often when the assistant cannot adequately reach the vagina of an obese patient.
After a survey of the pelvic cavity to rule out any sign of metastases in the abdominal cavity and to identify any associated pathology that needs to be treated, such as adhesions that need to be lysed, we proceed with the lymphadenectomy.
The procedure is usually performed with bipolar forceps placed through the left robotic port, and a monopolar electrosurgical spatula, or scissors, placed through the right port. If necessary, a 10-mm clips applier or blood vessel sealing devices can be placed through the assistant's port.
Pelvic wall dissection involves coagulating and cutting the round ligaments on either side of the pelvic wall and then making an incision over the peritoneum between the infundibular pelvic ligament and the vessels in the pelvic side wall.
The retroperitoneal space is developed and the ureter is identified medially, and if the ovary is to be removed, which is the case in most patients, the infundibular ligament is isolated, desiccated, and divided using the bipolar forceps and scissors.
The paravesical and pararectal spaces are then developed by retracting the umbilical ligament (the superior vesicle artery) medially and performing blunt dissection between this artery and the pelvic side wall.
The obturator nerve can usually be identified at this point, and the obturator fossa nodes and hypogastric lymph nodes can be removed. Occasionally, when the obturator nerve cannot be identified initially, the obturator fossa nodes must be dissected and retracted medially, under the external iliac vein. Then, when the nerve is identified under these lymph nodes using blunt dissection, all nodes from the obturator fossa all the way up to the hypogastric vessels can be resected (
After removing the lymphatic nodes from the obturator fossa and the hypogastric vessels, we remove all nodes along the external iliac vessels from the external common iliac artery down to the deep circumflex vein.
Blunt and sharp dissection performed with the scissors, forceps, and suction irrigator is used for resection of all these nodes, and bipolar and unipolar forceps are used to achieve hemostasis and to clear the lymphatic channels (
This is the same process we follow during conventional laparoscopic lymphadenectomy, except that the conventional laparoscopic approach can be done using ultrasonic shears, which are multifunctional and may lower the risk for tissue damage. With the current da Vinci system, we are limited to using electrosurgery instrumentation for coagulation and cutting, but we have found that these instruments are more than adequate.
Para-Aortic Lymphadenectomy
For para-aortic lymphadenectomies in which node dissection will extend up to the inferior mesenteric artery, the trocar positioning is the same as for pelvic lymphadenectomy.
If node dissection above the inferior mesenteric artery is planned, however, trocar placement must be modified, with the camera port placed approximately 5–8 cm above the umbilicus and the other trocars adjusted accordingly, based on the different camera port placement (
The peritoneum is incised over the right common iliac artery, and the incision is extended cephalad over the inferior vena cava and lower abdominal aorta to the level of the duodenum, above the inferior mesenteric artery. The right ureter should be identified first, with the retroperitoneal space gradually developed toward the left side, and the left ureter then identified (
The assistant port or the fourth arm of the robot is used to retract the ureter or the bowel laterally. The lymph adenectomy starts from below and gradually extends upward toward the insertion of the ovarian vein to the vena cava on the right side and the renal vein on the left side.
The nodes are removed using the same technique as for pelvic lymphadenectomy, with bipolar forceps used as a grasping forceps and for coagulation of the small blood vessels and unipolar forceps used for cutting and achieving hemostasis for these vessels (
Final Steps, Outcomes
In patients also undergoing a hysterectomy, lymphadenectomy can be performed before or after the hysterectomy, depending on the indication.
Lymph nodes dissected with the robotic approach can be stored and removed in a laparoscopic bag that is introduced through the assistant's port. In patients undergoing a hysterectomy, the bag can be stored in the abdomen during the procedure and then removed through the vagina afterward.
After we complete lymphadenectomy, the pelvic cavity is thoroughly irrigated, Seprafilm slurry is applied to prevent adhesions, and all trocar sites are routinely closed. Closing all ports, even the 8-mm sites, is important since a small bowel trocar-site herniation has been reported. We also inject Marcaine in all trocar sites. Depending on the patient's condition, she can be discharged on the same day or after 1 or 2 days.
Gynecologic surgeons have developed various techniques for robotic-assisted laparoscopic lymphadenectomy that include different placement of the trocar sites. We have been performing robotic lymphadenectomy and radical hysterectomy since 2003 and have modified our technique to be as feasible and reproducible as possible.
We recently compared the experiences of 43 women with early cervical cancer who were treated with either robotic radical hysterectomy with pelvic lymphadenectomy or laparoscopic radical hysterectomy with pelvic lymphadenectomy.
The treatments—using either conventional laparoscopy or robotic-assisted laparoscopy—were equivalent with respect to operative time, blood loss, hospital stay, and oncologic outcome. The mean pelvic lymph node count was similar in the two groups (JSLS 2008;12:227–37).
While this analysis did not include cases involving open radical hysterectomy and lymphadenectomy, we know from other series and reports that the number of resected lymph nodes increases with a laparoscopic approach, whether or not it is robotically performed.
In studies in our fellowship training program, moreover, we have found that fellows who have less experience with laparoscopic surgery than attendings achieved the same number of lymph node retrievals as the attendings through either conventional laparoscopic or robotic lymphadenectomy. Such ease and reproducibility portends well for the future of robotic technology in gynecologic oncology.
Some of the major advantages of robotic-assisted surgery are that it provides 3-D views, allows intuitive motions, and involves less operator fatigue. In addition, tremor filtration facilitates more precise movements. It entails a shorter learning curve than does conventional laparoscopy. Robotic-assisted surgery has also paved a pathway to telesurgery and telementoring. This may expand the availability of advanced minimally invasive surgeries throughout the globe.
Dr. Nezhat had no financial conflicts of interest to disclose.
Robotic-Assisted Lymphadenectomy
Despite the early, pioneering efforts of physicians such as Dr. Denis Querleu in France, as well as Dr. Joel Childers and our author, Dr. Farr R. Nezhat, in the United States, the acceptance of laparoscopic surgery by gynecologic oncologists has been lackluster at best. Lately, however, no area of our specialty has shown faster adaptation to minimally invasive surgery than has gynecologic oncology. In fact, secondary to the interest in laparoscopic oncologic procedures, the AAGL has recently created a gynecologic oncology specialty group. Due to his vast experience, Dr. Nezhat has been given a leadership role in this endeavor. It is this editor's belief that the utilization of robotics is the single factor that has created such a rapid movement within the gyne-oncology community to embrace laparoscopic surgery. The 3-D visualization, combined with the seven degrees of motion of robotic instrumentation, has enabled the gynecologic oncologist to work precisely and efficiently. Despite his vast experience in laparoscopic surgery, our guest author was an early convert to robotic-assisted surgery.
Dr. Nezhat is the director of minimally invasive surgery and gynecologic robotics, as well as chief of the gynecologic robotic, minimally invasive surgery fellowship, in the division of gynecologic oncology at St. Luke's-Roosevelt Hospital Center, New York. He has written more than 100 articles in peer-reviewed journals, many of which involve laparoscopic surgery. Dr. Nezhat is truly one of the thought leaders of our specialty. It is an honor to have him write this current column of the Master Class in gynecologic surgery.
The tepid response is due largely to conventional laparoscopy having significant drawbacks. In a standing position, surgeons use a flat, 2-D image and instruments that are long and nonarticulating. Motions are counterintuitive and the learning curve, consequently, is long.
With the robotic technology currently available, such limitations are largely overcome. Advantages of the technology include a 3-D view, an increase in instrument “wrist” mobility from four to seven degrees, and movements that are significantly more intuitive.
These improvements facilitate better vision, easier suturing, and more precise dissection of tissue around sensitive areas such as major blood vessels and the ureters. And because the surgeon sits at a console unit instead of in an awkward position at the operating table, surgeon fatigue is significantly reduced.
This merging of the advantages of laparotomy and laparoscopy—and the more precise gynecologic surgery that results—is changing lymphadenectomy just as it is other types of gynecologic surgery.
The first laparoscopic radical hysterectomy was performed in June 1986; however, until recently, fewer than 1,000 cases of laparoscopic radical hysterectomy with lymphadenectomy had been reported. Now, with the availability of the da Vinci robotic system, more and more gynecologic oncologists in both teaching and community hospitals are routinely performing this procedure and other lymphadenectomies in patients with endometrial, cervical, early ovarian, fallopian tube, and other gynecologic malignancies.
In fellowship training programs specifically, the application of the technology has increased the usage of laparoscopy in gynecologic oncology—with learning curves documented as being significantly shorter than the learning curves associated with conventional laparoscopy.
Pelvic Lymphadenectomy
In terms of patient selection, there are no more limitations to the use of the robotic approach than with conventional laparoscopy. Robotic lymph node dissection can be offered to all patients for whom laparoscopy is deemed appropriate. It is advantageous, in fact, for women who are obese since the robotic approach bypasses the fulcrum effect that is especially challenging in patients with a thick abdominal wall.
As with other robotic-assisted gynecologic procedures, robotic lymphadenectomy is performed using the da Vinci system, an integrated computer-based system consisting of three interactive robotic arms and a camera arm with a remote control console. The system is the only robotic device with FDA approval for use in gynecologic surgery at the present time.
For pelvic lymphadenectomy, with the patient under general endotracheal anesthesia, we place our primary robotic trocar (a 12-mm port) through the umbilicus for the laparoscope. Two 8-mm trocars are placed 8–10 cm bilaterally and 2–3 cm lower than the umbilicus. Such placement enables optimal movement of the robotic arms and minimizes the risk of collisions (
A 10- to 12-mm assistant port is then placed on one side (most often the right side) of the umbilicus (between the camera port and one of the 8-mm trocars, 1–2 cm high). Through this port, the assistant can introduce suture and instrumentation used for retraction and suction/irrigation, as well as remove specimens. We use the Harris-Kronner Uterine Manipulator-Injector (Humi) for our gynecologic cancer patients whenever possible. Although some physicians believe its use during either conventional or robotic-assisted laparoscopy may cause dissemination of the cancer, we have found this not to be the case.
In a series of cases in which we performed laparoscopic staging for both cervical and endometrial cancer using the manipulator and compared it with conventional staging through laparotomy, we found no compromise in recurrence or in the survival rate (Int. J. Gynecol. Cancer 2007:17;1075–82 and J. Minim. Invasive Gynecol. 2008:15;181–7).
Once the trocars are placed, the patient is placed in a steep Trendelenburg's position and the robotic tower is docked between the patient's legs. The surgeon sits at a console, and the assistant stands to the patient's left or right side. Occasionally, we use a second assistant—most often when the assistant cannot adequately reach the vagina of an obese patient.
After a survey of the pelvic cavity to rule out any sign of metastases in the abdominal cavity and to identify any associated pathology that needs to be treated, such as adhesions that need to be lysed, we proceed with the lymphadenectomy.
The procedure is usually performed with bipolar forceps placed through the left robotic port, and a monopolar electrosurgical spatula, or scissors, placed through the right port. If necessary, a 10-mm clips applier or blood vessel sealing devices can be placed through the assistant's port.
Pelvic wall dissection involves coagulating and cutting the round ligaments on either side of the pelvic wall and then making an incision over the peritoneum between the infundibular pelvic ligament and the vessels in the pelvic side wall.
The retroperitoneal space is developed and the ureter is identified medially, and if the ovary is to be removed, which is the case in most patients, the infundibular ligament is isolated, desiccated, and divided using the bipolar forceps and scissors.
The paravesical and pararectal spaces are then developed by retracting the umbilical ligament (the superior vesicle artery) medially and performing blunt dissection between this artery and the pelvic side wall.
The obturator nerve can usually be identified at this point, and the obturator fossa nodes and hypogastric lymph nodes can be removed. Occasionally, when the obturator nerve cannot be identified initially, the obturator fossa nodes must be dissected and retracted medially, under the external iliac vein. Then, when the nerve is identified under these lymph nodes using blunt dissection, all nodes from the obturator fossa all the way up to the hypogastric vessels can be resected (
After removing the lymphatic nodes from the obturator fossa and the hypogastric vessels, we remove all nodes along the external iliac vessels from the external common iliac artery down to the deep circumflex vein.
Blunt and sharp dissection performed with the scissors, forceps, and suction irrigator is used for resection of all these nodes, and bipolar and unipolar forceps are used to achieve hemostasis and to clear the lymphatic channels (
This is the same process we follow during conventional laparoscopic lymphadenectomy, except that the conventional laparoscopic approach can be done using ultrasonic shears, which are multifunctional and may lower the risk for tissue damage. With the current da Vinci system, we are limited to using electrosurgery instrumentation for coagulation and cutting, but we have found that these instruments are more than adequate.
Para-Aortic Lymphadenectomy
For para-aortic lymphadenectomies in which node dissection will extend up to the inferior mesenteric artery, the trocar positioning is the same as for pelvic lymphadenectomy.
If node dissection above the inferior mesenteric artery is planned, however, trocar placement must be modified, with the camera port placed approximately 5–8 cm above the umbilicus and the other trocars adjusted accordingly, based on the different camera port placement (
The peritoneum is incised over the right common iliac artery, and the incision is extended cephalad over the inferior vena cava and lower abdominal aorta to the level of the duodenum, above the inferior mesenteric artery. The right ureter should be identified first, with the retroperitoneal space gradually developed toward the left side, and the left ureter then identified (
The assistant port or the fourth arm of the robot is used to retract the ureter or the bowel laterally. The lymph adenectomy starts from below and gradually extends upward toward the insertion of the ovarian vein to the vena cava on the right side and the renal vein on the left side.
The nodes are removed using the same technique as for pelvic lymphadenectomy, with bipolar forceps used as a grasping forceps and for coagulation of the small blood vessels and unipolar forceps used for cutting and achieving hemostasis for these vessels (
Final Steps, Outcomes
In patients also undergoing a hysterectomy, lymphadenectomy can be performed before or after the hysterectomy, depending on the indication.
Lymph nodes dissected with the robotic approach can be stored and removed in a laparoscopic bag that is introduced through the assistant's port. In patients undergoing a hysterectomy, the bag can be stored in the abdomen during the procedure and then removed through the vagina afterward.
After we complete lymphadenectomy, the pelvic cavity is thoroughly irrigated, Seprafilm slurry is applied to prevent adhesions, and all trocar sites are routinely closed. Closing all ports, even the 8-mm sites, is important since a small bowel trocar-site herniation has been reported. We also inject Marcaine in all trocar sites. Depending on the patient's condition, she can be discharged on the same day or after 1 or 2 days.
Gynecologic surgeons have developed various techniques for robotic-assisted laparoscopic lymphadenectomy that include different placement of the trocar sites. We have been performing robotic lymphadenectomy and radical hysterectomy since 2003 and have modified our technique to be as feasible and reproducible as possible.
We recently compared the experiences of 43 women with early cervical cancer who were treated with either robotic radical hysterectomy with pelvic lymphadenectomy or laparoscopic radical hysterectomy with pelvic lymphadenectomy.
The treatments—using either conventional laparoscopy or robotic-assisted laparoscopy—were equivalent with respect to operative time, blood loss, hospital stay, and oncologic outcome. The mean pelvic lymph node count was similar in the two groups (JSLS 2008;12:227–37).
While this analysis did not include cases involving open radical hysterectomy and lymphadenectomy, we know from other series and reports that the number of resected lymph nodes increases with a laparoscopic approach, whether or not it is robotically performed.
In studies in our fellowship training program, moreover, we have found that fellows who have less experience with laparoscopic surgery than attendings achieved the same number of lymph node retrievals as the attendings through either conventional laparoscopic or robotic lymphadenectomy. Such ease and reproducibility portends well for the future of robotic technology in gynecologic oncology.
Some of the major advantages of robotic-assisted surgery are that it provides 3-D views, allows intuitive motions, and involves less operator fatigue. In addition, tremor filtration facilitates more precise movements. It entails a shorter learning curve than does conventional laparoscopy. Robotic-assisted surgery has also paved a pathway to telesurgery and telementoring. This may expand the availability of advanced minimally invasive surgeries throughout the globe.
Dr. Nezhat had no financial conflicts of interest to disclose.
Robotic-Assisted Lymphadenectomy
Despite the early, pioneering efforts of physicians such as Dr. Denis Querleu in France, as well as Dr. Joel Childers and our author, Dr. Farr R. Nezhat, in the United States, the acceptance of laparoscopic surgery by gynecologic oncologists has been lackluster at best. Lately, however, no area of our specialty has shown faster adaptation to minimally invasive surgery than has gynecologic oncology. In fact, secondary to the interest in laparoscopic oncologic procedures, the AAGL has recently created a gynecologic oncology specialty group. Due to his vast experience, Dr. Nezhat has been given a leadership role in this endeavor. It is this editor's belief that the utilization of robotics is the single factor that has created such a rapid movement within the gyne-oncology community to embrace laparoscopic surgery. The 3-D visualization, combined with the seven degrees of motion of robotic instrumentation, has enabled the gynecologic oncologist to work precisely and efficiently. Despite his vast experience in laparoscopic surgery, our guest author was an early convert to robotic-assisted surgery.
Dr. Nezhat is the director of minimally invasive surgery and gynecologic robotics, as well as chief of the gynecologic robotic, minimally invasive surgery fellowship, in the division of gynecologic oncology at St. Luke's-Roosevelt Hospital Center, New York. He has written more than 100 articles in peer-reviewed journals, many of which involve laparoscopic surgery. Dr. Nezhat is truly one of the thought leaders of our specialty. It is an honor to have him write this current column of the Master Class in gynecologic surgery.
The tepid response is due largely to conventional laparoscopy having significant drawbacks. In a standing position, surgeons use a flat, 2-D image and instruments that are long and nonarticulating. Motions are counterintuitive and the learning curve, consequently, is long.
With the robotic technology currently available, such limitations are largely overcome. Advantages of the technology include a 3-D view, an increase in instrument “wrist” mobility from four to seven degrees, and movements that are significantly more intuitive.
These improvements facilitate better vision, easier suturing, and more precise dissection of tissue around sensitive areas such as major blood vessels and the ureters. And because the surgeon sits at a console unit instead of in an awkward position at the operating table, surgeon fatigue is significantly reduced.
This merging of the advantages of laparotomy and laparoscopy—and the more precise gynecologic surgery that results—is changing lymphadenectomy just as it is other types of gynecologic surgery.
The first laparoscopic radical hysterectomy was performed in June 1986; however, until recently, fewer than 1,000 cases of laparoscopic radical hysterectomy with lymphadenectomy had been reported. Now, with the availability of the da Vinci robotic system, more and more gynecologic oncologists in both teaching and community hospitals are routinely performing this procedure and other lymphadenectomies in patients with endometrial, cervical, early ovarian, fallopian tube, and other gynecologic malignancies.
In fellowship training programs specifically, the application of the technology has increased the usage of laparoscopy in gynecologic oncology—with learning curves documented as being significantly shorter than the learning curves associated with conventional laparoscopy.
Pelvic Lymphadenectomy
In terms of patient selection, there are no more limitations to the use of the robotic approach than with conventional laparoscopy. Robotic lymph node dissection can be offered to all patients for whom laparoscopy is deemed appropriate. It is advantageous, in fact, for women who are obese since the robotic approach bypasses the fulcrum effect that is especially challenging in patients with a thick abdominal wall.
As with other robotic-assisted gynecologic procedures, robotic lymphadenectomy is performed using the da Vinci system, an integrated computer-based system consisting of three interactive robotic arms and a camera arm with a remote control console. The system is the only robotic device with FDA approval for use in gynecologic surgery at the present time.
For pelvic lymphadenectomy, with the patient under general endotracheal anesthesia, we place our primary robotic trocar (a 12-mm port) through the umbilicus for the laparoscope. Two 8-mm trocars are placed 8–10 cm bilaterally and 2–3 cm lower than the umbilicus. Such placement enables optimal movement of the robotic arms and minimizes the risk of collisions (
A 10- to 12-mm assistant port is then placed on one side (most often the right side) of the umbilicus (between the camera port and one of the 8-mm trocars, 1–2 cm high). Through this port, the assistant can introduce suture and instrumentation used for retraction and suction/irrigation, as well as remove specimens. We use the Harris-Kronner Uterine Manipulator-Injector (Humi) for our gynecologic cancer patients whenever possible. Although some physicians believe its use during either conventional or robotic-assisted laparoscopy may cause dissemination of the cancer, we have found this not to be the case.
In a series of cases in which we performed laparoscopic staging for both cervical and endometrial cancer using the manipulator and compared it with conventional staging through laparotomy, we found no compromise in recurrence or in the survival rate (Int. J. Gynecol. Cancer 2007:17;1075–82 and J. Minim. Invasive Gynecol. 2008:15;181–7).
Once the trocars are placed, the patient is placed in a steep Trendelenburg's position and the robotic tower is docked between the patient's legs. The surgeon sits at a console, and the assistant stands to the patient's left or right side. Occasionally, we use a second assistant—most often when the assistant cannot adequately reach the vagina of an obese patient.
After a survey of the pelvic cavity to rule out any sign of metastases in the abdominal cavity and to identify any associated pathology that needs to be treated, such as adhesions that need to be lysed, we proceed with the lymphadenectomy.
The procedure is usually performed with bipolar forceps placed through the left robotic port, and a monopolar electrosurgical spatula, or scissors, placed through the right port. If necessary, a 10-mm clips applier or blood vessel sealing devices can be placed through the assistant's port.
Pelvic wall dissection involves coagulating and cutting the round ligaments on either side of the pelvic wall and then making an incision over the peritoneum between the infundibular pelvic ligament and the vessels in the pelvic side wall.
The retroperitoneal space is developed and the ureter is identified medially, and if the ovary is to be removed, which is the case in most patients, the infundibular ligament is isolated, desiccated, and divided using the bipolar forceps and scissors.
The paravesical and pararectal spaces are then developed by retracting the umbilical ligament (the superior vesicle artery) medially and performing blunt dissection between this artery and the pelvic side wall.
The obturator nerve can usually be identified at this point, and the obturator fossa nodes and hypogastric lymph nodes can be removed. Occasionally, when the obturator nerve cannot be identified initially, the obturator fossa nodes must be dissected and retracted medially, under the external iliac vein. Then, when the nerve is identified under these lymph nodes using blunt dissection, all nodes from the obturator fossa all the way up to the hypogastric vessels can be resected (
After removing the lymphatic nodes from the obturator fossa and the hypogastric vessels, we remove all nodes along the external iliac vessels from the external common iliac artery down to the deep circumflex vein.
Blunt and sharp dissection performed with the scissors, forceps, and suction irrigator is used for resection of all these nodes, and bipolar and unipolar forceps are used to achieve hemostasis and to clear the lymphatic channels (
This is the same process we follow during conventional laparoscopic lymphadenectomy, except that the conventional laparoscopic approach can be done using ultrasonic shears, which are multifunctional and may lower the risk for tissue damage. With the current da Vinci system, we are limited to using electrosurgery instrumentation for coagulation and cutting, but we have found that these instruments are more than adequate.
Para-Aortic Lymphadenectomy
For para-aortic lymphadenectomies in which node dissection will extend up to the inferior mesenteric artery, the trocar positioning is the same as for pelvic lymphadenectomy.
If node dissection above the inferior mesenteric artery is planned, however, trocar placement must be modified, with the camera port placed approximately 5–8 cm above the umbilicus and the other trocars adjusted accordingly, based on the different camera port placement (
The peritoneum is incised over the right common iliac artery, and the incision is extended cephalad over the inferior vena cava and lower abdominal aorta to the level of the duodenum, above the inferior mesenteric artery. The right ureter should be identified first, with the retroperitoneal space gradually developed toward the left side, and the left ureter then identified (
The assistant port or the fourth arm of the robot is used to retract the ureter or the bowel laterally. The lymph adenectomy starts from below and gradually extends upward toward the insertion of the ovarian vein to the vena cava on the right side and the renal vein on the left side.
The nodes are removed using the same technique as for pelvic lymphadenectomy, with bipolar forceps used as a grasping forceps and for coagulation of the small blood vessels and unipolar forceps used for cutting and achieving hemostasis for these vessels (
Final Steps, Outcomes
In patients also undergoing a hysterectomy, lymphadenectomy can be performed before or after the hysterectomy, depending on the indication.
Lymph nodes dissected with the robotic approach can be stored and removed in a laparoscopic bag that is introduced through the assistant's port. In patients undergoing a hysterectomy, the bag can be stored in the abdomen during the procedure and then removed through the vagina afterward.
After we complete lymphadenectomy, the pelvic cavity is thoroughly irrigated, Seprafilm slurry is applied to prevent adhesions, and all trocar sites are routinely closed. Closing all ports, even the 8-mm sites, is important since a small bowel trocar-site herniation has been reported. We also inject Marcaine in all trocar sites. Depending on the patient's condition, she can be discharged on the same day or after 1 or 2 days.
Gynecologic surgeons have developed various techniques for robotic-assisted laparoscopic lymphadenectomy that include different placement of the trocar sites. We have been performing robotic lymphadenectomy and radical hysterectomy since 2003 and have modified our technique to be as feasible and reproducible as possible.
We recently compared the experiences of 43 women with early cervical cancer who were treated with either robotic radical hysterectomy with pelvic lymphadenectomy or laparoscopic radical hysterectomy with pelvic lymphadenectomy.
The treatments—using either conventional laparoscopy or robotic-assisted laparoscopy—were equivalent with respect to operative time, blood loss, hospital stay, and oncologic outcome. The mean pelvic lymph node count was similar in the two groups (JSLS 2008;12:227–37).
While this analysis did not include cases involving open radical hysterectomy and lymphadenectomy, we know from other series and reports that the number of resected lymph nodes increases with a laparoscopic approach, whether or not it is robotically performed.
In studies in our fellowship training program, moreover, we have found that fellows who have less experience with laparoscopic surgery than attendings achieved the same number of lymph node retrievals as the attendings through either conventional laparoscopic or robotic lymphadenectomy. Such ease and reproducibility portends well for the future of robotic technology in gynecologic oncology.
Some of the major advantages of robotic-assisted surgery are that it provides 3-D views, allows intuitive motions, and involves less operator fatigue. In addition, tremor filtration facilitates more precise movements. It entails a shorter learning curve than does conventional laparoscopy. Robotic-assisted surgery has also paved a pathway to telesurgery and telementoring. This may expand the availability of advanced minimally invasive surgeries throughout the globe.
Dr. Nezhat had no financial conflicts of interest to disclose.
Robotic-Assisted Lymphadenectomy
Despite the early, pioneering efforts of physicians such as Dr. Denis Querleu in France, as well as Dr. Joel Childers and our author, Dr. Farr R. Nezhat, in the United States, the acceptance of laparoscopic surgery by gynecologic oncologists has been lackluster at best. Lately, however, no area of our specialty has shown faster adaptation to minimally invasive surgery than has gynecologic oncology. In fact, secondary to the interest in laparoscopic oncologic procedures, the AAGL has recently created a gynecologic oncology specialty group. Due to his vast experience, Dr. Nezhat has been given a leadership role in this endeavor. It is this editor's belief that the utilization of robotics is the single factor that has created such a rapid movement within the gyne-oncology community to embrace laparoscopic surgery. The 3-D visualization, combined with the seven degrees of motion of robotic instrumentation, has enabled the gynecologic oncologist to work precisely and efficiently. Despite his vast experience in laparoscopic surgery, our guest author was an early convert to robotic-assisted surgery.
Dr. Nezhat is the director of minimally invasive surgery and gynecologic robotics, as well as chief of the gynecologic robotic, minimally invasive surgery fellowship, in the division of gynecologic oncology at St. Luke's-Roosevelt Hospital Center, New York. He has written more than 100 articles in peer-reviewed journals, many of which involve laparoscopic surgery. Dr. Nezhat is truly one of the thought leaders of our specialty. It is an honor to have him write this current column of the Master Class in gynecologic surgery.
Advantages of Open Sacrocolpopexy With Decreased Morbidity
Some surgeons perform the procedure laparoscopically in an effort to decrease morbidity and recovery time, with some success. Overall, however, a laparoscopic approach has not been widely adopted because of the complex suturing and dissection involved, and the subsequently significant learning curve.
Robotic sacrocolpopexy is a new addition to our armamentarium and is an exciting option for me and other surgeons because it combines the advantages of open sacrocolpopexy with the decreased morbidity of laparoscopy.
A robotic approach to the tried-and-true abdominal sacrocolpopexy takes full advantage of all that robotic surgery offers. Instrument articulation, three-dimensional vision, tremor reduction, and improved ergonomics for the surgeon all make managing the mesh and intracorporeal suturing—as well as dissecting in the rectovaginal and presacral spaces—so much easier than would be the case with a standard laparoscopic approach.
Overall, sacrocolpopexy performed with the da Vinci surgical system—the only Food and Drug Administration-approved robotic device for use in gynecologic surgery—offers better access to the pelvis, compared with both the open and laparoscopic approaches.
We can truly replicate what we do in an open approach, but with less postoperative pain, less blood loss and scarring, and faster recovery. Robotic sacrocolpopexy can also be combined with total or supracervical hysterectomy for uterine prolapse.
Outcomes data are emerging. At the American Urogynecologic Society annual meeting last month, we presented our initial short-term data comparing robotic with traditional abdominal sacrocolpopexy for the treatment of both uterine and vaginal vault prolapse.
Postoperatively, based on a 6-week POPQ (Pelvic Organ Prolapse Quantification) examination, there was a similar degree of pelvic organ support in the 73 patients who underwent robotic surgery and the 105 patients who underwent traditional surgery. The length of hospital stay was significantly shorter with the robotic approach (1.3 days vs. 2.7 days), and estimated blood loss was significantly lower (103 mL vs. 255 mL).
The operative time for the colpopexy and all other procedures, including hysterectomy and slings, was significantly longer in the robotic group (328 vs. 225 minutes). This time is expected to decrease, however, as all members of the surgical team, including fellows, residents, and surgical staff, progress through the learning curve.
Patient Selection and Positioning
I now offer the procedure to any patient to whom I would recommend a sacrocolpopexy. In the initial stages of adopting a robotic approach, however, it makes sense to be more selective and to perform relatively straightforward surgeries. This means starting with patients who are relatively thin (with body mass indices less than 30 kg/m
Initial patients should also have a reasonably sized uterus (if present) and few comorbidities. Pulmonary morbidity (emphysema or chronic obstructive pulmonary disease, for instance) is a relative contraindication, especially for initial cases, because these patients may not tolerate the Trendelenburg position, which is required for the surgery.
In addition, although robotic sacrocolpopexy can be used for uterine prolapse, I recommend starting with patients who have vaginal vault prolapse so that the surgeon can focus on a single robotic procedure. As their experience grows, surgeons can easily perform a combined robotic hysterectomy with sacrocolpopexy for the treatment of uterine prolapse. I primarily perform a supracervical hysterectomy in combination with a sacrocolpopexy in an attempt to reduce the risk of mesh erosion.
When the patient is positioned at the start of the surgery, her arms and shoulders and all “pressure points” should be well padded with foam, but I do not find a need for shoulder pads. I typically use an extra-large vacuum bean bag to keep the patient firmly in place while she is in the moderate to steep Trendelenburg position, but the use of a gel pad placed between the patient and the bed is an alternative approach to keep the patient from sliding cephalad during the surgery.
Port Placement, Setup, and Preparation
For robotic sacrocolpopexy, five trocar sites are used with a four-arm robotic system: three for operative robotic arms, one for the camera, and one to be used as the assistant's port for suction and irrigation, assistance with traction/countertraction, and the introduction of suture and mesh. (The bedside assistant is also helpful for instrument swaps, during uterine morcellation, and for any trocar depth repositioning that is necessary.)
Initially, we tried several different port locations. We have found that a “W-like” configuration for our port placement works well. We place the camera trocar at the umbilicus to accommodate the endoscope and the camera arm. This represents the middle of our “W.”
We then place two robotic ports at the two inferior apices of the “W.” The lateral ends of the “W” are each located about 2 cm inferior to the level of the umbilicus. The right lateral port is the assistant's port, which is used to introduce mesh, suture, and the like. The left lateral port is for the third robotic operative arm and is particularly helpful in moving the sigmoid laterally to expose the sacrum.
Using this configuration, we have reduced any competition between the two left robotic arms while we operate either in the pelvis or at the sacrum.
Some surgeons place the camera port higher (above the umbilicus), but I do not care for this placement because it can partially impede the view over the sacral promontory. (Placement of the camera port above the umbilicus is necessary for enlarged uteri, however.) After initial entry, a 0-degree scope should be used to place the other ports.
It is important to maintain at least 10 cm between robotic ports, and at least 6 cm between the robotic port and the assistant's port to reduce external collision of the robotic instrument arms.
Before docking the robotic arms of the patientside cart and placing the various EndoWrist instruments, I laparoscopically remove any small-bowel adhesions or other abdominal wall adhesions. This way, I have the tactile sensation that robotics does not provide. I then retract the sigmoid and move the small bowel out of the pelvis to expose the sacrum and the sacral promontory.
At this point and still prior to docking, it is also important to identify the ureters, the sacral promontory, the midline with the sigmoid retracted, the middle sacral vessels, and the iliac vessels. The left common iliac vessels, particularly the vein, can occasionally be identified crossing very close to the sacral promontory.
The operating table should be lowered and the patientside cart should be positioned as high as possible to clear the patient's legs, and then—after all overhead lights and equipment are moved to the side—the cart can be rolled into position between the patient's legs and aligned in a straight line with the camera arm and umbilical camera port. Docking can then be easily accomplished.
Open communication with the anesthesiology team is important. Robotic sacrocolpopexy is associated with significantly less blood loss (typically less than 25 mL) and less insensible loss than is open sacrocolpopexy. Therefore intravenous fluids should generally be limited to a liter or less.
Surgical Steps
If the patient has uterine prolapse, this can be addressed first with a supracervical or total hysterectomy. I prefer supracervical hysterectomies, assuming that the patient's Pap smears have been normal, in an attempt to reduce the risk of mesh erosion. After the hysterectomy, I place the uterus along the left lateral gutter for morcellation at the end of the procedure and after the system is undocked.
With either type of hysterectomy, the use of a colpotomy ring—either a KOH cup or a VCARE device—works nicely. We find this helpful in manipulating the uterus and defining the cervical-vaginal junction, even during supracervical hysterectomies, because it helps in the dissection of the bladder flap.
After the bladder flap is dissected off the anterior vaginal wall (close to the anterior vaginal wall to avoid cystotomy and to identify the avascular plane), the rectovaginal septum is developed. Approximately 6-8 cm of anterior vaginal wall are exposed.
The placement of round, 31- to 33-mm EEA (end-to-end anastomosis) sizers in the vagina to manipulate the vaginal apex helps with the bladder flap dissection, which can be challenging in patients who have had a previous cesarean section, hysterectomy, or vaginal reconstructive procedure—especially those performed with vaginally placed mesh. Occasionally, the bladder is found densely adherent over the apex of the vagina and adherent to the proximal posterior vaginal wall.
I frequently have an additional, smaller (29-mm) sizer placed in the rectum to help clearly identify the rectovaginal septum and facilitate the dissection.
During the rectovaginal dissection, the vaginal EEA sizer should be oriented anteriorly to better expose the posterior vaginal wall. Between 6 cm and 10 cm of the posterior vaginal wall should be dissected, while the camera is kept at midline and oriented to the horizon.
At this point, I frequently switch to a 30-degree down scope to develop the presacral space. This enables me to see over the sacral promontory and enhances my view. Depending on the configuration of the sacrum, it is possible to complete the surgery with a 0-degree scope. However, the view of the presacral space is generally significantly improved with the 30-degree down scope.
The sigmoid is retracted laterally by the third operative arm, and the peritoneum is lifted up, or tented, over the sacrum in the midline to avoid injury to a vessel. Our goal is to identify the anterior longitudinal ligament, and this area can be fairly vascular. Once the anterior longitudinal ligament is identified, the presacral peritoneal dissection can be extended inferiorly to the vagina.
I use a Y-shaped polypropylene mesh (AMS) and introduce it, trimmed to the appropriate width and length, in the proper anatomical orientation. I place the distal and lateral sutures on the anterior vaginal wall first, and then place several (four to eight) additional sutures to secure the mesh to the anterior vaginal wall. To suture, I use a Mega needle driver in the left hand and a SutureCut needle driver in the right. The SutureCut needle driver is similar to the Mega needle driver, but it also has a cutting mechanism that provides enhanced autonomy to the console surgeon and makes suturing more efficient overall.
Using the third operative robotic arm, I then roll the sacral end of the mesh and lift it anteriorly, which allows the posterior mesh to drape nicely over the posterior vaginal wall. The longer posterior mesh can then be easily sutured to the posterior wall of the vagina. For the posterior vaginal-wall mesh attachment, I usually start at the vaginal apex and work my way inferiorly. Throughout the surgery, I use permanent sutures of CV-2 Gore-Tex.
I then adjust the mesh tension, ensuring that it will be attached to the sacrum without undue tension and with equal distribution of support to the anterior and posterior of the vagina. Once this is determined, the excess mesh is trimmed.
I typically place three sacral sutures to secure the mesh to the sacrum. I place the inferiormost suture first, using a slip (or sliding) knot. This is a one-way knot that allows the mesh to be easily attached to the sacrum without the need for an assistant to hold the mesh against the sacrum while the suturing and knot tying are completed. Two additional sacral sutures are then placed superiorly to allow for adequate visualization of the sacrum during the suturing, and the excess mesh is trimmed.
The mesh should then be retroperitonealized to reduce the risk of small-bowel obstruction. The closure of the peritoneum is facilitated by the extension of the initial peritoneal incision from the sacrum inferiorly in the midline through the cul-de-sac and along the posterior vaginal wall at the time of sacral dissection. An enterocele repair can be accomplished as closure over the mesh obliterates the cul de sac. The peritoneum is closed with a running, locking, braided, absorbable suture.
I typically perform cystoscopy at the end of the procedure to confirm bilateral ureteral patency using intravenous indigo carmine.
Fortunately, presacral bleeding is rare. However, if presacral hemorrhage does occur, it is important to remain calm and remember that pressure can be applied with most available robotic instruments. (For example, even scissors work well if the wrist of the instrument is used.) If the bleeding does not respond to pressure, a bipolar forceps can be used, depending on the location and source of the bleeding. If bleeding continues, then FloSeal—a thrombin matrix that will usually and very effectively stop the bleeding—can be considered.
If the clinical situation warrants additional procedures, such as a posterior repair or a suburethral sling for urinary incontinence, these can easily be performed after the robot is undocked. If necessary, we perform uterine morcellation after undocking the robot.
Our typical patient at Duke has an overnight stay in our 23-hour observation unit and requires minimal oral pain medication.
Dr. Visco is a consultant for Intuitive Surgical Inc.
Port placement: A “W-like” configuration for port placement works well. This configuration reduces any competition between the two left robotic arms. Intuitive Surgical
Presacral dissection: The presacral space is generally best viewed with a 30-degree down scope.
Anterior suturing: A Mega needle driver and SutureCut needle driver are used for anterior vaginal wall suturing.
Mesh to sacrum: The first and most inferior of the three sacral sutures is placed with a sliding knot. Photos courtesy Dr. Anthony Visco
Robotic Sacrocolpopexy
This is the third installment of the Master Class in Gynecologic Surgery dedicated to robotic surgery.
Whether the procedure is called robotic sacrocolpopexy or robotic-assisted laparoscopic sacrocolpopexy, Dr. Anthony Visco's excellent description will help the reader understand how the robot and the laparoscope can be used to modify the standard treatment for vaginal vault prolapse—the abdominal sacrocolpopexy—into a minimally invasive gynecologic procedure that can be incorporated into one's practice.
As Dr. Visco points out, the robotic procedure involves an obligatory learning curve and a need for practiced, efficient teamwork. However, as the surgeon and staff gain experience, robotic sacrocolpopexy can lead to outcomes similar to those of abdominal sacrocolpopexy, but with less blood loss and quicker recovery time.
Dr. Visco is director of the division of urogynecology and reconstructive pelvic surgery; director of gynecologic robotic surgery; and vice chair of the department of obstetrics and gynecology at Duke University Medical Center in Durham, N.C. Dr. Visco has authored or coauthored nearly 50 peer-reviewed articles on, or related to, urogynecology.
In 2007, Dr. Visco performed a live robotic sacrocolpopexy in Madrid for an international conference on pelvic floor disorders, and a second live robotic sacrocolpopexy for the AAGL's 2007 annual meeting.
Some surgeons perform the procedure laparoscopically in an effort to decrease morbidity and recovery time, with some success. Overall, however, a laparoscopic approach has not been widely adopted because of the complex suturing and dissection involved, and the subsequently significant learning curve.
Robotic sacrocolpopexy is a new addition to our armamentarium and is an exciting option for me and other surgeons because it combines the advantages of open sacrocolpopexy with the decreased morbidity of laparoscopy.
A robotic approach to the tried-and-true abdominal sacrocolpopexy takes full advantage of all that robotic surgery offers. Instrument articulation, three-dimensional vision, tremor reduction, and improved ergonomics for the surgeon all make managing the mesh and intracorporeal suturing—as well as dissecting in the rectovaginal and presacral spaces—so much easier than would be the case with a standard laparoscopic approach.
Overall, sacrocolpopexy performed with the da Vinci surgical system—the only Food and Drug Administration-approved robotic device for use in gynecologic surgery—offers better access to the pelvis, compared with both the open and laparoscopic approaches.
We can truly replicate what we do in an open approach, but with less postoperative pain, less blood loss and scarring, and faster recovery. Robotic sacrocolpopexy can also be combined with total or supracervical hysterectomy for uterine prolapse.
Outcomes data are emerging. At the American Urogynecologic Society annual meeting last month, we presented our initial short-term data comparing robotic with traditional abdominal sacrocolpopexy for the treatment of both uterine and vaginal vault prolapse.
Postoperatively, based on a 6-week POPQ (Pelvic Organ Prolapse Quantification) examination, there was a similar degree of pelvic organ support in the 73 patients who underwent robotic surgery and the 105 patients who underwent traditional surgery. The length of hospital stay was significantly shorter with the robotic approach (1.3 days vs. 2.7 days), and estimated blood loss was significantly lower (103 mL vs. 255 mL).
The operative time for the colpopexy and all other procedures, including hysterectomy and slings, was significantly longer in the robotic group (328 vs. 225 minutes). This time is expected to decrease, however, as all members of the surgical team, including fellows, residents, and surgical staff, progress through the learning curve.
Patient Selection and Positioning
I now offer the procedure to any patient to whom I would recommend a sacrocolpopexy. In the initial stages of adopting a robotic approach, however, it makes sense to be more selective and to perform relatively straightforward surgeries. This means starting with patients who are relatively thin (with body mass indices less than 30 kg/m
Initial patients should also have a reasonably sized uterus (if present) and few comorbidities. Pulmonary morbidity (emphysema or chronic obstructive pulmonary disease, for instance) is a relative contraindication, especially for initial cases, because these patients may not tolerate the Trendelenburg position, which is required for the surgery.
In addition, although robotic sacrocolpopexy can be used for uterine prolapse, I recommend starting with patients who have vaginal vault prolapse so that the surgeon can focus on a single robotic procedure. As their experience grows, surgeons can easily perform a combined robotic hysterectomy with sacrocolpopexy for the treatment of uterine prolapse. I primarily perform a supracervical hysterectomy in combination with a sacrocolpopexy in an attempt to reduce the risk of mesh erosion.
When the patient is positioned at the start of the surgery, her arms and shoulders and all “pressure points” should be well padded with foam, but I do not find a need for shoulder pads. I typically use an extra-large vacuum bean bag to keep the patient firmly in place while she is in the moderate to steep Trendelenburg position, but the use of a gel pad placed between the patient and the bed is an alternative approach to keep the patient from sliding cephalad during the surgery.
Port Placement, Setup, and Preparation
For robotic sacrocolpopexy, five trocar sites are used with a four-arm robotic system: three for operative robotic arms, one for the camera, and one to be used as the assistant's port for suction and irrigation, assistance with traction/countertraction, and the introduction of suture and mesh. (The bedside assistant is also helpful for instrument swaps, during uterine morcellation, and for any trocar depth repositioning that is necessary.)
Initially, we tried several different port locations. We have found that a “W-like” configuration for our port placement works well. We place the camera trocar at the umbilicus to accommodate the endoscope and the camera arm. This represents the middle of our “W.”
We then place two robotic ports at the two inferior apices of the “W.” The lateral ends of the “W” are each located about 2 cm inferior to the level of the umbilicus. The right lateral port is the assistant's port, which is used to introduce mesh, suture, and the like. The left lateral port is for the third robotic operative arm and is particularly helpful in moving the sigmoid laterally to expose the sacrum.
Using this configuration, we have reduced any competition between the two left robotic arms while we operate either in the pelvis or at the sacrum.
Some surgeons place the camera port higher (above the umbilicus), but I do not care for this placement because it can partially impede the view over the sacral promontory. (Placement of the camera port above the umbilicus is necessary for enlarged uteri, however.) After initial entry, a 0-degree scope should be used to place the other ports.
It is important to maintain at least 10 cm between robotic ports, and at least 6 cm between the robotic port and the assistant's port to reduce external collision of the robotic instrument arms.
Before docking the robotic arms of the patientside cart and placing the various EndoWrist instruments, I laparoscopically remove any small-bowel adhesions or other abdominal wall adhesions. This way, I have the tactile sensation that robotics does not provide. I then retract the sigmoid and move the small bowel out of the pelvis to expose the sacrum and the sacral promontory.
At this point and still prior to docking, it is also important to identify the ureters, the sacral promontory, the midline with the sigmoid retracted, the middle sacral vessels, and the iliac vessels. The left common iliac vessels, particularly the vein, can occasionally be identified crossing very close to the sacral promontory.
The operating table should be lowered and the patientside cart should be positioned as high as possible to clear the patient's legs, and then—after all overhead lights and equipment are moved to the side—the cart can be rolled into position between the patient's legs and aligned in a straight line with the camera arm and umbilical camera port. Docking can then be easily accomplished.
Open communication with the anesthesiology team is important. Robotic sacrocolpopexy is associated with significantly less blood loss (typically less than 25 mL) and less insensible loss than is open sacrocolpopexy. Therefore intravenous fluids should generally be limited to a liter or less.
Surgical Steps
If the patient has uterine prolapse, this can be addressed first with a supracervical or total hysterectomy. I prefer supracervical hysterectomies, assuming that the patient's Pap smears have been normal, in an attempt to reduce the risk of mesh erosion. After the hysterectomy, I place the uterus along the left lateral gutter for morcellation at the end of the procedure and after the system is undocked.
With either type of hysterectomy, the use of a colpotomy ring—either a KOH cup or a VCARE device—works nicely. We find this helpful in manipulating the uterus and defining the cervical-vaginal junction, even during supracervical hysterectomies, because it helps in the dissection of the bladder flap.
After the bladder flap is dissected off the anterior vaginal wall (close to the anterior vaginal wall to avoid cystotomy and to identify the avascular plane), the rectovaginal septum is developed. Approximately 6-8 cm of anterior vaginal wall are exposed.
The placement of round, 31- to 33-mm EEA (end-to-end anastomosis) sizers in the vagina to manipulate the vaginal apex helps with the bladder flap dissection, which can be challenging in patients who have had a previous cesarean section, hysterectomy, or vaginal reconstructive procedure—especially those performed with vaginally placed mesh. Occasionally, the bladder is found densely adherent over the apex of the vagina and adherent to the proximal posterior vaginal wall.
I frequently have an additional, smaller (29-mm) sizer placed in the rectum to help clearly identify the rectovaginal septum and facilitate the dissection.
During the rectovaginal dissection, the vaginal EEA sizer should be oriented anteriorly to better expose the posterior vaginal wall. Between 6 cm and 10 cm of the posterior vaginal wall should be dissected, while the camera is kept at midline and oriented to the horizon.
At this point, I frequently switch to a 30-degree down scope to develop the presacral space. This enables me to see over the sacral promontory and enhances my view. Depending on the configuration of the sacrum, it is possible to complete the surgery with a 0-degree scope. However, the view of the presacral space is generally significantly improved with the 30-degree down scope.
The sigmoid is retracted laterally by the third operative arm, and the peritoneum is lifted up, or tented, over the sacrum in the midline to avoid injury to a vessel. Our goal is to identify the anterior longitudinal ligament, and this area can be fairly vascular. Once the anterior longitudinal ligament is identified, the presacral peritoneal dissection can be extended inferiorly to the vagina.
I use a Y-shaped polypropylene mesh (AMS) and introduce it, trimmed to the appropriate width and length, in the proper anatomical orientation. I place the distal and lateral sutures on the anterior vaginal wall first, and then place several (four to eight) additional sutures to secure the mesh to the anterior vaginal wall. To suture, I use a Mega needle driver in the left hand and a SutureCut needle driver in the right. The SutureCut needle driver is similar to the Mega needle driver, but it also has a cutting mechanism that provides enhanced autonomy to the console surgeon and makes suturing more efficient overall.
Using the third operative robotic arm, I then roll the sacral end of the mesh and lift it anteriorly, which allows the posterior mesh to drape nicely over the posterior vaginal wall. The longer posterior mesh can then be easily sutured to the posterior wall of the vagina. For the posterior vaginal-wall mesh attachment, I usually start at the vaginal apex and work my way inferiorly. Throughout the surgery, I use permanent sutures of CV-2 Gore-Tex.
I then adjust the mesh tension, ensuring that it will be attached to the sacrum without undue tension and with equal distribution of support to the anterior and posterior of the vagina. Once this is determined, the excess mesh is trimmed.
I typically place three sacral sutures to secure the mesh to the sacrum. I place the inferiormost suture first, using a slip (or sliding) knot. This is a one-way knot that allows the mesh to be easily attached to the sacrum without the need for an assistant to hold the mesh against the sacrum while the suturing and knot tying are completed. Two additional sacral sutures are then placed superiorly to allow for adequate visualization of the sacrum during the suturing, and the excess mesh is trimmed.
The mesh should then be retroperitonealized to reduce the risk of small-bowel obstruction. The closure of the peritoneum is facilitated by the extension of the initial peritoneal incision from the sacrum inferiorly in the midline through the cul-de-sac and along the posterior vaginal wall at the time of sacral dissection. An enterocele repair can be accomplished as closure over the mesh obliterates the cul de sac. The peritoneum is closed with a running, locking, braided, absorbable suture.
I typically perform cystoscopy at the end of the procedure to confirm bilateral ureteral patency using intravenous indigo carmine.
Fortunately, presacral bleeding is rare. However, if presacral hemorrhage does occur, it is important to remain calm and remember that pressure can be applied with most available robotic instruments. (For example, even scissors work well if the wrist of the instrument is used.) If the bleeding does not respond to pressure, a bipolar forceps can be used, depending on the location and source of the bleeding. If bleeding continues, then FloSeal—a thrombin matrix that will usually and very effectively stop the bleeding—can be considered.
If the clinical situation warrants additional procedures, such as a posterior repair or a suburethral sling for urinary incontinence, these can easily be performed after the robot is undocked. If necessary, we perform uterine morcellation after undocking the robot.
Our typical patient at Duke has an overnight stay in our 23-hour observation unit and requires minimal oral pain medication.
Dr. Visco is a consultant for Intuitive Surgical Inc.
Port placement: A “W-like” configuration for port placement works well. This configuration reduces any competition between the two left robotic arms. Intuitive Surgical
Presacral dissection: The presacral space is generally best viewed with a 30-degree down scope.
Anterior suturing: A Mega needle driver and SutureCut needle driver are used for anterior vaginal wall suturing.
Mesh to sacrum: The first and most inferior of the three sacral sutures is placed with a sliding knot. Photos courtesy Dr. Anthony Visco
Robotic Sacrocolpopexy
This is the third installment of the Master Class in Gynecologic Surgery dedicated to robotic surgery.
Whether the procedure is called robotic sacrocolpopexy or robotic-assisted laparoscopic sacrocolpopexy, Dr. Anthony Visco's excellent description will help the reader understand how the robot and the laparoscope can be used to modify the standard treatment for vaginal vault prolapse—the abdominal sacrocolpopexy—into a minimally invasive gynecologic procedure that can be incorporated into one's practice.
As Dr. Visco points out, the robotic procedure involves an obligatory learning curve and a need for practiced, efficient teamwork. However, as the surgeon and staff gain experience, robotic sacrocolpopexy can lead to outcomes similar to those of abdominal sacrocolpopexy, but with less blood loss and quicker recovery time.
Dr. Visco is director of the division of urogynecology and reconstructive pelvic surgery; director of gynecologic robotic surgery; and vice chair of the department of obstetrics and gynecology at Duke University Medical Center in Durham, N.C. Dr. Visco has authored or coauthored nearly 50 peer-reviewed articles on, or related to, urogynecology.
In 2007, Dr. Visco performed a live robotic sacrocolpopexy in Madrid for an international conference on pelvic floor disorders, and a second live robotic sacrocolpopexy for the AAGL's 2007 annual meeting.
Some surgeons perform the procedure laparoscopically in an effort to decrease morbidity and recovery time, with some success. Overall, however, a laparoscopic approach has not been widely adopted because of the complex suturing and dissection involved, and the subsequently significant learning curve.
Robotic sacrocolpopexy is a new addition to our armamentarium and is an exciting option for me and other surgeons because it combines the advantages of open sacrocolpopexy with the decreased morbidity of laparoscopy.
A robotic approach to the tried-and-true abdominal sacrocolpopexy takes full advantage of all that robotic surgery offers. Instrument articulation, three-dimensional vision, tremor reduction, and improved ergonomics for the surgeon all make managing the mesh and intracorporeal suturing—as well as dissecting in the rectovaginal and presacral spaces—so much easier than would be the case with a standard laparoscopic approach.
Overall, sacrocolpopexy performed with the da Vinci surgical system—the only Food and Drug Administration-approved robotic device for use in gynecologic surgery—offers better access to the pelvis, compared with both the open and laparoscopic approaches.
We can truly replicate what we do in an open approach, but with less postoperative pain, less blood loss and scarring, and faster recovery. Robotic sacrocolpopexy can also be combined with total or supracervical hysterectomy for uterine prolapse.
Outcomes data are emerging. At the American Urogynecologic Society annual meeting last month, we presented our initial short-term data comparing robotic with traditional abdominal sacrocolpopexy for the treatment of both uterine and vaginal vault prolapse.
Postoperatively, based on a 6-week POPQ (Pelvic Organ Prolapse Quantification) examination, there was a similar degree of pelvic organ support in the 73 patients who underwent robotic surgery and the 105 patients who underwent traditional surgery. The length of hospital stay was significantly shorter with the robotic approach (1.3 days vs. 2.7 days), and estimated blood loss was significantly lower (103 mL vs. 255 mL).
The operative time for the colpopexy and all other procedures, including hysterectomy and slings, was significantly longer in the robotic group (328 vs. 225 minutes). This time is expected to decrease, however, as all members of the surgical team, including fellows, residents, and surgical staff, progress through the learning curve.
Patient Selection and Positioning
I now offer the procedure to any patient to whom I would recommend a sacrocolpopexy. In the initial stages of adopting a robotic approach, however, it makes sense to be more selective and to perform relatively straightforward surgeries. This means starting with patients who are relatively thin (with body mass indices less than 30 kg/m
Initial patients should also have a reasonably sized uterus (if present) and few comorbidities. Pulmonary morbidity (emphysema or chronic obstructive pulmonary disease, for instance) is a relative contraindication, especially for initial cases, because these patients may not tolerate the Trendelenburg position, which is required for the surgery.
In addition, although robotic sacrocolpopexy can be used for uterine prolapse, I recommend starting with patients who have vaginal vault prolapse so that the surgeon can focus on a single robotic procedure. As their experience grows, surgeons can easily perform a combined robotic hysterectomy with sacrocolpopexy for the treatment of uterine prolapse. I primarily perform a supracervical hysterectomy in combination with a sacrocolpopexy in an attempt to reduce the risk of mesh erosion.
When the patient is positioned at the start of the surgery, her arms and shoulders and all “pressure points” should be well padded with foam, but I do not find a need for shoulder pads. I typically use an extra-large vacuum bean bag to keep the patient firmly in place while she is in the moderate to steep Trendelenburg position, but the use of a gel pad placed between the patient and the bed is an alternative approach to keep the patient from sliding cephalad during the surgery.
Port Placement, Setup, and Preparation
For robotic sacrocolpopexy, five trocar sites are used with a four-arm robotic system: three for operative robotic arms, one for the camera, and one to be used as the assistant's port for suction and irrigation, assistance with traction/countertraction, and the introduction of suture and mesh. (The bedside assistant is also helpful for instrument swaps, during uterine morcellation, and for any trocar depth repositioning that is necessary.)
Initially, we tried several different port locations. We have found that a “W-like” configuration for our port placement works well. We place the camera trocar at the umbilicus to accommodate the endoscope and the camera arm. This represents the middle of our “W.”
We then place two robotic ports at the two inferior apices of the “W.” The lateral ends of the “W” are each located about 2 cm inferior to the level of the umbilicus. The right lateral port is the assistant's port, which is used to introduce mesh, suture, and the like. The left lateral port is for the third robotic operative arm and is particularly helpful in moving the sigmoid laterally to expose the sacrum.
Using this configuration, we have reduced any competition between the two left robotic arms while we operate either in the pelvis or at the sacrum.
Some surgeons place the camera port higher (above the umbilicus), but I do not care for this placement because it can partially impede the view over the sacral promontory. (Placement of the camera port above the umbilicus is necessary for enlarged uteri, however.) After initial entry, a 0-degree scope should be used to place the other ports.
It is important to maintain at least 10 cm between robotic ports, and at least 6 cm between the robotic port and the assistant's port to reduce external collision of the robotic instrument arms.
Before docking the robotic arms of the patientside cart and placing the various EndoWrist instruments, I laparoscopically remove any small-bowel adhesions or other abdominal wall adhesions. This way, I have the tactile sensation that robotics does not provide. I then retract the sigmoid and move the small bowel out of the pelvis to expose the sacrum and the sacral promontory.
At this point and still prior to docking, it is also important to identify the ureters, the sacral promontory, the midline with the sigmoid retracted, the middle sacral vessels, and the iliac vessels. The left common iliac vessels, particularly the vein, can occasionally be identified crossing very close to the sacral promontory.
The operating table should be lowered and the patientside cart should be positioned as high as possible to clear the patient's legs, and then—after all overhead lights and equipment are moved to the side—the cart can be rolled into position between the patient's legs and aligned in a straight line with the camera arm and umbilical camera port. Docking can then be easily accomplished.
Open communication with the anesthesiology team is important. Robotic sacrocolpopexy is associated with significantly less blood loss (typically less than 25 mL) and less insensible loss than is open sacrocolpopexy. Therefore intravenous fluids should generally be limited to a liter or less.
Surgical Steps
If the patient has uterine prolapse, this can be addressed first with a supracervical or total hysterectomy. I prefer supracervical hysterectomies, assuming that the patient's Pap smears have been normal, in an attempt to reduce the risk of mesh erosion. After the hysterectomy, I place the uterus along the left lateral gutter for morcellation at the end of the procedure and after the system is undocked.
With either type of hysterectomy, the use of a colpotomy ring—either a KOH cup or a VCARE device—works nicely. We find this helpful in manipulating the uterus and defining the cervical-vaginal junction, even during supracervical hysterectomies, because it helps in the dissection of the bladder flap.
After the bladder flap is dissected off the anterior vaginal wall (close to the anterior vaginal wall to avoid cystotomy and to identify the avascular plane), the rectovaginal septum is developed. Approximately 6-8 cm of anterior vaginal wall are exposed.
The placement of round, 31- to 33-mm EEA (end-to-end anastomosis) sizers in the vagina to manipulate the vaginal apex helps with the bladder flap dissection, which can be challenging in patients who have had a previous cesarean section, hysterectomy, or vaginal reconstructive procedure—especially those performed with vaginally placed mesh. Occasionally, the bladder is found densely adherent over the apex of the vagina and adherent to the proximal posterior vaginal wall.
I frequently have an additional, smaller (29-mm) sizer placed in the rectum to help clearly identify the rectovaginal septum and facilitate the dissection.
During the rectovaginal dissection, the vaginal EEA sizer should be oriented anteriorly to better expose the posterior vaginal wall. Between 6 cm and 10 cm of the posterior vaginal wall should be dissected, while the camera is kept at midline and oriented to the horizon.
At this point, I frequently switch to a 30-degree down scope to develop the presacral space. This enables me to see over the sacral promontory and enhances my view. Depending on the configuration of the sacrum, it is possible to complete the surgery with a 0-degree scope. However, the view of the presacral space is generally significantly improved with the 30-degree down scope.
The sigmoid is retracted laterally by the third operative arm, and the peritoneum is lifted up, or tented, over the sacrum in the midline to avoid injury to a vessel. Our goal is to identify the anterior longitudinal ligament, and this area can be fairly vascular. Once the anterior longitudinal ligament is identified, the presacral peritoneal dissection can be extended inferiorly to the vagina.
I use a Y-shaped polypropylene mesh (AMS) and introduce it, trimmed to the appropriate width and length, in the proper anatomical orientation. I place the distal and lateral sutures on the anterior vaginal wall first, and then place several (four to eight) additional sutures to secure the mesh to the anterior vaginal wall. To suture, I use a Mega needle driver in the left hand and a SutureCut needle driver in the right. The SutureCut needle driver is similar to the Mega needle driver, but it also has a cutting mechanism that provides enhanced autonomy to the console surgeon and makes suturing more efficient overall.
Using the third operative robotic arm, I then roll the sacral end of the mesh and lift it anteriorly, which allows the posterior mesh to drape nicely over the posterior vaginal wall. The longer posterior mesh can then be easily sutured to the posterior wall of the vagina. For the posterior vaginal-wall mesh attachment, I usually start at the vaginal apex and work my way inferiorly. Throughout the surgery, I use permanent sutures of CV-2 Gore-Tex.
I then adjust the mesh tension, ensuring that it will be attached to the sacrum without undue tension and with equal distribution of support to the anterior and posterior of the vagina. Once this is determined, the excess mesh is trimmed.
I typically place three sacral sutures to secure the mesh to the sacrum. I place the inferiormost suture first, using a slip (or sliding) knot. This is a one-way knot that allows the mesh to be easily attached to the sacrum without the need for an assistant to hold the mesh against the sacrum while the suturing and knot tying are completed. Two additional sacral sutures are then placed superiorly to allow for adequate visualization of the sacrum during the suturing, and the excess mesh is trimmed.
The mesh should then be retroperitonealized to reduce the risk of small-bowel obstruction. The closure of the peritoneum is facilitated by the extension of the initial peritoneal incision from the sacrum inferiorly in the midline through the cul-de-sac and along the posterior vaginal wall at the time of sacral dissection. An enterocele repair can be accomplished as closure over the mesh obliterates the cul de sac. The peritoneum is closed with a running, locking, braided, absorbable suture.
I typically perform cystoscopy at the end of the procedure to confirm bilateral ureteral patency using intravenous indigo carmine.
Fortunately, presacral bleeding is rare. However, if presacral hemorrhage does occur, it is important to remain calm and remember that pressure can be applied with most available robotic instruments. (For example, even scissors work well if the wrist of the instrument is used.) If the bleeding does not respond to pressure, a bipolar forceps can be used, depending on the location and source of the bleeding. If bleeding continues, then FloSeal—a thrombin matrix that will usually and very effectively stop the bleeding—can be considered.
If the clinical situation warrants additional procedures, such as a posterior repair or a suburethral sling for urinary incontinence, these can easily be performed after the robot is undocked. If necessary, we perform uterine morcellation after undocking the robot.
Our typical patient at Duke has an overnight stay in our 23-hour observation unit and requires minimal oral pain medication.
Dr. Visco is a consultant for Intuitive Surgical Inc.
Port placement: A “W-like” configuration for port placement works well. This configuration reduces any competition between the two left robotic arms. Intuitive Surgical
Presacral dissection: The presacral space is generally best viewed with a 30-degree down scope.
Anterior suturing: A Mega needle driver and SutureCut needle driver are used for anterior vaginal wall suturing.
Mesh to sacrum: The first and most inferior of the three sacral sutures is placed with a sliding knot. Photos courtesy Dr. Anthony Visco
Robotic Sacrocolpopexy
This is the third installment of the Master Class in Gynecologic Surgery dedicated to robotic surgery.
Whether the procedure is called robotic sacrocolpopexy or robotic-assisted laparoscopic sacrocolpopexy, Dr. Anthony Visco's excellent description will help the reader understand how the robot and the laparoscope can be used to modify the standard treatment for vaginal vault prolapse—the abdominal sacrocolpopexy—into a minimally invasive gynecologic procedure that can be incorporated into one's practice.
As Dr. Visco points out, the robotic procedure involves an obligatory learning curve and a need for practiced, efficient teamwork. However, as the surgeon and staff gain experience, robotic sacrocolpopexy can lead to outcomes similar to those of abdominal sacrocolpopexy, but with less blood loss and quicker recovery time.
Dr. Visco is director of the division of urogynecology and reconstructive pelvic surgery; director of gynecologic robotic surgery; and vice chair of the department of obstetrics and gynecology at Duke University Medical Center in Durham, N.C. Dr. Visco has authored or coauthored nearly 50 peer-reviewed articles on, or related to, urogynecology.
In 2007, Dr. Visco performed a live robotic sacrocolpopexy in Madrid for an international conference on pelvic floor disorders, and a second live robotic sacrocolpopexy for the AAGL's 2007 annual meeting.
Robot-Assisted Laparoscopic Myomectomy
Hysterectomy has been a first natural and successful application for robotics in gynecologic and reproductive care, but it is also now clear that robot-assisted laparoscopic myomectomy takes full advantage—even more so—of what robotic technology brings to the table.
Conventional laparoscopic myomectomy has been so challenging that relatively few gynecologic surgeons have been willing and/or able to move away from the traditional open approach for treating symptomatic leiomyomata. Laparotomy thus has remained the standard for myomectomy, leaving many women with a limited number of minimally invasive options if they want to preserve their uterus or fertility, and leaving our health care system shouldering millions of dollars in costs associated with invasive approaches.
It is interesting to note that the total direct cost of treating uterine fibroids in 2000 was estimated at $2.1 billion. Most of the cost, the authors wrote, resulted from inpatient care, particularly hysterectomy (Am. J. Obstet. Gynec. 2006;195:955-64).
With all that robotics offers to us, I believe this is about to change.
The Rationale
Two prospective trials have shown less postoperative morbidity and faster recovery with laparoscopic myomectomy. Yet the endoscopic management of leiomyomata is so technically challenging that the majority of cases are still performed via laparotomy. (Few would challenge the notion, I believe, that it is one of the more challenging procedures in minimally invasive surgery.)
The complexity of dissection and, in particular, the complexity of repair with multilayer-sutured closures present challenges that not only require advanced laparoscopic skills but also are associated with a steep learning curve. These challenges have consistently raised concerns about whether laparoscopy increases conversion rates and whether it can lead to uterine rupture.
There also are longstanding, published limitations placed on the kinds of tumors that can be treated with conventional laparoscopy in order to minimize the risk of conversion to laparotomy. It is often stated that cases involving fibroids greater than or equal to 5 cm, intramural fibroids, an anterior location, and preoperative use of GnRH agonists are too difficult to handle laparoscopically and are likely to increase the conversion rate (Human Reprod. 2001;16:1726-31).
Current robotic technology essentially erases almost all of the limitations of conventional laparoscopy. The features of the technology—improved dexterity and precision of the instruments as well as the three-dimensional imaging—allow the endoscopic approach to be more accurately modeled after (and reflective of) traditional open techniques.
The da Vinci surgical system, which is the only Food and Drug Administration-approved robotic device for use in gynecologic surgery, provides us with a means to overcome the difficulties associated with hysterotomy, enucleation, repair, and extraction that we encounter with the conventional laparoscopic management of fibroids.
The Setup
The da Vinci system comprises a surgeon's console, a vision system that provides three-dimensional imaging through a 12-mm endoscope, and a patientside cart with robotic arms and various EndoWrist instruments.
At the console, the surgeon controls the instruments, the camera, and an energy source, all via a stereoscopic viewer, hand manipulators, and foot pedals. One of the robotic arms holds the endoscope while the other two or three arms hold the instruments.
The instruments come in either 8- or 5-mm sizes and possess 7 degrees of movement, a range that replicates or surpasses the human hand's full range of motion.
Overall, the technique itself for robot-assisted laparoscopic myomectomy does not differ significantly from what is done in conventional laparoscopy, except that the critical steps of hysterotomy, enucleation, and repair are dramatically facilitated while the surgeon adheres to the principles of open surgery.
The bottom line is that robotics affords us the ability to perform the procedure as if it were being done as an open procedure, with the only change being the route of access.
We first place a 12-mm port at or above the umbilicus, depending on the size of the uterus, to accommodate the endoscope and camera arm. As a general rule, I advise leaving at least a handsbreadth distance (approximately 8-10 cm) between the endoscope and the top of an elevated uterus or leiomyoma during bimanual examination, with the patient under anesthesia.
This spacing is important during myomectomy because the enucleation process will result in the leiomyoma projecting out toward the endoscope. By leaving an adequate working space at the beginning, we are able to compensate for a loss of optical working distance and maintain our ability to manipulate our instruments.
We then place an 8-mm port in the left and right lower quadrants, placing them more cephalad and lateral in the case of larger uteri or leiomyomata. These ports will mount directly to the operating robotic arms.
A fourth trocar (a 12- to 15-mm port that will facilitate the introduction of suture as well as instrumentation used for retraction, suction/irrigation, and other tasks of the assistant) can be placed between the camera port and either the left or right lower-quadrant port.
Just as with robotic hysterectomy, a fourth robotic arm can be added for patients who are obese or have a large uterus; this can be used for added retraction of tissues.
The key point to be made about setup is that the ports must be placed far enough away from each other and from the target tissue to avoid instrument-arm collisions.
We recommend that all patients undergo radiologic imaging prior to myomectomy. In our practice, we favor MRI for assessing the size, number, and location of the fibroids as well as for ruling out adenomyosis and for planning the location(s) of the hysterotomy incision. All of this information is particularly helpful given the absence of haptic (tactile) feedback with the robotic approach.
The Technique
Prior to hysterotomy, a dilute concentration of vasopressin is injected into the myometrium surrounding the myoma, as an adjunct for hemostasis. Once adequate blanching is noted, we begin each case with either a bipolar Maryland forceps or Gyrus ACMI Inc.'s PK dissecting forceps on the left arm, and hot shears or a permanent cautery hook (both monopolar devices) on the right arm. Our hysterotomy can be made in either a horizontal or vertical axis because we will be less limited with robotic instruments than we would be in a conventional laparoscopy.
The fibroid can then be enucleated while the bedside assistant provides additional traction/countertraction with a conventional laparoscopic tenaculum or corkscrew. An alternative is to use the fourth robotic arm with an EndoWrist tenaculum. Care must be taken to avoid excessive traction during the enucleation phase in order to maintain hemostasis and to not prematurely avulse the fibroid. Patience is key.
The removed fibroid is placed in the posterior cul-de-sac—or in one of the paracolic gutters if it is larger—for retrieval at the end of the surgery. When we remove multiple and smaller fibroids, it is important to maintain a myoma count. Tagging each of them with long suture can be helpful for retrieval at the end of the case.
At this point, we usually exchange our instruments for a large needle driver on the left arm and a mega needle driver with a high-force grip and integrated cutting mechanism on the right arm. We typically incorporate a multilayer closure for the myometrium, using either interrupted sutures of 0-Vicryl on CT-2 needles cut to 6 inches, or running sutures of 0-Vicryl on CT-2 needles cut to 11 inches.
With the increased articulation and dexterity of our instruments, our ability to repair a defect is affected much less by the orientation of the incisions or the location than it would be in conventional laparoscopy.
To close the uterine serosa, we use a running baseball stitch with 3-0 Vicryl on an SH needle. If multiple fibroids must be removed, we prefer to repair each uterine defect after enucleation before moving on to another tumor. This way, we're taking advantage of the effects of vasopressin at each site. We try to remove as many fibroids as possible through a given hysterotomy.
Before retrieving excised fibroids, the robot-assist device is undocked. Specimens are then retrieved via a tissue morcellator that is placed through the accessory port. Another option is to use the endoscopic port site, but this requires the use of a 5-mm 0-degree laparoscope placed through one of the lateral trocars.
All operative sites are irrigated, hemostasis is ensured under low-pressure settings, and an adhesion barrier is placed over all uterine incisions. We typically apply a slurry of finely chopped Seprafilm as an adhesion barrier (an off-label use).
With robotic myomectomy, as with any of the robotically assisted gynecologic procedures, the importance of the bedside assistant cannot be overestimated. In addition to providing traction/countertraction (we usually don't need to use a fourth robotic arm because our assistants are skilled), the assistant introduces and removes suture, provides irrigation, and manages any accessory port activity (J. Robotic Surg. 2007;1:69-74).
The Patients, the Outcomes
With robotics, there really are not many patients we cannot address. There are no absolute inclusion criteria, and no absolute cutoffs. It's all relative. We determine whether a patient is a candidate for a robotic myomectomy based on the size and mobility of her uterus as well as the size, number, and location of her fibroids.
For example, a patient whose height is 4 feet 10 inches and who is obese with a short truncated torso, a uterus that is not very mobile, and an 8-cm fibroid located over the broad ligament may be a poorer candidate than would a taller patient of average weight with an 8-cm intramural fibroid in a uterus that is extremely mobile. This is where the art of medicine comes into play.
Overall, however, the robotic approach overcomes challenges like obesity, and puts us at a greater advantage as surgeons—giving us an ability to suture more effectively and to approach complex pathology much more aggressively—than does conventional laparoscopy.
It takes some time to get used to the dramatic paradigm shift of operating remotely from the patient through a robotic interface. Learning to overcome the lack of tactile feedback is also part of the learning curve. The key is to not attempt more than you can handle early in the learning process. Then, as your experience grows, your ability to tackle complex gynecologic pathology will come. In other words, start with a symptomatic 4- to 5-cm fundal subserosal fibroid before approaching the 10-cm broad-ligament fibroid.
We started doing robotic myomectomies in 2001. In our first published series of 35 cases, the mean myoma weight was 223.2 g. The mean number of myomas removed was 1.6, and the mean diameter was 7.9 cm. The average estimated blood loss was 169 mL and no blood transfusions were necessary. Three of the cases were converted to laparotomy, two because of the absence of tactile feedback and a third because of cardiogenic shock secondary to vasopressin (J. Am. Assoc. Gynecol. Laparosc. 2004;11:511-8).
Since that early experience, we have not had to convert a patient to a laparotomy secondary to an absence of tactile feedback.
When we later compared surgical outcomes with those of traditional laparotomy through a retrospective case-matched analysis of 58 patients, we found that although operative times were significantly longer in the robotic group (a mean of 231 minutes vs. a mean of 154 minutes), postoperative complication rates were higher in the laparotomy group.
In all, there were 14 postoperative complications in 12 patients in the laparotomy group, including wound dehiscence; hematoma; blood loss and anemia requiring transfusion; and deep vein thrombosis followed by respiratory arrest and renal failure. In the robotic group, there were three postoperative complications: aspiration pneumonia, port-site cellulitis, and chest pain.
Estimated blood loss was significantly higher in the laparotomy group than in the robotic group (a mean of 365 mL v. 196 mL), and transfusions were required in two patients who underwent laparotomy. Length of stay was also higher: 3.6 days in the laparotomy group, compared with 1.5 days in the robotic group. (J. Min. Invasive Gynecol. 2007;14:698-705).
We have also analyzed the effects of our experience over time and have presented these data at the AAGL annual meeting in November 2007. We found a notable trend toward both lower blood loss and shorter operative time with experience. Additionally, we evolved from an average length of stay of 1.5 days to a completely outpatient procedure. We even noted an increasing ability to tackle more complex fibroid cases over time, particularly those involving submucosal and deep intramural fibroids.
More recently, we have begun long-term follow-up of our patients. Preliminary pregnancy data show us that women who have undergone a robot-assisted laparoscopic myomectomy in the past 5 years have indeed become pregnant and have carried their pregnancies through with no complications and no uterine ruptures.
A hysterotomy is underway with an EndoWrist cautery hook and Gyrus dissecting forceps.
A fibroid enucleation is facilitated by an EndoWrist tenaculum.
A myometrial defect is repaired with EndoWrist needle drivers and 0-Vicryl suture. Photos courtesy Dr. Arnold Advincula
Robotic Myomectomy: The Time Has Come
In the last edition of the Master Class in gynecology, Dr. Javier Magrina, professor of ob.gyn. and director of female pelvic medicine and reconstructive surgery at the Mayo Clinic in Scottsdale, Ariz., ably described the benefits and technique of robotic-assisted hysterectomy.
In this second installment on robotic-assisted surgery, I have asked Dr. Arnold P. Advincula, clinical associate professor of ob.gyn. at the University of Michigan, Ann Arbor, to discuss robotic-assisted laparoscopic myomectomy.
Other than laparoscopic tubal anastomosis, there is no procedure in minimally invasive gynecologic surgery that is more dependent on the ability to be facile with laparoscopic suturing techniques than laparoscopic myomectomy. Certainly, the physician's need to visualize the repair on a television screen while using limited wrist motion for suture placement limits the vast majority of gynecologists from routinely and effectively performing this procedure.
Dr. Advincula holds several departmental positions at the University of Michigan. He is the director of the minimally invasive surgery and chronic pelvic pain program, the director of the minimally invasive surgery fellowship, and the codirector of the university's endometriosis center. Dr. Advincula is also a member of the board of trustees of the AAGL and is associate editor of the journal The Female Patient, coeditor of the Journal of Robotic Surgery, and a member of the editorial board of the International Journal of Gynecology & Obstetrics.
Dr. Advincula not only is an avid clinical researcher and educator, having published nearly 50 articles in peer-reviewed journals, but also is a fixture on both the national and international lecture circuits on the topic of minimally invasive gynecologic surgery.
Hysterectomy has been a first natural and successful application for robotics in gynecologic and reproductive care, but it is also now clear that robot-assisted laparoscopic myomectomy takes full advantage—even more so—of what robotic technology brings to the table.
Conventional laparoscopic myomectomy has been so challenging that relatively few gynecologic surgeons have been willing and/or able to move away from the traditional open approach for treating symptomatic leiomyomata. Laparotomy thus has remained the standard for myomectomy, leaving many women with a limited number of minimally invasive options if they want to preserve their uterus or fertility, and leaving our health care system shouldering millions of dollars in costs associated with invasive approaches.
It is interesting to note that the total direct cost of treating uterine fibroids in 2000 was estimated at $2.1 billion. Most of the cost, the authors wrote, resulted from inpatient care, particularly hysterectomy (Am. J. Obstet. Gynec. 2006;195:955-64).
With all that robotics offers to us, I believe this is about to change.
The Rationale
Two prospective trials have shown less postoperative morbidity and faster recovery with laparoscopic myomectomy. Yet the endoscopic management of leiomyomata is so technically challenging that the majority of cases are still performed via laparotomy. (Few would challenge the notion, I believe, that it is one of the more challenging procedures in minimally invasive surgery.)
The complexity of dissection and, in particular, the complexity of repair with multilayer-sutured closures present challenges that not only require advanced laparoscopic skills but also are associated with a steep learning curve. These challenges have consistently raised concerns about whether laparoscopy increases conversion rates and whether it can lead to uterine rupture.
There also are longstanding, published limitations placed on the kinds of tumors that can be treated with conventional laparoscopy in order to minimize the risk of conversion to laparotomy. It is often stated that cases involving fibroids greater than or equal to 5 cm, intramural fibroids, an anterior location, and preoperative use of GnRH agonists are too difficult to handle laparoscopically and are likely to increase the conversion rate (Human Reprod. 2001;16:1726-31).
Current robotic technology essentially erases almost all of the limitations of conventional laparoscopy. The features of the technology—improved dexterity and precision of the instruments as well as the three-dimensional imaging—allow the endoscopic approach to be more accurately modeled after (and reflective of) traditional open techniques.
The da Vinci surgical system, which is the only Food and Drug Administration-approved robotic device for use in gynecologic surgery, provides us with a means to overcome the difficulties associated with hysterotomy, enucleation, repair, and extraction that we encounter with the conventional laparoscopic management of fibroids.
The Setup
The da Vinci system comprises a surgeon's console, a vision system that provides three-dimensional imaging through a 12-mm endoscope, and a patientside cart with robotic arms and various EndoWrist instruments.
At the console, the surgeon controls the instruments, the camera, and an energy source, all via a stereoscopic viewer, hand manipulators, and foot pedals. One of the robotic arms holds the endoscope while the other two or three arms hold the instruments.
The instruments come in either 8- or 5-mm sizes and possess 7 degrees of movement, a range that replicates or surpasses the human hand's full range of motion.
Overall, the technique itself for robot-assisted laparoscopic myomectomy does not differ significantly from what is done in conventional laparoscopy, except that the critical steps of hysterotomy, enucleation, and repair are dramatically facilitated while the surgeon adheres to the principles of open surgery.
The bottom line is that robotics affords us the ability to perform the procedure as if it were being done as an open procedure, with the only change being the route of access.
We first place a 12-mm port at or above the umbilicus, depending on the size of the uterus, to accommodate the endoscope and camera arm. As a general rule, I advise leaving at least a handsbreadth distance (approximately 8-10 cm) between the endoscope and the top of an elevated uterus or leiomyoma during bimanual examination, with the patient under anesthesia.
This spacing is important during myomectomy because the enucleation process will result in the leiomyoma projecting out toward the endoscope. By leaving an adequate working space at the beginning, we are able to compensate for a loss of optical working distance and maintain our ability to manipulate our instruments.
We then place an 8-mm port in the left and right lower quadrants, placing them more cephalad and lateral in the case of larger uteri or leiomyomata. These ports will mount directly to the operating robotic arms.
A fourth trocar (a 12- to 15-mm port that will facilitate the introduction of suture as well as instrumentation used for retraction, suction/irrigation, and other tasks of the assistant) can be placed between the camera port and either the left or right lower-quadrant port.
Just as with robotic hysterectomy, a fourth robotic arm can be added for patients who are obese or have a large uterus; this can be used for added retraction of tissues.
The key point to be made about setup is that the ports must be placed far enough away from each other and from the target tissue to avoid instrument-arm collisions.
We recommend that all patients undergo radiologic imaging prior to myomectomy. In our practice, we favor MRI for assessing the size, number, and location of the fibroids as well as for ruling out adenomyosis and for planning the location(s) of the hysterotomy incision. All of this information is particularly helpful given the absence of haptic (tactile) feedback with the robotic approach.
The Technique
Prior to hysterotomy, a dilute concentration of vasopressin is injected into the myometrium surrounding the myoma, as an adjunct for hemostasis. Once adequate blanching is noted, we begin each case with either a bipolar Maryland forceps or Gyrus ACMI Inc.'s PK dissecting forceps on the left arm, and hot shears or a permanent cautery hook (both monopolar devices) on the right arm. Our hysterotomy can be made in either a horizontal or vertical axis because we will be less limited with robotic instruments than we would be in a conventional laparoscopy.
The fibroid can then be enucleated while the bedside assistant provides additional traction/countertraction with a conventional laparoscopic tenaculum or corkscrew. An alternative is to use the fourth robotic arm with an EndoWrist tenaculum. Care must be taken to avoid excessive traction during the enucleation phase in order to maintain hemostasis and to not prematurely avulse the fibroid. Patience is key.
The removed fibroid is placed in the posterior cul-de-sac—or in one of the paracolic gutters if it is larger—for retrieval at the end of the surgery. When we remove multiple and smaller fibroids, it is important to maintain a myoma count. Tagging each of them with long suture can be helpful for retrieval at the end of the case.
At this point, we usually exchange our instruments for a large needle driver on the left arm and a mega needle driver with a high-force grip and integrated cutting mechanism on the right arm. We typically incorporate a multilayer closure for the myometrium, using either interrupted sutures of 0-Vicryl on CT-2 needles cut to 6 inches, or running sutures of 0-Vicryl on CT-2 needles cut to 11 inches.
With the increased articulation and dexterity of our instruments, our ability to repair a defect is affected much less by the orientation of the incisions or the location than it would be in conventional laparoscopy.
To close the uterine serosa, we use a running baseball stitch with 3-0 Vicryl on an SH needle. If multiple fibroids must be removed, we prefer to repair each uterine defect after enucleation before moving on to another tumor. This way, we're taking advantage of the effects of vasopressin at each site. We try to remove as many fibroids as possible through a given hysterotomy.
Before retrieving excised fibroids, the robot-assist device is undocked. Specimens are then retrieved via a tissue morcellator that is placed through the accessory port. Another option is to use the endoscopic port site, but this requires the use of a 5-mm 0-degree laparoscope placed through one of the lateral trocars.
All operative sites are irrigated, hemostasis is ensured under low-pressure settings, and an adhesion barrier is placed over all uterine incisions. We typically apply a slurry of finely chopped Seprafilm as an adhesion barrier (an off-label use).
With robotic myomectomy, as with any of the robotically assisted gynecologic procedures, the importance of the bedside assistant cannot be overestimated. In addition to providing traction/countertraction (we usually don't need to use a fourth robotic arm because our assistants are skilled), the assistant introduces and removes suture, provides irrigation, and manages any accessory port activity (J. Robotic Surg. 2007;1:69-74).
The Patients, the Outcomes
With robotics, there really are not many patients we cannot address. There are no absolute inclusion criteria, and no absolute cutoffs. It's all relative. We determine whether a patient is a candidate for a robotic myomectomy based on the size and mobility of her uterus as well as the size, number, and location of her fibroids.
For example, a patient whose height is 4 feet 10 inches and who is obese with a short truncated torso, a uterus that is not very mobile, and an 8-cm fibroid located over the broad ligament may be a poorer candidate than would a taller patient of average weight with an 8-cm intramural fibroid in a uterus that is extremely mobile. This is where the art of medicine comes into play.
Overall, however, the robotic approach overcomes challenges like obesity, and puts us at a greater advantage as surgeons—giving us an ability to suture more effectively and to approach complex pathology much more aggressively—than does conventional laparoscopy.
It takes some time to get used to the dramatic paradigm shift of operating remotely from the patient through a robotic interface. Learning to overcome the lack of tactile feedback is also part of the learning curve. The key is to not attempt more than you can handle early in the learning process. Then, as your experience grows, your ability to tackle complex gynecologic pathology will come. In other words, start with a symptomatic 4- to 5-cm fundal subserosal fibroid before approaching the 10-cm broad-ligament fibroid.
We started doing robotic myomectomies in 2001. In our first published series of 35 cases, the mean myoma weight was 223.2 g. The mean number of myomas removed was 1.6, and the mean diameter was 7.9 cm. The average estimated blood loss was 169 mL and no blood transfusions were necessary. Three of the cases were converted to laparotomy, two because of the absence of tactile feedback and a third because of cardiogenic shock secondary to vasopressin (J. Am. Assoc. Gynecol. Laparosc. 2004;11:511-8).
Since that early experience, we have not had to convert a patient to a laparotomy secondary to an absence of tactile feedback.
When we later compared surgical outcomes with those of traditional laparotomy through a retrospective case-matched analysis of 58 patients, we found that although operative times were significantly longer in the robotic group (a mean of 231 minutes vs. a mean of 154 minutes), postoperative complication rates were higher in the laparotomy group.
In all, there were 14 postoperative complications in 12 patients in the laparotomy group, including wound dehiscence; hematoma; blood loss and anemia requiring transfusion; and deep vein thrombosis followed by respiratory arrest and renal failure. In the robotic group, there were three postoperative complications: aspiration pneumonia, port-site cellulitis, and chest pain.
Estimated blood loss was significantly higher in the laparotomy group than in the robotic group (a mean of 365 mL v. 196 mL), and transfusions were required in two patients who underwent laparotomy. Length of stay was also higher: 3.6 days in the laparotomy group, compared with 1.5 days in the robotic group. (J. Min. Invasive Gynecol. 2007;14:698-705).
We have also analyzed the effects of our experience over time and have presented these data at the AAGL annual meeting in November 2007. We found a notable trend toward both lower blood loss and shorter operative time with experience. Additionally, we evolved from an average length of stay of 1.5 days to a completely outpatient procedure. We even noted an increasing ability to tackle more complex fibroid cases over time, particularly those involving submucosal and deep intramural fibroids.
More recently, we have begun long-term follow-up of our patients. Preliminary pregnancy data show us that women who have undergone a robot-assisted laparoscopic myomectomy in the past 5 years have indeed become pregnant and have carried their pregnancies through with no complications and no uterine ruptures.
A hysterotomy is underway with an EndoWrist cautery hook and Gyrus dissecting forceps.
A fibroid enucleation is facilitated by an EndoWrist tenaculum.
A myometrial defect is repaired with EndoWrist needle drivers and 0-Vicryl suture. Photos courtesy Dr. Arnold Advincula
Robotic Myomectomy: The Time Has Come
In the last edition of the Master Class in gynecology, Dr. Javier Magrina, professor of ob.gyn. and director of female pelvic medicine and reconstructive surgery at the Mayo Clinic in Scottsdale, Ariz., ably described the benefits and technique of robotic-assisted hysterectomy.
In this second installment on robotic-assisted surgery, I have asked Dr. Arnold P. Advincula, clinical associate professor of ob.gyn. at the University of Michigan, Ann Arbor, to discuss robotic-assisted laparoscopic myomectomy.
Other than laparoscopic tubal anastomosis, there is no procedure in minimally invasive gynecologic surgery that is more dependent on the ability to be facile with laparoscopic suturing techniques than laparoscopic myomectomy. Certainly, the physician's need to visualize the repair on a television screen while using limited wrist motion for suture placement limits the vast majority of gynecologists from routinely and effectively performing this procedure.
Dr. Advincula holds several departmental positions at the University of Michigan. He is the director of the minimally invasive surgery and chronic pelvic pain program, the director of the minimally invasive surgery fellowship, and the codirector of the university's endometriosis center. Dr. Advincula is also a member of the board of trustees of the AAGL and is associate editor of the journal The Female Patient, coeditor of the Journal of Robotic Surgery, and a member of the editorial board of the International Journal of Gynecology & Obstetrics.
Dr. Advincula not only is an avid clinical researcher and educator, having published nearly 50 articles in peer-reviewed journals, but also is a fixture on both the national and international lecture circuits on the topic of minimally invasive gynecologic surgery.
Hysterectomy has been a first natural and successful application for robotics in gynecologic and reproductive care, but it is also now clear that robot-assisted laparoscopic myomectomy takes full advantage—even more so—of what robotic technology brings to the table.
Conventional laparoscopic myomectomy has been so challenging that relatively few gynecologic surgeons have been willing and/or able to move away from the traditional open approach for treating symptomatic leiomyomata. Laparotomy thus has remained the standard for myomectomy, leaving many women with a limited number of minimally invasive options if they want to preserve their uterus or fertility, and leaving our health care system shouldering millions of dollars in costs associated with invasive approaches.
It is interesting to note that the total direct cost of treating uterine fibroids in 2000 was estimated at $2.1 billion. Most of the cost, the authors wrote, resulted from inpatient care, particularly hysterectomy (Am. J. Obstet. Gynec. 2006;195:955-64).
With all that robotics offers to us, I believe this is about to change.
The Rationale
Two prospective trials have shown less postoperative morbidity and faster recovery with laparoscopic myomectomy. Yet the endoscopic management of leiomyomata is so technically challenging that the majority of cases are still performed via laparotomy. (Few would challenge the notion, I believe, that it is one of the more challenging procedures in minimally invasive surgery.)
The complexity of dissection and, in particular, the complexity of repair with multilayer-sutured closures present challenges that not only require advanced laparoscopic skills but also are associated with a steep learning curve. These challenges have consistently raised concerns about whether laparoscopy increases conversion rates and whether it can lead to uterine rupture.
There also are longstanding, published limitations placed on the kinds of tumors that can be treated with conventional laparoscopy in order to minimize the risk of conversion to laparotomy. It is often stated that cases involving fibroids greater than or equal to 5 cm, intramural fibroids, an anterior location, and preoperative use of GnRH agonists are too difficult to handle laparoscopically and are likely to increase the conversion rate (Human Reprod. 2001;16:1726-31).
Current robotic technology essentially erases almost all of the limitations of conventional laparoscopy. The features of the technology—improved dexterity and precision of the instruments as well as the three-dimensional imaging—allow the endoscopic approach to be more accurately modeled after (and reflective of) traditional open techniques.
The da Vinci surgical system, which is the only Food and Drug Administration-approved robotic device for use in gynecologic surgery, provides us with a means to overcome the difficulties associated with hysterotomy, enucleation, repair, and extraction that we encounter with the conventional laparoscopic management of fibroids.
The Setup
The da Vinci system comprises a surgeon's console, a vision system that provides three-dimensional imaging through a 12-mm endoscope, and a patientside cart with robotic arms and various EndoWrist instruments.
At the console, the surgeon controls the instruments, the camera, and an energy source, all via a stereoscopic viewer, hand manipulators, and foot pedals. One of the robotic arms holds the endoscope while the other two or three arms hold the instruments.
The instruments come in either 8- or 5-mm sizes and possess 7 degrees of movement, a range that replicates or surpasses the human hand's full range of motion.
Overall, the technique itself for robot-assisted laparoscopic myomectomy does not differ significantly from what is done in conventional laparoscopy, except that the critical steps of hysterotomy, enucleation, and repair are dramatically facilitated while the surgeon adheres to the principles of open surgery.
The bottom line is that robotics affords us the ability to perform the procedure as if it were being done as an open procedure, with the only change being the route of access.
We first place a 12-mm port at or above the umbilicus, depending on the size of the uterus, to accommodate the endoscope and camera arm. As a general rule, I advise leaving at least a handsbreadth distance (approximately 8-10 cm) between the endoscope and the top of an elevated uterus or leiomyoma during bimanual examination, with the patient under anesthesia.
This spacing is important during myomectomy because the enucleation process will result in the leiomyoma projecting out toward the endoscope. By leaving an adequate working space at the beginning, we are able to compensate for a loss of optical working distance and maintain our ability to manipulate our instruments.
We then place an 8-mm port in the left and right lower quadrants, placing them more cephalad and lateral in the case of larger uteri or leiomyomata. These ports will mount directly to the operating robotic arms.
A fourth trocar (a 12- to 15-mm port that will facilitate the introduction of suture as well as instrumentation used for retraction, suction/irrigation, and other tasks of the assistant) can be placed between the camera port and either the left or right lower-quadrant port.
Just as with robotic hysterectomy, a fourth robotic arm can be added for patients who are obese or have a large uterus; this can be used for added retraction of tissues.
The key point to be made about setup is that the ports must be placed far enough away from each other and from the target tissue to avoid instrument-arm collisions.
We recommend that all patients undergo radiologic imaging prior to myomectomy. In our practice, we favor MRI for assessing the size, number, and location of the fibroids as well as for ruling out adenomyosis and for planning the location(s) of the hysterotomy incision. All of this information is particularly helpful given the absence of haptic (tactile) feedback with the robotic approach.
The Technique
Prior to hysterotomy, a dilute concentration of vasopressin is injected into the myometrium surrounding the myoma, as an adjunct for hemostasis. Once adequate blanching is noted, we begin each case with either a bipolar Maryland forceps or Gyrus ACMI Inc.'s PK dissecting forceps on the left arm, and hot shears or a permanent cautery hook (both monopolar devices) on the right arm. Our hysterotomy can be made in either a horizontal or vertical axis because we will be less limited with robotic instruments than we would be in a conventional laparoscopy.
The fibroid can then be enucleated while the bedside assistant provides additional traction/countertraction with a conventional laparoscopic tenaculum or corkscrew. An alternative is to use the fourth robotic arm with an EndoWrist tenaculum. Care must be taken to avoid excessive traction during the enucleation phase in order to maintain hemostasis and to not prematurely avulse the fibroid. Patience is key.
The removed fibroid is placed in the posterior cul-de-sac—or in one of the paracolic gutters if it is larger—for retrieval at the end of the surgery. When we remove multiple and smaller fibroids, it is important to maintain a myoma count. Tagging each of them with long suture can be helpful for retrieval at the end of the case.
At this point, we usually exchange our instruments for a large needle driver on the left arm and a mega needle driver with a high-force grip and integrated cutting mechanism on the right arm. We typically incorporate a multilayer closure for the myometrium, using either interrupted sutures of 0-Vicryl on CT-2 needles cut to 6 inches, or running sutures of 0-Vicryl on CT-2 needles cut to 11 inches.
With the increased articulation and dexterity of our instruments, our ability to repair a defect is affected much less by the orientation of the incisions or the location than it would be in conventional laparoscopy.
To close the uterine serosa, we use a running baseball stitch with 3-0 Vicryl on an SH needle. If multiple fibroids must be removed, we prefer to repair each uterine defect after enucleation before moving on to another tumor. This way, we're taking advantage of the effects of vasopressin at each site. We try to remove as many fibroids as possible through a given hysterotomy.
Before retrieving excised fibroids, the robot-assist device is undocked. Specimens are then retrieved via a tissue morcellator that is placed through the accessory port. Another option is to use the endoscopic port site, but this requires the use of a 5-mm 0-degree laparoscope placed through one of the lateral trocars.
All operative sites are irrigated, hemostasis is ensured under low-pressure settings, and an adhesion barrier is placed over all uterine incisions. We typically apply a slurry of finely chopped Seprafilm as an adhesion barrier (an off-label use).
With robotic myomectomy, as with any of the robotically assisted gynecologic procedures, the importance of the bedside assistant cannot be overestimated. In addition to providing traction/countertraction (we usually don't need to use a fourth robotic arm because our assistants are skilled), the assistant introduces and removes suture, provides irrigation, and manages any accessory port activity (J. Robotic Surg. 2007;1:69-74).
The Patients, the Outcomes
With robotics, there really are not many patients we cannot address. There are no absolute inclusion criteria, and no absolute cutoffs. It's all relative. We determine whether a patient is a candidate for a robotic myomectomy based on the size and mobility of her uterus as well as the size, number, and location of her fibroids.
For example, a patient whose height is 4 feet 10 inches and who is obese with a short truncated torso, a uterus that is not very mobile, and an 8-cm fibroid located over the broad ligament may be a poorer candidate than would a taller patient of average weight with an 8-cm intramural fibroid in a uterus that is extremely mobile. This is where the art of medicine comes into play.
Overall, however, the robotic approach overcomes challenges like obesity, and puts us at a greater advantage as surgeons—giving us an ability to suture more effectively and to approach complex pathology much more aggressively—than does conventional laparoscopy.
It takes some time to get used to the dramatic paradigm shift of operating remotely from the patient through a robotic interface. Learning to overcome the lack of tactile feedback is also part of the learning curve. The key is to not attempt more than you can handle early in the learning process. Then, as your experience grows, your ability to tackle complex gynecologic pathology will come. In other words, start with a symptomatic 4- to 5-cm fundal subserosal fibroid before approaching the 10-cm broad-ligament fibroid.
We started doing robotic myomectomies in 2001. In our first published series of 35 cases, the mean myoma weight was 223.2 g. The mean number of myomas removed was 1.6, and the mean diameter was 7.9 cm. The average estimated blood loss was 169 mL and no blood transfusions were necessary. Three of the cases were converted to laparotomy, two because of the absence of tactile feedback and a third because of cardiogenic shock secondary to vasopressin (J. Am. Assoc. Gynecol. Laparosc. 2004;11:511-8).
Since that early experience, we have not had to convert a patient to a laparotomy secondary to an absence of tactile feedback.
When we later compared surgical outcomes with those of traditional laparotomy through a retrospective case-matched analysis of 58 patients, we found that although operative times were significantly longer in the robotic group (a mean of 231 minutes vs. a mean of 154 minutes), postoperative complication rates were higher in the laparotomy group.
In all, there were 14 postoperative complications in 12 patients in the laparotomy group, including wound dehiscence; hematoma; blood loss and anemia requiring transfusion; and deep vein thrombosis followed by respiratory arrest and renal failure. In the robotic group, there were three postoperative complications: aspiration pneumonia, port-site cellulitis, and chest pain.
Estimated blood loss was significantly higher in the laparotomy group than in the robotic group (a mean of 365 mL v. 196 mL), and transfusions were required in two patients who underwent laparotomy. Length of stay was also higher: 3.6 days in the laparotomy group, compared with 1.5 days in the robotic group. (J. Min. Invasive Gynecol. 2007;14:698-705).
We have also analyzed the effects of our experience over time and have presented these data at the AAGL annual meeting in November 2007. We found a notable trend toward both lower blood loss and shorter operative time with experience. Additionally, we evolved from an average length of stay of 1.5 days to a completely outpatient procedure. We even noted an increasing ability to tackle more complex fibroid cases over time, particularly those involving submucosal and deep intramural fibroids.
More recently, we have begun long-term follow-up of our patients. Preliminary pregnancy data show us that women who have undergone a robot-assisted laparoscopic myomectomy in the past 5 years have indeed become pregnant and have carried their pregnancies through with no complications and no uterine ruptures.
A hysterotomy is underway with an EndoWrist cautery hook and Gyrus dissecting forceps.
A fibroid enucleation is facilitated by an EndoWrist tenaculum.
A myometrial defect is repaired with EndoWrist needle drivers and 0-Vicryl suture. Photos courtesy Dr. Arnold Advincula
Robotic Myomectomy: The Time Has Come
In the last edition of the Master Class in gynecology, Dr. Javier Magrina, professor of ob.gyn. and director of female pelvic medicine and reconstructive surgery at the Mayo Clinic in Scottsdale, Ariz., ably described the benefits and technique of robotic-assisted hysterectomy.
In this second installment on robotic-assisted surgery, I have asked Dr. Arnold P. Advincula, clinical associate professor of ob.gyn. at the University of Michigan, Ann Arbor, to discuss robotic-assisted laparoscopic myomectomy.
Other than laparoscopic tubal anastomosis, there is no procedure in minimally invasive gynecologic surgery that is more dependent on the ability to be facile with laparoscopic suturing techniques than laparoscopic myomectomy. Certainly, the physician's need to visualize the repair on a television screen while using limited wrist motion for suture placement limits the vast majority of gynecologists from routinely and effectively performing this procedure.
Dr. Advincula holds several departmental positions at the University of Michigan. He is the director of the minimally invasive surgery and chronic pelvic pain program, the director of the minimally invasive surgery fellowship, and the codirector of the university's endometriosis center. Dr. Advincula is also a member of the board of trustees of the AAGL and is associate editor of the journal The Female Patient, coeditor of the Journal of Robotic Surgery, and a member of the editorial board of the International Journal of Gynecology & Obstetrics.
Dr. Advincula not only is an avid clinical researcher and educator, having published nearly 50 articles in peer-reviewed journals, but also is a fixture on both the national and international lecture circuits on the topic of minimally invasive gynecologic surgery.