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Surgical Technology International XXIV contains 48 articles with color illustrations.

 

 

San Francisco, March, 2014

ISBN: 1-890131-20-2

 

1 year Institutional Subscription 

both electronic and print versions.

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Sections

Gynecology

 

Stryker
  • Stryker Stryker

 

 

Systematic Review and Classification of Complications after Anterior, Posterior, Apical, and Total Vaginal Mesh Implantation for Prolapse Repair

Dimitri Barski, MD, Resident, Department of Urology, Lukas Hospital, Neuss, Germany, Thomas Otto, MD, Professor, Head of Department,  Department of Urology, Lukas Hospital, Neuss, Germany, Director, German Centre for Assessment and Evaluation of Innovative Techniques in Medicine, Neuss, Germany, Holger Gerullis, MD, Specialist in Urology, Department of Urology,  Lukas Hospital, Neuss, Germany, Research Associate, German Centre for Assessment and Evaluation of Innovative Techniques in Medicine, Neuss, Germany

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PMID: 24700225

Abstract

In this review we focus on the transvaginal meshes used for pelvic organ prolapse (POP) repair and possible changes in application after the first FDA warning in 2008. A systematic review of the literature was performed. The data was reviewed for reoperation rates and complications following the Clavien–Dindo classification. A total of 11 randomized controlled and 9 prospective studies with 2,289 patients (most POP-Q≥II, median follow-up 12 mos) were included. The results showed a mean total complication rate of 27% in anterior, 20% in posterior, and 40% in combined mesh repair group (ns). Grade ≥III complications occurred in 8% anterior, 3.5% posterior, and 13% combined (p < 0.05) mesh repairs. No differences were found for reoperation rates for POP (2% to 3%). The following risk factors for complications were identified: operative technique, surgeon experience, previous prolapse repair, concomitant hysterectomy, total mesh repair, mesh properties (light weight, collagen coating were positive factors), young age, sexual activity, and smoking. Due to high complication rates (especially mesh erosion, voiding dysfunction, and dyspareunia) a careful individualized selection of patients and materials, education of patients, and elimination of identified risk factors are urgent prior to implantation of vaginal meshes.

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The LION Procedure to the Pelvic Nerves for Treatment of Urinary and Faecal Disorders
Marc Possover, MD, PhD, Possover International Medical Center, Zuerich, Switzerland, Professor of Neuropelveology, University of Aarhus, Aarhus, Denmark

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PMID: 24700226

Abstract

Bladder dysfunctions have been treated for decades through medical treatments or surgical procedures, especially in the context of prolapse conditions and stress incontinence. Over the last decade, sacral nerve modulation (SNM) has been introduced as a further option in the treatment of some urinary and fecal symptoms. Current techniques of percutaneous implantation are limited to superficial extrapelvic nerves that expose patients to lead migration and dislocation or infections, complications that cannot be ignored. Access to endopelvic nerves and plexuses will be mandatory in the future, especially to the sacral plexus area that is the crossroads of all vesical-sphincteric, anorectal, and sexual functions. The endopelvic location of electrodes protects against the above mentioned complications. Some open-surgical approaches have been described in the past, but all of them were extremely laborious and dangerous. All these limitations were overcome with the introduction of laparoscopy into the field of pelvic oncology. Laparoscopic retroperitoneal surgery and the development of video-endoscopy and appropriate instruments allows for access and visibility to all pelvic nerves and plexuses as well as laparoscopic pelvic neurosurgical procedures. One of these methods is the implantation of neuroprothesis—a technique called the “LION procedure”—which permits selective electrical stimulation of pelvic nerves and plexuses. One very interesting site of implantation for treatment of urinary and faecal symptoms is the pudendal nerve (PN). Stimulation of this nerve induces two different actions: a strong contraction of the sphincters—treatment of urinary and faecal incontinence and an inhibitory effect on the bladder—and treatment for bladder overactivity.

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Laparoscopic Re-anastomosis of a Uterine Avulsion Following Cold-knife Conization

Samuel Santos-Ribeiro, MD, Resident, Obstetrics and Gynecology, Ana Coelho, MD, Assistant, Obstetrics and Gynecology, Teresa Diniz da Costa, MD, Assistant, Obstetrics and Gynecology, Sónia Barata, MD, Assistant, Obstetrics and Gynecology, Conceição Alho, MD, Senior Assistant, Obstetrics and Gynecology, Filipa Osório, MD, Assistant, Obstetrics and Gynecology, Carlos Calhaz-Jorge, MD, PhD, Coordinator, Service of Gynecology, Obstetrics and Gynecology Department, University Hospital of Santa Maria, Lisbon, Portugal

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PMID: 24532481

Abstract

This report presents an exceptional case of uterine avulsion following a cold-knife conization, an unprecedented surgical complication of a common gynecological procedure. Furthermore, it describes the outcomes of the conservative laparoscopic reconstruction that was performed. A 30-year-old nulliparous was referred to our department with secondary amenorrhea and cyclic pelvic pain following a cold-knife conization performed 9 months previous in another institution. The patient underwent a diagnostic laparoscopy, which confirmed that the cervix had been completely resected and that the uterine and vaginal cavities were no longer in contact. We performed an end-to-end utero-vaginal anastomosis followed by a prophylactic cerclage. No intraoperative or postoperative complications were observed. One month after surgery the patient was asymptomatic with normal withdrawal bleeding and remained asymptomatic during her 12-month follow-up consult. To our knowledge, this is the first time that this serious complication with a potential for irreversible damage to reproductive function is reported as a complication of cervical conization. Although our conservative surgical correction repaired the anatomy and reestablished menstruation outflow, further follow-up is necessary to confirm the extent to which reproductive function was restored.

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Richard Wolf
  • Richard Wolf Richard Wolf

 

 

Simulation Study Comparing the Effectiveness of the Gynecare Morcellex®, the MOREsolution™, and the Rotocut™ G1 Tissue Morcellators

Mena Bekhit, BA, Medical Student, University of Central Florida College of Medicine, Orlando, FL, Tiffany Jackson, MD, Medical Director of Robotic Surgery, Department of Gynecology, Baylor Medical Center at Garland, Garland, Texas, Arnold P. Advincula, MD, Vice-Chair & Chief of Gynecology, Columbia University Medical Center, New York, NY

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PMID: 24574011

Abstract

Laparoscopic surgery has revolutionized the manner in which many operations are performed today. The volume of tissue to be removed during some operations can be a limiting factor for laparoscopy and is frequently a reason for converting from a minimally invasive laparoscopic surgical approach to the conventional open surgical approach. The introduction of the electronic morcellator has helped facilitate the removal of large specimens via minimally invasive surgery. The purpose of this study is to evaluate the effectiveness of the Gynecare Morcellex® morcellator (Ethicon, Inc., Somerville, NJ), the MOREsolution™ morcellator (Blue Endo, Lenexa, Kansas), and the Rotocut™ G1 morcellator (Karl Storz, Tuttlingen, Germany) tissue morcellators based upon their ease of use and efficacy in a simulation setting among an unbiased cohort of novice surgeons. University of Central Florida College of Medicine students were observed using the three different morcellators in a randomized order on 250 g beef tissue models and were surveyed on the ease of use of the morcellators. The MOREsolution™ tissue morcellator demonstrated significantly faster tissue morcellation times (544.6 ± 123.0 sec) and produced a higher number of long tissue fragments (7.44 ± 0.683) compared to the Rotocut™ G1 morcellators’ time (609.7 ± 153.2 sec) and number of long tissue fragments (6.00 ± 0.638). No significant differences were found between the Gynecare Morcellex® and other morcellators in the total number of fragments obtained nor study participant opinion on the ease of use of the three morcellators. This study demonstrates that the MOREsolution™ morcellator is a faster morcellator and produces larger tissue fragments as compared to the Rotocut™ G1; however, more studies should be performed to confirm these findings in a clinical setting.

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Disc Resection Is the First Option in the Management of Rectal Endometriosis for Unifocal Lesions with Less than 3 Centimeters of Longitudinal Diameter

Amélia de Almeida, MD, Gynecologist, Department of Obstetrics and Gynecology, Centro Hospitalar Tâmega e Sousa, Penafiel-Porto, Portugal, Luiz F. Fernandes, MD, Gynecological Surgeon, Sirio Libanes Hospital, São Paulo, Brazil, Marcelo Averbach, MD, Colorectal Surgeon, Sirio Libanes Hospital, São Paulo, Brazil, Mauricio S. Abrão, MD, Gynecological Surgeon, Sirio Libanes Hospital, Associate Professor, Obstetrics and Gynecology Department, Sao Paulo University, Sao Paulo, Brazil

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PMID: 24526427

Abstract

Rectosigmoid endometriosis is one of the most advanced forms of the disease affecting 3% to 37% of patients with endometriosis. Some patients are asymptomatic but others can develop severe symptoms such as abdominal and pelvic pain, diarrhea, constipation, and rectal bleeding. Transvaginal ultrasonography (USG-TV) with bowel preparation is the first-line investigation in patients with suspected bowel endometriosis and allows accurate determination of the presence of the disease. When endometriosis of rectosigmoid is diagnosed, the USG-TV helps the surgical team to define the appropriate therapeutic strategy, be it surgical or conservative. The surgical management of rectosigmoid endometriosis includes disc resection or segmental bowel resection. In recent years, disc resection has gained adherents; this approach allows the resection of macroscopic disease with fewer complications than segmental bowel resection. However, disc resection is only indicated when a lesion is unifocal, the size does not exceed 3 cm, and it does not involve more than 50% to 60% of circumference of the rectum or sigmoid wall. This article describes the laparoscopic disc resection surgical technique for intestinal deep endometriosis, its feasibility, and its current status.

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The Anatomical Outcome of Robotic Sacrocolpopexy for Treatment of Pelvic Organ Prolapse: A Comparison of Obese and Non-Obese Patients

Ali Azadi, MD, MSc, Assistant Professor, Associate Director of Residency Program, Department of  Obstetrics and Gynecology and Women’s Health, University of Louisville, Louisville, KY, Sean L. Francis, MD, Associate Professor, Division Chief & Fellowship Director, FPMRS, Department of Obstetrics and Gynecology and Women’s Health, University of Louisville, Louisville, KY, Kira C. Taylor, PhD, Assistant Professor, School of Public Health and Information Sciences, University of Louisville, Louisville, KY, Sara I. Diaz, MD, MSc, Female Pelvic Medicine and Reconstructive Surgery, Urology of Indiana, Greenwood, IN , Resad Pasic, MD, PhD, Professor, Department of Obstetrics and Gynecology and Women’s Health, University of Louisville, Louisville, KY, Taraneh Yeganeh, MS, College of Arts and Science, University of Louisville, Louisville, KY, Donald R. Ostergard, MD, Professor, Harbor-UCLA Medical Center, Torrance CA

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PMID: 24700227

Abstract

The purpose of this study is to compare the anatomical outcome of robotic sacrocolpopexy for pelvic organ prolapse in women with a body mass index (BMI) of 30 and higher to those with a BMI under 30. This is a retrospective chart review. POP-Q measurements preoperatively and 12 months postoperatively were evaluated using non-parametric statistical analysis. The primary outcome was to compare postoperative POPQ measurements at 12 months following surgery. Secondary outcomes were age at the time of surgery, mesh erosion rate, blood loss, length of hospital stay, and baseline anatomical support. A total of 71 patients were identified: 44 patients had a BMI below 30, and 27 had a BMI equal to or greater than 30. We found no significant relationship between BMI and anatomical support at 12 months post operation. However, obese patients were younger at the time of prolapse surgery (53.6 versus 60.6 years of age, p=0.0022). In regards to the ICS prolapse stage, no difference was found between obese and non-obese patients (2.81 versus 2.95, p=0.17).

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Evaluation of Sexual Function Outcomes in Women Undergoing Vaginal Rejuvenation/Vaginoplasty Procedures for Symptoms of Vaginal Laxity/Decreased Vaginal Sensation Utilizing Validated Sexual Function Questionnaire (PISQ-12)

Robert D. Moore, DO, FPMRS, FACOG, FACS, Director, Advanced Pelvic Surgery, Co-Director, International Urogynecology Associates, Atlanta, Georgia, and Beverly Hills, California, John R. Miklos, MD, FPMRS, FACOG, FACS, Director, , International Urogynecology Associates, Atlanta, Georgia, and Beverly Hills, California, Orawee Chinthakanan, MD, MPH, RTCOG, Female Pelvic Medicine and Reconstructive Surgery Fellow, International Urogynecology Associates, Atlanta, Georgia, and Beverly Hills, California

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PMID: 24700228

Abstract

Sexual function outcomes were analyzed in a group of women (n = 78) presenting for vaginal rejuvenation/vaginoplasty procedure for a chief complaint of vaginal laxity and decreased sensation with intercourse. Outcomes were analyzed utilizing the validated Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire-12 (PISQ-12) before and at least 6 months after repair with vaginal rejuvenation/vaginoplasty procedure (VR). Mean age was 43.6 ± 7.9 (range 25–62), and 19 patients (24.3%) were found to have prolapse at time of initial exam and underwent vaginal vault suspension in addition to VR. Compared preoperatively and postoperatively, the overall sexual function (Total PISQ-12) statistically improved (30.3 ± 6.6 vs. 38.2 ± 5.2, P < 0.001). All individual scores statistically improved except in 3 categories in which there was no change (Q1-desire, Q5-pain, and Q11- partner premature ejaculation). Overall sexual satisfaction improved as well as subcategories of increased sexual excitement during intercourse and overall increase in intensity of orgasms. Pain with intercourse subscores were found to be no different from preoperatively to postoperatively. Previous studies have shown that sexual function improves with repair of prolapse; however, this is the first study to show improved function using a validated questionnaire in patients undergoing VR for laxity.

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