Task Analysis of Laparoscopic Pectopexy for Prolapse Uterus
Dr. ELAVARASI.E DGO, DNB ( D.MAS OCT 2019)
1. Laparoscopy is the gold standard for the management of uterine prolapse except for procidentia.
2. Laparoscopically we can correct uterine prolapse by either sacrohysteropexy or pectopexy. Both methods are equally good.
3. In young women who have not completed the family, laparoscopic sacrohysteropexy is better.
4. Laparoscopic pectopexy is preferred especially in obese women because of the difficulty in assessing the sacral promontory.
5. Pregnant women who have undergone laparoscopic pectopexy or sacrohysteropexy earlier should be delivered only by elective cesarean section.
6. During cesarean, care should be taken to avoid the mesh and the incision on the uterus should be above the level of mesh.
PRE OP EVALUATION:
1. Proper history taking and clinical examination of the patient
2. Routine investigations and additional investigations based on comorbidities
3. Urodynamic study with MRI contrast lateral view
4. Anesthetic fitness
5. Informed Consent
1. 11 no. scalpel
2. Veress needle
3. Two 10 mm and one 5 mm port
4. 10 mm telescope
6. Atraumatic grasper
8. Needle holder
9. Dacron ( Ethibond) or silk 1 no suture
12.T shaped mesh ( ultra-fine polypropylene or vypro mesh)
PROCEDURE OF PECTOPEXY:
1. UV fold of peritoneum is opened up to the deep ring on either side.
2. The vertical limb of the T shaped mesh is attached to the cervix
3. Both the horizontal limbs are attached to the Cooper’s ligament on the respective side
4. UV fold of peritoneum closed.
5. The mesh should not be too tight so that once fibrosis develops and mesh shrinks, it will give needed support and keeps the uterus anteverted.
COMPLICATIONS OF SURGERY:
1. Vaginal mesh extrusion/ visible mesh
2. Vaginal pain/ painful intercourse
3. Mesh erosion of bladder or rectum
4. Infection/abscess of mesh
PREOPERATIVE CHECKLIST - confirmed
PATIENT POSITION- :
The Surgeon on the left,
1 st Assistant on the right
2nd Assistant between the legs for uterine manipulation
Anesthetist on the head end
Scrub nurse as usual
PORT- 3 port technique,
Either Contralateral or Ipsilateral
SURGICAL STEPS PROPER:
1. After successful pneumoperitoneum with veress, an 11mm smiling incision is made in the inferior crease of the umbilicus using no.11scalpel.
2. Use mosquito forceps to dilate the obliterated Vitello intestinal duct (Scandinavian technique).
3. Insert the 10 mm cannula with trocar with guarded screwing movement, perpendicular to the abdominal wall till give away sensation is perceived.
4. Remove the trocar and push the cannula in.
5. Introduce the 30-degree telescope in after white balancing and focussing at 10 cm distance and visualise the area directly under the port for presence of any bleeding or injury.
6. Transilluminate the abdominal wall and insert one 10 mm port on the left and one 5mm port on the right under vision by the Baseball Diamond concept. You can also use the ipsilateral port with a 7.5 cm distance in between.
7. Do a complete examination of the abdomen and pelvis and push the bowel above the sacral promontory.
8. Introduce the uterine manipulator carefully under vision and keep the uterus retroverted at 6o’ clock position.
9. Lift and stretch the utero vesical fold of peritoneum in the midline with an atraumatic grasper and dissect the uv fold of peritoneum on the right side up to the deep inguinal ring with harmonic or scissors.
10. Gently dissect the space between the medial umbilical ligament and deep ring and reflect the medial umbilical ligament medially. Care should be taken not to cut the medial umbilical ligament or the peritoneum medial to the medial umbilical ligament to avoid bladder injury.
11. Repeat the same steps on the left side to identify the cooper’s ligament on the left side.
12. Bladder dissection is done adequately by holding the bladder with atraumatic forceps and gently dissecting and pushing the bladder down by blunt dissection and harmonic wherever necessary.
13. Fold the T shaped mesh and hold the tip with a grasper and introduce it through the 10 mm port.
14. Spread the mesh in such a way the vertical limb of T lie over the cervix
15. Make an Endoski needle with 20 cm Dacron or silk and introduce it through the 10 mm port.
16. Take 3 rows of intracorporeal surgeon’s knot on either side of cervix fixing the vertical limb of mesh firmly over the cervix.
17. Take a transverse bite on the right Cooper’s ligament and a bite on the right end of the horizontal limb of mesh and tie intracorporeal surgeon’s knot.
18. Take a bite on the left side horizontal limb of mesh and a transverse bite on left Cooper’s ligament and tie intracorporeal surgeon’s knot.
19. You can alternatively fire tacker and fix the mesh on both the cooper’s ligament. But tacker should not be fired on the cervix and vagina. In the case of using vypro mesh, tackers do not hold well and sutures should be taken.
20. Close the utero vesical fold of peritoneum by continuous intracorporeal suturing. You can also use Dundee jamming knot with Aberdeen termination. Care should be taken not to include the mesh while suturing the peritoneum.
21. Desufflation of abdomen done
22. Ports are withdrawn under direct visualisation and optical cannula is withdrawn by sliding over the telescope
23. Skin incisions are either sutured or stapled.
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