Reconstructive Surgery in Urogynecology/Uro

Transcription

Reconstructive Surgery in
Urogynecology/Uro-jinekoloji
Rekonstrüktif Cerrahi
Felipe Ojeda, MD
Hospital General Granollers
Barcelona (SPAIN)
jueves 29 de abril de 2010
Perfection concept
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West: formal concept (greeklatin)
East: holistic concept
Thats is the question
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Anatomy vs Function
Anatomical adequacy vs functional
adecuacy and life quality
Anatomical success vs functional
success
The resulting forces pression
4
Balanced model
5
Tension free
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Hammock theory
Use mesh to reinforce damaged
ligaments and fascies.
No traction
6
Why use a mesh?
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Increase the anatomic result and
decrease the re-interventions.
Increase the functional results.
Decrease morbility and get reproductive
surgeries with minimally invasive.
Increase the quality of life.
7
Uretral hipermobility
8
Incontinence treatment

Single incision TOT: Needleless®
System
Readjustable sling: Remeex ®
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PROLAPSE TREATMENT
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Surelift® Contasure Prolapse System
History
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1986: Ulmsted: TVT
2001: Delorme, TOT outside-in
2003: Leval, TOT inside-out
needle
inguinal pain
bladder perforation risk (TVT)
10
Needleless: NO minisling
138 % more surface area than mini-slings
1,2 cm in central area vs 1 cm
Needleless
Indications:

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The CONTASURE NEEDLELESS SLING is
intended for treatment of female stress
urinary incontinence
resulting from urethral hypo mobility or
hyper mobility and / or intrinsic
sphincter deficiency.
Warnings and Precautions:
Do not implant the CONTASURE NEEDLELESS SLING:
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1.- in patients under anticoagulant
treatment.
2.- in patients with urinary infection.
3.- in pregnant women.
Procedure
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With the scalpel performed 2 cm
anterior vaginal wall incision.
Distance urethra: 1 cm
Periurethral dissection with scissor
No fascial dissection
15
focus
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Insert into dissected space. Ten o’clock.
Advanced until resistance is felt,
until it perforates the internal fascia of
obturator internus
Opened the clamp and removed
Repeated a Two o’clock position with
the other arm.
19
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If necessary sling can be tightened by
closing/rotating and reinserting.
Advancing more or less.
The blue suture should be centered,
and remove it.
Close the vaginal incision.
20
office surgery
Adverse reactions:
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1.- Transitory local irritation at the
wound sites or a transitory foreign body
response may occur.
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These reactions could result in extrusion,
fistula formation and inflammation.
2.- As with all foreign bodies, the
CONTASURE NEEDLELESS SLING may
thrive an existing infection.
Indications

Surgical treatment of stress female urinary
incontinence, including patients with:
 Fixed urethra
 Urethral hipermobility
 Intrinsic Sphincteric deficiency
 Previous incontinence surgical interventions

Try again with another sling or...
Remmex ® TRT
Tension free Readjustable Tape
Abdominal incision
Make a small transversal incision (4 cm) at the abdominal midline, just over
the pubis. Dissect the fat tissue until clear exposure of the abdominal rectal
muscles fascia.
With an electrocautery make
two marks where the suture
traction threads should cross the
fascia of the abdominal rectal
muscles.
The marks should be in the
midline just over the pubis and
separated approx. 3 cm one
from each other.
Vaginal incision
Incision at the anterior vaginal wall and
make a good dissection of the area.
Introduction of the traction thread
passers through the Retzius space
Introduce the passers in the
paraurethral spaces, through the
Retzius space, maintaining the tips
of the suture passer always away
from the urethra and in continuous
contact with the posterior wall of
the pubis.
Connect and use the passer handle to drive the traction thread passer
across the fascia of the abdominal muscles, through the points
previously marked with the electrocautery.
Cystoscopy
With the passers in place, perform a cystoscopy to check the bladder integrity.
In case of bladder perforation, withdraw the passer and repeat step 4C.
Placement of the Remeex
system
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Placement of the sling and traction
suture threads
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Place the sling at the mid urethra.
The sling must be in full contact with the
submucosal tissue.
Introduce the traction threads through the passer
proximal holes. Pull the tip of the passer from the
abdominal incision, and clamp the traction thread
tips with a forceps.

Once this step is completed,
ask the surgical assistant to
keep the Remeex Varitensor
prosthesis in the midline,
(10 cm over the fascia of
the abdominal rectal
muscles).
Varitensor placement
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Then insert the traction
suture threads through the
Varitensor’s respective side
reception holes, so that the
suture threads come out
through the central outcome
hole (at theVaritensor
midline).
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Then take a Disconnector and adjust the
screw to tighten the traction suture thread to
the Varitensor.
It is important to make sure to leave the
same length of traction suture thread at
each side between the Varitensor and the
fascia.
Cut, remove, and discard the excess traction
suture thread.
Rotate the Manipulator clockwise, winding the traction threads into the
varitensor, until 3 cm of suture threads remains between the varitensor
and the fascia (two fingertips must pass easily under the varitensor)
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Vaginal and abdominal
incision closure
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Close the abdominal
incision with the
manipulator protruding
perpendicular to the
abdominal wall.
Close the vaginal incision.
Result
Post-surgical regulation and
manipulator disconnection

The following morning, through the
urethral catheter, fill the bladder with 300
cc.of saline, ask the patient to stand up
and invite her to perform valsalva maneuvers.

If necessary, rotate the manipulator
clockwise checking the continence level
every 4 complete turns, until incontinence
disappears.
Test

Then invite the patient to urinate and
measure the residual in bladder after it.,
through a urethral catheter.
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If residual is under 100 – 150 cc., disconnect the
manipulator and discharge the patient.
If the residual is more than 150 cc., decrease the
sling tension rotating the manipulator
counterclockwise, helping the descend of the
urethra with a rigid probe.
Disconnect

To disconnect the manipulator
from the varitensor, insert the
disconnector inside the
manipulator and rotate 1/4 turn
the disconnector in relation to
the manipulator while pulling
slightly the manipulator.
Follow-up
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It is important to explain the patient
that even she is leaving the hospital
with perfect continence, some degree of
incontinence may appear during the
first month after intervention.
If this is the case, we will be able to
readjust the sling level in a very easy
office procedure.
Sling level re-adjustment:
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In doctors office, after injecting local anesthesia,
make a minimal incision in the abdominal midline,
just over the pubis, to locate the varitensor.
Connect the manipulator to the varitensor, fill the
bladder with 300 c.c of saline serum, and rotate the
manipulator clockwise, until full continence is
reached.
This regulation will be done with the patient in the
standing position, performing the normal pressure
maneuvers that drives the patient to incontinence.
Prolapse
46
47
Objectives in prolapse surgery

1.- Repair functionality and anatomy
(long,wide, continence)
2.- Not to create deleterous effects
3.- Long term correction
4.- Less complications
5.- Improved quality of life
6.- Reproductible
7.- Easy to learn
48
Ideal mesh properties

1.- Inert
2.- Resistant
3.- Non-allergenic
4.- Not induce reaction
5.- Sterile
6.- Unalterable
7.- Acceptable cost
49
Synthetic meshes
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1.- Monofilament
2.- Macroporous (>75 micra)
3.- Woven (not thermos sealed)
4.- Flexible
5.- Polipropilene
50
Complications
!
Rejection
!
Contamination
!
Erosion
!
Extrusion
!
Scars
!
Pain
! Visceral
lessions
51
Surelift ®
6 arms: surplus arms CUT
Anterior or posterior mesh
53
Surgical Instruments
Harpoon: needleless?
Using only the harpoons migth perform a Richter surgery
Versatile: surplus arms CUT
İlginiz için teşekkürler


Thank you for your attention
Moltes gracies per la vostra
atenció.

Reconstructive Surgery in Urogynecology/Uro

Transcription

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