Native Tissue Repair After Failed Synthetic Materials



Fig. 20.1
(a, b) A vertical incision is made over the vaginal wall, extending anterior to the bladder base and posterior to the prerectal area



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Fig. 20.2
(a, b) Using sharp dissection, the peritoneal sac is dissected free from the vaginal wall, posterior from the rectum and anterior toward the bladder base. The dissection is extended to isolate the base of the sac. Care should be taken to avoid bladder injury during the anterior dissection or rectal injury during the posterior dissection. A rectal finger can help during this phase of the surgery. Illumination of the bladder lumen with a cystoscopic light can help to define the bladder base. In case of doubt, the bladder should be irrigated in order to rule out perforation. Branches of the uterine artery are very often found at the base of the enterocele sac; they must be coagulated or suture ligated


For our suspension, we prefer polydioxanone (PDS II™, Ethicon) sutures as they are the longest-lasting absorbable suture readily available. #0 delayed absorbable suspension sutures are first placed through the posterolateral vaginal wall, in the area previously marked 3 cm lateral to the vaginal incision (Fig. 20.3). Next, the suture is passed through the pre-rectal fascia to provide additional posterior support of the rectal wall. The suture is then placed at the origin of the sacrouterine ligament approximately 10–12 cm from the introitus (Fig. 20.4). The site of fixation is distal to the sacrospinous ligament, medial to the levator muscle, lateral to the sacrum, and posterolateral to the rectum (Fig. 20.5). This location is free from vessels or nerves that can be damaged during the placement of the suspension sutures. The sutures must be placed just lateral to the sacrum as incorporating tissue from the lateral or anterior segments can compromise the ureters either by direct injury or kinking. After incorporating a strong bite of tissue, the suspension suture is then brought back through the vaginal wall 1–2 cm from the original entrance and placed aside, to be tied after all other vaginal repairs are completed (Fig. 20.6). Placement of the suspension suture is then repeated on the contralateral side, and the suture placed aside.

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Fig. 20.3
A #1 PDS suture is inserted in the right posterior lateral aspect of the vaginal cuff


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Fig. 20.4
The needle is transferred lateral to medial, distal to the sacrospinous ligament, lateral to the sacrum, lateral to the rectum, and medial to the iliococcygeus muscle. At least two passes of the needle are done to provide a strong anchoring point


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Fig. 20.5
(a) The point of anchoring sutures for the vault suspension (blue dot) will be 12–14 cm from the introitus in the groove lateral to the sacrum, medial to the iliococcygeus muscle, and distal to the sacrospinous ligament. The suture will incorporate the origin of the sacrouterine ligaments just distal to the coccygeus, providing a fibrous, strong anchoring tissue that will not cause postoperative pain; there are no vessels or nerves in the area. (b) Anatomical drawing showing the point of insertion of the vault suspension sutures, distal to the sacrospinous ligaments, lateral to the sacrum, and medial to the iliococcygeus muscle


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Fig. 20.6
The needle is transferred from the peritoneum to outside the vaginal wall, at least 1 cm from the original entrance

Two purse-string sutures of #0 delayed absorbable suture, preferably polydioxanone, are then placed through the prerectal fascia (Fig. 20.7), the distal residual sacro-uterine ligament, and perivesical tissue at the bladder base (pubocervical fascia) (Fig. 20.8) to close the peritoneum after removal of the laparotomy pads (Fig. 20.9). The vaginal cuff is then closed in running fashion. The suspension sutures are then tied with an Allis supporting the vaginal cuff to secure the apex in its final position. This fixation suspends the vaginal cuff at a physiologic position restoring the axis of the vagina to sacral vertebral bodies four through five, with a banana-shaped curve posteriorly, similar to the native anatomy (Fig. 20.10). This procedure requires no specialized equipment and can be performed without inpatient admission if without concurrent hysterectomy. When hysterectomy is performed concurrently, a short inpatient stay is recommended. Patients experience good cosmetic outcomes, without any abdominal incisions.

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Fig. 20.7
Two #1 PDS sutures will be used to apply a purse-string suture to close the vaginal cuff. The first pass of the suture includes the prerectal fascia posterior to the distal segment of the cuff


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Fig. 20.8
After including the lateral peritoneum, the needle incorporates the bladder base to include the peritoneum and the pubocervical fascia. A large segment of tissue is incorporated


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Fig. 20.9
After removal of the laparotomy pads from the peritoneum, traction is applied to the purse-string sutures, and they are tied individually. Optionally, the excess of peritoneum can be excised. Any posterior vaginal wall defect should be repaired at this time


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Fig. 20.10
Diagram of the posterior vaginal anatomy, with the distal third of the vagina in a 45-degree angulation and the proximal vagina in a more horizontal axis ending at the sacrococcygeal area



Case Presentation


Six months later, our index patient’s vaginal bleeding, vaginal pain, dyspareunia, and recurrent UTIs were resolved. While she felt like much of her life had been reclaimed, she now complained of persistent urinary incontinence, desiring intervention for her SUI (currently 5 pads a day). On exam, she had hypermobility of the urethra and grossly visualized incontinence per meatus with Valsalva; there was minimal laxity of the anterior and posterior vaginal walls, with a well-supported apex. She underwent a video-urodynamic study, secondary to her complex history, which confirmed SUI; no evidence of fistula was seen on fluoroscopic imaging.


Surgical Description


Depending on the degree of incontinence, patients can undergo surgical correction of SUI with either suture bladder neck suspension/vaginal wall sling or variants of sling utilizing a fascial graft. While not useful for patients who have severe incontinence or patients with prior surgical failures, radiation, neurogenic incontinence, or resting incontinence, bladder neck suspension/vaginal wall sling can be effective for patients with mild, bothersome SUI. The idea is to create a hammock of vaginal wall and nonabsorbable sutures. With the patient in lithotomy position, two oblique incisions are made in the distal vaginal wall on either side of the urethra (Fig. 20.11). After entering into the retropubic space sharply and freeing any adhesions in that location, the urethropelvic fascia is separated from the arcus tendinous fascia pelvis (Fig. 20.12). The first pass of the suspension suture of #0 nonabsorbable (preferably polypropylene) suture incorporates the free edge of the urethropelvic fascia and then the suburethral periurethral fascia to create a helical stitch extending almost to the midline underneath the urethra (Fig. 20.13). A second pass encompasses the periurethral fascia at the mid urethra and the perivesical fascia at the bladder neck, extending to the midline (Fig. 20.14). After placing the suture, traction is applied to confirm a strong anchor of tissue of the anterior urethra and bladder neck. A second suspension suture is placed in similar fashion contralaterally (Fig. 20.15). The suture is again extended towards the midline in close proximity to the suture from the contralateral side to create a hammock of support of suture and the vaginal wall from the midurethra to the bladder neck. A small stab incision 1 cm above the superior ramus of the pubis on the abdomen is made. A double-pronged ligature carrier (Raz needle passer) is then transferred from this incision under direct finger guidance through the retropubic space and brought out of the vaginal incision (Fig. 20.16). After capturing the ipsilateral suspension suture, withdrawal of the passer from the suprapubic incision transfers the suspension suture retropubically (Fig. 20.17). This procedure is repeated contralaterally. Traction of the sutures will produce elevation of the urethra and bladder neck. There is no specific maneuver that can help to identify the appropriate tensioning of these sutures while tying over the anterior rectus fascia; we use the cystoscope to guide tensioning. After cystoscopy to rule out bladder injury, the instrument sheath is kept in the urethra at a 45° angulation, and the sutures are tied without tension in the suprapubic area (Fig. 20.18). The vaginal incisions are then closed with 2-0 absorbable suture, taking care not to incorporate the suspension sutures in the closure.

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Fig. 20.11
(a) Two oblique incisions are made in the anterior vaginal wall, extending a few centimeters proximal to the bladder neck. The incision is made 1 cm from the lateral vaginal wall. (b) Two Allis clamps are placed on each side at the apex of the incisions (arrows) for traction and improved exposure


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Fig. 20.12
(a, b) To enter the retropubic space, curved scissors are placed parallel to the urethra, under the pubic bone and in an upward direction, abutting the pubic bone at all times


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Fig. 20.13
A #0 monofilament nonabsorbable suture is used to incorporate the lateral margin of urethropelvic fascia. Care should be taken not to insert the needle deeply, to avoid penetrating the wall of the bladder or urethra


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Fig. 20.14
The periurethral and perivesical fasciae are also included


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Fig. 20.15
(a , b) The same procedure is performed again on the contralateral side


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Fig. 20.16
A double-pronged ligature carrier (Raz needle passer) is used to transfer each of the Prolene® sutures from the vagina to the suprapubic region. Under finger control, the tips of the passer are transferred from the suprapubic incision to the vaginal incisions


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Fig. 20.17
The sutures are transferred through the eyes of the needle and retracted to the suprapubic area


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Fig. 20.18
(a) The suprapubic incision and sutures are seen. (b) Cystoscopy will be performed, the sutures will be tied using two Allis clamps to keep the sling in an horizontal plane and the anterior vaginal wall will be closed with several delayed absorbable sutures

For patients with urethral trauma, radiation, failed surgeries, prior mesh removal, or significant incontinence with a fixed, non-mobile urethra, a bladder neck suspension/vaginal wall sling is not indicated. Mesh and mesh removal will cause sufficient damage to the periurethral tissues and support structures such that a fascial sling will be necessary. While other biologic materials are available for use, the use of autologous fascia provides far superior results than other biologic grafts; patients with cadaveric grafts experience high rates of recurrence and reoperation [7]. The decrease in durability may result from increased resorption of the graft; re-exploration of cadaveric allografts at re-operation for failure reveals severe or complete degeneration [8]. Cadaveric tissue also demonstrates increased rates of vaginal extrusion in multiple studies in comparison to the near-zero rates seen with autologous fascial grafts [9, 10].

A wide range of xenografts are also available for commercial use, the most common being porcine dermal and small intestine submucosa (SIS) grafts, both cross-linked and non-cross-linked. The non-cross linked forms of these tissues are rapidly degraded after implantation, losing most of their mechanical integrity within 3 months, without any tissue regeneration or reorganization. Cross-linking of these xenografts confers increased tensile strength and resistance to degradation. Long-term data is still lacking, but several studies have detailed inflammatory complications and extrusions at similar rates to those experienced with mesh products [11, 12]. Given the high cost of these products and their uncertain safety and efficacy, we highly recommend the use of autologous tissue grafts whenever possible.

Most surgeons harvest abdominal rectus fascia for use in native tissue anti-incontinence surgeries because it is easier and faster to harvest. We, however, have abandoned the use of rectus fascia in favor of harvesting tensor fascia lata (iliotibial band). This technique is significantly less morbid and provides improved cosmesis for patients. The technique is particularly useful in obese patients in whom accessing the rectus fascia is more challenging and in patients with prior abdominal surgeries when adequate graft may be difficult to obtain due to scarring. In our experience, harvest of rectus fascia is associated with increased pain at the harvest site, a slower return to normal activities due to the increased tension of the abdominal wall fascial closure, and an increased risk of post-operative complications, such as abdominal wall hernia, that frequently require re-operation to correct. Although this technique does require repositioning of the patient during surgery, the complications are rare and preventable, such as thigh hematoma or wound infection, almost all of which can be managed non-operatively.

For fascia lata harvest, the patient is placed in a lateral decubitus position with flexion of the knees, along with elevation of the thigh and knee using pillows (Fig. 20.19). We prefer the left leg in all patients when possible to allow the patient to return to driving with less discomfort. A transverse incision is made approximately 3–4 cm above the knee over the palpable iliotibial band, which is marked on the patient prior to surgical preparation. The tendinous section of the fascia is then exposed, and two parallel incisions are made in line with the fascial fibers approximately 1 cm apart. A right-angle clamp is used to develop the plane beneath the fascia and to separate it from the underlying musculature (Fig. 20.20). The fascial segment is transected inferiorly and a #1 delayed absorbable suture placed at this margin with multiple passes to anchor the stitch without fraying the fascial border (Fig. 20.21). Using a combination of sharp and blunt dissection, the fascia is separated from the subcutaneous tissue and underlying musculature for approximately 10 cm cephalad to the skin incision. This can be accomplished mostly with the Crawford stripper, used to separate and transect the 10 cm segment (Fig. 20.22). Alternatively, the incisions in the fascial tendon can be extended cephalad and the fascial strip transected at its most proximal aspect using a right angle scissors, such as a Jorgenson scissor. The suture and the caudad margin of the fascial strip is passed through the tip of the stripper, and the stripper advanced 10–12 cm along the direction of the fascial fibers. The device is then activated to transect the cephalad margin of the fascial strip, and a second anchoring #1 delayed absorbable suture is placed at this fascial margin (Fig. 20.23). The fascial strip is then placed in antibiotic solution until later use. Prior to closure, the wound is irrigated extensively with antibiotic solution and immaculate hemostasis obtained. The incision is closed in two layers in standard fashion. A pressure dressing using self-adherent elastic wrap, such as Coban™ (3 M, St. Paul, MN), is used to prevent hematoma formation. Placement of a fascial sling using anterior rectus fascia is identical to that described here for fascia lata; the harvest procedure for abdominal fascial harvest can be found in cited sources (see Chap. 5) [13].

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Fig. 20.19
The first part of the surgery is the retrieval of the fascial segment. The patient is placed in the tort position with elevation of the thigh and knee over a pillow. The inferior part of the lateral thigh and knee is prepared and draped


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Fig. 20.20
A right-angle clamp is used to isolate the strip of fascia from the underlying musculature


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Fig. 20.21
Sharp and blunt dissection is used superior to the fascia to separate the fascia from the subcutaneous tissues for a distance of 10 cm. The fascia is also dissected sharply and bluntly from the underlying lateral musculature to facilitate the fascial incision


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Fig. 20.22
A clamp is applied to the end of the fascial segment to provide countertraction at the time of the advancement of the stripper


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Fig. 20.23
The fascial strip is removed and another #1 delayed absorbable suture is applied to the free end. The fascia lata segment is placed in antibiotic solution. The wound is closed in two layers of #2-0 delayed absorbable sutures in the subcutaneous and #4-0 in the skin

To place a sling, two oblique incisions are made lateral to the urethra on the distal vaginal wall. The retropubic space is entered, and all retropubic adhesions freed. A right-angle clamp is then used to create a tunnel underneath the vaginal wall suburethrally (Fig. 20.24). The fascial strip is transferred through this tunnel (Fig. 20.25). The fascia is sutured in place to the periurethral tissue unilaterally to prevent displacement of the sling. A small puncture is made approximately 1 cm above the pubic symphysis. Passage of the double-pronged sling passer from this incision to the vagina through the ipsilateral retropubic space allows transfer of the sling and suture retropubically (Fig. 20.26). This procedure is repeated contralaterally. Gentle countertraction is applied by two Allis clamps on the sling lateral to the urethra bilaterally; they are maintained in a horizontal plane while the suspension sutures are tied to the anterior rectus fascia without tension. The vaginal wall is then closed and cystoscopy performed to rule our iatrogenic bladder or urethral injury.
Jul 13, 2017 | Posted by in GASTROENTEROLOGY | Comments Off on Native Tissue Repair After Failed Synthetic Materials

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