The Ins and Outs of Laparoscopic Abdominal Sacrocolpoperineopexy

47 Pages·2011·3.59 MB·English

by  Windows User

The Ins and Outs of Laparoscopic Abdominal Sacrocolpoperineopexy
W23, 30 August 2011 09:00 - 12:00

Start End Topic Speakers
09:00 09:10 Introduction  Patrick Woodman
09:10 09:30 Overview: Why Laparoscopic Abdominal  Colleen McDermott
Sacralcolpoperineopexy?
09:30 09:45 Pelvic Floor Reconstruction Graft Materials  Douglass Hale
09:45 10:00 Suture Techniques  Colleen McDermott
10:00 10:20 Deep Anterior and Posterior Dissection and Vaginal  Douglass Hale
Graft Application
10:20 10:30 Discussion All
10:30 11:00 Break None
11:00 11:20 Laparoscopic Technique: Port Placement, Mechanics  Colleen McDermott
& Pitfalls
11:20 11:35 Robotic-Assisted LASCP: Port Placement, Mechanics  Patrick Woodman
& Pitfalls
11:35 11:50 Concomitant Urinary Incontinence Surgery  Douglass Hale
11:50 12:00 Questions All

Aims of course/workshop
1. To review the pertinent anatomy pursuant to laparoscopic pelvic reconstructive surgery.
2. To discuss the advantages and disadvantages of laparoscopic repairs.
3. To describe the Laparoscopic Abdominal Sacralcolpoperineopexy (LASCP) technique, with and without Robotic Assistance, as
well as reveal laparoscopic “pearls” to make the job easier.
4. To review the evidence-based literature about these repairs
5. To answer the question: "The uterus: does it need to come out?"
6. To discuss the addition of concomitant procedures to the LASCP.

Educational Objectives
Laparoscopic Sacral Colpoperineopexy (LASCP)offers similar excellent success rates to its open counterpart, and these minimally-
invasive procedures are becoming more popular. Laparoscopic approaches offer benefits of lower blood loss, quicker short-term
and long-term convalescence, better visualization and improved retraction. However, outside of a training program and/or
without specialized surgical assistants, it is difficult to gain sufficient experience in advanced laparoscopic skills.
This workshop would help guide the experienced surgeon through the process of adding advanced laparoscopic reconstructive
surgery skills to their armamentarium. There are several specialized and improvised devices available that can assist in
laparoscopic procedures. Graft materials, port placement, instrumentation, technique, and "pearls" on how to assist oneself will
also be discussed. Finally, the evidence-based medical literature will also be reviewed.
6/6/2011
The Ins and Outs of Laparoscopic
Disclosures
Abdominal Sacrocolpoperineopexy
• Patrick J. Woodman, DO, MS; FACS,
ICS Annual Scientific Meeting 2011 FACOOG
Glasgow, Scotland – Speakers’ Bureau, Pfizer Pharmaceuticals
– Unrestricted Educational Research Grant, Ethicon
Women’s Health & Urology
Patrick J. Woodman, DO, MSCR; FACS, FACOOG • Colleen McDermott, MD, MS; FRCOG
Associate Clinical Professor Obstetrics & Gynecology
Asst. Director Female Pelvic Medicine & Reconstructive Surgery Fellowship • Douglass S. Hale, MD; FACOG
Department of Obstetrics & Gynecology – Consultant, Ethicon Women’s Health & Urology
Indiana University School of Medicine
– Research Support, Urogynecology Advisory Board,
Allergan Pharmaceuticals
23 --Laparoscopic Abdominal Sacrocolpoperineopexy August 30th, 2011
Workshop #23 Schedule:
Educational Objectives The Ins and Outs of Laparoscopic Abdominal
Sacrocolpoperineopexy
• To review the pertinent anatomy pursuant to Time Title Lecturer
laparoscopic pelvic reconstructive surgery 09:00-09:10 Introduction Woodman
• To discuss the advantages & disadvantages of 09:10-09:3 Overview: Why LASCP-P? McDermott
laparoscopic repairs 09:30-09:45 Pelvic FloorRecnstrGraft Materials Hale
• To describe the LASCP technique, with & without 09:45-10:00 Suture Techniques McDermott
Robotic assistance and “pearls” 10:00-10:20 Deep Dissection& Vaginal Graft Appln Hale
• Review the evidence-based literature 10:20-10:30 Discussion Panel
10:30-11:00 ***Break ***
• Does the uterus need to come out?
11:00-11:20 Laparoscopic Technique McDermott
• To discuss the addition of concomitant procedures 11:20-11:35 Robotic-Assisted LASCP Technique Woodman
to LASCP 11:35-11:50 ConcomitantIncontinence Surgery Hale
11:50-12:00 Questions? Panel
23 --Laparoscopic Abdominal Sacrocolpoperineopexy August 30th, 2011 23 --Laparoscopic Abdominal Sacrocolpoperineopexy August 30th, 2011
Housekeeping
• Restrooms
• Break 10:30-11:00
• Syllabus / Handouts
• Evaluations
23 --Laparoscopic Abdominal Sacrocolpoperineopexy August 30th, 2011
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OBJECTIVES
Procedure Evolution
What’s the Evidence?
Advantages/Disadvan
tages
Colleen D. McDermott MSc, MD, FRCSC
August 30th, 2011
Procedure Evolution Procedure Evolution
POP: prevalent condition, 11.1% lifetime risk of
requiring surgical correction by the age of 801 1957 Arthure & Savage: anchored posterior uterine
fundus to the anterior longitudinal ligament1
Key to surgical correction: FIX THE APEX!
1958 Huguier & Scali; 1962 Lane: addition of graft
Sacral Colpopexy: material between the vagina and sacral promontory2-3
Gold standard for correction of all three vaginal 1970’s Birnbaum: proximal placement of graft at S3 to S4
compartments2-4 to recreate the natural vaginal plane4
Re-suspends the vaginal apex to the anterior longitudinal 1970’s Sutton: proximal end of the graft be attached at the
ligament overlying the sacrum using graft material
S1 to S2 vertebral level to see the middle sacral vessels5
1Arthure HG, Savage D. J Obstet Gynaecol Br Emp. 1957; 64: 355-60.
1234OAMBrdlasudehbinesa rokA nCeL r,W, eLet,.t aeAaltlm. . a COl .Jo bJOc shGbtreysatnt neGetec y GoDnly eaTncteaeoccblh.oa .1ls .91e 991 9S979y6; 5s8; t;93 1R7:7 :e5 3v60: .911 -26-6709.400.7-5; .3: CD004014. 2345LHSBuaiurntngteoub FnaieEu Gr.m JPO,, SSbecJts.a taAellit.m PGA. JmyP Onr eeJb csOssoteble. ts M 1tG9eet6yd 2nG. ;e 1y2c9n0o5el:8c . 7;o1 269l.-67 713:.9 ;7 81811;15 -1:44 4.011: -893.6-7.
Procedure Evolution Procedure Evolution
Graft Configurations: single piece cone  Biologic Grafts
Y-mesh 2-strap
autologous, allograft, xenograft
Advantage: reduced erosion rates
Disadvantage: reduced longevity
Synthetic Grafts
Advantage: durability
Disadvantage: increased erosion rates
type I polypropylene mesh: excellent anatomic cure rates,
few complications 1-2
1Iglesia CB, et al. Int Urogynecol J Pelvic Floor Dysfunct. 1997; 8: 105-15.
CostantiniE, et al. EurUrol. 2005; 48: 642-9. 2Ridgeway B, et al. Clin Obstet Gynecol. 2008; 51: 136-52.
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Procedure Evolution Procedure Evolution
1997: posterior graft extension to perineum Sacral SCP
Colpoperineopexy (SCP)1
1. Abdominal-vaginal approach starting at
recreate entire length of rectovaginal septum 
vagina
correct posterior wall defects and perineal descent
 open posterior vaginal wall, dissect laterally to levator
ani muscles, dissect superiorly to enterocele sac
 anchor graft laterally to pelvic sidewall into the fascia
overlying the levator ani muscles and distally to the
perineal body
 enter peritoneal cavity and place proximal portion of
graft into cavity
 perineorrhaphy
1Cundiff GW, et al. Am J Obstet Gynecol. 1997; 177: 1345-53.  abdominal portion of case
Figure: Walters and Karram, Urogynecology and Reconstructive Pelvic Surgery, 2nded.
Procedure Evolution Procedure Evolution
SCP SCP
2. Abdominal-vaginal approach starting Abdominal-vaginal approaches (1 & 2):
abdominally
 narrow the vaginal introitus
 posterior graft placed at the level of the perineal  rebuild the perineal body
body during the abdominal portion of the case
 at the end of the case, a perineorrhaphy is  require copious pelvic irrigation with
performed and the distal portion of the graft is antibiotic solution after sacral graft
attached to the perineal body attachment
Procedure Evolution Procedure Evolution
SCP open laparotomy, traditional laparoscopy,
3. Abdominal approach robotic-assisted laparoscopy
attachment to perineal body done solely through Dorsey and Cundiff 19941LSC
an abdominal approach improve pelvic visualization
commonly done when a perineorrhaphy is not reduce operative morbidity
required
improve post-operative function
strong distal fixation is more difficult to attain
Di Marco et al. 20042Robotic LSC
shorten learning curve associated with LSC
simplify execution of laparoscopic maneuvers
1Dorsey JH, Cundiff G. Curr Opin Obstet Gynecol. 1994;6(3):223-230.
2Di Marco Dset al. Urology. 2004;63(2):373-376.
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Procedure Evolution What’s the Evidence?
LSC
Approach Selection
observational studies only
level of comfort and expertise no clinical trials
need for concomitant procedures no systematic reviews
Ross et al151 patients, 5 years post-op
patient factors age, BMI,
93% objective cure rate
previous surgery, co-morbidities
3 patients had recurrent vault prolapse
that limit anesthesia time
1Ross JW, Preston M. J Minim Invasive Gynecol. 2005;12(3):221-226.
What’s the Evidence? What’s the Evidence?
LSC
Higgs et al1 103 patients, mean follow-up Bladder Function after LSC
92% had successful vault support 86% improvement or no change1
35% had non-vault prolapse recurrence
79% subjectively cured or improved 2.8% post-operative stress urinary
incontinence, 18% de novo or persistent urge
Claerhout et al2 132 patients, 12.5 months post-op
2% vault recurrence urinary incontinence2
3% anterior wall recurrence 5 to 7% de novo urinary symptoms3
18% posterior wall recurrence
92% subjective cure rate
1Higgs PJ, et al. BJOG. Aug 2005;112(8):1134-1138.
1Higgs PJ, et al. BJOG. Aug 2005;112(8):1134-1138. 2Agarwala N, et al. J Minim Invasive Gynecol. 2007;14(5):577-583.
2Claerhout F, et al. European Urology. 2009;55:1459-1468. 3Claerhout F, et al. European Urology. 2009;55:1459-1468.
What’s the Evidence? What’s the Evidence?
Bowel Function after LSC LSC Complications1
17% persistent obstructed defecation 1 402 cases of LSC no significant difference in
>50% persistent constipation and 5% with intra-or peri-operative complications
de novo constipation 2 overall complication rates
Sexual Function after LSC 0.75% for hematoma
2.2% for ileus or small bowel obstruction
9-23% de novo dyspareunia1,2 1.5% for bladder injury
~50% with pre-operative dyspareunia 0.75% for bowel injury
improve after LSC1,2 0.25% for ureteric injury
1.2% mesh erosion rate
12RColasse JrWho, uPt rFe,s teot na Ml. E. uJ Mroipneiman I nUvraosloivgey G. 2y0n0ec9o;5l.5 2:010455;912-1(34)6:282.1 -226. 1Stepanian AA, J Minim Invasive Gynecol. 2008;15(2):188-196.
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What’s the Evidence? What’s the Evidence?
LSCP
LSC versus ASC
McDermott et al151 A-LSCP patients and 17
AV-LSCP patients, 1 year post-op 3 studies
no differences in POP-Q measurements
all showed LSC has longer OR
A-LSCP group had fewer mesh erosions and a
lower rate of dyspareunia time, less blood loss, and
AV-LSCP group had fewer recurrent symptoms of shorter hospital stay
prolapse
both groups had similar rates of surgical
satisfaction
1McDermott CD, et al. Int Urogynecol J Pelvic Floor Dysfunct. 2011: 22(4):469-475.
What’s the Evidence? What’s the Evidence?
LSC versus ASC
LSCP versus ASCP
 Paraiso et al1 56 LSC patients versus 61 ASC patients; similar complication
and re-operation rates Su et al120 LSCP (11 robotic) versus 29 ASCP
 Hsiao et al225 LSC patients versus 22 ASC patients  both groups had significant improvement in QoL scores and POP-Q
 apical recurrence: LSC=0; ASC=1 measurements at 6 months post-op
 apnnoot speteorirloyiorp rrr eorecpucyurlrerernnreec nmec: eeL:sS hLC Se=Cr2o=;s 1Ai;o SAnCS=C4=3  bshoothw gnr boyu pths eh 2a dc msi gpnoisfitc-oanp tr iemdupcrotivoenm ienn tth ien G pHer i+n PeaBl ldeensgctehn.t , as
 critical point in the learning curve for LSC was 10cases  anterior recurrence: LSCP=2, ASCP=2
 Klauschie et al344 LSC patients versus 41 ASC patients  posterior recurrence: LSCP=0; ASCP=3
 similar intra-and peri-op complication rates  apical recurrence: LSCP=0; ASCP=0
 npoo ianpt iCca sli fganiliufirceasntly higher in ASC group at 6 weeks and 6 months post-op, but this  2 LSCP patients an 0 ASCP patients had mesh erosions
difference was gone by 1 year post-op  4 LSCP patients and 1 ASCP patient had suture erosions
 anterior recurrence: LSC=3; ASC=5
 posterior recurrence: LSC=3; ASC=6
1Paraiso Mfet al. Am J Obstet Gynecol. May 2005;192(5):1752-1758.
23KHlsaiuaosc KhCie, JeLt ,a elt. Ja lE. nIndto uUrrool.g yAnuegc o2l0 J0 P7e;2lv1(ic8 )F:9lo2o6r- 9D3y0s.funct. Mar 2009;20(3):273-279. 1Su KC, et al. Journal of Pelvic Medicine and Surgery. 2007;14(4):181-190.
What’s the Evidence? What’s the Evidence?
Robotic LSC
Robotic LSC
case series and cohort studies
Moreno Sierra et al131 patients, 2 years
Elliott et al121 patients, 1 year post-op post-op
95% apical cure rate 51. no recurrences
100% surgical satisfaction rate Shariatiet al277 patients, 1 year after
Aklet al280 patients, ? post-op robotic LSCP54
recurrent prolapserate of 3.7% (one apical, one patient with stage II recurrence
one anterior, and one posterior) 53.
94% surgical satisfaction rate after 1 year of
follow-up
1Elliott DS, et al. J Urol. Aug 2006;176(2):655-659. 1Moreno Sierra J, et al. UrolInt. 2011; Feb Epubahead of print.
2Akl M, et al. Surg Endosc. 2009; 23(10):2390-4. 2Shariati A, et al. Journal of Pelvic Medicine and Surgery. 2008;14(3):163-171.
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What’s the Evidence? What’s the Evidence?
Bladder Function after Robotic LSC Robotic Complications
not well investigated Akl et al1 robotic LSC complication rates
9.5% post-op urinary incontinence (de novo/type 1.2% cystotomy
not specified)1 1.2% enterotomy
1.2% ureteric injury
urodynamic parameters not significantly changed 1.2% post-operative ileus
by this procedure2 6% mesh erosion 53.
1% persistent overactive bladder symptoms, 19.5% Shariati et al2robotic LSCP complication rates
de novo urge incontinence3 5.2% cystotomy
1.3% proctotomy
No studies on bowel or sexual function 6.5% post-operative ileus
9.1% suture and/or mesh erosion rate 54.
1Elliott DS, et al. J Urol. Aug 2006;176(2):655-659.
2Kramer BA, et al. J Endourol. Apr 2009;23(4):655-658. 1Akl M, et al. SurgEndosc. 2009; 23(10):2390-4.
3Shariati A, et al. Journal of Pelvic Medicine and Surgery. 2008;14(3):163-171 2Shariati A, et al. Journal of Pelvic Medicine and Surgery. 2008;14(3):163-171.
What’s the Evidence? What’s the Evidence?
Robotic LSC versus ASC Cost Differences
Geller et al173 robotic LSC patients and Patel et al1direct and total hospital costs between LSC,
robotic LSC, ASC
105 ASC patients, 6 weeks post-op
15 cases reviewed, 5 per group
robotic group had significantly higher POP-Q OR costs: LSC and robotic LSC >>> ASC
point C values (-9cm versus -8cm), other other direct costs (anesthesia, hospital room, lab tests, and
medications): not different
anatomic measures were similar
total charges: LSC and robotic LSC >>> ASC
robotic group had longer OR time, less blood LSC $19,308.94; RLSC $24,161.48; ASC $13,149.99
loss, and shorter hospital stay conclusion: RLSC has highest direct and total costs, ASC was the
least expensive
no significant differences for intra-and post-
operative complications
1Geller EJ, et al. Obstet Gynecol. Dec 2008;112(6):1201-1206. 1Patel M, et al. Int Urogynecol J Pelvic Floor Dysfunct. Feb 2009;20(2):223-228.
Advantages/Disadvantages Advantages/Disadvantages
LSC LSCP
Advantages Advantages
minimally invasive (less blood loss, shorter hospital stay,
shorter recovery, less pain) better posterior outcomes (?)
excellent visualization of pelvis and presacral space reduced perineal descent (?)
comparable cure rates to ASC Disadvantages
Disadvantages
technically challenging, need for skilled assistant more extensive posterior dissection
operator learning curve abdominal-vaginal approach increased
longer OR times (?) risk of mesh complications (?)
cost
1Su KC, et al. Journal of Pelvic Medicine and Surgery. 2007;14(4):181-190.
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Advantages/Disadvantages
Robotic LSC
Advantages
skilled surgical assist not necessary
improved instrument dexterity
minimally invasive (less blood loss, shorter hospital stay, shorter
recovery, less pain)
excellent visualization of pelvis and presacral space
comparable cure rates to ASC
Disadvantages
availability
operator learning curve
no tactile feedback
cost
1Su KC, et al. Journal of Pelvic Medicine and Surgery. 2007;14(4):181-190.
6
Disclosures
Pelvic Floor
Reconstruction: Graft Relevant financial relationships exist with
the following commercial interests:
Materials
–Consultant: Women’s Health and Urology
–Funded Research: Allergan
Douglass S. Hale, M.D., FACOG, FACS
Director Female Pelvic Medicine and
Reconstructive Surgery Fellowship
Indiana University Health System
How do we reestablish support
Objectives
once its lost?
1. Outline the different graft materials Use native tissue
available for use in pelvic surgery. Use a graft
2. Describe the characteristics of synthetic
grafts.
3. Choose an appropriate mesh for use in
prolapse repair.
ANTERIOR and POSTERIOR
MRI of Levator Ani
VAGINAL WALLS
Rest Ballooning
Posterior wall
Anterior wall
DeLancey,1999
Weber,1997
1
Open Mesh vs. Non-Mesh
Hernia
for Groin Hernia Repair
RCT –Primary or First Repeat Incisional Cochrane Database of Systematic Reviews
Hernia Repair (Suture vs. mesh), N=200, 2001, Issue 3, Art. No.:002197.
F/U 3yrs –20 studies
–Most frequent operation in general surgery
Recurrence Rates
700,000 in US in 1993.
–Primary: Suture 43% vs. Mesh 24%
–Reduction in recurrence between 50-75%
–First Repeat: Suture 58% vs. Mesh 20%
–Some evidence of quicker return to work
and lower rates of persisting pain
–NEJM 343(6):392-8.2000, Aug 10.
Surgical Route for Prolapse or
Graft vs. Native Tissue
Prospective, randomized study n=80
– Follow up = 2.5 years (1-5.5) Difference is graft vs. native
– Reoperation rate 33% for vaginal, 16% for abdominal
– 2 x the success rate with abdominal surgery for prolapse tissue repair
(Benson, Am J Obstet Gynecol, 1996)
Retrospective n=117 / f/u = 101pts
– Follow up approximately 2 years for each group
– Recurrent prolapse = 33% vaginal / 19% abdominal
(Sze, Int Urogynecol J Pelvic Floor Dysfunct, 1999)
Lo and Wang (1998) –sacral colpopexy superior
Maher (2004) –prospective, randomized, n=95
– ”Both highly effective”
– Apex failure was 17% in sacrospinous vs. 4% in sacral colpopexy (to
intoitus)
Amid Classification of Surgical
GRAFT MATERIALS
Meshes
Type I –monofilament, macroporous (>75μm)
Synthetics
Type II –microporous (<10μm)
–Absorbable / permanent
Autografts Type III –macroporous with either
–Rectus / fascia lata / patellar multifilaments or microporous elements
Allografts –homograft (same species)
Type IV –biomaterials with submicronic pores
–Fascia lata / Duramater / pericardium / patellar / etc.
Xenografts –heterograft (different species)
–SIS = small intestine submucosa
–Porcine Dermis
Amid, Hernia1997.
–Bovine pericardium
2