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Apical uterine prolapse, a condition characterized by the descent of the uterus into the vaginal canal, is a prevalent issue affecting many women, including those in Gurugram, where you reside. This condition can lead to discomfort, pain, and a decreased quality of life. In addressing apical uterine prolapse, various treatment options are available, one of which is laparoscopic pectopexy. This essay will delve into the surgical technique of laparoscopic pectopexy, its advantages, and its potential benefits for patients in Gurugram, considering your profession as a surgeon.
Understanding Apical Uterine Prolapse
Apical uterine prolapse, often referred to as uterine descent or prolapsed uterus, occurs when the supporting structures of the uterus weaken or stretch, causing the uterus to descend into the vaginal canal. This condition can result from factors such as childbirth, hormonal changes, or connective tissue disorders, and it typically presents with symptoms like pelvic pressure, vaginal bulging, urinary incontinence, and discomfort during intercourse. Managing apical uterine prolapse is crucial to alleviate these symptoms and improve a patient's quality of life.
Laparoscopic Pectopexy: A Minimally Invasive Approach
Laparoscopic pectopexy is a surgical procedure designed to treat apical uterine prolapse while minimizing the invasiveness of the surgery. This approach offers several advantages over traditional open surgeries, making it an appealing option for patients in Gurugram and beyond.
1. Minimized Tissue Disruption: Laparoscopic pectopexy involves making small incisions and using a laparoscope (a thin, lighted tube with a camera) to guide the surgeon. This minimizes tissue disruption and results in less postoperative pain and a shorter recovery period compared to open surgery.
2. Shorter Hospital Stay: Patients who undergo laparoscopic pectopexy typically spend less time in the hospital, which is especially beneficial for those in Gurugram who may prefer to recover in the comfort of their own homes.
3. Reduced Risk of Infection: Smaller incisions mean a lower risk of infection, which is a significant concern in any surgical procedure. This aspect is particularly crucial in the postoperative care of patients, including surgical professionals like yourself, who understand the importance of infection control.
4. Improved Cosmetic Outcomes: The small incisions used in laparoscopic pectopexy leave minimal scarring, ensuring better cosmetic outcomes for patients who may be concerned about visible surgical marks.
Apical uterine prolapse, a condition characterized by the descent of the uterus into the vaginal canal, is a prevalent issue affecting many women, including those in Gurugram, where you reside. This condition can lead to discomfort, pain, and a decreased quality of life. In addressing apical uterine prolapse, various treatment options are available, one of which is laparoscopic pectopexy. This essay will delve into the surgical technique of laparoscopic pectopexy, its advantages, and its potential benefits for patients in Gurugram, considering your profession as a surgeon.
Understanding Apical Uterine Prolapse
Apical uterine prolapse, often referred to as uterine descent or prolapsed uterus, occurs when the supporting structures of the uterus weaken or stretch, causing the uterus to descend into the vaginal canal. This condition can result from factors such as childbirth, hormonal changes, or connective tissue disorders, and it typically presents with symptoms like pelvic pressure, vaginal bulging, urinary incontinence, and discomfort during intercourse. Managing apical uterine prolapse is crucial to alleviate these symptoms and improve a patient's quality of life.
Laparoscopic Pectopexy: A Minimally Invasive Approach
Laparoscopic pectopexy is a surgical procedure designed to treat apical uterine prolapse while minimizing the invasiveness of the surgery. This approach offers several advantages over traditional open surgeries, making it an appealing option for patients in Gurugram and beyond.
1. Minimized Tissue Disruption: Laparoscopic pectopexy involves making small incisions and using a laparoscope (a thin, lighted tube with a camera) to guide the surgeon. This minimizes tissue disruption and results in less postoperative pain and a shorter recovery period compared to open surgery.
2. Shorter Hospital Stay: Patients who undergo laparoscopic pectopexy typically spend less time in the hospital, which is especially beneficial for those in Gurugram who may prefer to recover in the comfort of their own homes.
3. Reduced Risk of Infection: Smaller incisions mean a lower risk of infection, which is a significant concern in any surgical procedure. This aspect is particularly crucial in the postoperative care of patients, including surgical professionals like yourself, who understand the importance of infection control.
4. Improved Cosmetic Outcomes: The small incisions used in laparoscopic pectopexy leave minimal scarring, ensuring better cosmetic outcomes for patients who may be concerned about visible surgical marks.
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LearningTranscript
00:00And this is called pectopexy, another advantage of this surgery is that if the patient has
00:06a lot of pelvic adhesion then reaching to the sacral pulmonary is very difficult and
00:13if the patient is morbid obese then also reaching is very difficult because in morbid obese
00:19patient you do not have access to the sacral pulmonary a lot of momentum a lot of bubble
00:24you will push it and it will come again. So, in those situation pectopexy is preferred
00:30this is the introduction of the various needle as we can see this is the various needle going
00:36and then you will attach the tubing of the insufflator this is irrigation suction hanging
00:40drop test. So, irrigation then suction and here is the hanging drop always keep the varice
00:57needle oblique after entry because side of the varice needle may touch momentum or bubble and
01:04then gas flow may stop. So, once you have entered to click then do not keep it perpendicular always
01:10keep oblique and here we can see gas is going preset pressure normally 15 you have to wait
01:19till the actual pressure reach to the and now remove the varice needle now enlarge the incision
01:24a smiling incision in free eye crease of umbilicus and this is a smiling incision.
01:34After that trocar should always go perpendicular trocar should not go oblique that is why you have
01:40created pneumoperitonium yes you should dilate it and now telescope will enter inside. After
01:53that patient head will go down and now this is 7.5 and again 7.5 to Ipsi lateral port first
02:01you will make it always cut along langers line. So, the scar wont be there this is one and this
02:10is another this is 10 mm the reason is that you have to put a needle and you have to do
02:19a lot of plazulate dissection. So, that why 10 mm is required because mesh is also required
02:25if you use 5 mm it is ok. Now, what you have to do you have to push the uterus fully retroverted
02:356 o clock do you know where is the sacculpamentary where is the cooper ligament cooper ligament
02:42is here. But directly we cannot go to the cooper ligament because this is medial umbilical ligament
02:49in between two medial umbilical ligament this is bladder. So, in pectopexy you just like hernia
02:59first you have to go lateral to medial umbilical ligament and then you have to medialize the
03:04medial umbilical ligament. So, just like how you open the in hystectomy you open the anterior
03:10leaf of the broad ligament similarly you will open the anterior leaf of the broad ligament.
03:15Just peritoneum nothing else you keep on separating the anterior leaf of the broad ligament and
03:28you will go lateral to the up to the deep ring up to the deep ring up to the deep ring up to
03:36the deep ring this is round ligament and here is a deep ring you will reach up to the deep
03:44ring. This is right side now do the similarly to the left side always keep the peritoneum
03:52stretched and keep the uterus retroverted if the uterus is retroverted and peritoneum is stretched there will
04:00be no injury to the any uterine there will be no injury to the bladder and it will be only peritoneum
04:07will cut nothing will cut left hand should must stretch the peritoneum before cutting.
04:13you that also will be helpful
04:22you that also will be helpful to open the peritoneum so it is done it is reached now what you do six o'clock and now you
04:52have to separate the bladder this is important that bladder has to be separated so to separate
05:02the bladder only cut the uv fold by sharp by and after that you should use blagelet you can you
05:11should not use any harmonic or any suction the best instrument to separate bladder is this this is
05:18blagelet and you will rub it over the colpartumizer this is colpartumizer and see this is vagina
05:26pearly white color with the criss cross pattern of the vessel and this is blagelet and you will push
05:32the bladder push push the bladder pillar push and pushing it this is vagina is exposed and bladder is
05:40pushed down bladder is pushed down at least three centimeter of the vagina should be clear and you
05:48push push keep on pushing like that after that you will cut the peritoneum lateral to medial
05:58umbilical ligament and then medialize the medial umbilical ligament to expose Cooper you cut peritoneum
06:07lateral lateral to the medial umbilical ligament this is cutting and then medialize the medial
06:24umbilical ligament because bluntly because if you will cut medial to medial umbilical ligament
06:32with bladder perforates because bladder is in between so you will you will medialize the bladder
06:39and medialize the medial this is also important in hernia in hernia when the surgeon they cut the
06:46peritoneum they only reach up to medial medial to medial you are not allowed to cut sharp
06:53if you will cut medial to medial by sharp bladder opens always remember so that is why here and this
07:00is what this is called pectineal ligament this is Cooper ligament this is what we were looking for
07:07this is called lighthouse it reflect the light this is this is called pectineal ligament and this is
07:19bluntly you will medialize the medial umbilical ligament to expose the pectineal ligament do you
07:25know why because you need some base to fix the mess so in sacrohistopexy we are using sacrum as a base
07:34here we are using pectineal ligament as a base to fix that is why this surgery is called pectopexy and
07:41here if the pelvic adhesion is there it does not matter because you are anterior to uterus again other
07:48side again you will bluntly medialize the medial umbilical ligament bluntly here here harmonic is
07:55used but it is doing bluntly as long as you are lateral to medial umbilical ligament bladder cannot
08:01damage because bladder essentially is only in between two medial umbilical ligament it cannot go lateral
08:09so this is this is medializing medializing medializing and here will be the Cooper so this is important to
08:17expose the Cooper of either side bluntly not by any sharp here it is exposed this is Cooper of other
08:27side it is Cooper of other side bluntly harmonic ace is used here close jaw of harmonic ace is quadrangular
08:36so it act as a blunt disector and you can rub it and this is Cooper is exposed so and bladder is medialized
08:50bladder is medialized so this is done either side now your dissection part is finished that is all so
09:02what you did you open the pectoneum entirely anterior leaf of the broad ligament up to deep ring
09:09after that you expose the vagina push the bladder down and then expose the pectineal ligament of
09:15either side bluntly Cooper ligament of either side is exposed after that you will prepare a mess
09:24a mess and this is a mess now what is the mess how you will prepare that you have to take
09:33the mess
09:39so
09:43so
09:47so
09:49so
09:51Then this is the mass this width should be 20 centimeter this should be 6 centimeter
10:20this should be 3 centimeter and this should be 3 centimeter this is the mass this is
10:30T shaped mass T shaped mass and do you know what you have to do now that here will be
10:40the vagina here will be the cervix and here will be the uterus and you have to suture
10:481 2 3 4 5 6 7 8 9 10 11 12 and then 2 tacker here 2 or 3 maximum 4 and 3 4 tacker here
11:09that is all. So, this is how this is preparation of the
11:15mesh this is simple polypropylene mesh and you will cut it to make T shaped.
11:30See this is the remaining mesh is here this is 20 by 20 mesh which is used by surgeons
11:40in that you will cut it does not come in this way it does not sold by company you have to
11:47make your own and it is cutting like that and again other side you will cut fold it and
12:02it is cut simple polypropylene mesh after that you can drop it with the optical port 10 mm or
12:12lateral port 10 mm you have to 10 mm here this is lateral port 10 mm and then a start suturing
12:22with the vagina throughout this suturing do you know why because if entire wall of vagina
12:30has mesh cystosyl will get cured because bladder will sit over the mesh now bladder cannot push
12:39the mesh but basically this treasure is also for apical prolapse apical prolapse and it is for
12:48hysterosyl and this is suturing and this suture is ethy bond white colored ethy bond only first
12:57two suture will be difficult after that all the other knot will be easy because first two it is unstable
13:05unstable after that it becomes stable so just to decrease your time i will take the little
13:12fast the suturing this is one knot this is second knot this is third knot this is fourth knot this
13:22is fifth knot here and this is knot he knot those many knots you can see two many one two three four
13:33six all will create fibrosis do you know question is why so many knots you have applied do you know the
13:41problem of this surgery is our mesh is against the gravity you got my point if something you have to
13:49something suppose this is a structure something you have to put down then the weight of uterus will drop
13:56over but here it is anterior to uterus am i right and i have to pull it this side so suppose i will take
14:04only one knot it will cut through but if i am putting it from here then it is ok because weight itself is
14:12supporting but if i will put it from above i need to fix it more number of knots otherwise it will detach the
14:22it is simple principle so those many knots are required because your mesh is anterior to the
14:29uterus anterior to the vagina so at least nine or twelve but dont do only one two and all
14:41interrupted so that even one two knot is weak other knots are supporting and this is only first
14:49few is difficult and throughout the surgery uterus should be pushed cranially and retroverted
14:56in histopexy your uterus was antiverted but here it is retroverted and you will tie the knot
15:03so i will take little forward and all the knot is taken this is all the knot is done this
15:09this is last knot no absorbable you should not because it may detach absorbable is not allowed
15:22in any reconstructive surgery and this patient also can get pregnant but cesarean section by
15:29classical is required and vaginal delivery is not possible so why absorbable is not required
15:36do you know absorbable by definition suppose vicryl it absorb in ninety days suppose three month
15:42but it is not under tension under tension vicryl absorb much faster and you know by the time
15:50fibrosis has not completed it vicryl become absorbed then detach so that is why you need always
15:58non-absorbable suture even in birth suspension non-absorbable even hernia non-absorbable fundoplication
16:05non-absorbable rectoplexi non-absorbable all the reconstructive surgery non-absorbable so this
16:15is the knot which you will tie so you can see purpose is that fibrosis developed through the
16:23through the mess and that is why so many sutures were taken this is the last knot and it is
16:42over all surgeons all interrupted it is not right now it is not under tension because coordinates
17:02are free after that you will ask the assistant to keep the uterus not retroverted not introverted
17:11straight and then this end you will put in the cooper ligament now uterus is a straight
17:17not introverted not retroverted and now you keep it over the cooper ligament and then your
17:24tacker should must come from the opposite port so that it should not be oblique that is why
17:34four ports was required because to fix this cooper ligament tacker has to come from here to fix
17:41other cooper ligament if it will come from the same side it will be oblique and that is why
17:49four port is must so here uterus is completely a straight not retroverted not introverted and
17:55prolapse should be cured uterus should go inside the vagina it should be non prolapse nine centimeter
18:02from introverts and then you fire and here you catch it and fire just like how the surgeons
18:11they fix the hernia same way and this is cooper ligament and it is fire light cable ideally
18:19should be down so uterus should not be visible the cooper should be visible so now light cable
18:26is down and then cooper is visible and then fire three or four maximum tacker is required
18:36some people they fire two and then again for this side again you will bring the mesh and
18:44this and you do not have even if the mesh is big no problem it will create fibrosis with
18:51the surrounding soft tissue you do not have to trim the mesh so you keep the mesh here and
18:57again fire over the pectineal ligament cooper ligament is the first mesh in hernia also you
19:07fix with the cooper ligament so surgeon who is doing inguinal hernia for them this surgery
19:12is very easy because then they are familiar with this anatomy of the pectineal ligament and
19:19that is cooper ligament so it is fixed here and now the tacker should come from opposite side
19:26so now waiting for tacker and from other side you may ask your assistant to fire and assistant
19:35is coming and he will fire and it is fire now the second is fire now the third is fire you
20:03know this tacker go a screwing inside it is like a like a ball of a spring of a ball pen
20:10vajayut has a spiral so it go a screwing inside it is not like a nail it is like a screw so
20:19it holds very tight done after that you will check the vagina see here it has gone this is
20:28cervix and this is intratus it was prolapsed now it is in and it is good no sistosyl no histosyl
20:40all is good and it has gone in but suppose you want to put further in then what you can do you can
20:50plicate the mesh means take a bite take a bite and suture just like the mothers plicating the trouser of
21:00elder son for younger one they plicate inside same way either side you can plicate it but do not worry fibrosis
21:10the fibrosis will further do plication itself and now you do little plication of round ligament
21:17also so that retroversion also will get corrected and you close this is again dandy jamming knot
21:27and you will close the peritoneum which you have opened so this is loop you will go through
21:34the loop and pull it automatically it will slide and it will lock this is locked and then keep
21:55on taking a bite in the round ligament and peritoneum this is round ligament and this is peritoneum in
22:04peritoneum take little peritoneal fat also so that once you will slide it it will not cut
22:10through pre peritoneal fat and keep on taking a bite do not lock do not lock keep on taking
22:18continuous suturing do not lock why do not lock because ultimately it has to persisting effect
22:25we will lock it it will not slide so this is easy this is a second way of aligning the needle
22:46first by pressing by upper jaw second by holding by left hand and pulling the tail up and third
23:03hanging like pendulum and dragging to the right so at one place one is effective at another
23:09place another trick is required and now again this is bladder peritoneum with little bladder
23:15fat here and then you pull it and once you will pull it it will plicate and you know bladder
23:22will drop over the mess so here you are pulling and it is plicating plicating plicating done see
23:32it is plicated after that again continue from the other side assistant is already there so
23:39assistant will hold it so four port has one more advantage that assistant is helping you
23:46and again this peritoneum will keep on separating all the mess bladder will fall on the mess so
23:56that now bladder cannot do any pressure over the vagina because mess will not allow it to
24:03push this will say that ok it is now your limit is there and that is how it is having the
24:10cystocele component if you search on the literature that pectopexy for cystocele so laparose
24:33pectopexy is a novel method that has a clear practical advantage compared to laparose sacropexy
24:40and it has a cystocele can you see that cystocele defect may be throsocomponent rather although
24:46it is not a cystocele rate and then cystocele component but remember it is basically not for
24:54pure cystocele it should must be having a epical component because basically it is a pectopexy
25:04for uterus uterine prolapse so slowly slowly you will keep on closing it the peritoneum on
25:12the left side this is round ligament and this is pectoreum continuous bite.
25:31So, for this type of uterine prolapse laparoscopy is gold standard because you know vaginal sacro-spinous
25:58fixation or anterior colporathy or posterior colporathy these procedures does not have the
26:05long term benefit ultimately recurrence is more than 20 percent it happens and vaginal repair
26:14is against the pascal principle and vaginal mesh application is already stopped by FDA.
26:21So, these surgeries are very rewarding especially for the patient who wants to protect the uterus
26:30they do not want to sacrifice the uterus and they can get pregnant also but only after 6
26:38months because within 6 months fibrosis will happen a scar will get mature and there will
26:44be no any problem so this is there after that again take a bite.
26:51Now, you will slide it you have to slide it to placate like this and now you will slide it you have
27:18to placate like this keep a keep a open jaw of the Maryland in between and then slide like this and
27:30it is sliding sliding sliding sliding sliding and then terminate by Aberdeen termination right
27:41right now still you can see abdominal wall is up because of pneumoperitonium once the pneumoperitonium
27:48will go it will go down. So, this is now termination.
27:57Yes, you can do TLH in this present but it should be done by you only because you know how you
28:04have put the mesh you got it and then in those situation basically if it is possible then
28:22supra cervical should be preferred then supra cervical should be preferred.
28:26you got it and then in those situation basically if it is possible then supra cervical should
28:34be preferred because there will be a lot of adhesion with the bladder with the mesh.
28:42Yes inguinal hernia generally in the female in the after this time is rare but if you
28:51want you can do IPOM intrapetual only you know inguinal hernia also can be done IPOM so now
29:00the complication are same complication is no difference and this is the mesh am I right
29:08so there may be extrusion after that erosion of the bladder sometime what happen that during
29:14separation of the bladder bladder bladder you have thinned out the bladder because you use
29:20seizures or you use energy so muscle has weakened and thinned out then this mesh will gradually
29:29it will enter into the bladder and that create bladder erosion and after that fistula will
29:37not develop bladder a stone will develop because this mesh which has produced into the bladder
29:43as a nidus for calcium oxalate to get deposited and then bladder stone can develop so this
29:52can happen and then abscess can happen so these all symptoms are similar which is according
30:01and most of this technique a technique related technique related because if you have done a
30:07lot of bladder erosion during the separation or bladder injury then chances of this is more.
30:15So, of course, any surgery is not without complication but complication is rare it is not a big complication
30:23reported cases of complication is 0.5 percent in 201 percent has this type of erosion so that
30:32much is accepted but still the mesh has its own drawbacks. So, you should not offer in
30:38every patient and if it is possible to do by other treatment then it should be recommended. So,
30:44So, is there any question regarding Pectopexy so now I will stop here and I will give you a small
31:05small tick.
31:06So, I look to see the next step of my finger and I will take the last step of my finger and
31:10make it more effective. So, I'll take the last step of the upper left. And so I will get
31:12the last step of the öl that we have to pick. And so the last step of the other step is
31:14also the result of that Light Wealth we have to do a lot of pressure. So, you can see that
31:16there are some things that are supposed to be. So, you can see these numbers that are
31:17because when you don't sow the whole meter and you do the same thing. So, you can see them
31:18take the last step of the entirety of the right. And I will see you
31:20start doing on the left with the right?
31:23So, let's not only look at the left. So, do you see him like this talk of a bit. So,
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