Your SlideShare is downloading. ×
0
Culligan lecture
Culligan lecture
Culligan lecture
Culligan lecture
Culligan lecture
Culligan lecture
Culligan lecture
Culligan lecture
Culligan lecture
Culligan lecture
Culligan lecture
Culligan lecture
Culligan lecture
Culligan lecture
Culligan lecture
Culligan lecture
Culligan lecture
Culligan lecture
Culligan lecture
Culligan lecture
Culligan lecture
Culligan lecture
Culligan lecture
Culligan lecture
Culligan lecture
Culligan lecture
Culligan lecture
Culligan lecture
Culligan lecture
Culligan lecture
Culligan lecture
Culligan lecture
Culligan lecture
Culligan lecture
Culligan lecture
Culligan lecture
Culligan lecture
Culligan lecture
Culligan lecture
Culligan lecture
Culligan lecture
Culligan lecture
Culligan lecture
Culligan lecture
Culligan lecture
Culligan lecture
Culligan lecture
Culligan lecture
Culligan lecture
Culligan lecture
Culligan lecture
Culligan lecture
Culligan lecture
Culligan lecture
Culligan lecture
Culligan lecture
Upcoming SlideShare
Loading in...5
×

Thanks for flagging this SlideShare!

Oops! An error has occurred.

×
Saving this for later? Get the SlideShare app to save on your phone or tablet. Read anywhere, anytime – even offline.
Text the download link to your phone
Standard text messaging rates apply

Culligan lecture

1,083

Published on

Robotic-assisted Laparoscopic Sacropcolpopexy

Robotic-assisted Laparoscopic Sacropcolpopexy

Published in: Health & Medicine, Business
0 Comments
0 Likes
Statistics
Notes
  • Be the first to comment

  • Be the first to like this

No Downloads
Views
Total Views
1,083
On Slideshare
0
From Embeds
0
Number of Embeds
0
Actions
Shares
0
Downloads
12
Comments
0
Likes
0
Embeds 0
No embeds

Report content
Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
No notes for slide

Transcript

  • 1. Robotic-Assisted SacrocolpopexyPatrick Culligan, MD, FACOG, FACSDirectorAtlantic HealthDivision of Urogynecology & Reconstructive Pelvic SurgeryProfessor of Obstetrics Gynecology & ReproductiveScienceMount Sinai School of Medicine
  • 2. Key Components of Sacrocolpopexy
  • 3. Sacrocolpopexy - History  Sacral Colpopexy first described by Lane in 1962  “Modern Version” described and refined by Addison in the 1980’s and 1990’s  Dubbed the “main abdominal approach to prolapse surgery” in a systematic review article 2004 (Nygaard et al)  That status solidified by a Cochrane review in 2005 (Maher et al)
  • 4. “Tried & True”  3 studies including greater than 200 patients & long-term follow-up:   Sullivan et al Dis Colon Rectum 2001.   Culligan et al. Am J Obstet Gynecol 2002.   Lindeque et al. S Afr Med J 2002. Objective Anatomic Success Rates 85 – 100%
  • 5. PATIENT SELECTION
  • 6. My progression to robotic surgery Does the patient have a uterus? YES NO vaginal hysterectomy + OPEN Sacrocolpopexyadditional vaginal procedures 2002 – switched to laparoscopic Sacrocolpopexy Now I frequently combine supracervical hyst and daVinci sacrocolpopexy 2005 First daVinci Sacrocolpopexy
  • 7. My Current Approach to Prolapse Surgery What is the age and activity level of the patient? “Younger” “Older” “Very Active” “Less Active” Vaginal Mesh PlacementLaparoscopic Sacral Colpopexy (+ / - supracervical hyst) (probably no hysterectomy)
  • 8. Severe Uterovaginal Prolapse (before and after robotic sacrocolpopexy)45 year oldG2 P2AthleticVery active(physically , sexually, etc…)
  • 9. But.... Should this patient have a laparoscopic surgery?78 year oldG5 P5Significant co-morbiditiesNot sexually active
  • 10. Patient Positioning: # 3 arm comes in from patient’s LEFT Use side-docking when patient does NOT have a uterus Patient’s Skin Directly Shoulder PadsAgainst “Megadyne” Gel Pad
  • 11. Port Placement - always the same...Camera port - 12mm long bladed disposableAssistant port - 11 or 12 mm disposable (“Excel”) - sizedepends on whether you need to morcellate4th arm port - WAY lateral and WAY high (a few cm lower thancostal margin)
  • 12. InstrumentationMonopolar shears Maryland Bipolar PK Dissector SutureCut Large Needle Driver Tenaculum ProGrasp
  • 13. Comparison of Type-1 Polypropylene Mesh Products Brand Name Pore Size (mm) Density (g/m2) Thickness (mm)Alyte Y-mesh 2.8 x x1.3 17.67 0.29(CR Bard)Restorelle Y 1.8 x 1.8 18.96 0.31(Coloplast)IntePro Y-graft 1.6 x 2.1 52.4 0.53(AMS)Gynemesh 2.5 x 1.7 42.38 0.42(Ethicon)Polyform (Boston 1.8 x 1.5 40.19 0.16Scientific)Novasilk 1.5 x 1.7 18.66 0.25(Coloplast)
  • 14. SACROCOLPOPEXYsteps of the procedure
  • 15. First Steps
  • 16. Supracervical HysterectomyWhy supracervical as opposed to TOTAL hyst...??Probably decreases incidence of mesh erosionCuts down or eliminates need for vaginal instrumentation
  • 17. Anterior Dissection No Vaginal InstrumentationKey Aspects:Have a specific goal in mind for each patientCreate “fingers” by pushing most of tissueUse small amount of cautery when cutting these fingers
  • 18. Posterior Dissection - No vaginal or rectal instrumentationKey Points:Get in “the room”Have a specific “length goal” in mindKeep scope right on top of the actionMaintain traction / counter-traction with each move
  • 19. Posterior Dissection off to a bad start
  • 20. Suggested Vaginal Instrumentation  Lucite Dilators available from:  Progressive Medical Instruments, Louisville, KY  (800) 775-7644
  • 21. If there is no uterus / cervix to grab...  Lucite Probe helps  Side-docking helps
  • 22. If there is no uterus...  Try to leave “dome” of peritoneum intact at apex....   Doing so may cut down mesh erosion risk
  • 23. Long, Wide Briesky retractor helpswith posterior dissection
  • 24. Vasculature in Pre-Sacral Space Lateral Sacral Plexus Be Afraid ! Middle Sacrals: Standard Hemostatic Measures Work Well
  • 25. Sacral Dissection  Find “window of opportunity” at promontory  Dissect at least 1/2 way down paracolic gutter  Use minimal cautery  Usually no need to cauterize middle sacral vessels.
  • 26. More Sacral Dissection
  • 27. Sacral Bleeding
  • 28. Sacral Bleeding
  • 29. Similar case...better result
  • 30. Mesh Placement  Plan specific lengths of the mesh - i.e. have a goal in mind  When using Y-Mesh, place a loose suture to fold anterior portion back out of your way  Start with Posterior mesh  In the Posterior compartment - It’s helpful to place sutures BETWEEN mesh and vaginal tissue – working your way from the perineum to the vaginal apex
  • 31. Mesh Preparation
  • 32. Posterior Mesh Placement
  • 33. Anterior Mesh Placement
  • 34. Peritoneal Closure:Step 1...Purse string
  • 35. Sacral SuturingKey Aspects:You only need to expose enough of the ligament to allow suture placementUsually minimal cautery neededUsually no need to change from zero degree to 30 degree scope
  • 36. Mesh Tensioning / Sacral Suturing  When setting mesh tension at the sacrum:  No substitute for experienced hand  Either you or your assistant should place hand in vagina during tensioning step  Goal - normal vaginal axis...not too tight...not too loose
  • 37. Step 2 - paracolic gutter to sacrum(after sacral suturing)
  • 38. Tricky Situations  Prior Abdominoplasty  Lung or Heart Disease  Prior abdominal prolapse repair  High BMI  Very small women
  • 39. OUR RESULTS
  • 40. A Double-Blind Randomized Trial Comparing Porcine Dermis & Polypropylene Mesh for Laparoscopic Sacrocolpopexy OBJECTIVETo compare objective and subjective outcomes≥ 12 months after laparoscopic sacrocolpopexyusing organic or synthetic graft material
  • 41. Methods  Randomization on the day of surgery  Surgery = Laparoscopic Sacrocolpopexy   Approximately 80% were robotic  All outcome measures collected by one research nurse  PATIENTS & RESEARCH NURSE were blinded as to their graft material throughout the study period
  • 42. Definitions of Cure “POP-Q Cure” (both criteria required)  All POP-Q points ≤ Stage 1  Point C -5 or better “Clinical Cure” (all 3 criteria required)  All POP-Q points < ZERO  Point C -5 or better  NO POP symptoms on PFDI / PFIQ
  • 43. Sample Size CalculationBased on “POP-Q Cure” (aka NIH definition) Culligan et al 2004  Randomized trial comparing cadaver fascia lata and synthetic mesh for OPEN sacrocolpopexy   91% “cure” for mesh versus 68% “cure” for fascia lata (23% difference)  With 57 patients per group we had 90% power to detect a difference of 23% (α = 0.05)
  • 44. Enrollment period 2005 - 2008 Patients eligible for study N = 184 Patients declined enrollment N = 64 Patients randomized to receive either organic or synthetic mesh N = 120 One patient converted to vaginal case on OR table (organic group) Organic Group Synthetic Group N = 57 N = 62 Lost to follow-up Lost to follow-up N=0 N=4Completing 12 month trial Completing 12 month trial N = 57 (organic) N = 58 (synthetic)
  • 45. 12 Month “POP-Q Cure”(i.e. stage 0 or 1) Porcine Dermis 80.4% Synthetic Mesh 84.1% p = 0.29 No Apical Failures
  • 46. 12 month “Clinical Cure” Porcine Dermis 84.2% Synthetic Mesh 84% p = 0.96 No Apical Failures
  • 47. Point C over time(pre-op to 12 months)
  • 48. Point Aa over time(pre-op to 12 months)
  • 49. Point Bp over time(pre-op to 12 months)
  • 50. Single-Arm Cohort Study  120 patients  Robotic Sacrocolpopexy using Restorelle Y-Mesh
  • 51. Perioperative details (120 patients)  Mean operative time 140 minutes (range 80-225)   Defined as incision time to removal of trocars  Mean EBL 49 mL (range 5 - 300 mL)  No conversions to laparotomy  One cystotomy ; No Rectal Injuries  No Erosions  No Transfusions  All patients discharged on POD # 1
  • 52. Cure Rates at 12 Months “POP-Q Cure” 89%(i.e. stage 0 or 1) Text“Clinical Cure” 95% No Apical Failures
  • 53. Current Study (150 patients)Alyte Y-Mesh (CR Bard)  Our
  • 54. Interesting Situations
  • 55. Patient with prior (failed) anteriorvaginal mesh “kit”
  • 56. “Gap Failure” (prior mesh kit)

×