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Jean pierre-giolitto.laparoscopic sacropexy.swiss endos
Jean pierre-giolitto.laparoscopic sacropexy.swiss endos
Jean pierre-giolitto.laparoscopic sacropexy.swiss endos
Jean pierre-giolitto.laparoscopic sacropexy.swiss endos
Jean pierre-giolitto.laparoscopic sacropexy.swiss endos
Jean pierre-giolitto.laparoscopic sacropexy.swiss endos
Jean pierre-giolitto.laparoscopic sacropexy.swiss endos
Jean pierre-giolitto.laparoscopic sacropexy.swiss endos
Jean pierre-giolitto.laparoscopic sacropexy.swiss endos
Jean pierre-giolitto.laparoscopic sacropexy.swiss endos
Jean pierre-giolitto.laparoscopic sacropexy.swiss endos
Jean pierre-giolitto.laparoscopic sacropexy.swiss endos
Jean pierre-giolitto.laparoscopic sacropexy.swiss endos
Jean pierre-giolitto.laparoscopic sacropexy.swiss endos
Jean pierre-giolitto.laparoscopic sacropexy.swiss endos
Jean pierre-giolitto.laparoscopic sacropexy.swiss endos
Jean pierre-giolitto.laparoscopic sacropexy.swiss endos
Jean pierre-giolitto.laparoscopic sacropexy.swiss endos
Jean pierre-giolitto.laparoscopic sacropexy.swiss endos
Jean pierre-giolitto.laparoscopic sacropexy.swiss endos
Jean pierre-giolitto.laparoscopic sacropexy.swiss endos
Jean pierre-giolitto.laparoscopic sacropexy.swiss endos
Jean pierre-giolitto.laparoscopic sacropexy.swiss endos
Jean pierre-giolitto.laparoscopic sacropexy.swiss endos
Jean pierre-giolitto.laparoscopic sacropexy.swiss endos
Jean pierre-giolitto.laparoscopic sacropexy.swiss endos
Jean pierre-giolitto.laparoscopic sacropexy.swiss endos
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Jean pierre-giolitto.laparoscopic sacropexy.swiss endos

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  • 1. Laparoscopic sacropexy: an approach to pelvic prolapse Jean Pierre Giolitto, M.D. Polyclinique les Bleuets REIMS - France SWISS-ENDOS December 2004
  • 2. Introduction19921996 strict reproduction of the technique by laparotomy.19962000 innovative aspects new anatomic spaces endoscopic vision pneumo dissection20002004 simplification of the technique reproducibility with acceptable operating time excellent results with anatomical correction and good functional results
  • 3. Preoperative evaluationEvaluation of the prolapse degree of prolapse: uterus bladder rectum enterocele cystocele central: break of vesico vaginal fascia, vaginal rugae absent lateral: vaginal rugae present higher rectocele (fascia detachment) lower rectocele (deficient levator ani muscle)
  • 4. Preoperative evaluationEvaluation of the (in)continence clinical examination urodynamic investigation  prolapse plus pure SUI  prolapse and hidden SUI  prolapse without urinary problemEvaluation of the rectal dysfunction constipation fecal or gas incontinenceEvaluation of the enteroceleMRI
  • 5. Preoperative evaluationEvaluation of the feasibility of laparoscopy  general anesthesia with pneumo peritoneum  Trendelenburg position  older and obese patients  the vaginal route will not be forgotten
  • 6. Preoperative preparationBowel preparation  empty the bowel and enlarge operating space  low residual diet 4-5 days prior to surgery  local enema one day beforeVaginal oestrogens 3 or 4 weeks beforeVaginal and parietal disinfection
  • 7. Preoperative assessment Clinical reexamination under general anesthesia search for new information which might modify the strategy Morphology of the abdominal wall position of trocars  pubis – umbilicus distance  first trocar Ø 10mm: umbilical or supra umbilical  one 5 or 10mm trocar suprapubic on midline; at least 6cm between 1st and 2nd  two 5mm lateral trocars at level of anterior superior iliac spines
  • 8. Preoperative assessmentExposition of the operating field  fixation of the uterus to the anterior abdominal wall  fixation of the bowel: sigmoid colon to the left abdominal wall Use a 5 or 6cm straight needle with a nylon suture
  • 9. Operating strategy Dissection  promontory: peritoneum to the Douglas  rectovaginal space ( hysterectomy)  anterior bladder dissection Reconstruction  first posterior mesh with culdoplasty with immediate peritonization  second anterior mesh  fixation to the promontory  complete reperitonization
  • 10. Operating strategyDissection of the promontory  Trendelenburg position  level L5-S1  anterior vertebral ligament  good care should be taken regarding to  left iliac vein  right ureter  median sacral artery and vein  lower bifurcation of aorta and obese patients Incision of the right lateral peritoneum :  vertical dissection to Douglas pouch  particular attention should be given to the right ureter
  • 11. Operating strategyDissection of the rectovaginal space  opening of the peritoneum of the Douglas pouch between the two uterosacral ligaments  dissection downwards to the posterior vaginal wall  identify the rectum and the laterally levator ani muscles  use vaginal retractor
  • 12. Operating strategyFixation of the posterior mesh  both lateral sides  levator ani muscles – 2 or 4 non absorbable sutures  medially and laterally fixation of the mesh to the vaginal wall without transfixion Culdoplasty – Douglas pouch closing without douglassectomy Utero sacral ligaments suture and mesh reperitonization Restore normal anatomy rectum/vagina
  • 13. Operating strategyFixation of the second mesh anteriorly  bladder dissection just above the balloon of the bladder catheter  fixation of the mesh with 3 or 5 non absorbable sutures, non transfixing  no staples on vagina wall  passage on the right side through broad ligament (or bilateral passage)
  • 14. Operating strategySacral colpopexy  1 or 2 non absorbable suture (staples)  proper tension with help of vaginal retractor ++ posterior mesh = no tension ++ anterior mesh = tension to correct cystocele  strong extracorporeal knot  upper reperitonization if uterus is left in place: avoid a peritoneum window between right broad ligament and posterior peritoneum
  • 15. Operating strategyPost operative care Foley catheter 1 or 2 days Antibio prophylaxis Prevention of phlebitis Hospital stay 2 or 3 days No heavy loads for 6 weeks No sexual intercourse for 4 weeks
  • 16. Results Few short term or long term studies Follow-up Authors Year N 1 year 2 years Nezhat 1994 15 100% Vancaillie 1995 42 90% Ross 1996 89 95% Gaston 1999 214 90% Mandron 2003 263 98% Bruyere 2002 76 96%
  • 17. ResultsKouri, Cosson: Comparaison de la voiechirurgicale et coelioscopique, à propos de 218cas Group I (SCALI) 100 cases 1990-1995 Group II (laparoscopy) 118 cases 1997-2000 CYSTOCELE 2 or 3 Repaired RECTOCELE: Group I: 14 posterior perineum Group II: 2nd laparoscopic sling – 7 cases
  • 18. ResultsKouri, Cosson: Comparaison de la voiechirurgicale et coelioscopique, à propos de 218cas Results at 12 months GROUP I GROUP II Anatomic result 98 94 Per-op complications 2% 8% Post-op complications 8% 7% Hospital stay 8D 5D Re-intervention rate 2 cases 4 cases
  • 19. Results Operative time 2 meshes Year N mn Cosson 2002 83 292  180 270  100 Bruyere 2001 73 (164) 75 Mandron 2003 100 (45  115) 80 Giolitto 2004 170 (60  110)
  • 20. Results Cystocele results Year N 1 year results Ross 1997 19 100% Wattiez 1997 92% Gaston 1999 214 94% Mandron 2003 263 98% Giolitto 2004 170 97%  cystocele degree 4  2  wait and see  1 case: second lower mesh  proper tension with vaginal retractor
  • 21. Results Rectocele results  few series with posterior rectal mesh  open surgery (1 mesh) 33% recurrent rectocele Year N Results Lyons 1997 20 80% Ross 1997 19 84% Gaston 1999 63 87% Giolitto 2004 170 95%  lower rectocele  posterior mesh  higher rectocele
  • 22. Results Operative complications Open conversion Cosson 6/83 Technical difficulties Nezhat 1/15 Sacral artery injury Giolitto 2/170 Technical difficulties previous abdominal surgery obesity
  • 23. Results Bladder injuries  about 1%  Giolitto: 4 cases/170 - suture vicryl-monocryl 3-0 - bladder catheter 2-3 days - antibioprophylaxis 5 days - negative preoperative urine culture - no contraindication to fix the mesh
  • 24. Results Post-operative complications  brochial plexus injury Bruyere 1 case  post operative bowel obstruction Gaston 4 cases 1 hernia trocar 3 inadequate reperitonizations (1 ileal resection) Giolitto 3 cases 3 inadequate reperitonizations (1 ileal resection)
  • 25. Results Post-operative complications Spondylitis Giolitto 0 Gaston 2 cases 1 case with post operative haematoma 1 case with hysterectomy Butreau 1 case Diagnostic - at 2 to 6 months - removal of the meshes
  • 26. Results Long term complications  Second vagina mesh displacement Gaston 9 cases/429 posterior mesh but fixation with continuous sutures (vagina ischemia) prevention fixation with 3 or 5 separate nonabsorbable sutures on posterior vagina  Post operative constipation 1 month 6 months Previous posterior fixation 90% 13% New posterior fixation with 15% 10% broad mesh Mandron 70 cases - 2004
  • 27. Conclusion Laparoscopy advantage of the treatment by laparotomy low morbidity such as the vaginal route reproducibility of the technique time: around 90 minutes further studies required

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