Tto laparoscopico defecto medio y anterior

eloy.moral.santamarina@sergas.es
COMPLEXO HOSPITALARIO DE PONTEVEDRA
Tratamiento Laparoscópico
de la patología del
COMPARTIMENTO MEDIO y ANTERIOR
( PROMONTOPEXIA Y REPARACIÓN PARAVAGINAL)

PROLAPSO DE ÓRGANOS PÉLVICOS
VÍA ABDOMINALVÍA VAGINAL
ÚTERO / CÉRVIX / CÚPULA
PARED ANTERIOR Y POSTERIOR
DEFECTOS PARAVAGINALES
HIPERMOVILIDAD URETRAL
REPARACIÓN CLÁSICA
MATERIALES PROTÉSICOS
QUÉ
OPERAMOS

CÓMO

CARACTERÍSTICAS

PRIMERA ELECCIÓN
MUY EFICAZ Y POCO INVASIVA
BUENA RECUPERACIÓN
PERMITE TRATAR MÚLTIPLES DEFECTOS
NO SIEMPRE MANTIENE BUENA FUNCIÓN COITAL
Prolapso ÚTERO/ CÚPULA
HIPERMOVILIDAD URETRAL
DEFECTOS PARAVAGINALES
ENTEROCELES
PREVENCIÓN ENTEROCELE
REPARACIÓN CLÁSICA
MATERIALES PROTÉSICOS
QUÉ
OPERAMOS

CÓMO

CARACTERÍSTICAS

SOBRE TODO PARA DEFECTOS APICALES
MANTIENE LONGITUD DE VAGINA
MENOS DISPAREUNIA
SIMILAR EFICACIA
pero…
+ COMPLICACIONES y PEOR RECUPERACIÓN

REPRODUCE
LA
CIRUGÍA

Y
REDUCE
LA
MORBILIDAD
DE
LA
VÍA
ABIERTA

-‐

NO
SE
ABRE
VAGINA

-‐

PROCEDIMIENTO
ABDOMINAL
CERRADO

IGUALA
O
MEJORA
LA
EFICACIA
DE
LA
VIA
ABDOMINAL.

MEJOR
RECUPERACIÓN
DE
TODAS
LAS
VÍAS

(↓
estancia,
menos
sangrado,

<
dolor
y
recuperación
)

NO
ACORTA
VAGINA
ELECCIÓN
SI
DESEA
MANTENER
FUNCIÓN
COITAL

<
TASA
DE
INFECCIÓN

VÍA ABDOMINALVÍA VAGINAL
VÍA LAPAROSCÓPICA
HT Laparoscópica 1989 Reich
Burch Laparoscópico1991
Colposacropéxia 1994 Nezhat
Colposacropexia 1957 Savage
Colposuspensión 1962 Burch

HISTEROSACROPÉXIAS

/

CERVICOSACROPÉXIA

COLPOSACROPÉXIA
(1957 Savage )

PECTOPEXIA
/
POPS

REPARACIÓN
PARAVAGINAL

COLPOSUSPENSIÓN
(
1962
Burch)

SUSPENSIÓN
A
ÚTERO-‐SACROS

REPARACIÓN
ENTEROCELE

¿ QUÉ OPERAMOS ACTUALMENTE ?
VÍA LAPAROSCÓPICA

ENCUESTA SECCIÓN DE SUELO PÉLVICO DE LA SEGO 2012
TRATAMIENTO DEL PROLAPSO DE CÚPULA VAGINAL
43,5 %
Mallas
Mallas

Vaginales
25,2
%

Colpectomía-‐Cleisis

PROMONTOPÉXIA

Laparoscópica

7,8 %
Colpoespinoﬁjación

(Richter)

8,5
%

43,5
%

SACROPÉXIA

Abierta

LIMITACIONES de la LAPAROSCOPIA
( cada vez menos…)

-  Historia de múltiples cirugías abdominales o EIP.
-  Patología que contraindique anestesia general e
insuflación abdominal.
-  Abordajes previos para cirugia del prolapso.
-  IMC muy altos
- Limitaciones del cirujano (sutura, nudos).

INTERVENCIONES LAPAROSCÓPICAS
•  COMPARTIMENTO ANTERIOR
Reparación de defecto paravaginal
Colposuspensión Burch para IUE
Colposacropexia
POPS (cinta de malla subperitoneal parietal)
Pectopexia ( fijación con malla a lig.ileopectíneo)
•  COMPARTIMENTO APICAL
Mc Call Laparoscopico (fijación a Lig.US)
Colposacropexia
Histeropromontopexia
POPS
Pectopexia

DEFECTOS DEL COMPARTIMENTO ANTERIOR

Desinserción LATERAL de la fascia pubocervical +++
DeLancey, AJOG 187:93;2002

Defecto paravaginal
Es posible corregir el cistocele por LPS (reparación paravaginal).
Curación (POP-Q: Ba ≤0): 96% (12 m); 76% (5 a) .
O´Shea, Behnia-‐‑Willison, et al. Laparoscopic paravaginal repair. Objective outcomes. J Minim Invasive
Gynecol 2012;19: S61.
PERO …
No existe evidencia que apoye la superioridad de los resultados
anatómicos con respecto a cirugía vaginal clásica o mallas
Karram. Int Urogynecol J 2004; 15:1-‐‑2.

Frick, Paraiso. Clin Obstet Gynecol 2009; 52:390-‐‑400.

Shippey. Int Urogynecol J 2010; 21:279-‐‑83.

REPARACIÓN PARAVAGINAL LAPAROSCÓPICA

ORIGINAL
La colposacropexia laparosco´pica en el tratamiento
del cistocele
Rodolfo Moreno Mira a,*, Cristina Martinez Canto b
, Marta Ramis Barcelo´ b
,
Ricardo Lizarbe Iranzo b
y Ańgel Martıń Jimeńez b
a
Servicio de Obstetricia y Ginecologıá, Hospital Can Misses, Ibiza, Islas Baleares, Espanã
b
Unidad de Salud de la Mujer, Hospital Son Lla`tzer, Palma de Mallorca, Islas Baleares, Espanã
Recibido el 31 de agosto de 2013; aceptado el 12 de octubre de 2013
Disponible en Internet el 2 de diciembre de 2013
PALABRAS CLAVE
Prolapso;
Cistocele;
Colposacropexia;
Laparoscopia
Resumen
Objetivo: Estudiar los resultados de la colposacropexia sobre el cistocele.
Material y me´todos: Setenta y siete pacientes con cistocele sometidas a colposacropexia. Con
seguimiento mıńimo de 6 meses, se practico´ la exploracioń y la deteccioń de sıńtomas de
prolapso, urinarios rectales y sexuales. La curacioń objetivo se definio´ como un grado < II en la
clasificacioń de Baden-Walker.
Resultados: La edad media Æ desviacioń estańdar era de 53,8 Æ 8,9 anõs. El tiempo medio
operatorio de 193,6 Æ 44 min. Las complicaciones intraoperatorias existieron en el 11,6% y las
postoperatorias en el 19,4%. La estancia media fue de 2,7 dıás (1-8). Con un seguimiento medio
de 15,5 Æ 12,8 meses, la curacioń subjetiva se alcanzo´ en el 89,6% y la mejorıá en el 6,4%. Hubo
en el seguimiento un 11,6% de pacientes con cistoceles con criterios de recidiva anato´mica.
Setenta y cinco pacientes se declararon satisfechas o moderadamente satisfechas (97,7%).
Conclusioń: La colposacropexia es tambień efectiva para corregir el compartimento anterior.
ß 2013 SEGO. Publicado por Elsevier Espanã, S.L. Todos los derechos reservados.
Prog Obstet Ginecol. 2014;57(2):62—65
PROGRESOS de
OBSTETRICIA Y
GINECOLOGIÁ
www.elsevier.es/pog
Documento descargado de http://www.elsevier.es el 07/11/2016. Copia para uso personal, se prohíbe la transmisión de este documento por cualquier medio o formato.

We found no difference concerning symptoms, quality of life, improvement (PFDI-20, PFIQ-7, ICIQ-SF, EQ5D
Barber score [3]. There was no difference in the rate of patients still sexually active at one year (LSC = 87.2% v
but the rate of dyspareunia was lower after LSC (14.1%) than after VRM (29.5%, p = 0.031), as was the r
worsening of dyspareunia (8.5% vs. 19.7%, p = 0.061). At 12 months, there was a significant difference in favour
the Obstructed Defecation Score (ODS) at 12 months (see Table), however the difference was no longer signific
for posterior mesh placement (p=0.167).
Outcome Measure LSC group
n/N (%)
VRM group
n/N (%)
OR [95% CI]
No. with Point Ba < -10 mm 73/127 (57.5) 75/127 (59.1) 0.94 [0.57-1.54]
No. with Point C < -10 mm 125/127 (98.4) 114/126 (90.5) 6.58 [1.44 - 30.03]
No. with Point Bp < -10 mm 106/127 (83.5) 102/127 (80.3) 1.24 [0.65-2.35]
No. Prolapse stage 0 or 1 59/127 (53.5) 59/127 (53.5) 1.00 (0.61 - 1.64)
Barber score 109/127 (85.8) 112/127 (88.2) 0.81 (0.39 – 1.69)
No. with Symptom of vaginal
bulge
118/128 (92.2) 122/127 (96.1) 0.48 (0.16 - 1.46)
No. of patients still sexually
active
67/78 (87.2) 59/67 (88.1) 0.92 (0.34 - 2.49)
No. with Dyspareunia 7/68(10.3) 16/59 (27.1) 0.308 (0.12 – 0.81)
No. with Improvement (PGI-I) 117/128 (91.4) 111/127 (87.4) 1.53 (0.68 – 3.45)
Mean (95% CI) mean (95% CI) mean difference [95%
CI]*
PFDI score 25.0 (20.0-29.9) 26.1 (21.2 -31.1) -1.14 (-8.16 - 5.88)
POPDI subscale 5.7 (3.9- 7.6) 6.5 (4.7- 8.4) -0.80 (-3.41 - 1.81)
DDI-8 subscale 11.1 (9.2 - 13.1) 9.2 (7.3 - 11.2) 1.92 (-0.82 - 4.67)
UDI subscale 8.3 (5.9 - 10.6) 10.4 (8.1 - 12.8) -2.15 (-5.49 - 1.19)
PFIQ-7 score 6.1 (2.9- 9.3) 9.8 (6.6 – 13.1) -3.74 (-8.29 – 0.82)
EuroQoL5D scale 82.4 (76.7 - 85.1) 81.9 (79.2 -
84.7)
0.48 (-3.37 - 4.34)
FSFI score for sexually active
patients
27.4 (26.1 - 28.8) 26.8 (25.4 -
28.2)
0.63 (-1.36 - 2.61)
ICIQ-UI SF score (0-21) 1.7 (1.1- 2.3) 2.2 (1.6 - 2.8) -0.48 (-1.33 - 0.36)
ODS score 4.8 (4.2 to 5.5) 3.9 (3.2 to 4.6) 0.94 (0.01 to 1.89)
Tratamiento del CISTOCELE
Histeropéxia Laparoscópica vs. Mallas vaginales
376
Fauconnier A1, Cosson M2, Debodinance P3, Bader G4, Youssef Azer Akladios C5, Salet-Lizee D6, Campagne-
Loiseau S7, Deffieux X8, Ferry P9, de Tayrac R10, Fritel X11, Lucot J12
1. CHI Poissy-Saint-Germain, Poissy, EA 7285 RISCQ, Université Versailles Saint-Quentin, France, 2. Univ. Hosp.
Jeanne de Flandre, Lille, France,, 3. Centre Hosp. de Dunkerque, Dunkerque, France, 4. CHI Poissy-Saint-Germain,
Poissy, France, 5. Ho^pital de Hautepierre, Strasbourg, France, 6. Groupe Hosp. Diaconesses Croix St-Simon, Paris,
France, 7. CHU Estaing, Clermont-Ferrand, France, 8. Hôpital Antoine Béclère, Clamart, France, 9. La Rochelle
Hosp., La Rochelle, France, 10. Caremeau Univ. Hosp., Nîmes, France, 11. CHU de Poitiers, Poitiers, France, 12.
Univ. Hosp. Jeanne de Flandre, Lille, France
ANATOMICAL AND FUNCTIONAL OUTCOMES OF VAGINAL MESH SURGERY VERSUS
LAPAROSCOPIC SACROCOLPOHYSTEROPEXY FOR CYSTOCELE REPAIR: 12-MONTH
RESULTS OF THE PROSPERE (PROSTHETIC PELVIC FLOOR REPAIR) RANDOMISED
CONTROLLED TRIAL.
Hypothesis / aims of study
Cystocele is a frequent and sometimes disabling type of pelvic organ prolapse (POP) in women. Sacrocolpohysteropexy using
synthetic mesh is considered as the surgical gold standard, and the laparoscopic approach (LSC) has supplanted the open
abdominal route because it offers the same anatomical results with lower morbidity. The use of mesh during vaginal repair (VRM)
may have many advantages: easiness to perform, shorter operative time and recovery [1]. At the present time only one RCT has
compared LSC and VRM: the results were in favour of LSC in terms of anatomical results, but it was a single-site study with only
2 surgeons (consultant and fellow urogynaecologist) that may limit the generalisability of the findings [2]. Both the French HAS
(Haute Autorité de Santé) and the UK Department of Health have highlighted the need for a comparative study to properly evaluate
the risk and benefit ratio of surgery including mesh procedures. A French national multicentre randomised study, including centres
with experience of both the vaginal and laparoscopic approach, was designed for comparison of the safety, functional and
anatomical results of these approaches. We present here the results of functional and anatomical outcomes at one year.
Study design, materials and methods
376
CONTROLLED TRIAL.
PROSPERE RCT is a randomised multicentre controlled trial conducted in 12 participating French hospital referral centres for
pelvic reconstructive surgery. Inclusion criteria were: patients aged 45 to 75 years old, with cystocele ≥ stage 2 of the POP-Q
classification. Exclusion criteria were a previous surgical POP repair, and inability or contra-indication for one or the other
technique.
Both LSC and VRM surgery were standardised using a consensus Delphi method. For LSC, the mesh had to be fixed to the
promontory by stitches; peritonisation of the mesh was mandatory. For vaginal repair, the mesh had to be suspended by four

Tratamiento del CISTOCELE
Histeropéxia Laparoscópica vs. Mallas vaginales
Mejoría funcional y de CdV significativa tras cirugía
sin diferencias entre mallas vaginales/laparoscopia
(excepto menos dispareunia en laparoscopia)
la laparoscopia debería favorecerse en pacientes sexualmente activas
376
CONTROLLED TRIAL.
376
CONTROLLED TRIAL.
PROSPERE RCT is a randomised multicentre controlled trial conducted in 12 participating French hospital referral centres for
pelvic reconstructive surgery. Inclusion criteria were: patients aged 45 to 75 years old, with cystocele ≥ stage 2 of the POP-Q
classification. Exclusion criteria were a previous surgical POP repair, and inability or contra-indication for one or the other
technique.
Both LSC and VRM surgery were standardised using a consensus Delphi method. For LSC, the mesh had to be fixed to the
promontory by stitches; peritonisation of the mesh was mandatory. For vaginal repair, the mesh had to be suspended by four

2017
DEFECTO DE COMPARTIMENTO MEDIO . ÚTERO
similar mejoría en síntomas de POP
similares tasas de recurrencia de POP
similares tasas de IUE de novo

Cochrane Database of Systematic Reviews
Surgery for women with apical vaginal prolapse (Review)
Maher C, Feiner B, Baessler K, Christmann-Schmid C, Haya N, Brown J
Sacral colpopexy has superior outcomes to a variety of vaginal procedures
including sacrospinous colpopexy, uterosacral colpopexy and transvaginal
mesh “
DEFECTO DE COMPARTIMENTO MEDIO . CÚPULA
Lower risk of awareness of prolapse, recurrent prolapse on examination,
repeat surgery for prolapse, postoperative SUI and dyspareunia
2016
Cochrane Database of Systematic Reviews
Surgery for women with apical vaginal prolapse (Rev
Maher C, Feiner B, Baessler K, Christmann-Schmid C, Haya N, Brown J

Comparativos con mallas vaginales
LPS > tasa de curación subjetiva y objetiva
LPS < morbilidad perioperatoria y tasa de reintervenciones
LSC
TVM

Tiempo
operatorio
191
+/-‐
48
101
+/-‐
31
P=0.001

Complicaciones
intra
1.6%
6.5%
ND

Hospitalización
4.02
+/-‐
1.37
5.27
+/-‐
2.2
ND

Dispareunia
de
novo
1.6%
13.1%
P=0.015

Estreñimiento
post
27.8%
6.5%
P=0.02

ReIQ
complicaciones
8.2%
14.75%
ND

ReIQ
prolapso
3.3%
4.9%
ND

Maher. Am J Obstet Gynecol 2011

RESULTADOS CSP LAPAROSCOPICA.

EUROPEAN UROLOGY 2014

REVIEWARTICLE
The treatment of post-hysterectomy vaginal vault prolapse:
a systematic review and meta-analysis
Anne-Lotte W. M. Coolen1
& Bich Ngoc Bui1
& Viviane Dietz2
& Rui Wang3
&
Aafke P. A. van Montfoort4
& Ben Willem J. Mol3
& Jan-Paul W. R. Roovers5
&
Marlies Y. Bongers1,4
Received: 13 May 2017 /Accepted: 13 September 2017
# The Author(s) 2017. This article is an open access publication
Abstract
Introduction and hypothesis The treatment of post-
hysterectomy vaginal vault prolapse (VVP) has been investi-
gated in several randomized clinical trials (RCTs), but a sys-
tematic review of the topic is still lacking. The aim of this
study is to compare the effectiveness of treatments for VVP.
Methods We performed a systematic review and meta-
analysis of the literature on the treatment of VVP found in
PubMed and Embase. Reference lists of identified relevant
articles were checked for additional articles. A network plot
was constructed to illustrate the geometry of the network of
the treatments included. Only RCTs reporting on the treatment
of VVP were eligible, conditional on a minimum of 30 par-
ticipants with VVP and a follow-up of at least 6 months.
Results Nine RCTs reporting 846 women (ranging from 95 to
168 women) met the inclusion criteria. All surgical techniques
were associated with good subjective results, and without dif-
ferences between the compared technique, with the exception
of the comparison of vaginal mesh (VM) vs laparoscopic
sacrocolpopexy (LSC). LSC is associated with a higher satis-
faction rate. The anatomical results of the sacrocolpopexy
(laparoscopic, robotic [RSC]. and abdominal [ASC]) are the
best (62–91%), followed by the VM. However, the ranges of
the anatomical outcome of VM were wide (43–97%). The
poorest results are described for the sacrospinal fixation
(SSF; 35–81%), which also correlates with the higher reoper-
ation rate for pelvic organ prolapse (POP; 5–9%). The highest
percentage of complications were reported after ASC (2–
19%), VM (6–29%), and RSC (54%). Mesh exposure was
seen most often after VM (8–21%). The rate of reoperations
carried out because of complications, recurrence prolapse, and
incontinence of VM was 13–22%. Overall, sacrocolpopexy
reported the best results at follow-up, with an outlier of one
trial reporting the highest reoperation rate for POP (11%). The
results of the RSC are too small to make any conclusion, but
LSC seems to be preferable to ASC.
Conclusions A comparison of techniques was difficult be-
cause of heterogeneity; therefore, a network meta-analysis
was not possible. All techniques have proved to be effective.
The reported differences between the techniques were negli-
gible. Therefore, a standard treatment for VVP could not be
given according to this review.
Results were presented at a previous conference: Poster EUGA,
Amsterdam, the Netherlands
Electronic supplementary material The online version of this article
(https://doi.org/10.1007/s00192-017-3493-2) contains supplementary
material, which is available to authorized users
* Anne-Lotte W. M. Coolen
anne_lotte_coolen@hotmail.com
1
Department of Obstetrics and Gynecology, Máxima Medical Centre,
De Run 4600, 5500 MB Veldhoven, The Netherlands
2
Department of Obstetrics and Gynecology, Catharina Hospital,
Michelangelolaan 2, 5623 EJ Eindhoven, The Netherlands
3
Robinson Research Institute, Adelaide Medical School, University of
Adelaide, Adelaide, SA, Australia
4
Department of Obstetrics and Gynaecology, Maastricht University,
Grow School for Oncology and Developmental Biology,
Minderbroedersberg 4, 6211 LK Maastricht, The Netherlands
Int Urogynecol J
https://doi.org/10.1007/s00192-017-3493-2
Int Urogyn J 2017
Revisión Sistemática y Metaanálisis
n: 846 mujeres
Seguimiento > 6 meses
Todas las técnicas dan buenos resultados
( CSP abierta y Lap // Mallas Vaginales // RICHTER)
CSP Lap. mejores resultados
> Satisfacción // < Tasa Reoperaciones
Restauración Anatómica ( 62-91%)
(Mejor CSP à malla vaginal à Richter el peor 35-81%)
Complicaciones 1º CSP abd à Mallas vaginales
RESULTADOS CSP LAPAROSCOPICA.
COMPARACIÓN DIFICIL POR HETEROGENEIDAD

CURVA DE APRENDIZAJE
Hsiao, 2007 220 min reducción Tpo. del 30% tras 10 cx
Claerhout, 2009 206 min reducción Tpo significativa tras 30 cx
Akladios, 2010 237 min reducción Tpo del 25% tras 20 cx
Mustafá, 2012 176 min reducción Tpo del 20% tras 15 cx
Tiempo operatorio (97-276 min)
•  ( entrenamiento y habilidad con
las suturas ) Akladios, 2010
CURVAS DE APRENDIZAJE
POP SURGERY REVIEW
Apical prolapse
Matthew D. Barber & Christopher Maher
Abstract
Introduction and hypothesis The aim was to review the safe-
ty and efficacy of pelvic organ prolapse surgery for vaginal
apical prolapse.
Methods Every 4 years and as part of the Fifth International
Collaboration on Incontinence we reviewed the English-
language scientific literature after searching PubMed, Medline,
Cochrane library and Cochrane database of systematic reviews,
published up to January 2012. Publications were classified as
level 1 evidence (randomised controlled trials (RCT) or sys-
tematic reviews), level 2 (poor quality RCT, prospective cohort
studies), level 3 (case series or retrospective studies) and level 4
case reports. The highest level of evidence was utilised by the
committee to make evidence-based recommendations based
upon the Oxford grading system. Grade A recommendation
usually depends on consistent level 1 evidence. Grade B rec-
ommendation usually depends on consistent level 2 and or 3
studies, or “majority evidence” from RCTs. Grade C recom-
mendation usually depends on level 4 studies or “majority
evidence from level 2/3 studies or Delphi processed expert
opinion. Grade D “no recommendation possible” would be
used where the evidence is inadequate or conflicting and when
expert opinion is delivered without a formal analytical process,
such as by Delphi.
Results Abdominal sacral colpopexy (ASC) has a higher suc-
cess rate than sacrospinous colpopexy with less SUI and
postoperative dyspareunia for vault prolapse. ASC had greater
morbidity including operating time, inpatient stay, slower
return to activities of daily living and higher cost (grade A).
ASC has the lowest inpatient costs compared with laparo-
scopic sacral colpopexy (LSC) and robotic sacral colpopexy
(RSC). LSC has lower inpatient costs than RSC (grade B).In
single RCTs the RSC had longer operating time than both
ASC and LSC (grade B). In small trials objective outcomes
appear similar although postoperative pain was greater in
RSC. LSC is as effective as ASC with reduced blood loss
and admission time (grade C). The data relating to operating
time are conflicting. ASC performed with polypropylene mesh
has superior outcomes to fascia lata (level I), porcine dermis
and small intestine submucosa (level 3; grade B). In a single
Int Urogynecol J (2013) 24:1815–1833
DOI 10.1007/s00192-013-2172-1
# ICUD-EAU 2013

Técnica clásica Clermond-Ferrand
•  - Corrección integral de todos los defectos existentes a nivel
de los diferentes compartimentos
•  - Previene defectos secundarios a la misma cirugía.
•  - Mallas por laparoscopia < complicaciones en comparación
a la vía vaginal.
Mejor visión anatómica
Mejor resolución quirúrgica
Menor sangrado
Wa$iez et al. Promontoﬁxation for the treatment of prolapse. Urol Clin North Am 2001

Preparación del campo pélvico
Suspensión de sigma a pared pélvica

incisión peritoneo cara posterior cúpula

Preparación de accesos laterales pararectales hasta MEA (fasciculo puborectal)

Incisión / disección/ Preparación pared anterior

Incisión / disección/ Preparación promontorio sacro

Incisión / disección/ Preparación promontorio

Anclaje de sutura irreabsorbible en MEA

Puntos de fijación de “patas” posteriores de la malla en MEA

Puntos de fijación de malla posterior a muscularis vaginal posterior

Puntos de fijación de malla anterior a muscularis vaginal anterior

Punto sobre ligamento sacro anterior en promontorio

Fijación extremo craneal de la malla sobre promontorio ( sutura irreabsorbible)

Peritonización sobre la malla con sutura continua reabsorbible

INTERVENCIONES LAPAROSCÓPICAS
•  COMPARTIMENTO ANTERIOR
Reparación de defecto paravaginal
Colposuspensión Burch para IUE
Colposacropexia
POPS (cinta de malla subperitoneal parietal)
Pectopexia ( fijación con malla a lig.ileopectíneo)
•  COMPARTIMENTO MEDIO
Mc Call Laparoscopico (fijación a Lig.US)
Colposacropexia
Histeropromontopexia
POPS
Pectopexia

Fijación a lig. úterosacros útero

Laparoscopic vaginal vault suspension using uterosacral ligaments: a review of 133 cases.
Lin, Phelps, Liu. J Minim Invasive Gynecol, 2005

Colpopexia a lig úterosacros:

133 pacientes con prolapso severo de cúpula.
Tpo seguimiento: 2-7,3 a.
87.2% no recurrencia del prolapso.

Uterosacral colpopexy at the time of vaginal hysterectomy: comparison of laparoscopic and vaginal
approaches. Rardin, Erekson. J Reprod Med 2009.

HT + colpopexia a lig úterosacros:
• N=96. V.VAGINAL (seguimiento medio: 8.8m)
• N=22. V.LAPAROSCÓPICA (seguimiento medio: 10.8m)
< Compromiso ureteral 4.2% vs 0%
< Recurrencia del prolapso sintomático de cúpula 10% vs 0%
Fijación a lig. úterosacros cúpula

Fijación de cúpula vaginal a lig.úterosacros
post Histerectomía total laparoscópica

Laparoscopia vs. Robótica
Paraiso. Laparoscopic compared with Robotic Sacrocolpopexy for Vaginal Prolapse. Obstet Gynecol 2011

Anger. Robotic compared with laparoscopic sacrocolpopexy: a randomized controlled trial. Obstet Gynecol 2014
Barber. Apical prolapse. Int Urogynecol J 2013
> tiempos operatorios
> dolor postoperatorio
> coste económico
NO superioridad en ningún parámetro clínico.

Conclusiones
•  El objetivo de la cirugía laparoscópica es reproducir los
resultados de las técnicas abiertas mediante técnicas
mínimamente invasivas
•  Adecuada valoración preoperatoria para la elección
de la técnica quirúrgica.
•  El tratamiento completo del prolapso genital por vía
laparoscópica es una técnica efectiva y reproducible.
•  Curva de aprendizaje y habilidades quirúrgicas (sutura)

LA LAPAROSCOPIA EN PATOLOGÍAS DE SUELO PÉLVICO
….NO ES SENCILLA … PERO TAMPOCO UNA “MISIÓN IMPOSIBLE”

Tto laparoscopico defecto medio y anterior

Tto laparoscopico defecto medio y anterior

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