I recently had a patient who was referred to me for treatment of pelvic pain and pain with intercourse. She had multiple prior surgeries for “endometriosis”. During one of her prior surgeries she was noted to have “adhesions of her rectum to the uterus.
On her office exam, there was a nodule behind the uterus that I could feel. It appeared to be pulling her rectum into the back side of the uterus. This is the third patient I have seen with this similar presentation and history.
During surgery, she was noted to have a nodule of endometriosis that pulled the rectum forward and blocked her normal “pelvic cul-de-sac” (the area between the uterus and the rectum. During dissection, this nodule was dissected off the uterus and the rectum and freed up. After identifying the rectum, ureters and uterine blood vessels, the nodule was removed.
When treating endometriosis surgically, it is important to use the physical examination to know what to expect at the time of surgery. It is also important for the surgeon to feel comfortable removing endometriosis in difficult areas such as over the ureters or bowel. There are many times endometriosis surgeries are performed and the surgeon takes a look and then stops the surgery because the endometriosis is too bad or in locations “too risky” to remove.
This patient is an ideal example of the necessity to know how to identify and adequately excise the endometriosis encountered during surgery.
Showing posts with label laparoscopy ogden. Show all posts
Showing posts with label laparoscopy ogden. Show all posts
Tuesday, September 25, 2007
Thursday, June 14, 2007
Large Ovarian Cyst
I had a very interesting surgery a little while ago. I had a elderly woman who was referred with a large, complex, cystic mass on her ovary. After my discussion with her, she chose to have an evaluation through the laparoscope with possible removal of the ovary.
At the time of surgery, her ovary was noted to be free, without adhesions, and with a smooth surface. She did have multiple cysts on the ovary. The largest cyst was about 15 centimeters in size. Because there were no adhesions, no abnormal fluid within her abdomen, and no concerning features on the surface of the ovary, I elected to drain the cyst and removed the ovary laparoscopically.
A 5 millimeter incision was made just above the pubic bone. A small tube was inserted through this incision and into the cyst. A suture was placed around the cyst and tube and the cyst was then drained. As the cyst collapsed, the suture was tightened around the cyst to prevent spilling.
After the largest cyst was drained, I was able to remove the ovary and place it inside a sterile, plastic bag. Once contained within the plastic bag, the opening of the bag was brought through the 2 centimeter incision in her belly button. The cyst was then removed through that small incision.
The patient went home the same day and two days later was feeling well and off of pain medication.
In appropriate patients, laparoscopy can be safely used to treat cysts and masses of the ovaries and fallopian tubes. Even large masses such as described above can be managed with the benefits of minimally invasive, laparoscopic surgery.
At the time of surgery, her ovary was noted to be free, without adhesions, and with a smooth surface. She did have multiple cysts on the ovary. The largest cyst was about 15 centimeters in size. Because there were no adhesions, no abnormal fluid within her abdomen, and no concerning features on the surface of the ovary, I elected to drain the cyst and removed the ovary laparoscopically.
A 5 millimeter incision was made just above the pubic bone. A small tube was inserted through this incision and into the cyst. A suture was placed around the cyst and tube and the cyst was then drained. As the cyst collapsed, the suture was tightened around the cyst to prevent spilling.
After the largest cyst was drained, I was able to remove the ovary and place it inside a sterile, plastic bag. Once contained within the plastic bag, the opening of the bag was brought through the 2 centimeter incision in her belly button. The cyst was then removed through that small incision.
The patient went home the same day and two days later was feeling well and off of pain medication.
In appropriate patients, laparoscopy can be safely used to treat cysts and masses of the ovaries and fallopian tubes. Even large masses such as described above can be managed with the benefits of minimally invasive, laparoscopic surgery.
Tuesday, May 15, 2007
Urinary Incontinence Surgery
Stress Incontinence occurs when the pressure on the bladder overcomes the mechanisms in place to keep urine from leaking. To begin with, stress incontinence must be differentiated from urge incontinence or detrussor instability. Urge incontinence occurs when the bladder muscle begins to contract in an attempt to empty the bladder. The most common occurrence with this type of incontinence is feeling the urge to go and not being able to make it to the restroom in time. This type of incontinence is treated with medicines as opposed to surgery.
Stress incontinence can be divided into two categories: 1. Urethral hypermobility and , 2. Instrinsic sphincter deficiency. Urethral hypermobility occurs usually in conjunction with other anatomic pelvic prolapse. Normally the bladder and bladder neck is supported within the realm of the abdominal and pelvic cavity. As the pressure within the abdomen increases, the rise in pressure also surrounds the bladder neck helping to close off the area where urine leaves the bladder and enters the urethra. If this area has lost its support, the increased pressure can no longer be used to assist in controlling the urine. The entire increase in pressure is transmitted to the dome or “balloon” part of the bladder. This in effect causes a greater force of urine on the bladder neck. The muscles surrounding the urethra are often not strong enough to hold the urine in.
Intrinsic sphincter deficiency occurs when the bladder and bladder neck are held in a normal position, but the closing pressure of the muscle surrounding the bladder neck is insufficient to prevent urine from leaking.
It is not uncommon for patients to have “mixed incontinence.” This includes a combination of stress and urge incontinence. In difficult cases or in patients with medical complications affecting the bladder innervation, special urodynamic testing can be performed to evaluate the pressures of the bladder and the muscle activity.
Common procedures for “stress incontinence” include: Burch urethropexy, suburethral sling procedures, and injection procedures. For many years the Burch procedure was and is considered the “gold standard.” This is performed with through and open “c-section” type incision or can be performed laparoscopically. The area behind the pubic bone is entered and the tissue on either side of the urethra is grasped with permanent suture and attached to a ligament on the pubic bone. This provides support to the urethra and bladder neck to prevent leaking.
Suburethral slings have been a remarkable addition to the surgical treatment of stress incontinence. Data regarding slings is very promising and studies have shown the efficacy to rival or exceed that of the Burch. A small incision (1-2 cm) is made in the vaginal mucosa underneath the urethra and the area is dissected with a scissor tip to the space behind the pubic bone. Two 1 cm incisions are then made just above the pubic bone. A permanent mesh is then passed underneath the urethra, behind the pubic bone, and through the incisions on the abdomen. This procedure is much less invasive than the Burch procedure and patients go home the same day after a voiding trial.
Some physicians can also perform bulking or injection procedures to assist in closing off the urethra. These injections are good procedures for patients who are not good candidates for longer more complex surgeries.
I perform suburethral sling procedures as well as laparoscopic Burch procedures for patients with stress incontinence.
Stress incontinence can be divided into two categories: 1. Urethral hypermobility and , 2. Instrinsic sphincter deficiency. Urethral hypermobility occurs usually in conjunction with other anatomic pelvic prolapse. Normally the bladder and bladder neck is supported within the realm of the abdominal and pelvic cavity. As the pressure within the abdomen increases, the rise in pressure also surrounds the bladder neck helping to close off the area where urine leaves the bladder and enters the urethra. If this area has lost its support, the increased pressure can no longer be used to assist in controlling the urine. The entire increase in pressure is transmitted to the dome or “balloon” part of the bladder. This in effect causes a greater force of urine on the bladder neck. The muscles surrounding the urethra are often not strong enough to hold the urine in.
Intrinsic sphincter deficiency occurs when the bladder and bladder neck are held in a normal position, but the closing pressure of the muscle surrounding the bladder neck is insufficient to prevent urine from leaking.
It is not uncommon for patients to have “mixed incontinence.” This includes a combination of stress and urge incontinence. In difficult cases or in patients with medical complications affecting the bladder innervation, special urodynamic testing can be performed to evaluate the pressures of the bladder and the muscle activity.
Common procedures for “stress incontinence” include: Burch urethropexy, suburethral sling procedures, and injection procedures. For many years the Burch procedure was and is considered the “gold standard.” This is performed with through and open “c-section” type incision or can be performed laparoscopically. The area behind the pubic bone is entered and the tissue on either side of the urethra is grasped with permanent suture and attached to a ligament on the pubic bone. This provides support to the urethra and bladder neck to prevent leaking.
Suburethral slings have been a remarkable addition to the surgical treatment of stress incontinence. Data regarding slings is very promising and studies have shown the efficacy to rival or exceed that of the Burch. A small incision (1-2 cm) is made in the vaginal mucosa underneath the urethra and the area is dissected with a scissor tip to the space behind the pubic bone. Two 1 cm incisions are then made just above the pubic bone. A permanent mesh is then passed underneath the urethra, behind the pubic bone, and through the incisions on the abdomen. This procedure is much less invasive than the Burch procedure and patients go home the same day after a voiding trial.
Some physicians can also perform bulking or injection procedures to assist in closing off the urethra. These injections are good procedures for patients who are not good candidates for longer more complex surgeries.
I perform suburethral sling procedures as well as laparoscopic Burch procedures for patients with stress incontinence.
Friday, April 6, 2007
Bladder Drop and Incontinence
Many women have problems with what doctors refer to as prolapse. One specific area of prolapse is with the bladder. Most prolapse is considered some form of a hernia. Similar to hernias of the groin or "belly button," pelvic hernias and prolapse are caused by a break in the tough tissue or fascia that acts as a supportive layer. When the fascia is broken or separated, other organs or areas can bulge through.
One of the most common areas of prolapse is the bladder. The bladder sits right in front of the anterior vagina. If the support of the bladder is disrupted, such as in childbirth or just over time, the bladder can bulge into the vagina or even out through the vaginal opening.
Some forms of urinary incontinence can be caused by or complicated by bladder drop. Frequently, patients who leak urine with coughing, sneezing, or with exercise, have a defect in the bladder support that contributes to the leaking.
Dr. Cullen Richardson studied the defects involved with bladder support problems and found three different support areas that can break and cause a bladder hernia. The first and most common site is where the bladder fascia attaches to the pelvic bones. This is referred to as a lateral defect or paravaginal defect cystocele. As the lateral support is broken, the bladder is allowed to drop down out of position. This is similar to spring support on a trampoline that attaches to the frame.
The other two types of hernia defects are transverse and midline defects. These two are less common and are likened to a tear in the trampoline fabric itself.
Common treatments for bladder prolapse include exercises to strengthen the pelvic muscles, pessary treatment, and surgery. Bladder prolapse is not a dangerous condition and many women live without any treatment. Pessaries are similar to contraceptive diaphragms which are placed in the vagina and act as a supporting "shelf" to hold the bladder in place and keep it from protruding out the vaginal opening.
Common surgeries for bladder prolapse include an "anterior repair." This is a god procedure for transverse and midline defects. Essentially the vaginal mucosa is opened exposing the supporting bladder fascia. This fascia is then sewn with stitches closing the defect.
Lateral or paravaginal defects are repaired either vaginally, laparoscopically or abdominally. Each surgeon has his/her preferred method of operating. The goal of the surgery is to re-attach the fascia to the lateral pelvic bones. I perform these surgeries laparoscopically. This allows a similar procedure to the abdominal method, but uses only small one centimeter incisions. Laparoscopy magnifies the view and the defects are identified. Permanent sutures are then placed to hold the support back into its normal position.
Incontinence surgery can be performed at the same time. There are minimally invasive procedures used to treat stress incontinence. These will be addressed in an upcoming post.
One of the most common areas of prolapse is the bladder. The bladder sits right in front of the anterior vagina. If the support of the bladder is disrupted, such as in childbirth or just over time, the bladder can bulge into the vagina or even out through the vaginal opening.
Some forms of urinary incontinence can be caused by or complicated by bladder drop. Frequently, patients who leak urine with coughing, sneezing, or with exercise, have a defect in the bladder support that contributes to the leaking.
Dr. Cullen Richardson studied the defects involved with bladder support problems and found three different support areas that can break and cause a bladder hernia. The first and most common site is where the bladder fascia attaches to the pelvic bones. This is referred to as a lateral defect or paravaginal defect cystocele. As the lateral support is broken, the bladder is allowed to drop down out of position. This is similar to spring support on a trampoline that attaches to the frame.
The other two types of hernia defects are transverse and midline defects. These two are less common and are likened to a tear in the trampoline fabric itself.
Common treatments for bladder prolapse include exercises to strengthen the pelvic muscles, pessary treatment, and surgery. Bladder prolapse is not a dangerous condition and many women live without any treatment. Pessaries are similar to contraceptive diaphragms which are placed in the vagina and act as a supporting "shelf" to hold the bladder in place and keep it from protruding out the vaginal opening.
Common surgeries for bladder prolapse include an "anterior repair." This is a god procedure for transverse and midline defects. Essentially the vaginal mucosa is opened exposing the supporting bladder fascia. This fascia is then sewn with stitches closing the defect.
Lateral or paravaginal defects are repaired either vaginally, laparoscopically or abdominally. Each surgeon has his/her preferred method of operating. The goal of the surgery is to re-attach the fascia to the lateral pelvic bones. I perform these surgeries laparoscopically. This allows a similar procedure to the abdominal method, but uses only small one centimeter incisions. Laparoscopy magnifies the view and the defects are identified. Permanent sutures are then placed to hold the support back into its normal position.
Incontinence surgery can be performed at the same time. There are minimally invasive procedures used to treat stress incontinence. These will be addressed in an upcoming post.
Wednesday, February 21, 2007
Dermoid Ovarian Cyst
Recently I had a patient that presented with a 4-5 centimeter ovarian cyst. Her initial complaint with this cyst was severe, intermittent pelvic pain. On ultrasound examination, she had a complex, solid and cystic, mass on her ovary. There was a high suspicion of what is called a "Dermoid Cyst".
Dermoid cysts are very interesting in that they can have many cell types within them. They have been known to grow an oily, sebaceous material, hair, teeth and other strange and interesting things to find in an ovary. They are very rarely of a malignant type which include nerve type tissue.
This patient elected to have her entire ovary removed although it would have been feasible to remove only the cyst itself. Either of these surgeries can be performed easily with a laparoscopic surgery.
As always if you have questions, please feel free to send me an email. You can find it under my profile link.
Dermoid cysts are very interesting in that they can have many cell types within them. They have been known to grow an oily, sebaceous material, hair, teeth and other strange and interesting things to find in an ovary. They are very rarely of a malignant type which include nerve type tissue.
This patient elected to have her entire ovary removed although it would have been feasible to remove only the cyst itself. Either of these surgeries can be performed easily with a laparoscopic surgery.
As always if you have questions, please feel free to send me an email. You can find it under my profile link.
Sunday, December 10, 2006
Large ovarian and tubal cysts
This last Tuesday I performed a surgery on a patient in her late twenties who had a large, cystic mass involving her left ovary. On ultrasound it measured approximately 8 centimeters. Her ovarian tumor markers were normal. The decision was made to remove the ovary and tube on the left. With all complex ovarian masses there is a concern for malignancy. For this reason, traditionally these surgeries are performed with a large, “open” incision.
With careful laparoscopic technique these masses and ovarian large ovarian cysts can be managed laparoscopically. With careful attention to keeping the cyst from rupturing and with careful removal techniques, patients can be treated with same day surgery with a much easier recovery.
AT the time of surgery this patient was noted to have an 8 cm cyst on her fallopian tube and a 6 cm cyst in her left ovary. The surface of both tube and ovary were otherwise normal appearing. The tube and ovary were removed separately to facilitate removal from the abdomen. Both cysts were unruptured throughout the surgery.
Once the tube and ovary were removed, a sterile bag was placed into the abdomen through the small incision at the belly button. The bag was then opened and the tube with was placed inside the bag. A laparoscopic needle was then used to aspirate the cyst fluid. Any spilled fluid remained in the bag. The cyst and tube were then removed through the belly button incision.
Because there is often more concern for malignancy with ovarian cysts, the ovary was placed in the bag. The belly button incision was then extended to approximately 3 cm. The opening of the bag was brought through the incision and the ovarian cyst was incised and drained into the bag. The ovary and its contents were then easily removed through this small incision.
The patient went home that same day and was doing very well at a follow up call two days later. Both cysts were benign. She incidentally had a small amount of endometriosis around her left ovary that was removed at the time of surgery.
With careful laparoscopic technique these masses and ovarian large ovarian cysts can be managed laparoscopically. With careful attention to keeping the cyst from rupturing and with careful removal techniques, patients can be treated with same day surgery with a much easier recovery.
AT the time of surgery this patient was noted to have an 8 cm cyst on her fallopian tube and a 6 cm cyst in her left ovary. The surface of both tube and ovary were otherwise normal appearing. The tube and ovary were removed separately to facilitate removal from the abdomen. Both cysts were unruptured throughout the surgery.
Once the tube and ovary were removed, a sterile bag was placed into the abdomen through the small incision at the belly button. The bag was then opened and the tube with was placed inside the bag. A laparoscopic needle was then used to aspirate the cyst fluid. Any spilled fluid remained in the bag. The cyst and tube were then removed through the belly button incision.
Because there is often more concern for malignancy with ovarian cysts, the ovary was placed in the bag. The belly button incision was then extended to approximately 3 cm. The opening of the bag was brought through the incision and the ovarian cyst was incised and drained into the bag. The ovary and its contents were then easily removed through this small incision.
The patient went home that same day and was doing very well at a follow up call two days later. Both cysts were benign. She incidentally had a small amount of endometriosis around her left ovary that was removed at the time of surgery.
Wednesday, December 6, 2006
Ovarian Remnant
I recently saw a patient who has struggled with pelvic pain for years. She has undergone numerous surgeries and treatments. She most recently had a laparoscopic supracervical hysterectomy (LSH) with removal of her tubes and ovaries. She was noted to have endometriosis at that time.
She presented to me with concerns over continued, worsening pain. She was being seen by a pain specialist and enrolled in a pain management program. Her pain affected many areas of her life. She struggled to work, be a mother, and a wife.
Her symptoms consisted of general pelvic pain which was sharp and debilitating. She also had pain with intercourse or dyspareunia.
During her surgery she was found to have her sigmoid colon attached to the side of her pelvis. This is called adhesions. The bowel was densely adhered to the pelvic sidewall and continuing down to and involving half of the area of her cervical stump.
As I began dissecting out the adhesions it became evident that a small portion of her ovary had been left behind with her previous surgery. This is known as “Ovarian Remnant Syndrome.” When a small piece of ovary is left behind due to difficult adhesions or other reasons, the ovary begins to grow in an invasive nature. It seeks out a new blood supply and in doing so invades into surrounding structures.
This patient had her ovary growing into the pelvic sidewall, completely encasing her ureter. It was also growing into the bowel wall.
During her surgery the ureter was identified high in the pelvis and carefully dissected along its course. As I approached the area of the ovary it became evident that it was “stuck” to the underlying structures. Using careful laparoscopic dissecting techniques, the ureter was unroofed and the adhesions were cleared off. The residual ovary was then dissected deeply and removed. A portion in the bowel wall was also removed.
At the end of the surgery, cystoscopy was performed to check the integrity of the bladder and ureter. I also perform a bowel integrity test any time there is concern for possible bowel injury.
I have hopes that removing the residual ovary will allow her more ability to do the things she likes to do and be the mother she wants to be.
She presented to me with concerns over continued, worsening pain. She was being seen by a pain specialist and enrolled in a pain management program. Her pain affected many areas of her life. She struggled to work, be a mother, and a wife.
Her symptoms consisted of general pelvic pain which was sharp and debilitating. She also had pain with intercourse or dyspareunia.
During her surgery she was found to have her sigmoid colon attached to the side of her pelvis. This is called adhesions. The bowel was densely adhered to the pelvic sidewall and continuing down to and involving half of the area of her cervical stump.
As I began dissecting out the adhesions it became evident that a small portion of her ovary had been left behind with her previous surgery. This is known as “Ovarian Remnant Syndrome.” When a small piece of ovary is left behind due to difficult adhesions or other reasons, the ovary begins to grow in an invasive nature. It seeks out a new blood supply and in doing so invades into surrounding structures.
This patient had her ovary growing into the pelvic sidewall, completely encasing her ureter. It was also growing into the bowel wall.
During her surgery the ureter was identified high in the pelvis and carefully dissected along its course. As I approached the area of the ovary it became evident that it was “stuck” to the underlying structures. Using careful laparoscopic dissecting techniques, the ureter was unroofed and the adhesions were cleared off. The residual ovary was then dissected deeply and removed. A portion in the bowel wall was also removed.
At the end of the surgery, cystoscopy was performed to check the integrity of the bladder and ureter. I also perform a bowel integrity test any time there is concern for possible bowel injury.
I have hopes that removing the residual ovary will allow her more ability to do the things she likes to do and be the mother she wants to be.
Saturday, December 2, 2006
Laparoscopy for Pelvic Prolapse
The latest addition to this blog is regarding pelvic prolapse. More common terms heard at your doctor’s office are: cystocele, rectocele, and uterine or uterovaginal prolapse. This occurs when the thick tissue, or fascia, which supports the female structures, becomes weakened over time. This is most likely due to injury sustained with labor during childbirth or with previous pelvic surgery such as hysterectomy. Anything that interrupts by tearing or disrupting nerve input to the supporting muscles can contribute to the problem of prolapse.
The most common symptoms of prolapse are pelvic pressure, a bulge either felt or seen at the vaginal opening. Many patients have problems with bowel movements even requiring “splinting” or use of a finger in the vagina to help express stool. With cystocele, patients can have either urinary retention (the inability to void), and or leaking urine with coughing, sneezing, etc. This is known as stress incontinence.
I would like to mention that a cystocele can be of three different natures. The support of the bladder runs underneath the bladder, runs to the side and attaches to the connective tissue of the side of the pelvis. This attaching tissue may have breaks at the lateral attachment, in the midline, or at the top of the bladder where the bladder sits on the anterior part of the lower uterus. The most common defect seen is the lateral attachment defect in greater than 90% of patients. These breaks in the fascia are considered to be hernias as they allow abdominal and pelvic contents to bulge through the fascia.
The most recent surgery performed was in a woman in her 60’s. She had problems with bowel movements, stress incontinence, and pelvic pressure. On her examination, she had a rectocele (bulging of the rectum into the vagina), cystocele (bulging of the bladder into the vagina), stress incontinence and prolapse of the uterus. She desired to preserve her uterus. This is appropriate as the uterus itself is not involved in support of the pelvic organs.
This patient underwent a laparoscopic surgery which, through laparoscopic suturing, re-established support of the upper vagina and uterus to the uterosacral ligaments. This is a relatively simple surgery for uterine prolapse that has an 80% success rate. The benefit of this is uterine preservation.
The second portion of the surgery was to correct cystocele. As this patient had a lateral defect, her repair consisted of re-attaching the supporting tissue to the side at the area it originally detached. If there is a large separation, a modification can be made that may increase the likelihood of a successful repair. This surgery, paravaginal repair, can be done vaginally, abdominally, or laparoscopically. Laparoscopic surgery allows much easier visualization of the area of concern with precise placement of sutures to correct the torn supporting tissue.
After this, a mesh “sling” was place underneath the urethra to correct the stress incontinence. This was done with a small one centimeter incision in the vagina with two small incisions on the lower abdominal wall. There are many ways to treat stress incontinence. The two “gold standard” treatments are Burch Urethropexy and suburethral slings.
The final part of the procedure was a traditional posterior repair correcting the defect in the supporting tissue between the rectum and vagina.
The surgery went well without any complications. The patient had a normal recovery and went home on the third day after surgery. She was urinating on her own and was holding urine with coughing. She had a quick return to normal diet and her pain was controlled with pain pills. Infact, this patient had adequate pain control with only Tylenol on day number three after surgery.
Laparoscopic correction of pelvic organ prolapse allows wonderful visualization of the specific defects causing prolapse. It also allows preservation of the uterus if desired. The traditional advantages of laparoscopy apply in these cases. These benefits include smaller incisions, quicker recovery, and shorter hospital stay.
The most common symptoms of prolapse are pelvic pressure, a bulge either felt or seen at the vaginal opening. Many patients have problems with bowel movements even requiring “splinting” or use of a finger in the vagina to help express stool. With cystocele, patients can have either urinary retention (the inability to void), and or leaking urine with coughing, sneezing, etc. This is known as stress incontinence.
I would like to mention that a cystocele can be of three different natures. The support of the bladder runs underneath the bladder, runs to the side and attaches to the connective tissue of the side of the pelvis. This attaching tissue may have breaks at the lateral attachment, in the midline, or at the top of the bladder where the bladder sits on the anterior part of the lower uterus. The most common defect seen is the lateral attachment defect in greater than 90% of patients. These breaks in the fascia are considered to be hernias as they allow abdominal and pelvic contents to bulge through the fascia.
The most recent surgery performed was in a woman in her 60’s. She had problems with bowel movements, stress incontinence, and pelvic pressure. On her examination, she had a rectocele (bulging of the rectum into the vagina), cystocele (bulging of the bladder into the vagina), stress incontinence and prolapse of the uterus. She desired to preserve her uterus. This is appropriate as the uterus itself is not involved in support of the pelvic organs.
This patient underwent a laparoscopic surgery which, through laparoscopic suturing, re-established support of the upper vagina and uterus to the uterosacral ligaments. This is a relatively simple surgery for uterine prolapse that has an 80% success rate. The benefit of this is uterine preservation.
The second portion of the surgery was to correct cystocele. As this patient had a lateral defect, her repair consisted of re-attaching the supporting tissue to the side at the area it originally detached. If there is a large separation, a modification can be made that may increase the likelihood of a successful repair. This surgery, paravaginal repair, can be done vaginally, abdominally, or laparoscopically. Laparoscopic surgery allows much easier visualization of the area of concern with precise placement of sutures to correct the torn supporting tissue.
After this, a mesh “sling” was place underneath the urethra to correct the stress incontinence. This was done with a small one centimeter incision in the vagina with two small incisions on the lower abdominal wall. There are many ways to treat stress incontinence. The two “gold standard” treatments are Burch Urethropexy and suburethral slings.
The final part of the procedure was a traditional posterior repair correcting the defect in the supporting tissue between the rectum and vagina.
The surgery went well without any complications. The patient had a normal recovery and went home on the third day after surgery. She was urinating on her own and was holding urine with coughing. She had a quick return to normal diet and her pain was controlled with pain pills. Infact, this patient had adequate pain control with only Tylenol on day number three after surgery.
Laparoscopic correction of pelvic organ prolapse allows wonderful visualization of the specific defects causing prolapse. It also allows preservation of the uterus if desired. The traditional advantages of laparoscopy apply in these cases. These benefits include smaller incisions, quicker recovery, and shorter hospital stay.
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