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Catalog
2009 Annual Meeting
Technique for Management Cervical Dysplasia Necess ...
Technique for Management Cervical Dysplasia Necessitating Trachelectomy After Supracervical Hysterectomy and Sacral Colpopexy
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Video Transcription
Management of High-Grade Cervical Dysplasia Warranting a Trachelectomy after Previous Sacral Copeplexy. This surgical video demonstrates management of high-grade cervical dysplasia diagnosed in a patient who had previously undergone a sacral copeplexy for advanced stage colonoscopy. This procedure was performed at the University of California, Los Angeles, David Geffen School of Medicine as a joint procedure by the Gynecology-Oncology Department and the Urogynecology Departments. Our shared patient had previously had normal cervical screening prior to a copeplexy. Post-operatively, she was followed with routine cervical screening and she subsequently developed an abnormal pap smear, which was then followed with colposcopy and a cervical excisional procedure, revealing high-grade dysplasia. After much discussion with her oncologist, she opted to proceed with a trachelectomy. Careful consideration for the best manner in which to approach this trachelectomy in light of desire to preserve her sacral copeplexy repair was given and after much determination, the Gynecology-Oncologist and Urogynecology Departments agreed that a minimally invasive robotic-assisted trachelectomy with re-approximation of the copeplexy mesh would be plausible. Upon entry into the peritoneal cavity, adhesions between the bowel and the cervix were noted. The robot was docked to assist with dissection of bowel away from the mesh and the cervix. A very tedious dissection was performed and it was clear during the dissection that not only was bowel adherent to the mesh, but a portion of rectal sigmoid had actually become caught between the two ends of the mesh. The mesh arms were carefully separated and the mesh was dissected away for both the posterior surface of the vagina and the anterior surface of the vagina in order to allow for the cervix to be easily removed and the margins clear of the mesh borders. The area where the bladder flap was to be created was demarcated by back-filling the bladder to better delineate the inferior portion of the mesh and the margin of the bladder. Despite the adhesions, we were able to free the mesh away from the underlying vaginal tissues. Once it was determined that we had an adequate border or adequate clearance from the vaginal tissues, attention was turned to making the bladder flap. Once the bladder flap was created, our gynecologic oncologist took over to determine the proper incision for copotomy. The anatomy for this patient was distorted after her previous cervical excision procedure and only a small portion of her cervix remained. For this reason, the EEA sizer was placed in the vagina to help demarcate the apex and an anterior copotomy was created using monopolar electrocautery. These facilitated identification of the cervix, both by location and by direct visualization. The cervix was then carefully excised, taking care to achieve adequate borders. The incurators were identified after entry into the retroperitoneal space bilaterally. The cervix was noted to be adherent to a portion of the anterior portion of the mesh and this was dissected away. The cervix was excised in its entirety and removed through the vagina. Attention was then turned to closing the vaginotomy. The cuff was closed in a figure-of-eight fashion with bifurcated two apices and PDS suture used in between. Intracorporeal knot tying was utilized and care was taken to ensure adequate purchases of the tissue to decrease risk of cuff dehiscence and mesh explosion. The portion of the cuff directly underlying the mesh was the most technically challenging portion of the closure and extra time was spent in this area to ensure that the edges were adequately re-approximated. Although it is rare for low-risk women to develop cervical dysplasia that necessitates a trachelectomy after supracervical hysterectomy and sacral colpopexy, it can be a challenging operative situation when it occurs. Discussion must be had with the patient regarding different surgical options for prolapse repair and the risks of mesh exposure with reaffixing sacral colpopexy mesh at the time of trachelectomy. This video demonstrates a minimally invasive technique that allows for preservation of the sacral colpopexy mesh support and prolapse repair for a woman undergoing a trachelectomy for cervical dysplasia. This patient tolerated this procedure well and was happy with her overall results. A special thanks goes out to Drs. Tarnay, Karam, and the Department of OBGYN.
Video Summary
This video demonstrates the surgical management of high-grade cervical dysplasia in a patient who had previously undergone a sacral colpopexy for advanced stage colonoscopy. The procedure, performed at the University of California, Los Angeles, involved a minimally invasive robotic-assisted trachelectomy with re-approximation of the colpopexy mesh. Adhesions between the bowel and the cervix were noted during the procedure, requiring careful dissection. The cervix was excised and the vaginal cuff closed using intracorporeal knot tying. The video highlights the challenges and considerations involved in performing a trachelectomy after sacral colpopexy. The patient had a successful outcome. Special thanks are given to Drs. Tarnay, Karam, and the Department of OBGYN.
Keywords
surgical management
high-grade cervical dysplasia
sacral colpopexy
minimally invasive robotic-assisted trachelectomy
colpopexy mesh
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