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AUGS/IUGA Scientific Meeting 2019
Abdominal Sacrocoplopexy with Autologous Rectus Fa ...
Abdominal Sacrocoplopexy with Autologous Rectus Fascia Graft Demonstration and Case Series
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Video Transcription
Abdominal Sacrocobal Plexus is a procedure performed to correct pelvic organ prolapse. In this video, we will discuss and demonstrate the novel technique of using an autologous rectus fascia graft during this procedure. Today, 50% of Paris females are affected by pelvic organ prolapse. Pelvic organ prolapse is the loss of tissue support in the pelvic floor which leads to prolapse of the vaginal apex or uterus and subsequently the bladder or rectum. In a Cochrane review, the abdominal sacrocobal plexus was described as the golden standard for treatment of pelvic organ prolapse. During an abdominal sacrocobal plexus, one end of a graft is secured to the vaginal apex. The other is then placed posteriorly and secured to the ligaments overlying the sacrum. This anchors the vaginal apex in a more natural position, lifting and restoring the vaginal wall structure. A synthetic mesh graft is usually used to perform this procedure. However, there continues to be concerns over pelvic mesh. In an analysis of the CARE trial, it was shown that the traditional abdominal sacrocobal plexus has a mesh erosion rate of 6% in 2 years and almost 10% in 7 years. Therefore, it is our goal to explore other options of graft material for abdominal sacrocobal plexus with autologous facial graft by demonstrating the technique and discussing a small case series. With this technique, the surgeon uses one abdominal incision to create the graft and to anchor it to the proper landmarks. Although literature shows that this method is not widely utilized, it may be a useful tool when customizing a patient's treatment plan who has a history of pelvic mesh erosion and inflammatory process near the surgical site, such as inflammatory bowel disease, or who strongly prefers an alternative to pelvic mesh. Our patient is a 61-year-old paratu postmenopausal female who presents with a vaginal bulge for 5 years and worsening urgency frequency with difficulty in urinating for 1 year. These symptoms have recently been interrupting her daily activities. She also noticed difficulty in starting urine flow but has adapted by standing in a squat-like position. She also expressed a desire to remain sexually active but has had difficulty due to the vaginal bulge. Her pertinent history includes one vaginal delivery, one C-section, and a laparoscopic-assisted vaginal hysterectomy. A physical exam and neurodynamics were done in the office, which showed an anterior wall vaginal prolapse and a cysticia with a POP-Q stage of 2. After hearing her treatment options, she chose an abdominal sacrocopal plexus with an autologous graft. First, the abdomen is prepped for a low transverse abdominal incision, the vagina is prepped with iodine, and a folic catheter is placed for proper intraoperative drainage of the bladder. Next, an EEA sizer is placed inside the vagina in order to visualize the vaginal apex in later steps. Once the initial preparation is complete, attention is then turned to the abdomen. A 10-centimeter low transverse abdominal incision is made with a surgical scalpel. This incision is then deepened through the subcutaneous tissue to the abdominal fascia. The abdominal fascia is then dissected from the overlying fatty layer until there is adequate exposure as shown here. It is now time to create the autologous fascial graft. A 1.5 by 10-centimeter portion of the rectus fascia is then outlined with a sharp scalpel and harvested from the underlying rectus muscles. Once the whole portion of the fascial graft is fully dissected, it is then placed in normal saline while awaiting fixture. Continuing on with abdominal access, the anterior abdominal muscles are separated and the abdominal peritoneum is then entered. To reduce trauma to the bowels, the small and large intestines are placed in the upper abdomen and secured with a combination of lap pads and a self-retaining retractor. It is now time to dissect the landmarks. First, the EEA sizer is advanced farther into the vagina in order to demonstrate the exact location of the apex. The bladder vesicle peritoneum, which is demonstrated with the Alice clamp, is identified and dissected from the apex to make space for graft fixation. The anterior and apical vaginal peritoneum are now exposed and marked with two dots where the graft will be secured. Next, access to the sacral promontory is gained by dissecting the right pararectal space. The right ureter is identified, taking care to avoid it, while the rectum is retracted to the left as shown here in the picture. The peritoneum overlying the sacral promontory can now be seen as a shiny layer over the S1-S2 junction. The peritoneum is gently grasped, tented up, and then opened with mezzanine scissors. We are now in the presacral space, which is then bluntly dissected to gain further access to the anterior longitudinal ligament. Now it is time to attach the fascial graft. First, the surgeon places a suture at each end of the graft by passing through the tissue twice to ensure a strong attachment. One end of the graft is then attached to the anterior peritoneum of the vaginal apex with two sutures of 0 proline. Here we see the relaxed vaginal peritoneum with the graft secured in place and reaching posteriorly to the sacral promontory, where it will be anchored to the ligaments. The remaining end of the fascial graft is then anchored by placing two sutures of 0 proline to the full thickness of the anterior longitudinal ligament, taking care to avoid the middle sacral vessels and left common iliac vein. From there, the usual techniques of sacral copoplexy are followed. The surrounding peritoneum on either side of the sacral promontory is then re-approximated with continuous 0 vicral sutures in order to make the entire length of the fascial graft retroperitoneal. Finally, all abdominal wall layers are re-approximated in usual fashion. In our institution, a small retrospective case series, which included seven postmenopausal women who underwent this procedure, was done. At their preoperative evaluation, each of the women were found to have either an anterior or apical vaginal wall prolapse. 100% reported urge incontinence and 42% reported stress incontinence. Interoperative and recovery times were noted to be comparable to traditional abdominal sacral copoplexy with mesh. And at the six-month follow-up, no graft complications had occurred, and all patients felt that the vaginal apex was well supported. 75% of patients reported resolution of their stress urinary incontinence and 86% resolution of their urge urinary incontinence. Our data is limited. However, it does seem to expand the current graft options and call for further use and analysis of the autologous rectus fascia graft in the abdominal sacral copoplexy procedure.
Video Summary
This video discusses a procedure called abdominal sacrocobal plexus, which is used to correct pelvic organ prolapse. It explores a novel technique using an autologous rectus fascia graft as an alternative to synthetic mesh grafts, which have been associated with complications. The video goes through the steps of the procedure, including creating the graft and anchoring it to the vaginal apex and ligaments over the sacrum. It also presents a small case series of postmenopausal women who underwent this procedure, showing positive outcomes in terms of support for the vaginal apex and resolution of urinary incontinence. Further research and analysis of the autologous rectus fascia graft are recommended.
Asset Caption
Melissa Keslar, DO
Keywords
abdominal sacrococcygeal plexus
pelvic organ prolapse
autologous rectus fascia graft
synthetic mesh grafts
postmenopausal women
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