The placement of mesh for vaginal repair of prolapse is controversial at this time. The reason for controversy is the risk of mesh extrusion or exposure and the complications that ensue because of that. We have developed a technique to try to reduce those risks and complications by making a transverse incision into the vaginal mucosa prior to mesh placement. We begin our incision at the level of the endopelvic fascial break and make a curvilinear incision. We then separate the vaginal mucosa from the underlying tissues. We begin sharply as shown here. The hydro dissection that we perform prior to the incision also helps us in finding our correct plane. We feel like that performing the dissection in this manner reduces the amount of multiple planes that are developed in the dissection and therefore less tissue trauma. Once we mobilize one side of the flap, we then begin to mobilize the other side of the flap as is shown here. Again, notice the clean plane that is easily developed in the sharp dissection. We also believe that there is less bleeding in doing the dissection in this manner as opposed to the more traditional vertical vaginal incision. The endopelvic fascia can easily be shown here by looking at the endopelvic fascia. The endopelvic fascia can easily be shown here in the endopelvic fascial break and subsequent defect. Once the anterior wall is done, we proceed to the posterior wall. This is performed in a similar fashion as the anterior dissection. The transverse incision was made at the level of the endopelvic fascial break and sharp dissection was performed mobilizing the tissue away from the vaginal epithelium. Again, as was shown, hydrodissection was performed prior to the beginning of the incision. Once we have adequately dissected back to the apex, we then again begin on the opposite flap. This dissection occurs down to the level of the perineal body. The endopelvic fascia can easily be seen and identified. Once the sharp dissection has occurred, we then complete the mobilization with the use of a moist open ratex. The mesh procedure is then performed. We measure 3 cm lateral and 3 cm posterior to the anus. The needle is placed through the ischiorectal fossa up along the vagina through the sacrospinous ligament. The snare is deployed. The mesh arm is placed into the snare and brought out through the incision. This is performed bilaterally. We then place the distal needle at the level of the introitus. The mesh arm is brought through. And again, this is performed bilaterally. We then place the anterior mesh. The markings are made. The incision is performed. We choose to place the trans-obdurator sling first, as is depicted here, at the level of the mid urethra. We choose to place the trans-obdurator sling first, as is depicted here, at the level of the mid urethra. The sling is placed loosely under the mid urethra. We then utilize the same incision for the anterior mesh kit, with the first arm being placed at the proximal urethra. With the first arm being placed at the proximal urethra. We then place the more proximal arm and mesh going through the posterior obdurator membrane, back along the anterior vagina, just above the ischial spine. The mesh arm is attached to the snare and brought out through the external incision. And at this point, the sling and anterior vaginal mesh have all been placed loosely. The stay sutures are then placed anteriorly and posteriorly. The sutures are placed at the level of the vaginal apex, as well as along the paravaginal line and along the proximal portion of the urethra. Once the mesh is flat and secure, the anterior vaginal incision is closed. The stay sutures are then placed on the posterior mesh wall, starting at the perineal body, going back along the pararectal line, and the posterior vaginal incision is closed. We then place an opticon valve catheter, so that the patient can have easy and early mobilization, and the patient is usually discharged on the first postoperative day.

vaginal repair

prolapse

mesh technique

mesh extrusion

complications