We begin our typical laparoscopy by evaluating the anatomy in its entirety. Once determining that the anatomy is not affected by innate effusions, we then perform an evaluation of the ureter, tracking it and tracing it all the way down from the sacral promontory all the way down into the pelvis. Once that's accomplished and identifying the anatomy, we go back to the sacral promontory, tent up the peritoneum and using a harmonic scalpel we enter into the peritoneum and creating a pocket using it to separate the peritoneum from the ureter for later use to bury our artificial uterus sacral ligament which will be the graft material. We dissect all the way down to the cervix and then are separating the old remnant of the uterus sacral ligament into the cervix. At this point we're dissecting into the rectovaginal septal area all the way down to the perineal body. Once down to that area we place the graft in and are using a new technology suture material called the quill which allows for knot tying technique that allows for no knots to be tied but just pinning the graft material onto the rectovaginal septum in this case as well as to the cervix with a running suture. The quill has a barbed aspect that goes in opposite direction from the middle of the graft which prevents a retraction of the suture material. It also has a memory to it so that any tension that may be on tissue is alleviated from having a recoil so therefore holding the tissue together thus preventing any kind of separation of the material as we're repairing. With again a running stitch attaching the graft material to the rectovaginal septum as well as out to the levator muscles out laterally. Once it's pinned on and established all the way back and attached to the cervix itself and out to the remnant of the uterus sacral ligament, we then are able to cut off the excess suture material as well as the needle. We then with it attached to the cervix thoroughly as well as the rectovaginal septum all the way down to the perineal body. We're then able to bring the graft material tail which is approximately 10 centimeters all the way up to the sacral promontory and using a hernia tacker we attach the graft material to the sacral promontory with five or six staples. Once accomplished we then use a OPDO quill 14 by 14 to end up re-peritonealizing the graft material. This is accomplished with a running stitch. This is particularly a good time for showing the ability of the quill material to end up holding the material together so that it doesn't retract on you and cause a separation of the tissues. So once you end up pulling it through all the way to the middle where the quill's barbs are running in the opposite direction, this locks the tissue together as you see here preventing it from sliding apart leaving a gap in the tissue base. Once this is accomplished we then end up covering the entire graft material all the way up to the sacral promontory running the quill in opposite directions and closing and retro-peritonealizing the graft material so that this does not leave a risk for any kind of hernias, internal hernias, or any attachment of the bowel to the graft material. The quill material that we end up using for the pelvis is a 20 proline 7 by 7 which is used to attach the graft to the rectovaginal septum, perineal body, and levators as well as the cervix. www.ottobock.com

laparoscopy

anatomy evaluation

ureter tracing

peritoneum tenting

suture material quill