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PFD Week 2016
Lefort Colpocleisis: A Split Screen Simulation Mod ...
Lefort Colpocleisis: A Split Screen Simulation Model
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Video Transcription
Lefort-Koppel-Kleises, a split-screen simulation model, a collaborative effort between University Hospitals Case Medical Center and MetroHealth Medical Center. The largest population growth in the United States is women over 60, and in their lives up to 10% will have surgery for pelvic organ prolapse, hence there's an increase in patients with prolapse in their 70s and 80s with medical comorbidities who are not sexually active. For patients with symptomatic prolapse who have medical comorbidities, are not sexually active, or have had previously failed prolapse surgery or pessary trials, obliterative procedures may be indicated. There are two types of obliterative procedures for pelvic organ prolapse. The Lefort-Koppel-Kleises in patients with a uterus, and the complete colpectomy with Koppel-Kleises in patients with a previous hysterectomy. In the United States, there is limited exposure to Koppel-Kleises in residency. Providers who graduated less than 10 years ago are less likely to offer Koppel-Kleises than otherwise. In our two hospitals, graduating residents have performed 1 to 3 Koppel-Kleises as surgeon. Therefore, the purpose of this video is to serve as an educational tool of a model for Lefort-Koppel-Kleises shown side by side with the real procedure, for those taking care of patients with pelvic floor disorders. The supplies needed to construct the model include cotton balls, pantyhose, a sock, surgical instruments, sutures, glue, marking pen, and an optional pelvic model. The total cost, excluding instruments, is $5. To set up the model, we stuff the cotton balls into the pantyhose, which serve as our fibromuscular connective tissue, as seen here. Glue is then copiously applied to the fibromuscular connective tissue and covered with a sock, which is the vaginal epithelium, as seen in the video. Once constructed, we are ready to perform the procedure. We begin by attaching Atlas clamps to the apex of the prolapse, which is the cervix in a Lefort model. We then draw the cervix and the rectangles for anterior and posterior dissection, from the apex to approximately the hymenal ring. Note that strips are created bilaterally, which are not excised in this procedure. These strips will serve as bilateral drainage tunnels. The planes are then hydrodissected using lidocaine with epinephrine or vasopressin. We now turn to our split-screen model. Note the stage 4 prolapse in the model, compared to the stage 3 prolapse in the actual patient. Despite the differences, the principles for Lefort-Copochlysis remain the same. Once the rectangles are demarcated, we use sharp dissection with curved male scissors or metzenbaum scissors to denude the vaginal epithelium from the underlying fibromuscular connective tissue, both anteriorly and posteriorly, as seen in both the model and in the procedure on the right. It is important not to excise too close to the midurethra in the case that a midurethral sling is placed at the end of the procedure. Care is taken not to enter the perineal cavity, or in the case of the model, the pantyhose. Once all the epithelium is denuded anteriorly and posteriorly, and strips of vaginal epithelium are developed bilaterally, we begin with the imbrication of the cervix and the strips, thereby forming tunnels bilaterally. In our practice, we go by the following mantra, with occasional deviations. We start with a tunnel and end with a tunnel. Therefore, as demonstrated, we begin imbricating the tunnel first, followed by the cervix, and ending with a tunnel on the opposite side, typically using a 2-ovicle delayed absorbable suture in an inside-out to outside-in fashion. Upon tying the tunnels, a forceps may be used to push the tissue inwards to develop them. ♪♪♪♪♪♪♪♪♪♪♪♪♪♪♪♪♪♪♪♪♪♪♪♪♪♪♪♪♪♪♪♪♪♪♪♪♪♪♪♪♪♪♪♪♪♪♪♪♪♪♪♪♪♪♪♪♪♪♪♪♪♪♪♪♪♪♪♪♪♪♪♪♪� from view we continue our mantra of start with a tunnel and end with a tunnel but this time we incorporate box stitches for the fibromuscular connective tissue as demonstrated in the video we begin on the same side where the last tunnel was developed and move across starting with the imbrication of a strip of vaginal epithelium to develop the tunnel attention is then turned to our box stitches where the connective tissue is first grasped anteriorly placated and then the same suture is used to placate posteriorly in a backhand fashion alternatively a purse string suture may be used as well a forceps may be used for assistance to tie the suture down approximately two box stitches are needed across we finish this portion with a development of another tunnel again we start with a tunnel and end with a tunnel given the extent of the prolapse in the model compared to the real procedure the model requires further suturing whereas the procedure is relatively complete in the live action sequence nonetheless the principles remain the same use a 20 vicryl delayed absorbable suture to start with a tunnel box box and with a tunnel until the prolapse is reduced as shown in our model here please note that for the sake of time only the key portions of the procedure are demonstrated do now with the prolapse reduced the vaginal epithelium is approximated in an interrupted or running fashion again with a delayed absorbable suture as seen in the video now cystoscopy is then performed to evaluate for bladder injury and ureteral patency this patient received 100 milligrams of pyridium preoperatively finally in our practice we perform a high perineoraphy with all our copal clyses at the end of the procedure as seen here we begin with an excision of a diamond from the perineum followed by mobilization of the tissue and re-approximation at the end of the procedure the tbl is two centimeters gh is three and the perineal body is five centimeters one year after surgery 85 to 95 percent of patients are satisfied with their procedure and in one study 90 would choose to have copal clysis again
Video Summary
The video discusses Lefort-Koppel-Kleises, a split-screen simulation model for pelvic organ prolapse surgery. It highlights that women over 60 years old have the highest population growth in the US and often require surgery for pelvic organ prolapse. The video explains that obliterative procedures may be necessary for symptomatic prolapse, especially for patients with medical comorbidities or failed previous surgeries. The video provides step-by-step instructions for constructing the simulation model using simple materials like cotton balls and pantyhose. It demonstrates the surgical technique for Lefort-Koppel-Kleises, emphasizing the importance of starting and ending with a tunnel. The video concludes by mentioning the high satisfaction rates and preference for copal clysis procedures. No specific credits were mentioned in the transcript.
Asset Subtitle
Andrey Petrikovets, MD
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Category
Education
Category
Pelvic Organ Prolapse
Keywords
Lefort-Koppel-Kleises
split-screen simulation model
pelvic organ prolapse surgery
obliterative procedures
copal clysis procedures
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