With the recent popularized use of synthetic mesh kits for the correction of pelvic organ prolapse, there's been a concomitant rise in the incidence of mesh-related complications such as exposure and or erosion. Surgical excision is commonly necessary when conservative management fails. In the submitted surgical video, we demonstrate a simplified approach to the management of an anterior vaginal wall mesh exposure along the suture line. Before our featured presentation, the first two video clips serve as examples of mesh exposures. One is that of an anteriorly placed mesh, while the other is that of a mesh placed posteriorly. In both examples, one can see that the mesh is well embedded into the subepithelial layer. Aside from having lost its overlying epithelial tissue, there are no other complications as there are no signs of infection or mesh malfunction. It is for this very reason that it's often difficult for one to decide how aggressive to be when excising mesh material. The featured case represents the typical appearance of a type I monofilament macroporous mesh exposure along the suture line. On examination, there's no granulation tissue, erythema, purulent discharge, or inflammatory infiltrate. The surrounding mucosa is healthy and the rest of the anterior vaginal wall has good integrity, support, and is well estrogenized. The mesh can be seen well incorporated into the unexposed area. First, we start by circumferentially infiltrating the area of interest with 1% lidocaine with epinephrine solution. This is done to help with maintaining hemostasis and to assist in the dissection. The area is demarcated and an elliptical incision is made along the healthy edges of the vaginal epithelium, thereby encircling the entire midline defect. Care is to be taken not to cut too deeply as underlying structures such as the bladder or the urethra can be damaged. The vaginal epithelium is undermined and mobilized laterally and circumferentially for approximately one to one and a half centimeters. The medial border of the incised mesh is grasped and progressively separated from the endopelvic fascia. Care is taken to stay within the subepithelial layer as type 1 mesh may be well incorporated into the fibromuscular tissue. Deep incorporation of such and subsequent deep dissection into this area can lead to a bladder injury. Also of note, the dissection is carried out far lateral as to provide enough tissue to perform a tension-free closure. Here, we excise the exposed portion of the mesh and note that it is well integrated into vaginal epithelium. Now, the midline weakness is being repaired. Unlike our prior mesh excisions, we have chosen to placate the lateral edges of the mesh along with endopelvic fascia to reestablish support. We grasp the lateral edges of the mesh along with fibromuscular tissue. Here, we use a permanent suture in an uninterrupted fashion. For this purpose, we have chosen a proline suture. We make sure to grasp a good purchase of tissue for the maintenance of good support. This may require three or more sutures for appropriate approximation. The strength of the embedded mesh remnant is taken advantage of and is incorporated into our repair. Care is also taken when placating endopelvic fascia and mesh material that it is done in a tension-free fashion. Copious irrigation is performed as to prevent infection as well as to identify any bleeding vessels. This step is rather crucial as hematoma formation is often the common culprit responsible for mesh exposure. Lastly, the vaginal epithelium is re-approximated with an absorbable suture in a run-in, non-lock-in fashion. Note that the adjacent mucosa is healthy and there is no reduction in the vaginal caliber. The epithelial integrity and anatomical support are all maintained. Thus far, in a small series of cases at our institution, this simplified approach to mesh exposure with use of mesh remnants to maintain support has not resulted in any complications. In fact, a retrospective query of our database was performed and identified all patients who underwent a mesh excision or revision procedure from April 2008 until February 2009. We specifically reviewed the cases of type 1 polypropylene mesh exposure and only selected those where we implemented the proposed simplified technique. Twenty-six patients underwent mesh revision during the aforementioned period. Eight underwent the described simplified surgical technique for the management of anterior vaginal wall mesh exposure, Group 1, and two patients for posterior wall exposures, Group 2. The demographic information for those two groups are illustrated in this slide. The average period of follow-up for each group was 13.1 weeks and 35 weeks, respectively. In Group 1, the mean preoperative and postoperative POPQ measurements for point AA were minus 2.4 and minus 2.5 centimeters above the hymen. For point BA, the pre- and post-measurements were minus 2.3 and minus 2.5 centimeters. The average total vaginal length measurements remained unchanged at 9.7 centimeters. For the two patients in Group 2, there was no change in points AP and BP postoperatively. Mesh exposure was resolved in all subjects. In conclusion, when synthetic mesh exposure does not respond or is not amendable to conservative management, the entire implanted material need not be removed. A simplified surgical technique of excision with reapproximation of the mesh edges and tension-free epithelial closure can be successful in reestablishing anatomical support and epithelial integrity.

anterior vaginal wall mesh exposure

simplified approach

surgical excision

mesh remnants

tension-free closure