Burch Colposuspension

After the retropubic space is entered, the urethra and anterior vaginal wall are depressed downward. No dissection should be performed in the midline over the urethra or at the urethrovesical junction, thus protecting the delicate musculature of the urethra from surgical trauma. Attention is directed to the tissue on either side of the urethra. The surgeon's nondominant hand is placed in the vagina, palm facing upward, with the index and middle fingers on each side of the proximal urethra. Most of the overlying fat should be cleared away, using a swab mounted on a curved forceps. This dissection is accomplished with forceful elevation of the surgeon's vaginal finger until glistening white periurethral fascia and vaginal wall are seen. This area is extremely vascular, with a rich, thin-walled venous plexus that should be avoided, if possible. The position of the urethra and the lower edge of the bladder is determined by palpating the Foley balloon and by partially distending the bladder to define the rounded lower margin of the bladder as it meets the anterior vaginal wall.

Once dissection lateral to the urethra is completed and vaginal mobility is judged to be adequate by using the vaginal fingers to lift the anterior vaginal wall upward and forward, sutures are placed. Number 0 or 1 delayed absorbable or nonabsorbable sutures are placed as far laterally in the anterior vaginal wall as is technically possible. We apply two sutures of No. 0 braided polyester on a SH needle (Ethibond; Ethicon, Inc., Somerville, NJ) bilaterally, using double bites for each suture. The distal suture is placed approximately 2 cm lateral to the proximal third of the urethra. The proximal suture is placed approximately 2 cm lateral to the bladder wall at, or slightly proximal to, the level of the urethrovesical junction. In placing the sutures, one should take a full thickness of vaginal wall, excluding the epithelium, with the needle parallel to the urethra (Figure 6-5.1). This maneuver is best accomplished by suturing over the surgeon's vaginal finger at the appropriate selected sites. On each side, after the two sutures are placed, they are passed through the pectineal (Cooper's) ligament, so that all four suture ends exit above the ligament (Figure 6-5.1). Before tying the sutures, a 1 x 4cm strip of Gelfoam may be placed between the vagina and obturator fascia below Cooper's ligament to aid adherence and hemostasis.

As noted previously, this area is extremely vascular, and visible vessels should be avoided if at all possible. When excessive bleeding occurs, it can be controlled by direct pressure, sutures, or vascular clips. Less-severe bleeding usually stops once the fixation sutures are tied.

After all four sutures are placed in the vagina and through the Cooper's ligaments, the assistant ties first the distal sutures and then the proximal ones, while the surgeon elevates the vagina with the vaginal hand. In tying the sutures, one should leave a suture bridge between the vaginal wall and Cooper's ligament, so as not to place too much tension on the vaginal wall. After the sutures are tied, one can easily insert two fingers between the pubic bone and the urethra, thus avoiding compression of the urethra against the pubic bone. Vaginal fixation and urethral support depend more on fibrosis and scarring of periurethral and vaginal tissues over the obturator internus and levator fascia than on the suture material itself.

How To Reduce Acne Scarring

How To Reduce Acne Scarring

Acne is a name that is famous in its own right, but for all of the wrong reasons. Most teenagers know, and dread, the very word, as it so prevalently wrecks havoc on their faces throughout their adolescent years.

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