Laparoscopic Burch Colposuspension

The choice of an extraperitoneal or intraperitoneal approach depends on whether concomitant pelvic procedures are being performed, whether the patient has had previous abdominal surgery, or by surgeon's preference. Previous retropubic surgery is a contraindication for extraperitoneal approach, and low transverse or midline incisions make the dissection more difficult and prone to failure. We prefer the intraperitoneal approach because it allows a larger operating space for safe, secure, and comfortable handling of the suture. Furthermore, other intraperitoneal surgery can be performed concomitantly. If a surgeon has performed a vaginal hysterectomy before laparoscopic concomitant colposuspension, hemostasis of the operative site can be evaluated. I will only describe the intraperitoneal route in this chapter for brevity.

The intraperitoneal approach begins with insertion of the 0-degree laparoscope through a 5- or 10-mm intra-or infraumbilical cannula followed by intraabdominal insufflation. We perform the direct puncture trocar technique either in a blind manner or with the use of an optical trocar. If infraumbilical adhesions are suspected, open laparoscopy or left upper quadrant puncture are applied.

Two to three additional trocars are placed under direct vision, as previously noted.

The bladder is filled retrograde with a three-way Foley catheter with 200 to 300 mL of sterile water or normal saline (indigo carmine or methylene blue is optional). Using sharp dissection with prudent use of electrocautery or harmonic scalpel, a transverse incision 2 cm above the bladder reflection between the medial umbilical folds is made. Identification of the loose areolar tissue at the point of incision confirms a proper plane of dissection. Blunt and sharp dissection aiming toward the posterior superior aspect of the pubic symphysis decreases risk of bladder injury. Blunt dissection is then performed inferolaterally on both sides to identify the pubic symphysis, Cooper's ligaments, and bladder neck.

After the space of Retzius is exposed, the surgeon places two fingers in the vagina and identifies the urethrovesical junction by placing gentile traction on the Foley catheter. With elevation of the vaginal fingers, the vaginal wall lateral to the bladder neck is exposed by using a laparoscopic blunt-tipped dissector or a suction irrigator tip. No dissection is performed within 2 cm of the bladder neck to avoid bleeding and damage to the periurethral musculature and nerve supply.

I prefer to use two disposable 10/12-mm trocars through which 5- to 10-mm instruments are introduced. These sites are used specifically for introduction and removal of the needles and suture. We place stitches in the vaginal wall excluding the vaginal epithelium at the level of, or just proximal to, the mid urethra and bladder neck (Figure 66.2). I prefer to introduce the double-armed No. 0 nonabsorbable suture in the left lower quadrant thus taking one bite through the endopelvic fascia and subsequently through the ipsilateral Cooper's ligament. I then remove

Figure 6-6.2. Laparoscopic panoramic view of a completed Burch colposuspension.

this needle through the right lower quadrant port. The second arm of the suture is then introduced in the left port and thrown at an angle to the first throw so that a double throw results. This suture is thrown through Cooper's ligament and is subsequently removed through the right lower quadrant port. The stitch is then tied extracorpore-ally above Cooper's ligament. This technique is one I developed for the sake of time efficiency and avoidance of locking sutures and suture dragging. Some surgeons prefer to backload suture through 5-mm ports and introduce and remove needles through the skin incisions, which is easily accomplished in thinner patients. Trauma to the subcutaneous and inferior epigastric vessels may result with this technique. Other surgeons prefer to use Gor-Tex suture because of ease in sliding through the tissue. Because this is not double-armed, the resultant knot is located in the suture bridge.

We place Gelfoam (Pharmacia and Upjohn, Inc., Kalamazoo, MI) between the vaginal wall and the obturator fascia before knot-tying to promote fibrosis. With simultaneous vaginal elevation, the suture is tied with six extracorporeal square knots. Two granny half hitches (equivalent to a surgical knot) and a flat square knot will secure the stitch. Our technique for laparoscopic Burch is illustrated in Figure 6-6.2. Sutures are tied as they are placed in order to avoid tangling. Mid urethral stitches are placed first, although this is a matter of preference. With port placement close to the anterior superior iliac spine it is easier to place stitches from the contralateral port.

If the lower quadrant ports are placed higher (at or slightly below the level of the umbilicus),placement of ipsi-lateral stitches is facilitated because the angle to the ipsi-lateral vaginal wall and Cooper's ligament is less acute. The appropriate level of bladder neck elevation is estimated with the assistant's vaginal hand. The assistant elevates the vaginal wall in order to place the urethra and bladder neck in a high retropubic position, which does not result in kinking or compression of the urethra. The goal is to elevate the vaginal wall to the level of the arcus tendineus fasciae pelvis bilaterally so that the bladder neck is supported and stabilized by the vaginal wall, which acts as a hammock between both arcus tendineus fasciae. In tying the sutures, the surgeon should not reapproximate the vaginal wall to Cooper's ligament or place too much tension on the vaginal wall. A suture bridge of 1.5 to 2.0 cm is common.

After all sutures are placed and tied, transurethral cys-toscopy or suprapubic teloscopy is done to document ureteral patency and absence of sutures in the bladder. A suprapubic catheter is placed, if desired. The surgeon must reinspect the space of Retzius for bleeding while reducing the carbon dioxide insufflation. Routine closure of the peritoneum is not performed. All ports are removed under direct visualization and the peritoneum and fascia of all 10/12-mm incisions are reapproximated with the Endo-close device (U.S. Surgical Corp.) or the Grice needle (New Ideas in Medicine, Inc., Clearwater, FL).

Constipation Prescription

Constipation Prescription

Did you ever think feeling angry and irritable could be a symptom of constipation? A horrible fullness and pressing sharp pains against the bladders can’t help but affect your mood. Sometimes you just want everyone to leave you alone and sleep to escape the pain. It is virtually impossible to be constipated and keep a sunny disposition. Follow the steps in this guide to alleviate constipation and lead a happier healthy life.

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