Operative Technique

A consistent operating room setup and a nursing staff, dedicated and trained in minimally invasive surgery, are essential in laparoscopic reconstructive pelvic surgery. The monitor screens should be placed lateral to the legs in direct view of the surgeon standing on the opposite side of the table. Ideal stirrups for combined laparovaginal cases are the Allen stirrups (Allen Medical, Garfield, OH).

For standard suturing technique, needle-holder preference is determined by comfort of the surgeon. The Storz Scarfi needle-holder and notched assistant needle-holder (Karl Storz Endoscopy, Culver City, CA) are most like conventional needle-holders; however, the tips tend to become magnetized, which makes needle placement difficult at times. The handles will pop as a result of overuse; therefore, regular maintenance is recommended. Conventional and 90-degree self-righting German needle-holders (Ethicon Endo-Surgery, Inc., Cincinnati, OH) have ratchet spring handles and are very sturdy. Disposable suturing devices have been introduced, which include the Endo-stitch (U.S. Surgical Corp., Norwalk, CT) and the Capio (Microvasive Boston Scientific, Inc., Natick, MA). Extracor-

poreal knot-tying is preferred because of technical facility and the ability to hold more tension on the suture. The choice of an open-ended or close-ended knot pusher for extracorporeal knot-tying depends on surgeon preference. Our suture of choice is the double-armed No. 0 Ethibond 30-in suture on a CT-2 needle (Ethicon, Inc., Somerville, NJ). Our alternate choice for suture is No. 0 Gore-Tex (W.L. Gore and Associates, Inc., Phoenix, AZ). Forty-eight-inch suture is preferred when suturing from ports at the level of the umbilicus. Sterile steel thimbles may be used by the surgeon or assistant when elevating the vagina while the surgeon is placing the stitches in the vaginal wall.

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