Surgical Techniques

CASE: Should appendectomy be included in total
laparoscopic hysterectomy?

A 39-year-old mother of two continues to experience severe dysmenorrhea and persistent menorrhagia despite undergoing endometrial ablation 2 years earlier. Her obstetric and gynecologic history is remarkable for a diagnosis of chronic pelvic pain, endometriosis, and failed endometrial ablation. Both her children were delivered by cesarean, and she has undergone tubal ligation. She requests hysterectomy to address the dysmenorrhea and menorrhagia once and for all.

A pelvic exam reveals an anteverted, 10-weeks’ size uterus with no adnexal masses or tenderness. After extensive discussion of the surgical procedure, the patient signs a consent for total laparoscopic hysterectomy.

Would you recommend appendectomy, too?

Prophylactic removal of the appendix during a benign gynecologic procedure is known as “elective incidental appendectomy.”¹ Incidental appendectomy at the time of cesarean delivery was reported initially in 1959.² Subsequent studies of removal of a normal-appearing appendix at the time of gynecologic surgery have met with considerable debate. Proponents argue that removal of the appendix at the time of abdominal hysterectomy does not increase operative time or postoperative morbidity. More important, it does prevent future appendicitis.^3-5

Some surgeons disagree, citing an increase in operative time, hospital costs, and patient morbidity as reasonable concerns. They also note that appendectomy requires an additional surgical procedure, which could increase the risk of infection and other complications and lead to adhesion formation.

Advantages of incidental appendectomy include technical ease, low patient morbidity and mortality, and significant diagnostic and protective value.⁶ It also prevents conflicting diagnoses, especially in patients who have chronic pelvic pain, a ruptured ovarian cyst, or endometriosis. Other patients likely to benefit from elective incidental appendectomy are those who are undergoing abdominal radiation or chemotherapy, women unable to communicate health complaints, and those who are planning to undergo complex abdominal or pelvic procedures that are likely to cause extensive adhesions.¹

In this article, we describe the rationale behind this procedure, as well as the technical steps involved.

The laparoscopic approach is preferred

Appendectomy is commonly performed laparoscopically. Semm first described this approach in 1983.⁷ Several studies since have reported that incidental laparoscopic appendectomy is safe, easy to perform, and should be offered to patients undergoing a concomitant gynecologic procedure.^8-10 Laparoscopic removal of a normal appendix does not add morbidity or prolong hospitalization, compared with diagnostic laparoscopy. A large study drawing from the Nationwide Inpatient Sample (NIS) database found laparoscopic removal of the appendix to be associated with lower mortality, fewer complications, shorter hospitalization, and lower mean hospital charges, compared with open appendectomy.¹¹ The same study found laparoscopic appendectomy to be the procedure of choice in both perforated and nonperforated appendicitis.

Overweight and obese patients also may benefit from the laparoscopic approach because it avoids problems associated with an open incision, such as the need for abdominal wall retraction, a longer hospital stay, and a risk of wound infection, compared with smaller incisions—especially in this high-risk population.¹²

Cost is another issue. Any prolonged surgical time and higher medical costs required for incidental appendectomy decrease as surgical proficiency and experience rise. The concomitant performance of endoscopic procedures can also reduce the risk associated with anesthesia for reoperations.

Endometriosis patients stand to benefit from appendectomy

There is compelling evidence that elective appendectomy is beneficial in patients who have endometriosis. Endometriosis of the bowel has been reported in 5.3% of all histologically proven endometriosis cases, with appendiceal endometriosis found in approximately 1% of women with endometriosis.¹³ Despite the low prevalence (2.8%) of appendiceal endometriosis,¹⁴ some studies reported a high incidence of appendiceal endometriosis when incidental appendectomy was performed. Patients who report right lower quadrant (RLQ) pain, chronic pelvic pain, and ovarian endometrioma had the highest incidence of abnormal histopathologic findings.^15-17 Because most women with endometriosis present with these symptoms, it is prudent to counsel patients preoperatively about the incidence of appendiceal endometriosis and to visually examine the appendix during gynecologic surgery to identify incidental appendiceal pathology.

Age may influence the appendectomy decision

The incidence of acute appendicitis is highest among people aged 10 to 19 years. The estimated lifetime risk of appendicitis is 6.7%.¹⁸ The surgical dilemma is whether to perform incidental appendectomy in the nonadolescent population, which is at lower risk for appendicitis, as a preventive measure.

We lack randomized trials on the benefit of incidental appendectomy. A retrospective study of open procedures supported incidental appendectomy in patients younger than 35 years; for patients 35 to 50, the decision was left to the clinical judgment of the surgeon, based on the patient’s clinical condition.⁴ The same study failed to support incidental appendectomy in women older than 50 years.

 

When the appendix is not easily accessible, or the surgical complexity of the gynecologic procedure prevents the surgeon from safely performing an appendectomy, it is better to complete the planned gynecologic surgery and forgo the appendectomy. It is acceptable to make the decision to refrain from the appendectomy intraoperatively if the risk of complications outweighs the likely benefits. The practice of cautionary discretion demonstrates sound judgment and avoids compromising the safety of the patient.

How to perform appendectomy

1. Maintain at least three laparoscopic sites

• After the laparoscopic gynecologic procedure, maintain three trocar sites—preferably, two 5-mm trocars and one 12-mm trocar.
• The first 5-mm trocar, at the umbilical incision, accommodates the laparoscopic camera. The second 5-mm trocar serves as an accessory port for laparoscopic instruments and is inserted into the RLQ.
• The 12-mm trocar in the left lower quadrant (LLQ) is also used to insert endoscopic instruments. This trocar site will be used at the conclusion of the appendectomy to accommodate the mechanical stapling device and the specimen bag for removal of the excised organ.

FIGURE 1: Visualize the appendix. Identify the cecum and ileocolic junction to locate the appendix.

2. Identify the appendix

• Perform a careful visual exploration of the abdominal contents to exclude other intra-abdominal pathology.
• Identify the cecum and ileocolic junction to locate the appendix (FIGURE 1).
• Visually inspect the appendix and identify any gross appendiceal pathology.

FIGURE 2: Divide the mesoappendix
Isolate, cauterize, and divide the mesoappendix using 5-mm ultrasonic shears.

3. Dissect the appendix (VIDEO 1)

• Insert an atraumatic forceps through the 5-mm right accessory trocar.
• Grasp the fatty tissue at the tip of the appendix and provide some traction.
• Elevate the appendix to facilitate visualization of the mesoappendix.
• Isolate the mesoappendix and cauterize and divide it using 5-mm ultrasonic shears inserted through the RLQ trocar (FIGURE 2).
• Release some of the upward tension from the specimen retraction by dropping the height of the instrument to prevent undue trauma and bleeding.
• Make a window between the mesentery and the base of the appendix to facilitate dissection.
• Skeletonize the mesoappendix at the junction of the appendiceal base and the cecum.
• During skeletonization, pay special attention to the appendiceal artery at the base of the mesoappendix.

FIGURE 3: Apply the stapling device
Apply the stapling device across the base of the appendix.

4. Resect the appendix (VIDEO 2)

• Insert an automatic stapling device through the 12-mm port and apply it across the base of the appendix (FIGURE 3).
• Apply the mechanical stapling device for 15 seconds to crush the base of the appendix and empty its contents.
• Visualize both sides of the stapler to ensure that it is placed at the base of the appendix.
• Always check the tip of the device to ensure that the jaws of the stapling device fully compress the appendix and have not inadvertently grasped other abdominal contents.
• With the stapling device compressing the base of the appendix, release some of the upward tension on the specimen by dropping the height of the retraction.
• Activate the stapling device and completely excise the appendix from its base
  (FIGURE 4).
• Thoroughly inspect the appendiceal stump to ensure hemostasis (FIGURE 5).

FIGURE 4: Excise the appendix
Activate the stapling device and completely excise the appendix from its base.

FIGURE 5: Ensure hemostasis
Thoroughly inspect the appendiceal stump and ensure hemostasis.

5. Remove the specimen (VIDEO 3)

• Remove the stapling device and replace it with a specimen retrieval bag, inserting it through the 12-mm port.
• Place the amputated appendix in the specimen retrieval bag to prevent abdominal contamination (FIGURE 6).
• Close the specimen retrieval bag inside the abdomen.
• Refrain from removing the specimen bag through the trocar or forcefully passing the appendix through a small incision. We usually withdraw the 12-mm trocar, then remove the cinched bag containing the resected appendix under direct visualization. We take all precautionary measures to prevent breakage of the bag, which would leak appendiceal contents into the abdomen.

FIGURE 6: Remove the specimen
Place the amputated appendix in the specimen retrieval bag and remove it, intact, through the patient’s abdomen.

6. Perform a few last measures

• If the surgeon chooses, suction and irrigation can be performed at the completion of the appendectomy procedure.
• Send all surgical specimens to pathology for evaluation.
• Complete the operation in the usual laparoscopic fashion. Remove all instruments, and close the 12-mm trocar port site using the Carter Thomason fascial closure device. Close the remaining port sites using 2-0 interrupted suture (Monocryl). Apply skin adhesive to all laparoscopic incisions.
• For more on surgical technique of appendectomy, see Baggish,¹⁹ Jaffe and Berger,²⁰ and Daniell and colleagues.²¹

 

Adequate training is essential

Surgical proficiency in laparoscopic appendectomy, like any surgical skill set, requires adequate training to ensure procedural familiarity and expertise and to encourage consistency. This training, preferably undertaken during residency, should be an essential part of obstetrics and gynecology education.

 

It is important to know which patient populations are at high risk for appendiceal pathology so that they can be assessed and counseled adequately prior to surgery. Among the components of patient counseling is a thorough and impartial discussion of procedural risks and benefits. Risk-benefit considerations should include the patient’s preferences so that she can be an active participant in her own health-care decisions.

Because the risks of appendectomy are minimal, and complications are rare, it is appropriate to offer elective laparoscopic appendectomy to patients scheduled to undergo benign gynecologic procedures, especially in the setting of chronic pelvic pain and endometriosis.

CASE: Resolved

The patient is counseled about the benefits and risks of laparoscopic incidental appendectomy, including the fact that it may be especially beneficial in women who have endometriosis. She consents to undergo the procedure at the time of her total laparoscopic hysterectomy.

Both procedures are performed safely, with no complications, and the patient’s immediate postoperative course is unremarkable. After one night of hospitalization, she is discharged home. The histopathologic report on the appendiceal specimen reveals endometriosis with fibrous obliteration of the lumen.

We want to hear from you! Tell us what you think.

CASE: Should appendectomy be included in total
laparoscopic hysterectomy?

A 39-year-old mother of two continues to experience severe dysmenorrhea and persistent menorrhagia despite undergoing endometrial ablation 2 years earlier. Her obstetric and gynecologic history is remarkable for a diagnosis of chronic pelvic pain, endometriosis, and failed endometrial ablation. Both her children were delivered by cesarean, and she has undergone tubal ligation. She requests hysterectomy to address the dysmenorrhea and menorrhagia once and for all.

A pelvic exam reveals an anteverted, 10-weeks’ size uterus with no adnexal masses or tenderness. After extensive discussion of the surgical procedure, the patient signs a consent for total laparoscopic hysterectomy.

Would you recommend appendectomy, too?

Prophylactic removal of the appendix during a benign gynecologic procedure is known as “elective incidental appendectomy.”¹ Incidental appendectomy at the time of cesarean delivery was reported initially in 1959.² Subsequent studies of removal of a normal-appearing appendix at the time of gynecologic surgery have met with considerable debate. Proponents argue that removal of the appendix at the time of abdominal hysterectomy does not increase operative time or postoperative morbidity. More important, it does prevent future appendicitis.^3-5

Some surgeons disagree, citing an increase in operative time, hospital costs, and patient morbidity as reasonable concerns. They also note that appendectomy requires an additional surgical procedure, which could increase the risk of infection and other complications and lead to adhesion formation.

Advantages of incidental appendectomy include technical ease, low patient morbidity and mortality, and significant diagnostic and protective value.⁶ It also prevents conflicting diagnoses, especially in patients who have chronic pelvic pain, a ruptured ovarian cyst, or endometriosis. Other patients likely to benefit from elective incidental appendectomy are those who are undergoing abdominal radiation or chemotherapy, women unable to communicate health complaints, and those who are planning to undergo complex abdominal or pelvic procedures that are likely to cause extensive adhesions.¹

In this article, we describe the rationale behind this procedure, as well as the technical steps involved.

The laparoscopic approach is preferred

Appendectomy is commonly performed laparoscopically. Semm first described this approach in 1983.⁷ Several studies since have reported that incidental laparoscopic appendectomy is safe, easy to perform, and should be offered to patients undergoing a concomitant gynecologic procedure.^8-10 Laparoscopic removal of a normal appendix does not add morbidity or prolong hospitalization, compared with diagnostic laparoscopy. A large study drawing from the Nationwide Inpatient Sample (NIS) database found laparoscopic removal of the appendix to be associated with lower mortality, fewer complications, shorter hospitalization, and lower mean hospital charges, compared with open appendectomy.¹¹ The same study found laparoscopic appendectomy to be the procedure of choice in both perforated and nonperforated appendicitis.

Overweight and obese patients also may benefit from the laparoscopic approach because it avoids problems associated with an open incision, such as the need for abdominal wall retraction, a longer hospital stay, and a risk of wound infection, compared with smaller incisions—especially in this high-risk population.¹²

Cost is another issue. Any prolonged surgical time and higher medical costs required for incidental appendectomy decrease as surgical proficiency and experience rise. The concomitant performance of endoscopic procedures can also reduce the risk associated with anesthesia for reoperations.

Endometriosis patients stand to benefit from appendectomy

There is compelling evidence that elective appendectomy is beneficial in patients who have endometriosis. Endometriosis of the bowel has been reported in 5.3% of all histologically proven endometriosis cases, with appendiceal endometriosis found in approximately 1% of women with endometriosis.¹³ Despite the low prevalence (2.8%) of appendiceal endometriosis,¹⁴ some studies reported a high incidence of appendiceal endometriosis when incidental appendectomy was performed. Patients who report right lower quadrant (RLQ) pain, chronic pelvic pain, and ovarian endometrioma had the highest incidence of abnormal histopathologic findings.^15-17 Because most women with endometriosis present with these symptoms, it is prudent to counsel patients preoperatively about the incidence of appendiceal endometriosis and to visually examine the appendix during gynecologic surgery to identify incidental appendiceal pathology.

Age may influence the appendectomy decision

The incidence of acute appendicitis is highest among people aged 10 to 19 years. The estimated lifetime risk of appendicitis is 6.7%.¹⁸ The surgical dilemma is whether to perform incidental appendectomy in the nonadolescent population, which is at lower risk for appendicitis, as a preventive measure.

We lack randomized trials on the benefit of incidental appendectomy. A retrospective study of open procedures supported incidental appendectomy in patients younger than 35 years; for patients 35 to 50, the decision was left to the clinical judgment of the surgeon, based on the patient’s clinical condition.⁴ The same study failed to support incidental appendectomy in women older than 50 years.

 

When the appendix is not easily accessible, or the surgical complexity of the gynecologic procedure prevents the surgeon from safely performing an appendectomy, it is better to complete the planned gynecologic surgery and forgo the appendectomy. It is acceptable to make the decision to refrain from the appendectomy intraoperatively if the risk of complications outweighs the likely benefits. The practice of cautionary discretion demonstrates sound judgment and avoids compromising the safety of the patient.

How to perform appendectomy

1. Maintain at least three laparoscopic sites

• After the laparoscopic gynecologic procedure, maintain three trocar sites—preferably, two 5-mm trocars and one 12-mm trocar.
• The first 5-mm trocar, at the umbilical incision, accommodates the laparoscopic camera. The second 5-mm trocar serves as an accessory port for laparoscopic instruments and is inserted into the RLQ.
• The 12-mm trocar in the left lower quadrant (LLQ) is also used to insert endoscopic instruments. This trocar site will be used at the conclusion of the appendectomy to accommodate the mechanical stapling device and the specimen bag for removal of the excised organ.

FIGURE 1: Visualize the appendix. Identify the cecum and ileocolic junction to locate the appendix.

2. Identify the appendix

• Perform a careful visual exploration of the abdominal contents to exclude other intra-abdominal pathology.
• Identify the cecum and ileocolic junction to locate the appendix (FIGURE 1).
• Visually inspect the appendix and identify any gross appendiceal pathology.

FIGURE 2: Divide the mesoappendix
Isolate, cauterize, and divide the mesoappendix using 5-mm ultrasonic shears.

3. Dissect the appendix (VIDEO 1)

• Insert an atraumatic forceps through the 5-mm right accessory trocar.
• Grasp the fatty tissue at the tip of the appendix and provide some traction.
• Elevate the appendix to facilitate visualization of the mesoappendix.
• Isolate the mesoappendix and cauterize and divide it using 5-mm ultrasonic shears inserted through the RLQ trocar (FIGURE 2).
• Release some of the upward tension from the specimen retraction by dropping the height of the instrument to prevent undue trauma and bleeding.
• Make a window between the mesentery and the base of the appendix to facilitate dissection.
• Skeletonize the mesoappendix at the junction of the appendiceal base and the cecum.
• During skeletonization, pay special attention to the appendiceal artery at the base of the mesoappendix.

FIGURE 3: Apply the stapling device
Apply the stapling device across the base of the appendix.

4. Resect the appendix (VIDEO 2)

• Insert an automatic stapling device through the 12-mm port and apply it across the base of the appendix (FIGURE 3).
• Apply the mechanical stapling device for 15 seconds to crush the base of the appendix and empty its contents.
• Visualize both sides of the stapler to ensure that it is placed at the base of the appendix.
• Always check the tip of the device to ensure that the jaws of the stapling device fully compress the appendix and have not inadvertently grasped other abdominal contents.
• With the stapling device compressing the base of the appendix, release some of the upward tension on the specimen by dropping the height of the retraction.
• Activate the stapling device and completely excise the appendix from its base
  (FIGURE 4).
• Thoroughly inspect the appendiceal stump to ensure hemostasis (FIGURE 5).

FIGURE 4: Excise the appendix
Activate the stapling device and completely excise the appendix from its base.

FIGURE 5: Ensure hemostasis
Thoroughly inspect the appendiceal stump and ensure hemostasis.

5. Remove the specimen (VIDEO 3)

• Remove the stapling device and replace it with a specimen retrieval bag, inserting it through the 12-mm port.
• Place the amputated appendix in the specimen retrieval bag to prevent abdominal contamination (FIGURE 6).
• Close the specimen retrieval bag inside the abdomen.
• Refrain from removing the specimen bag through the trocar or forcefully passing the appendix through a small incision. We usually withdraw the 12-mm trocar, then remove the cinched bag containing the resected appendix under direct visualization. We take all precautionary measures to prevent breakage of the bag, which would leak appendiceal contents into the abdomen.

FIGURE 6: Remove the specimen
Place the amputated appendix in the specimen retrieval bag and remove it, intact, through the patient’s abdomen.

6. Perform a few last measures

• If the surgeon chooses, suction and irrigation can be performed at the completion of the appendectomy procedure.
• Send all surgical specimens to pathology for evaluation.
• Complete the operation in the usual laparoscopic fashion. Remove all instruments, and close the 12-mm trocar port site using the Carter Thomason fascial closure device. Close the remaining port sites using 2-0 interrupted suture (Monocryl). Apply skin adhesive to all laparoscopic incisions.
• For more on surgical technique of appendectomy, see Baggish,¹⁹ Jaffe and Berger,²⁰ and Daniell and colleagues.²¹

 

Adequate training is essential

Surgical proficiency in laparoscopic appendectomy, like any surgical skill set, requires adequate training to ensure procedural familiarity and expertise and to encourage consistency. This training, preferably undertaken during residency, should be an essential part of obstetrics and gynecology education.

 

It is important to know which patient populations are at high risk for appendiceal pathology so that they can be assessed and counseled adequately prior to surgery. Among the components of patient counseling is a thorough and impartial discussion of procedural risks and benefits. Risk-benefit considerations should include the patient’s preferences so that she can be an active participant in her own health-care decisions.

Because the risks of appendectomy are minimal, and complications are rare, it is appropriate to offer elective laparoscopic appendectomy to patients scheduled to undergo benign gynecologic procedures, especially in the setting of chronic pelvic pain and endometriosis.

CASE: Resolved

The patient is counseled about the benefits and risks of laparoscopic incidental appendectomy, including the fact that it may be especially beneficial in women who have endometriosis. She consents to undergo the procedure at the time of her total laparoscopic hysterectomy.

Both procedures are performed safely, with no complications, and the patient’s immediate postoperative course is unremarkable. After one night of hospitalization, she is discharged home. The histopathologic report on the appendiceal specimen reveals endometriosis with fibrous obliteration of the lumen.

We want to hear from you! Tell us what you think.

CASE: Should appendectomy be included in total
laparoscopic hysterectomy?

A 39-year-old mother of two continues to experience severe dysmenorrhea and persistent menorrhagia despite undergoing endometrial ablation 2 years earlier. Her obstetric and gynecologic history is remarkable for a diagnosis of chronic pelvic pain, endometriosis, and failed endometrial ablation. Both her children were delivered by cesarean, and she has undergone tubal ligation. She requests hysterectomy to address the dysmenorrhea and menorrhagia once and for all.

A pelvic exam reveals an anteverted, 10-weeks’ size uterus with no adnexal masses or tenderness. After extensive discussion of the surgical procedure, the patient signs a consent for total laparoscopic hysterectomy.

Would you recommend appendectomy, too?

Prophylactic removal of the appendix during a benign gynecologic procedure is known as “elective incidental appendectomy.”¹ Incidental appendectomy at the time of cesarean delivery was reported initially in 1959.² Subsequent studies of removal of a normal-appearing appendix at the time of gynecologic surgery have met with considerable debate. Proponents argue that removal of the appendix at the time of abdominal hysterectomy does not increase operative time or postoperative morbidity. More important, it does prevent future appendicitis.^3-5

Some surgeons disagree, citing an increase in operative time, hospital costs, and patient morbidity as reasonable concerns. They also note that appendectomy requires an additional surgical procedure, which could increase the risk of infection and other complications and lead to adhesion formation.

Advantages of incidental appendectomy include technical ease, low patient morbidity and mortality, and significant diagnostic and protective value.⁶ It also prevents conflicting diagnoses, especially in patients who have chronic pelvic pain, a ruptured ovarian cyst, or endometriosis. Other patients likely to benefit from elective incidental appendectomy are those who are undergoing abdominal radiation or chemotherapy, women unable to communicate health complaints, and those who are planning to undergo complex abdominal or pelvic procedures that are likely to cause extensive adhesions.¹

In this article, we describe the rationale behind this procedure, as well as the technical steps involved.

The laparoscopic approach is preferred

Appendectomy is commonly performed laparoscopically. Semm first described this approach in 1983.⁷ Several studies since have reported that incidental laparoscopic appendectomy is safe, easy to perform, and should be offered to patients undergoing a concomitant gynecologic procedure.^8-10 Laparoscopic removal of a normal appendix does not add morbidity or prolong hospitalization, compared with diagnostic laparoscopy. A large study drawing from the Nationwide Inpatient Sample (NIS) database found laparoscopic removal of the appendix to be associated with lower mortality, fewer complications, shorter hospitalization, and lower mean hospital charges, compared with open appendectomy.¹¹ The same study found laparoscopic appendectomy to be the procedure of choice in both perforated and nonperforated appendicitis.

Overweight and obese patients also may benefit from the laparoscopic approach because it avoids problems associated with an open incision, such as the need for abdominal wall retraction, a longer hospital stay, and a risk of wound infection, compared with smaller incisions—especially in this high-risk population.¹²

Cost is another issue. Any prolonged surgical time and higher medical costs required for incidental appendectomy decrease as surgical proficiency and experience rise. The concomitant performance of endoscopic procedures can also reduce the risk associated with anesthesia for reoperations.

Endometriosis patients stand to benefit from appendectomy

There is compelling evidence that elective appendectomy is beneficial in patients who have endometriosis. Endometriosis of the bowel has been reported in 5.3% of all histologically proven endometriosis cases, with appendiceal endometriosis found in approximately 1% of women with endometriosis.¹³ Despite the low prevalence (2.8%) of appendiceal endometriosis,¹⁴ some studies reported a high incidence of appendiceal endometriosis when incidental appendectomy was performed. Patients who report right lower quadrant (RLQ) pain, chronic pelvic pain, and ovarian endometrioma had the highest incidence of abnormal histopathologic findings.^15-17 Because most women with endometriosis present with these symptoms, it is prudent to counsel patients preoperatively about the incidence of appendiceal endometriosis and to visually examine the appendix during gynecologic surgery to identify incidental appendiceal pathology.

Age may influence the appendectomy decision

The incidence of acute appendicitis is highest among people aged 10 to 19 years. The estimated lifetime risk of appendicitis is 6.7%.¹⁸ The surgical dilemma is whether to perform incidental appendectomy in the nonadolescent population, which is at lower risk for appendicitis, as a preventive measure.

We lack randomized trials on the benefit of incidental appendectomy. A retrospective study of open procedures supported incidental appendectomy in patients younger than 35 years; for patients 35 to 50, the decision was left to the clinical judgment of the surgeon, based on the patient’s clinical condition.⁴ The same study failed to support incidental appendectomy in women older than 50 years.

 

When the appendix is not easily accessible, or the surgical complexity of the gynecologic procedure prevents the surgeon from safely performing an appendectomy, it is better to complete the planned gynecologic surgery and forgo the appendectomy. It is acceptable to make the decision to refrain from the appendectomy intraoperatively if the risk of complications outweighs the likely benefits. The practice of cautionary discretion demonstrates sound judgment and avoids compromising the safety of the patient.

How to perform appendectomy

1. Maintain at least three laparoscopic sites

• After the laparoscopic gynecologic procedure, maintain three trocar sites—preferably, two 5-mm trocars and one 12-mm trocar.
• The first 5-mm trocar, at the umbilical incision, accommodates the laparoscopic camera. The second 5-mm trocar serves as an accessory port for laparoscopic instruments and is inserted into the RLQ.
• The 12-mm trocar in the left lower quadrant (LLQ) is also used to insert endoscopic instruments. This trocar site will be used at the conclusion of the appendectomy to accommodate the mechanical stapling device and the specimen bag for removal of the excised organ.

FIGURE 1: Visualize the appendix. Identify the cecum and ileocolic junction to locate the appendix.

2. Identify the appendix

• Perform a careful visual exploration of the abdominal contents to exclude other intra-abdominal pathology.
• Identify the cecum and ileocolic junction to locate the appendix (FIGURE 1).
• Visually inspect the appendix and identify any gross appendiceal pathology.

FIGURE 2: Divide the mesoappendix
Isolate, cauterize, and divide the mesoappendix using 5-mm ultrasonic shears.

3. Dissect the appendix (VIDEO 1)

• Insert an atraumatic forceps through the 5-mm right accessory trocar.
• Grasp the fatty tissue at the tip of the appendix and provide some traction.
• Elevate the appendix to facilitate visualization of the mesoappendix.
• Isolate the mesoappendix and cauterize and divide it using 5-mm ultrasonic shears inserted through the RLQ trocar (FIGURE 2).
• Release some of the upward tension from the specimen retraction by dropping the height of the instrument to prevent undue trauma and bleeding.
• Make a window between the mesentery and the base of the appendix to facilitate dissection.
• Skeletonize the mesoappendix at the junction of the appendiceal base and the cecum.
• During skeletonization, pay special attention to the appendiceal artery at the base of the mesoappendix.

FIGURE 3: Apply the stapling device
Apply the stapling device across the base of the appendix.

4. Resect the appendix (VIDEO 2)

• Insert an automatic stapling device through the 12-mm port and apply it across the base of the appendix (FIGURE 3).
• Apply the mechanical stapling device for 15 seconds to crush the base of the appendix and empty its contents.
• Visualize both sides of the stapler to ensure that it is placed at the base of the appendix.
• Always check the tip of the device to ensure that the jaws of the stapling device fully compress the appendix and have not inadvertently grasped other abdominal contents.
• With the stapling device compressing the base of the appendix, release some of the upward tension on the specimen by dropping the height of the retraction.
• Activate the stapling device and completely excise the appendix from its base
  (FIGURE 4).
• Thoroughly inspect the appendiceal stump to ensure hemostasis (FIGURE 5).

FIGURE 4: Excise the appendix
Activate the stapling device and completely excise the appendix from its base.

FIGURE 5: Ensure hemostasis
Thoroughly inspect the appendiceal stump and ensure hemostasis.

5. Remove the specimen (VIDEO 3)

• Remove the stapling device and replace it with a specimen retrieval bag, inserting it through the 12-mm port.
• Place the amputated appendix in the specimen retrieval bag to prevent abdominal contamination (FIGURE 6).
• Close the specimen retrieval bag inside the abdomen.
• Refrain from removing the specimen bag through the trocar or forcefully passing the appendix through a small incision. We usually withdraw the 12-mm trocar, then remove the cinched bag containing the resected appendix under direct visualization. We take all precautionary measures to prevent breakage of the bag, which would leak appendiceal contents into the abdomen.

FIGURE 6: Remove the specimen
Place the amputated appendix in the specimen retrieval bag and remove it, intact, through the patient’s abdomen.

6. Perform a few last measures

• If the surgeon chooses, suction and irrigation can be performed at the completion of the appendectomy procedure.
• Send all surgical specimens to pathology for evaluation.
• Complete the operation in the usual laparoscopic fashion. Remove all instruments, and close the 12-mm trocar port site using the Carter Thomason fascial closure device. Close the remaining port sites using 2-0 interrupted suture (Monocryl). Apply skin adhesive to all laparoscopic incisions.
• For more on surgical technique of appendectomy, see Baggish,¹⁹ Jaffe and Berger,²⁰ and Daniell and colleagues.²¹

 

Adequate training is essential

Surgical proficiency in laparoscopic appendectomy, like any surgical skill set, requires adequate training to ensure procedural familiarity and expertise and to encourage consistency. This training, preferably undertaken during residency, should be an essential part of obstetrics and gynecology education.

 

It is important to know which patient populations are at high risk for appendiceal pathology so that they can be assessed and counseled adequately prior to surgery. Among the components of patient counseling is a thorough and impartial discussion of procedural risks and benefits. Risk-benefit considerations should include the patient’s preferences so that she can be an active participant in her own health-care decisions.

Because the risks of appendectomy are minimal, and complications are rare, it is appropriate to offer elective laparoscopic appendectomy to patients scheduled to undergo benign gynecologic procedures, especially in the setting of chronic pelvic pain and endometriosis.

CASE: Resolved

The patient is counseled about the benefits and risks of laparoscopic incidental appendectomy, including the fact that it may be especially beneficial in women who have endometriosis. She consents to undergo the procedure at the time of her total laparoscopic hysterectomy.

Both procedures are performed safely, with no complications, and the patient’s immediate postoperative course is unremarkable. After one night of hospitalization, she is discharged home. The histopathologic report on the appendiceal specimen reveals endometriosis with fibrous obliteration of the lumen.

We want to hear from you! Tell us what you think.

More than 300 physicians attended the 15th annual Pelvic Anatomy and Gynecologic Surgery (PAGS) symposium December 13–15, 2012, in Las Vegas. One likely reason was an abundance of offerings, including:

• a laparoscopist’s view of pelvic and abdominal anatomy
• case-based discussion of the evaluation of female pelvic floor disorders
• a surgical video fest with expert discussion and audience participation
• an in-depth look at fibroid management
• a focus on hysterectomy, from the vaginal approach to single-port laparoscopy and robotics
• a panel discussion of pelvic pain and its management
• tips on avoiding and managing laparoscopic and other complications
• a breakout session on endometriosis surgery
• the latest on evaluation and management of fetal incontinence.

Here are a few additional highlights of the 2012 program:

Surgery for stress incontinence: Which sling is for which patient?

When it comes to slings, one size does not fit all. That point was emphasized by Mark Walters, MD, in a comprehensive session that described the surgical techniques behind various bladder-neck and midurethral sling procedures, as well as the associated cure rates, complications, and pros and cons. To watch a 7-minute video in which Dr. Walters elaborates on patient-selection criteria, CLICK HERE .

Surgical approach to prolapse—what I do and why I do it

John Gebhart, MD, MS, outlined his approach to the surgical correction of pelvic organ prolapse, but underscored his belief that the surgeon has to base her approach not only on the data, but on her own experience and resources.

“That’s something you have to come to grips with in your own practice—what’s best in your hands?” he said.

While showing videos of actual surgeries, he described specific techniques, pearls, and pitfalls, and emphasized the importance of cystoscopy to rule out bladder injury.

Keynote address: The economics of surgical gynecology

Dr. Barbara S. Levy, Vice President of Health Policy at the American Congress of Obstetricians and Gynecologists (ACOG), delivered an impassionate appeal to attendees of PAGS: Gynecologists need to take the lead in advocating for best practices in their specialty—before forces outside the specialty impose definitions and standards upon them.

She also described the current payment environment, explained why the current trend in health-care spending is unsustainable, and stressed the need to find areas in surgical gynecologic practice that may benefit from improvements in health-care delivery. CLICK HERE for Dr. Levy’s overview of the issues on video.

PAGS participants weigh in

After Dr. Levy’s keynote address on the economics of surgical gynecology, OBG Management gathered the opinions of four participants: Gary Bostrom, MD, of California; Richard Robinson, MD, of Georgia; Timothy Hall, MD, of North Carolina; and Todd Slater, MD, of Ohio. To hear their points of view, CLICK HERE .

Myomectomy: Open to robotic approaches

“Myomectomy is not a dying art by any stretch,” said PAGS Co-Chair Tommaso Falcone, MD, in opening this session. “In fact, it’s expected to increase,” he added, as more women seek to preserve their uterus.

He then proceeded to describe management approaches (including watchful waiting), indications for myomectomy, and surgical options, including data on both perioperative and reproductive outcomes.
CLICK HERE for a video summary of Dr. Falcone’s talk.

Laparoscopic supracervical hysterectomy

As more women seek to preserve their cervix at the time of hysterectomy, the supracervical approach is becoming increasingly common. Amy Garcia, MD, described the indications, technique, benefits, and risks associated with this procedure. CLICK HERE to hear Dr. Garcia highlight the key points of her talk.

Join me in Las Vegas for FUUS 2013!

Mickey Karram, MD, invites you to attend the 12th annual Female Urology and Urogynecology Symposium (FUUS) at the ARIA in Las Vegas, April 18–20, 2013.

“This is a unique meeting,” says Dr. Karram, “as it addresses both urologic and gynecologic issues related to female pelvic medicine and reconstructive surgery.” It’s also timely—with the first board exam for the subspecialty of female pelvic medicine and reconstructive surgery being held in June 2013. Prepare yourself to meet the demand for physicians who have the expertise to evaluate pelvic floor disorders.

“The meeting is attended by 50% gynecologists and 50% urologists, has many breakout sessions, and covers a variety of topics—everything from vaginal surgery for prolapse, voiding dysfunction, and types of reconstructive procedures with laparoscopic and robotic approaches,” says Dr. Karram, who is excited for this year’s special symposium by Karl J. Kreder, Jr, MD, on April 20 that addresses pelvic pain syndromes. For a complete agenda and registration details, visit www.fuus-cme.org.

More than 300 physicians attended the 15th annual Pelvic Anatomy and Gynecologic Surgery (PAGS) symposium December 13–15, 2012, in Las Vegas. One likely reason was an abundance of offerings, including:

• a laparoscopist’s view of pelvic and abdominal anatomy
• case-based discussion of the evaluation of female pelvic floor disorders
• a surgical video fest with expert discussion and audience participation
• an in-depth look at fibroid management
• a focus on hysterectomy, from the vaginal approach to single-port laparoscopy and robotics
• a panel discussion of pelvic pain and its management
• tips on avoiding and managing laparoscopic and other complications
• a breakout session on endometriosis surgery
• the latest on evaluation and management of fetal incontinence.

Here are a few additional highlights of the 2012 program:

Surgery for stress incontinence: Which sling is for which patient?

When it comes to slings, one size does not fit all. That point was emphasized by Mark Walters, MD, in a comprehensive session that described the surgical techniques behind various bladder-neck and midurethral sling procedures, as well as the associated cure rates, complications, and pros and cons. To watch a 7-minute video in which Dr. Walters elaborates on patient-selection criteria, CLICK HERE .

Surgical approach to prolapse—what I do and why I do it

John Gebhart, MD, MS, outlined his approach to the surgical correction of pelvic organ prolapse, but underscored his belief that the surgeon has to base her approach not only on the data, but on her own experience and resources.

“That’s something you have to come to grips with in your own practice—what’s best in your hands?” he said.

While showing videos of actual surgeries, he described specific techniques, pearls, and pitfalls, and emphasized the importance of cystoscopy to rule out bladder injury.

Keynote address: The economics of surgical gynecology

Dr. Barbara S. Levy, Vice President of Health Policy at the American Congress of Obstetricians and Gynecologists (ACOG), delivered an impassionate appeal to attendees of PAGS: Gynecologists need to take the lead in advocating for best practices in their specialty—before forces outside the specialty impose definitions and standards upon them.

She also described the current payment environment, explained why the current trend in health-care spending is unsustainable, and stressed the need to find areas in surgical gynecologic practice that may benefit from improvements in health-care delivery. CLICK HERE for Dr. Levy’s overview of the issues on video.

PAGS participants weigh in

After Dr. Levy’s keynote address on the economics of surgical gynecology, OBG Management gathered the opinions of four participants: Gary Bostrom, MD, of California; Richard Robinson, MD, of Georgia; Timothy Hall, MD, of North Carolina; and Todd Slater, MD, of Ohio. To hear their points of view, CLICK HERE .

Myomectomy: Open to robotic approaches

“Myomectomy is not a dying art by any stretch,” said PAGS Co-Chair Tommaso Falcone, MD, in opening this session. “In fact, it’s expected to increase,” he added, as more women seek to preserve their uterus.

He then proceeded to describe management approaches (including watchful waiting), indications for myomectomy, and surgical options, including data on both perioperative and reproductive outcomes.
CLICK HERE for a video summary of Dr. Falcone’s talk.

Laparoscopic supracervical hysterectomy

As more women seek to preserve their cervix at the time of hysterectomy, the supracervical approach is becoming increasingly common. Amy Garcia, MD, described the indications, technique, benefits, and risks associated with this procedure. CLICK HERE to hear Dr. Garcia highlight the key points of her talk.

Join me in Las Vegas for FUUS 2013!

Mickey Karram, MD, invites you to attend the 12th annual Female Urology and Urogynecology Symposium (FUUS) at the ARIA in Las Vegas, April 18–20, 2013.

“This is a unique meeting,” says Dr. Karram, “as it addresses both urologic and gynecologic issues related to female pelvic medicine and reconstructive surgery.” It’s also timely—with the first board exam for the subspecialty of female pelvic medicine and reconstructive surgery being held in June 2013. Prepare yourself to meet the demand for physicians who have the expertise to evaluate pelvic floor disorders.

“The meeting is attended by 50% gynecologists and 50% urologists, has many breakout sessions, and covers a variety of topics—everything from vaginal surgery for prolapse, voiding dysfunction, and types of reconstructive procedures with laparoscopic and robotic approaches,” says Dr. Karram, who is excited for this year’s special symposium by Karl J. Kreder, Jr, MD, on April 20 that addresses pelvic pain syndromes. For a complete agenda and registration details, visit www.fuus-cme.org.

More than 300 physicians attended the 15th annual Pelvic Anatomy and Gynecologic Surgery (PAGS) symposium December 13–15, 2012, in Las Vegas. One likely reason was an abundance of offerings, including:

• a laparoscopist’s view of pelvic and abdominal anatomy
• case-based discussion of the evaluation of female pelvic floor disorders
• a surgical video fest with expert discussion and audience participation
• an in-depth look at fibroid management
• a focus on hysterectomy, from the vaginal approach to single-port laparoscopy and robotics
• a panel discussion of pelvic pain and its management
• tips on avoiding and managing laparoscopic and other complications
• a breakout session on endometriosis surgery
• the latest on evaluation and management of fetal incontinence.

Here are a few additional highlights of the 2012 program:

Surgery for stress incontinence: Which sling is for which patient?

When it comes to slings, one size does not fit all. That point was emphasized by Mark Walters, MD, in a comprehensive session that described the surgical techniques behind various bladder-neck and midurethral sling procedures, as well as the associated cure rates, complications, and pros and cons. To watch a 7-minute video in which Dr. Walters elaborates on patient-selection criteria, CLICK HERE .

Surgical approach to prolapse—what I do and why I do it

John Gebhart, MD, MS, outlined his approach to the surgical correction of pelvic organ prolapse, but underscored his belief that the surgeon has to base her approach not only on the data, but on her own experience and resources.

“That’s something you have to come to grips with in your own practice—what’s best in your hands?” he said.

While showing videos of actual surgeries, he described specific techniques, pearls, and pitfalls, and emphasized the importance of cystoscopy to rule out bladder injury.

Keynote address: The economics of surgical gynecology

Dr. Barbara S. Levy, Vice President of Health Policy at the American Congress of Obstetricians and Gynecologists (ACOG), delivered an impassionate appeal to attendees of PAGS: Gynecologists need to take the lead in advocating for best practices in their specialty—before forces outside the specialty impose definitions and standards upon them.

She also described the current payment environment, explained why the current trend in health-care spending is unsustainable, and stressed the need to find areas in surgical gynecologic practice that may benefit from improvements in health-care delivery. CLICK HERE for Dr. Levy’s overview of the issues on video.

PAGS participants weigh in

After Dr. Levy’s keynote address on the economics of surgical gynecology, OBG Management gathered the opinions of four participants: Gary Bostrom, MD, of California; Richard Robinson, MD, of Georgia; Timothy Hall, MD, of North Carolina; and Todd Slater, MD, of Ohio. To hear their points of view, CLICK HERE .

Myomectomy: Open to robotic approaches

“Myomectomy is not a dying art by any stretch,” said PAGS Co-Chair Tommaso Falcone, MD, in opening this session. “In fact, it’s expected to increase,” he added, as more women seek to preserve their uterus.

He then proceeded to describe management approaches (including watchful waiting), indications for myomectomy, and surgical options, including data on both perioperative and reproductive outcomes.
CLICK HERE for a video summary of Dr. Falcone’s talk.

Laparoscopic supracervical hysterectomy

As more women seek to preserve their cervix at the time of hysterectomy, the supracervical approach is becoming increasingly common. Amy Garcia, MD, described the indications, technique, benefits, and risks associated with this procedure. CLICK HERE to hear Dr. Garcia highlight the key points of her talk.

Join me in Las Vegas for FUUS 2013!

Mickey Karram, MD, invites you to attend the 12th annual Female Urology and Urogynecology Symposium (FUUS) at the ARIA in Las Vegas, April 18–20, 2013.

“This is a unique meeting,” says Dr. Karram, “as it addresses both urologic and gynecologic issues related to female pelvic medicine and reconstructive surgery.” It’s also timely—with the first board exam for the subspecialty of female pelvic medicine and reconstructive surgery being held in June 2013. Prepare yourself to meet the demand for physicians who have the expertise to evaluate pelvic floor disorders.

“The meeting is attended by 50% gynecologists and 50% urologists, has many breakout sessions, and covers a variety of topics—everything from vaginal surgery for prolapse, voiding dysfunction, and types of reconstructive procedures with laparoscopic and robotic approaches,” says Dr. Karram, who is excited for this year’s special symposium by Karl J. Kreder, Jr, MD, on April 20 that addresses pelvic pain syndromes. For a complete agenda and registration details, visit www.fuus-cme.org.

Developed in Partnership with International Academy of Pelvic Surgery

CASE 1: Recurrent SUI and mesh erosion

A 50-year-old woman reports urinary incontinence that is associated with activity and exertion—stress urinary incontinence (SUI)—and says it has worsened over the past year. She mentions that she underwent vaginal hysterectomy, with placement of a tension-free vaginal tape (TVT), about 2 years earlier.

During physical examination, the patient becomes incontinent when abdominal pressure is increased, with some urethral mobility (cotton-swab deflection to 25° from the horizontal). She is also noted to have erosion of the TVT tape into the vaginal lumen.

Urodynamic testing reveals easily demonstrable SUI at a volume of 150 mL when she is in the sitting position, with a Valsalva leak-point pressure of 55 cm H₂O. Her bladder remains stable to a capacity of 520 mL. Cystoscopy yields unremarkable findings.

When she is offered surgical correction of her SUI, the patient expresses a preference for the use of her own tissues and says she does not want to have synthetic mesh placed.

Is this patient a candidate for a rectus fascia pubovaginal sling?

As more patients express reservations about the placement of synthetic mesh during sling procedures, the use of autologous rectus fascia pubovaginal slings has risen. The concept of using a patient’s own tissue as a sling to support the urethra dates to the early 20th century, but it was not until late in that century that the procedure gained widespread appreciation and evolved into its current form. Initially, the procedure entailed mobilizing a strip of abdominal muscle (either rectus or pyramidalis), freeing one end of the strip from its attachment, passing that end under the bladder neck, and reaffixing it to the abdominal muscle wall, forming a “U”-shaped sling around the bladder outlet. Subsequently, overlying abdominal fascia was included in the sling, eventually replacing the muscle altogether. The final innovation: An isolated strip of fascia was suspended by free sutures that were tied to the abdominal wall or attached on top of the abdominal rectus sheath.

The autologous pubovaginal sling supports the proximal urethra and bladder neck to achieve continence by providing a direct compressive force on the urethra and bladder outlet, or by reestablishing a reinforcing platform or hammock against which the urethra is compressed during the transmission of increased abdominal pressure.

The sling is suspended on each end by free sutures that are attached directly to the abdominal wall musculature or, more commonly, tied to each other on the anterior surface of the abdominal wall.

Long-term success depends on healing and fibrotic processes, which occur primarily where the sling passes through the endopelvic fascia.

Who is a candidate?

Although the pubovaginal sling procedure was pioneered as a surgical option for intrinsic sphincter deficiency (ISD), its indications have broadened to encompass all types of SUI. Its reliable results and durable outcomes make it one of the main standards of treatment, and the pubovaginal sling has been used extensively as primary therapy for:

• SUI related to ISD or urethral hypermobility
• as a salvage procedure for recurrent SUI
• as an adjunct to urethral and bladder reconstruction
• as a way to functionally close the urethra to abandon urethral access to the bladder.

In our opinion, the autologous pubovaginal sling is appropriate for patients with SUI who decline to have synthetic material implanted because of concerns related to long-term placement of synthetic mesh. Other good candidates are women who experience recurrent incontinence after placement of a synthetic sling or who develop a complication, such as vaginal erosion (VIDEO 1, Rectus fascia pubovaginal sling after an unsuccessful TVT), after placement of a synthetic sling. We also prefer to use an autologous sling in patients who have been radiated or who have sustained urethral injuries, as well as in patients who are undergoing simultaneous repair of urethrovaginal fistula or diverticulum—or those who have already undergone such repair.

What is the optimal sling material?

Rectus abdominis fascia versus fascia lata. The two most commonly used autologous tissues are rectus abdominus fascia and fascia lata. Both of these materials have been studied extensively and proven to be effective and reliable. Most surgeons prefer rectus fascia because it is easier and quicker to harvest.

Allogenic and xenogenic tissues. Allogenic (cadaveric) fascia lata and cadaveric dermis provide reasonable efficacy, but durability remains an issue, as high failure rates have been reported. Bovine and porcine dermis, as well as porcine small-intestine submucosa, are also effective for SUI, although durability remains a concern.

 

Synthetic materials. Synthetic graft materials of various designs and substances also have been used as sling material. Monofilament, large-pore weave grafts (Type 1 mesh) are recommended for implantation in the vagina. Although good efficacy can be achieved with synthetic mesh, the material also may increase the risk of serious complications, such as infection, vaginal extrusion, and genitourinary erosion, and is not recommended for use beneath the proximal urethra or bladder neck.

The autologous pubovaginal sling supports the proximal urethra and bladder neck to achieve continence by providing a direct compressive force on the urethra and bladder outlet, or by reestablishing a reinforcing platform or hammock against which the urethra is compressed during increased abdominal pressure.

How to harvest rectus fascia and create a sling

1. Choose anesthesia and perioperative antibiotics

Pubovaginal sling procedures are generally carried out under general anesthesia, but spinal or epidural anesthesia also is possible. Full-patient paralysis is not warranted but may facilitate closure of the rectus fascia after fascial harvesting.

Perioperative antibiotics usually are given to ensure appropriate coverage against skin and vaginal flora (for example, a cephalosporin or fluoroquinolone). In fact, perioperative antibiotics have become a mandated quality of care measure in the United States.

2. Position the patient for optimal access

Place the patient in the low lithotomy position with her legs in stirrups. The abdomen and perineum should be sterilely prepared and draped to provide access to the vagina and lower abdomen.

After the bladder is drained with a Foley catheter, place a weighted vaginal speculum and use either lateral labial retraction sutures or a self-retaining retractor system to facilitate vaginal exposure.

3. Make an abdominal incision

Make an 8- to 10-cm Pfannenstiel incision approximately 3 to 5 cm above the pubic bone, carry the dissection down to the level of the rectus fascia using a combination of electrocautery and blunt dissection, and sweep the fat and subcutaneous tissue clear of the rectus tissue (FIGURE 1).

FIGURE 1 Skin incision

Before initiating the operation, delineate the location of the transverse skin incision, which should measure 8 to 10 cm and be situated about 4 cm above the symphysis pubis. A vertical incision is also feasible, although it usually is less aesthetic.

4. Harvest the fascia

The rectus abdominis fascia can be harvested in a transverse or vertical orientation. A fascial segment at least 8 cm in length and 1.5 to 2 cm in width is recommended.

Delineate the fascial segment to be resected using a surgical marking pen or electrocautery, then incise the tissue sharply with a scalpel, scissors, or electrocautery along the drawn lines.

Virgin fascia is preferred, but the presence of fibrotic rectus fascia does not prohibit its use. If you are resecting the fascia close and parallel to the symphysis pubis, leave at least 0.5 to 1.0 cm attached to facilitate closure of the defect created in the fascia. Small Army/Navy retractors permit aggressive retraction of skin edges, making it possible to use a smaller skin incision (FIGURE 2).

FIGURE 2 Resect the fascial strip

After choosing the optimal location for excision, mark the area using electrocautery or a surgical marking pen. Then resect the strip using a scalpel or electrocautery. The strip should measure 8 to 10 cm in length and 1 to 2 cm in width. If the skin incision is small, Army/Navy retractors may enhance exposure.

5. Close the fascial defect

Use heavy-gauge (#1 or #0) delayed, absorbable suture in a running fashion. It may be necessary to mobilize the rectus abdominis fascial edges to ensure appropriate tension-free approximation. It is important that anesthesia be sufficient to ensure muscular relaxation and paralysis during closure.

6. Prepare the fascial sling

Affix a single #1 permanent (for example, polypropylene or polyester) suture to each end of the fascial segment by passing the needle through the undersurface of the sling and then back through the top of the sling. If necessary, defat the sling (FIGURE 3).

FIGURE 3 Attach suspensory sutures
A. Mark the midline of the fascial sling with a pen and gently grasp it using a hemostat. B. Attach a polyester suture to each end of the fascial sling after stripping it of any adipose tissue. Ensure that the initial entry and exit points of the polyester sutures are on the same side of the strip that originally abutted the rectus muscles.

7. Dissect the vagina

Use injectable-grade saline or a local analgesic, such as 1% lidocaine, to hydrodissect the subepithelial tissues of the distal portion of the anterior vaginal wall. Make a midline or inverted “U” incision into the vagina (FIGURE 4).

 

Create vaginal flaps that have sufficient mobility to ensure tension-free closure over the sling. Carry out dissection laterally and anteriorly until you encounter the endopelvic fascia, then incise the endopelvic fascia and dissect it from the posterior surface of the pubis to enter the retropubic space.

Although blunt dissection sometimes can be performed, sharp dissection with Mayo scissors is often required, especially in cases that involve recurrent stress incontinence (FIGURE 4).

FIGURE 4 Dissect the vagina
A. Use an inverted “U” or vertical incision on the vaginal mucosa overlying the midurethra and bladder. B. Carefully dissect the tissue to the pubic rami bilaterally until the urogenital diaphragm is identified, then sharply penetrate it using Mayo scissors. C. Enlarge the opening by repeating the procedure on the opposite side.

8. Pass retropubic needles

Pass Stamey needles or long clamps through the retropubic space from the open abdominal wound immediately posterior to the pubic bone, approximately 4 cm apart. You can maintain distal control of the needles by direct finger guidance through the vaginal incision. Be careful to advance the tip of the needle adjacent to the posterior surface of the pubic bone to avoid inadvertent bladder injury (FIGURE 5). Proper bladder drainage also helps to minimize injury to the bladder, which may be closely adherent to the pubis, especially if a prior retropubic procedure has been performed, as in Case 1.

FIGURE 5 Place the sling
A. Insert the Stamey needle through the rectus fascia and guide it into the vagina with the index finger placed against the tip of the needle. B. Thread both ends of the polyester suture into the eye of the Stamey needle and then retract the needle carefully until the suture ends are delivered abdominally at the level of the fascia.

9. Rule out bladder injury

Careful cystoscopic examination of the bladder is mandatory after passing the needles to rule out inadvertent injury. Injuries to the bladder typically occur at the 1 o’clock and 11 o’clock positions, so use a 70° lens, and fill the bladder completely to expand any mucosal redundancy. Wiggle the needles or clamps to help localize their position relative to the bladder wall.

10. Deploy the sling

Thread the free ends of the sutures affixed to the sling into the ends of the Stamey needles—or grasp them with clamps—and pull each suture up to the anterior abdominal wall through the retropubic space (FIGURE 5). Keep the sling centered and flat at the area of the bladder neck.

Some surgeons fix the sling in the midline to the underlying periurethral tissue using numerous delayed absorbable sutures. We prefer to leave the sling unattached to the underlying urethra and bladder neck.

11. Tension the sling

Various techniques are applicable. To ensure adequate “looseness,” we tie the sutures across the midline while holding a right-angle clamp between the sling material and the posterior urethral surface. The goal is for the sling to prevent the descent of the proximal urethra during increases in abdominal pressure without creating any outlet obstruction to the normal flow of urine (FIGURE 6).

FIGURE 6 Tension the sling
A. Tie the suspensory sutures abdominally above the fascial closure line. Tie the sutures across the assistant’s index finger to avoid excessive tension. B. Assess the tension using a right-angle clamp placed between the pubovaginal sling and the vagina.

12. Close the incisions

Close the abdominal skin incision using 3-0 and 4-0 absorbable sutures. Use 3-0 absorbable sutures to close the vaginal mucosa. We prefer to close the vagina after completion of the tensioning procedure, but some surgeons complete this step prior to tensioning.

13. Place a catheter, packing material

Place a bladder catheter and vaginal gauze packing. Both the catheter and gauze may be removed after 24 hours. If the patient is unable to void at that time, teach her intermittent self-catheterization, or place an indwelling Foley catheter for 1 week.

Outcomes show good efficacy

Pubovaginal slings are highly effective, with success rates between 50% and 75% after follow-up as long as 10 years.¹ In 2011, Blaivas and Chaikin reported 4-year follow-up data, with improvement or cure in 100% of patients with uncomplicated SUI and in as many as 93% of patients in more complicated cases.² Most failures were due to urge incontinence and occurred within the first 6 postoperative months; 3% of these urge patients were thought to have developed de novo urge incontinence.

Other studies have found de novo urgency and storage symptoms in as many as 23% of patients, with 11% of patients reporting voiding dysfunction and as many as 7.8% requiring long-term self-catheterization.¹

 

Flawed methodology in the few randomized, controlled trials that have compared the pubovaginal sling with the tension-free vaginal tape (TVT) has cast doubt on their findings.³ Basok and colleagues found an increased rate of de novo urgency in the women treated with a pubovaginal sling, compared with those who underwent intravaginal slingplasty,⁴ whereas Sharifiaghdas and Mortazavi found equal efficacy between pubovaginal and retropubic midurethral synthetic slings.⁵ The most scientifically valid randomized, controlled trial found equal subjective cure rates and complication rates when a biologic pubovaginal sling was compared with the TVT.⁶ In that study, the pubovaginal sling was of porcine origin.

In a comparison of autologous and autograft slings, Flynn found equal control of SUI over 2 years, with reduced postoperative discomfort in the allograft group.⁷

When autologous pubovaginal slings were compared with Burch colposuspension in a randomized, controlled trial, fascial slings were better at controlling incontinence despite an increased morbidity profile.⁸

A meta-analysis found equal subjective cure rates and overall efficacy between pubovaginal and midurethral synthetic slings.⁹

Voiding dysfunction is the most common complication

Transient urinary retention may occur in as many as 20% of patients and requires intermittent self-catheterization until resolution (typically 2–4 weeks). Prolonged postoperative voiding dysfunction (lasting more than 4–6 weeks), including de novo urgency, urgency incontinence, and obstructive symptoms, may occur to some degree in as many as 25% of patients. However, fewer than 3% of women require subsequent urethrolysis for treatment of prolonged retention or obstructive voiding symptoms.

A few technical suggestions

Harvest the fascia first. Because substantial bleeding can occur during vaginal dissection, it is advisable to harvest the autologous fascia and prepare the sling by affixing sutures to it before dissecting the vagina. This facilitates timely insertion of the sling and minimal blood loss. Retropubic bleeding from high in the space that occurs during dissection almost always resolves upon placement of the sling. We recommend against prolonged attempts at hemostasis.

In urethral reconstruction, tension the sling after reconstruction. When placing an autologous pubovaginal sling in the setting of urethral reconstruction or as tissue interposition, harvest the fascia and prepare and deploy the sling (with passage of the retropubic sutures) before reconstructing the urethra—but refrain from tensioning until after the reconstruction is completed. Then affix the sling in the appropriate location and tension it. When the sling is placed after reconstruction, it can damage the reconstruction through traction or direct injury.

Don’t worry about surface orientation. During placement of the autologous sling material, surface orientation does not matter. Conventionally, however, the “body-side” or underside of the graft is placed on the body-side of the patient.

Tensioning varies between patients. For most women, sling tensioning can be accomplished by tying the sutures over one or two fingers placed across the fascia. In patients who have undergone multiple procedures and who have a nonmobile urethra, however, tension should be tighter and must be individualized, based on the patient’s anatomy, lower urinary tract function, and willingness to perform intermittent self-catheterization for a prolonged period of time.

CASE 1: Resolved

After you advise the patient of the risks and benefits of the rectus fascia pubovaginal sling, in comparison with a repeat synthetic midurethral sling, she continues to insist on the use of autologous tissue. She undergoes the pubovaginal sling operation with excision of eroded mesh without complication.

We want to hear from you! Tell us what you think.

Developed in Partnership with International Academy of Pelvic Surgery

CASE 1: Recurrent SUI and mesh erosion

A 50-year-old woman reports urinary incontinence that is associated with activity and exertion—stress urinary incontinence (SUI)—and says it has worsened over the past year. She mentions that she underwent vaginal hysterectomy, with placement of a tension-free vaginal tape (TVT), about 2 years earlier.

During physical examination, the patient becomes incontinent when abdominal pressure is increased, with some urethral mobility (cotton-swab deflection to 25° from the horizontal). She is also noted to have erosion of the TVT tape into the vaginal lumen.

Urodynamic testing reveals easily demonstrable SUI at a volume of 150 mL when she is in the sitting position, with a Valsalva leak-point pressure of 55 cm H₂O. Her bladder remains stable to a capacity of 520 mL. Cystoscopy yields unremarkable findings.

When she is offered surgical correction of her SUI, the patient expresses a preference for the use of her own tissues and says she does not want to have synthetic mesh placed.

Is this patient a candidate for a rectus fascia pubovaginal sling?

As more patients express reservations about the placement of synthetic mesh during sling procedures, the use of autologous rectus fascia pubovaginal slings has risen. The concept of using a patient’s own tissue as a sling to support the urethra dates to the early 20th century, but it was not until late in that century that the procedure gained widespread appreciation and evolved into its current form. Initially, the procedure entailed mobilizing a strip of abdominal muscle (either rectus or pyramidalis), freeing one end of the strip from its attachment, passing that end under the bladder neck, and reaffixing it to the abdominal muscle wall, forming a “U”-shaped sling around the bladder outlet. Subsequently, overlying abdominal fascia was included in the sling, eventually replacing the muscle altogether. The final innovation: An isolated strip of fascia was suspended by free sutures that were tied to the abdominal wall or attached on top of the abdominal rectus sheath.

The autologous pubovaginal sling supports the proximal urethra and bladder neck to achieve continence by providing a direct compressive force on the urethra and bladder outlet, or by reestablishing a reinforcing platform or hammock against which the urethra is compressed during the transmission of increased abdominal pressure.

The sling is suspended on each end by free sutures that are attached directly to the abdominal wall musculature or, more commonly, tied to each other on the anterior surface of the abdominal wall.

Long-term success depends on healing and fibrotic processes, which occur primarily where the sling passes through the endopelvic fascia.

Who is a candidate?

Although the pubovaginal sling procedure was pioneered as a surgical option for intrinsic sphincter deficiency (ISD), its indications have broadened to encompass all types of SUI. Its reliable results and durable outcomes make it one of the main standards of treatment, and the pubovaginal sling has been used extensively as primary therapy for:

• SUI related to ISD or urethral hypermobility
• as a salvage procedure for recurrent SUI
• as an adjunct to urethral and bladder reconstruction
• as a way to functionally close the urethra to abandon urethral access to the bladder.

In our opinion, the autologous pubovaginal sling is appropriate for patients with SUI who decline to have synthetic material implanted because of concerns related to long-term placement of synthetic mesh. Other good candidates are women who experience recurrent incontinence after placement of a synthetic sling or who develop a complication, such as vaginal erosion (VIDEO 1, Rectus fascia pubovaginal sling after an unsuccessful TVT), after placement of a synthetic sling. We also prefer to use an autologous sling in patients who have been radiated or who have sustained urethral injuries, as well as in patients who are undergoing simultaneous repair of urethrovaginal fistula or diverticulum—or those who have already undergone such repair.

What is the optimal sling material?

Rectus abdominis fascia versus fascia lata. The two most commonly used autologous tissues are rectus abdominus fascia and fascia lata. Both of these materials have been studied extensively and proven to be effective and reliable. Most surgeons prefer rectus fascia because it is easier and quicker to harvest.

Allogenic and xenogenic tissues. Allogenic (cadaveric) fascia lata and cadaveric dermis provide reasonable efficacy, but durability remains an issue, as high failure rates have been reported. Bovine and porcine dermis, as well as porcine small-intestine submucosa, are also effective for SUI, although durability remains a concern.

 

Synthetic materials. Synthetic graft materials of various designs and substances also have been used as sling material. Monofilament, large-pore weave grafts (Type 1 mesh) are recommended for implantation in the vagina. Although good efficacy can be achieved with synthetic mesh, the material also may increase the risk of serious complications, such as infection, vaginal extrusion, and genitourinary erosion, and is not recommended for use beneath the proximal urethra or bladder neck.

The autologous pubovaginal sling supports the proximal urethra and bladder neck to achieve continence by providing a direct compressive force on the urethra and bladder outlet, or by reestablishing a reinforcing platform or hammock against which the urethra is compressed during increased abdominal pressure.

How to harvest rectus fascia and create a sling

1. Choose anesthesia and perioperative antibiotics

Pubovaginal sling procedures are generally carried out under general anesthesia, but spinal or epidural anesthesia also is possible. Full-patient paralysis is not warranted but may facilitate closure of the rectus fascia after fascial harvesting.

Perioperative antibiotics usually are given to ensure appropriate coverage against skin and vaginal flora (for example, a cephalosporin or fluoroquinolone). In fact, perioperative antibiotics have become a mandated quality of care measure in the United States.

2. Position the patient for optimal access

Place the patient in the low lithotomy position with her legs in stirrups. The abdomen and perineum should be sterilely prepared and draped to provide access to the vagina and lower abdomen.

After the bladder is drained with a Foley catheter, place a weighted vaginal speculum and use either lateral labial retraction sutures or a self-retaining retractor system to facilitate vaginal exposure.

3. Make an abdominal incision

Make an 8- to 10-cm Pfannenstiel incision approximately 3 to 5 cm above the pubic bone, carry the dissection down to the level of the rectus fascia using a combination of electrocautery and blunt dissection, and sweep the fat and subcutaneous tissue clear of the rectus tissue (FIGURE 1).

FIGURE 1 Skin incision

Before initiating the operation, delineate the location of the transverse skin incision, which should measure 8 to 10 cm and be situated about 4 cm above the symphysis pubis. A vertical incision is also feasible, although it usually is less aesthetic.

4. Harvest the fascia

The rectus abdominis fascia can be harvested in a transverse or vertical orientation. A fascial segment at least 8 cm in length and 1.5 to 2 cm in width is recommended.

Delineate the fascial segment to be resected using a surgical marking pen or electrocautery, then incise the tissue sharply with a scalpel, scissors, or electrocautery along the drawn lines.

Virgin fascia is preferred, but the presence of fibrotic rectus fascia does not prohibit its use. If you are resecting the fascia close and parallel to the symphysis pubis, leave at least 0.5 to 1.0 cm attached to facilitate closure of the defect created in the fascia. Small Army/Navy retractors permit aggressive retraction of skin edges, making it possible to use a smaller skin incision (FIGURE 2).

FIGURE 2 Resect the fascial strip

After choosing the optimal location for excision, mark the area using electrocautery or a surgical marking pen. Then resect the strip using a scalpel or electrocautery. The strip should measure 8 to 10 cm in length and 1 to 2 cm in width. If the skin incision is small, Army/Navy retractors may enhance exposure.

5. Close the fascial defect

Use heavy-gauge (#1 or #0) delayed, absorbable suture in a running fashion. It may be necessary to mobilize the rectus abdominis fascial edges to ensure appropriate tension-free approximation. It is important that anesthesia be sufficient to ensure muscular relaxation and paralysis during closure.

6. Prepare the fascial sling

Affix a single #1 permanent (for example, polypropylene or polyester) suture to each end of the fascial segment by passing the needle through the undersurface of the sling and then back through the top of the sling. If necessary, defat the sling (FIGURE 3).

FIGURE 3 Attach suspensory sutures
A. Mark the midline of the fascial sling with a pen and gently grasp it using a hemostat. B. Attach a polyester suture to each end of the fascial sling after stripping it of any adipose tissue. Ensure that the initial entry and exit points of the polyester sutures are on the same side of the strip that originally abutted the rectus muscles.

7. Dissect the vagina

Use injectable-grade saline or a local analgesic, such as 1% lidocaine, to hydrodissect the subepithelial tissues of the distal portion of the anterior vaginal wall. Make a midline or inverted “U” incision into the vagina (FIGURE 4).

 

Create vaginal flaps that have sufficient mobility to ensure tension-free closure over the sling. Carry out dissection laterally and anteriorly until you encounter the endopelvic fascia, then incise the endopelvic fascia and dissect it from the posterior surface of the pubis to enter the retropubic space.

Although blunt dissection sometimes can be performed, sharp dissection with Mayo scissors is often required, especially in cases that involve recurrent stress incontinence (FIGURE 4).

FIGURE 4 Dissect the vagina
A. Use an inverted “U” or vertical incision on the vaginal mucosa overlying the midurethra and bladder. B. Carefully dissect the tissue to the pubic rami bilaterally until the urogenital diaphragm is identified, then sharply penetrate it using Mayo scissors. C. Enlarge the opening by repeating the procedure on the opposite side.

8. Pass retropubic needles

Pass Stamey needles or long clamps through the retropubic space from the open abdominal wound immediately posterior to the pubic bone, approximately 4 cm apart. You can maintain distal control of the needles by direct finger guidance through the vaginal incision. Be careful to advance the tip of the needle adjacent to the posterior surface of the pubic bone to avoid inadvertent bladder injury (FIGURE 5). Proper bladder drainage also helps to minimize injury to the bladder, which may be closely adherent to the pubis, especially if a prior retropubic procedure has been performed, as in Case 1.

FIGURE 5 Place the sling
A. Insert the Stamey needle through the rectus fascia and guide it into the vagina with the index finger placed against the tip of the needle. B. Thread both ends of the polyester suture into the eye of the Stamey needle and then retract the needle carefully until the suture ends are delivered abdominally at the level of the fascia.

9. Rule out bladder injury

Careful cystoscopic examination of the bladder is mandatory after passing the needles to rule out inadvertent injury. Injuries to the bladder typically occur at the 1 o’clock and 11 o’clock positions, so use a 70° lens, and fill the bladder completely to expand any mucosal redundancy. Wiggle the needles or clamps to help localize their position relative to the bladder wall.

10. Deploy the sling

Thread the free ends of the sutures affixed to the sling into the ends of the Stamey needles—or grasp them with clamps—and pull each suture up to the anterior abdominal wall through the retropubic space (FIGURE 5). Keep the sling centered and flat at the area of the bladder neck.

Some surgeons fix the sling in the midline to the underlying periurethral tissue using numerous delayed absorbable sutures. We prefer to leave the sling unattached to the underlying urethra and bladder neck.

11. Tension the sling

Various techniques are applicable. To ensure adequate “looseness,” we tie the sutures across the midline while holding a right-angle clamp between the sling material and the posterior urethral surface. The goal is for the sling to prevent the descent of the proximal urethra during increases in abdominal pressure without creating any outlet obstruction to the normal flow of urine (FIGURE 6).

FIGURE 6 Tension the sling
A. Tie the suspensory sutures abdominally above the fascial closure line. Tie the sutures across the assistant’s index finger to avoid excessive tension. B. Assess the tension using a right-angle clamp placed between the pubovaginal sling and the vagina.

12. Close the incisions

Close the abdominal skin incision using 3-0 and 4-0 absorbable sutures. Use 3-0 absorbable sutures to close the vaginal mucosa. We prefer to close the vagina after completion of the tensioning procedure, but some surgeons complete this step prior to tensioning.

13. Place a catheter, packing material

Place a bladder catheter and vaginal gauze packing. Both the catheter and gauze may be removed after 24 hours. If the patient is unable to void at that time, teach her intermittent self-catheterization, or place an indwelling Foley catheter for 1 week.

Outcomes show good efficacy

Pubovaginal slings are highly effective, with success rates between 50% and 75% after follow-up as long as 10 years.¹ In 2011, Blaivas and Chaikin reported 4-year follow-up data, with improvement or cure in 100% of patients with uncomplicated SUI and in as many as 93% of patients in more complicated cases.² Most failures were due to urge incontinence and occurred within the first 6 postoperative months; 3% of these urge patients were thought to have developed de novo urge incontinence.

Other studies have found de novo urgency and storage symptoms in as many as 23% of patients, with 11% of patients reporting voiding dysfunction and as many as 7.8% requiring long-term self-catheterization.¹

 

Flawed methodology in the few randomized, controlled trials that have compared the pubovaginal sling with the tension-free vaginal tape (TVT) has cast doubt on their findings.³ Basok and colleagues found an increased rate of de novo urgency in the women treated with a pubovaginal sling, compared with those who underwent intravaginal slingplasty,⁴ whereas Sharifiaghdas and Mortazavi found equal efficacy between pubovaginal and retropubic midurethral synthetic slings.⁵ The most scientifically valid randomized, controlled trial found equal subjective cure rates and complication rates when a biologic pubovaginal sling was compared with the TVT.⁶ In that study, the pubovaginal sling was of porcine origin.

In a comparison of autologous and autograft slings, Flynn found equal control of SUI over 2 years, with reduced postoperative discomfort in the allograft group.⁷

When autologous pubovaginal slings were compared with Burch colposuspension in a randomized, controlled trial, fascial slings were better at controlling incontinence despite an increased morbidity profile.⁸

A meta-analysis found equal subjective cure rates and overall efficacy between pubovaginal and midurethral synthetic slings.⁹

Voiding dysfunction is the most common complication

Transient urinary retention may occur in as many as 20% of patients and requires intermittent self-catheterization until resolution (typically 2–4 weeks). Prolonged postoperative voiding dysfunction (lasting more than 4–6 weeks), including de novo urgency, urgency incontinence, and obstructive symptoms, may occur to some degree in as many as 25% of patients. However, fewer than 3% of women require subsequent urethrolysis for treatment of prolonged retention or obstructive voiding symptoms.

A few technical suggestions

Harvest the fascia first. Because substantial bleeding can occur during vaginal dissection, it is advisable to harvest the autologous fascia and prepare the sling by affixing sutures to it before dissecting the vagina. This facilitates timely insertion of the sling and minimal blood loss. Retropubic bleeding from high in the space that occurs during dissection almost always resolves upon placement of the sling. We recommend against prolonged attempts at hemostasis.

In urethral reconstruction, tension the sling after reconstruction. When placing an autologous pubovaginal sling in the setting of urethral reconstruction or as tissue interposition, harvest the fascia and prepare and deploy the sling (with passage of the retropubic sutures) before reconstructing the urethra—but refrain from tensioning until after the reconstruction is completed. Then affix the sling in the appropriate location and tension it. When the sling is placed after reconstruction, it can damage the reconstruction through traction or direct injury.

Don’t worry about surface orientation. During placement of the autologous sling material, surface orientation does not matter. Conventionally, however, the “body-side” or underside of the graft is placed on the body-side of the patient.

Tensioning varies between patients. For most women, sling tensioning can be accomplished by tying the sutures over one or two fingers placed across the fascia. In patients who have undergone multiple procedures and who have a nonmobile urethra, however, tension should be tighter and must be individualized, based on the patient’s anatomy, lower urinary tract function, and willingness to perform intermittent self-catheterization for a prolonged period of time.

CASE 1: Resolved

After you advise the patient of the risks and benefits of the rectus fascia pubovaginal sling, in comparison with a repeat synthetic midurethral sling, she continues to insist on the use of autologous tissue. She undergoes the pubovaginal sling operation with excision of eroded mesh without complication.

We want to hear from you! Tell us what you think.

Developed in Partnership with International Academy of Pelvic Surgery

CASE 1: Recurrent SUI and mesh erosion

A 50-year-old woman reports urinary incontinence that is associated with activity and exertion—stress urinary incontinence (SUI)—and says it has worsened over the past year. She mentions that she underwent vaginal hysterectomy, with placement of a tension-free vaginal tape (TVT), about 2 years earlier.

During physical examination, the patient becomes incontinent when abdominal pressure is increased, with some urethral mobility (cotton-swab deflection to 25° from the horizontal). She is also noted to have erosion of the TVT tape into the vaginal lumen.

Urodynamic testing reveals easily demonstrable SUI at a volume of 150 mL when she is in the sitting position, with a Valsalva leak-point pressure of 55 cm H₂O. Her bladder remains stable to a capacity of 520 mL. Cystoscopy yields unremarkable findings.

When she is offered surgical correction of her SUI, the patient expresses a preference for the use of her own tissues and says she does not want to have synthetic mesh placed.

Is this patient a candidate for a rectus fascia pubovaginal sling?

As more patients express reservations about the placement of synthetic mesh during sling procedures, the use of autologous rectus fascia pubovaginal slings has risen. The concept of using a patient’s own tissue as a sling to support the urethra dates to the early 20th century, but it was not until late in that century that the procedure gained widespread appreciation and evolved into its current form. Initially, the procedure entailed mobilizing a strip of abdominal muscle (either rectus or pyramidalis), freeing one end of the strip from its attachment, passing that end under the bladder neck, and reaffixing it to the abdominal muscle wall, forming a “U”-shaped sling around the bladder outlet. Subsequently, overlying abdominal fascia was included in the sling, eventually replacing the muscle altogether. The final innovation: An isolated strip of fascia was suspended by free sutures that were tied to the abdominal wall or attached on top of the abdominal rectus sheath.

The autologous pubovaginal sling supports the proximal urethra and bladder neck to achieve continence by providing a direct compressive force on the urethra and bladder outlet, or by reestablishing a reinforcing platform or hammock against which the urethra is compressed during the transmission of increased abdominal pressure.

The sling is suspended on each end by free sutures that are attached directly to the abdominal wall musculature or, more commonly, tied to each other on the anterior surface of the abdominal wall.

Long-term success depends on healing and fibrotic processes, which occur primarily where the sling passes through the endopelvic fascia.

Who is a candidate?

Although the pubovaginal sling procedure was pioneered as a surgical option for intrinsic sphincter deficiency (ISD), its indications have broadened to encompass all types of SUI. Its reliable results and durable outcomes make it one of the main standards of treatment, and the pubovaginal sling has been used extensively as primary therapy for:

• SUI related to ISD or urethral hypermobility
• as a salvage procedure for recurrent SUI
• as an adjunct to urethral and bladder reconstruction
• as a way to functionally close the urethra to abandon urethral access to the bladder.

In our opinion, the autologous pubovaginal sling is appropriate for patients with SUI who decline to have synthetic material implanted because of concerns related to long-term placement of synthetic mesh. Other good candidates are women who experience recurrent incontinence after placement of a synthetic sling or who develop a complication, such as vaginal erosion (VIDEO 1, Rectus fascia pubovaginal sling after an unsuccessful TVT), after placement of a synthetic sling. We also prefer to use an autologous sling in patients who have been radiated or who have sustained urethral injuries, as well as in patients who are undergoing simultaneous repair of urethrovaginal fistula or diverticulum—or those who have already undergone such repair.

What is the optimal sling material?

Rectus abdominis fascia versus fascia lata. The two most commonly used autologous tissues are rectus abdominus fascia and fascia lata. Both of these materials have been studied extensively and proven to be effective and reliable. Most surgeons prefer rectus fascia because it is easier and quicker to harvest.

Allogenic and xenogenic tissues. Allogenic (cadaveric) fascia lata and cadaveric dermis provide reasonable efficacy, but durability remains an issue, as high failure rates have been reported. Bovine and porcine dermis, as well as porcine small-intestine submucosa, are also effective for SUI, although durability remains a concern.

 

Synthetic materials. Synthetic graft materials of various designs and substances also have been used as sling material. Monofilament, large-pore weave grafts (Type 1 mesh) are recommended for implantation in the vagina. Although good efficacy can be achieved with synthetic mesh, the material also may increase the risk of serious complications, such as infection, vaginal extrusion, and genitourinary erosion, and is not recommended for use beneath the proximal urethra or bladder neck.

The autologous pubovaginal sling supports the proximal urethra and bladder neck to achieve continence by providing a direct compressive force on the urethra and bladder outlet, or by reestablishing a reinforcing platform or hammock against which the urethra is compressed during increased abdominal pressure.

How to harvest rectus fascia and create a sling

1. Choose anesthesia and perioperative antibiotics

Pubovaginal sling procedures are generally carried out under general anesthesia, but spinal or epidural anesthesia also is possible. Full-patient paralysis is not warranted but may facilitate closure of the rectus fascia after fascial harvesting.

Perioperative antibiotics usually are given to ensure appropriate coverage against skin and vaginal flora (for example, a cephalosporin or fluoroquinolone). In fact, perioperative antibiotics have become a mandated quality of care measure in the United States.

2. Position the patient for optimal access

Place the patient in the low lithotomy position with her legs in stirrups. The abdomen and perineum should be sterilely prepared and draped to provide access to the vagina and lower abdomen.

After the bladder is drained with a Foley catheter, place a weighted vaginal speculum and use either lateral labial retraction sutures or a self-retaining retractor system to facilitate vaginal exposure.

3. Make an abdominal incision

Make an 8- to 10-cm Pfannenstiel incision approximately 3 to 5 cm above the pubic bone, carry the dissection down to the level of the rectus fascia using a combination of electrocautery and blunt dissection, and sweep the fat and subcutaneous tissue clear of the rectus tissue (FIGURE 1).

FIGURE 1 Skin incision

Before initiating the operation, delineate the location of the transverse skin incision, which should measure 8 to 10 cm and be situated about 4 cm above the symphysis pubis. A vertical incision is also feasible, although it usually is less aesthetic.

4. Harvest the fascia

The rectus abdominis fascia can be harvested in a transverse or vertical orientation. A fascial segment at least 8 cm in length and 1.5 to 2 cm in width is recommended.

Delineate the fascial segment to be resected using a surgical marking pen or electrocautery, then incise the tissue sharply with a scalpel, scissors, or electrocautery along the drawn lines.

Virgin fascia is preferred, but the presence of fibrotic rectus fascia does not prohibit its use. If you are resecting the fascia close and parallel to the symphysis pubis, leave at least 0.5 to 1.0 cm attached to facilitate closure of the defect created in the fascia. Small Army/Navy retractors permit aggressive retraction of skin edges, making it possible to use a smaller skin incision (FIGURE 2).

FIGURE 2 Resect the fascial strip

After choosing the optimal location for excision, mark the area using electrocautery or a surgical marking pen. Then resect the strip using a scalpel or electrocautery. The strip should measure 8 to 10 cm in length and 1 to 2 cm in width. If the skin incision is small, Army/Navy retractors may enhance exposure.

5. Close the fascial defect

Use heavy-gauge (#1 or #0) delayed, absorbable suture in a running fashion. It may be necessary to mobilize the rectus abdominis fascial edges to ensure appropriate tension-free approximation. It is important that anesthesia be sufficient to ensure muscular relaxation and paralysis during closure.

6. Prepare the fascial sling

Affix a single #1 permanent (for example, polypropylene or polyester) suture to each end of the fascial segment by passing the needle through the undersurface of the sling and then back through the top of the sling. If necessary, defat the sling (FIGURE 3).

FIGURE 3 Attach suspensory sutures
A. Mark the midline of the fascial sling with a pen and gently grasp it using a hemostat. B. Attach a polyester suture to each end of the fascial sling after stripping it of any adipose tissue. Ensure that the initial entry and exit points of the polyester sutures are on the same side of the strip that originally abutted the rectus muscles.

7. Dissect the vagina

Use injectable-grade saline or a local analgesic, such as 1% lidocaine, to hydrodissect the subepithelial tissues of the distal portion of the anterior vaginal wall. Make a midline or inverted “U” incision into the vagina (FIGURE 4).

 

Create vaginal flaps that have sufficient mobility to ensure tension-free closure over the sling. Carry out dissection laterally and anteriorly until you encounter the endopelvic fascia, then incise the endopelvic fascia and dissect it from the posterior surface of the pubis to enter the retropubic space.

Although blunt dissection sometimes can be performed, sharp dissection with Mayo scissors is often required, especially in cases that involve recurrent stress incontinence (FIGURE 4).

FIGURE 4 Dissect the vagina
A. Use an inverted “U” or vertical incision on the vaginal mucosa overlying the midurethra and bladder. B. Carefully dissect the tissue to the pubic rami bilaterally until the urogenital diaphragm is identified, then sharply penetrate it using Mayo scissors. C. Enlarge the opening by repeating the procedure on the opposite side.

8. Pass retropubic needles

Pass Stamey needles or long clamps through the retropubic space from the open abdominal wound immediately posterior to the pubic bone, approximately 4 cm apart. You can maintain distal control of the needles by direct finger guidance through the vaginal incision. Be careful to advance the tip of the needle adjacent to the posterior surface of the pubic bone to avoid inadvertent bladder injury (FIGURE 5). Proper bladder drainage also helps to minimize injury to the bladder, which may be closely adherent to the pubis, especially if a prior retropubic procedure has been performed, as in Case 1.

FIGURE 5 Place the sling
A. Insert the Stamey needle through the rectus fascia and guide it into the vagina with the index finger placed against the tip of the needle. B. Thread both ends of the polyester suture into the eye of the Stamey needle and then retract the needle carefully until the suture ends are delivered abdominally at the level of the fascia.

9. Rule out bladder injury

Careful cystoscopic examination of the bladder is mandatory after passing the needles to rule out inadvertent injury. Injuries to the bladder typically occur at the 1 o’clock and 11 o’clock positions, so use a 70° lens, and fill the bladder completely to expand any mucosal redundancy. Wiggle the needles or clamps to help localize their position relative to the bladder wall.

10. Deploy the sling

Thread the free ends of the sutures affixed to the sling into the ends of the Stamey needles—or grasp them with clamps—and pull each suture up to the anterior abdominal wall through the retropubic space (FIGURE 5). Keep the sling centered and flat at the area of the bladder neck.

Some surgeons fix the sling in the midline to the underlying periurethral tissue using numerous delayed absorbable sutures. We prefer to leave the sling unattached to the underlying urethra and bladder neck.

11. Tension the sling

Various techniques are applicable. To ensure adequate “looseness,” we tie the sutures across the midline while holding a right-angle clamp between the sling material and the posterior urethral surface. The goal is for the sling to prevent the descent of the proximal urethra during increases in abdominal pressure without creating any outlet obstruction to the normal flow of urine (FIGURE 6).

FIGURE 6 Tension the sling
A. Tie the suspensory sutures abdominally above the fascial closure line. Tie the sutures across the assistant’s index finger to avoid excessive tension. B. Assess the tension using a right-angle clamp placed between the pubovaginal sling and the vagina.

12. Close the incisions

Close the abdominal skin incision using 3-0 and 4-0 absorbable sutures. Use 3-0 absorbable sutures to close the vaginal mucosa. We prefer to close the vagina after completion of the tensioning procedure, but some surgeons complete this step prior to tensioning.

13. Place a catheter, packing material

Place a bladder catheter and vaginal gauze packing. Both the catheter and gauze may be removed after 24 hours. If the patient is unable to void at that time, teach her intermittent self-catheterization, or place an indwelling Foley catheter for 1 week.

Outcomes show good efficacy

Pubovaginal slings are highly effective, with success rates between 50% and 75% after follow-up as long as 10 years.¹ In 2011, Blaivas and Chaikin reported 4-year follow-up data, with improvement or cure in 100% of patients with uncomplicated SUI and in as many as 93% of patients in more complicated cases.² Most failures were due to urge incontinence and occurred within the first 6 postoperative months; 3% of these urge patients were thought to have developed de novo urge incontinence.

Other studies have found de novo urgency and storage symptoms in as many as 23% of patients, with 11% of patients reporting voiding dysfunction and as many as 7.8% requiring long-term self-catheterization.¹

 

Flawed methodology in the few randomized, controlled trials that have compared the pubovaginal sling with the tension-free vaginal tape (TVT) has cast doubt on their findings.³ Basok and colleagues found an increased rate of de novo urgency in the women treated with a pubovaginal sling, compared with those who underwent intravaginal slingplasty,⁴ whereas Sharifiaghdas and Mortazavi found equal efficacy between pubovaginal and retropubic midurethral synthetic slings.⁵ The most scientifically valid randomized, controlled trial found equal subjective cure rates and complication rates when a biologic pubovaginal sling was compared with the TVT.⁶ In that study, the pubovaginal sling was of porcine origin.

In a comparison of autologous and autograft slings, Flynn found equal control of SUI over 2 years, with reduced postoperative discomfort in the allograft group.⁷

When autologous pubovaginal slings were compared with Burch colposuspension in a randomized, controlled trial, fascial slings were better at controlling incontinence despite an increased morbidity profile.⁸

A meta-analysis found equal subjective cure rates and overall efficacy between pubovaginal and midurethral synthetic slings.⁹

Voiding dysfunction is the most common complication

Transient urinary retention may occur in as many as 20% of patients and requires intermittent self-catheterization until resolution (typically 2–4 weeks). Prolonged postoperative voiding dysfunction (lasting more than 4–6 weeks), including de novo urgency, urgency incontinence, and obstructive symptoms, may occur to some degree in as many as 25% of patients. However, fewer than 3% of women require subsequent urethrolysis for treatment of prolonged retention or obstructive voiding symptoms.

A few technical suggestions

Harvest the fascia first. Because substantial bleeding can occur during vaginal dissection, it is advisable to harvest the autologous fascia and prepare the sling by affixing sutures to it before dissecting the vagina. This facilitates timely insertion of the sling and minimal blood loss. Retropubic bleeding from high in the space that occurs during dissection almost always resolves upon placement of the sling. We recommend against prolonged attempts at hemostasis.

In urethral reconstruction, tension the sling after reconstruction. When placing an autologous pubovaginal sling in the setting of urethral reconstruction or as tissue interposition, harvest the fascia and prepare and deploy the sling (with passage of the retropubic sutures) before reconstructing the urethra—but refrain from tensioning until after the reconstruction is completed. Then affix the sling in the appropriate location and tension it. When the sling is placed after reconstruction, it can damage the reconstruction through traction or direct injury.

Don’t worry about surface orientation. During placement of the autologous sling material, surface orientation does not matter. Conventionally, however, the “body-side” or underside of the graft is placed on the body-side of the patient.

Tensioning varies between patients. For most women, sling tensioning can be accomplished by tying the sutures over one or two fingers placed across the fascia. In patients who have undergone multiple procedures and who have a nonmobile urethra, however, tension should be tighter and must be individualized, based on the patient’s anatomy, lower urinary tract function, and willingness to perform intermittent self-catheterization for a prolonged period of time.

CASE 1: Resolved

After you advise the patient of the risks and benefits of the rectus fascia pubovaginal sling, in comparison with a repeat synthetic midurethral sling, she continues to insist on the use of autologous tissue. She undergoes the pubovaginal sling operation with excision of eroded mesh without complication.

We want to hear from you! Tell us what you think.

CASE: Adhesions complicate multiple surgeries

In early 2007, a 37-year-old woman with a history of hysterectomy, adhesiolysis, bilateral partial salpingectomy, and cholecystectomy underwent an attempted laparoscopic bilateral salpingo-oophorectomy (BSO) for pelvic pain. The operation was converted to laparotomy because of severe adhesions and required several hours to complete.

After the BSO, the patient developed hydronephrosis in her left kidney secondary to an inflammatory cyst. In March 2007, a urologist placed a ureteral stent to relieve the obstruction. One month later, the patient was referred to a gynecologic oncologist for chronic pelvic pain.

On October 29, 2007, the patient underwent operative laparoscopy for adhesiolysis and appendectomy. No retroperitoneal exploration was attempted at the time. According to the operative note, the 10-mm port incision was enlarged to 3 cm to enable the surgeon to inspect the descending colon. Postoperatively, the patient reported persistent abdominal pain and fever and was admitted to the hospital for observation. Although she had a documented temperature of 102°F on October 31, with tachypnea, tachycardia, and a white blood cell (WBC) count of 2.9 x 10³/μL, she was discharged home the same day.

The next morning, the patient returned to the hospital’s emergency room (ER) reporting worsening abdominal pain and shortness of breath. Her vital signs included a temperature of 95.8°F, heart rate of 135 bpm, respiration of 32 breaths/min, and blood pressure of 100/68 mm Hg. An examination revealed a tender, distended abdomen, and the patient exhibited guarding behavior upon palpation in all quadrants. Bowel sounds were hypoactive, and the WBC count was 4.2 x 10³/μL. No differential count was ordered. A computed tomography (CT) scan showed free air in the abdomen, pneumomediastinum, and subcutaneous emphysema of the abdominal wall and chest wall.

The next day, a differential WBC count revealed bands elevated at a 25% level. A cardiac consultant diagnosed heart failure and remarked that pneumomediastinum should not occur after abdominal surgery. In the evening, the gynecologic oncologist performed a laparotomy and observed enteric contents in the abdominal cavity, as well as a defect of approximately 2 mm in the lower portion of the rectosigmoid colon. According to the operative note, the gynecologic oncologist stapled off the area below the defect and performed a descending loop colostomy.

Postoperatively, the patient remained septic, and vegetable matter was recovered from one of the drains, so a surgical consultant was called. On November 9, a general surgeon performed an exploratory laparotomy and found necrosis, hemorrhage, acute inflammation of the colostomy, separation of the colostomy from its sutured position on the anterior abdominal wall, and mucosa at the end of the Hartman pouch, necessitating resection of this segment of the colon back to the rectum. Numerous intra-abdominal abscesses were also drained.

Two days later, the patient returned to the OR for further abscess drainage and creation of a left end colostomy. She was discharged 1 month later.

On January 4, 2008, she went to the ER for nausea and abdominal pain. Five days later, a plastic surgeon performed extensive skin grafting on the chronically open abdominal wound. On March 12, the patient returned to the ER because of abdominal pain and was admitted for nasogastric drainage and intravenous (IV) fluids. She returned to the ER again on April 26, reporting pain. A CT scan revealed a cystic mass in the pelvis, which was drained under CT guidance. In June and July, the patient was seen in the ER three times for pain, nausea, and vomiting.

In January 2009, she underwent another laparotomy for takedown of the colostomy, lysis of adhesions, and excision of a left 4-cm pelvic cyst (pathology later revealed the cyst to be ovarian tissue). She also underwent a left-sided myocutaneous flap reconstruction of an abdominal wall defect, and a right-sided myocutaneous flap with placement of a 16 x 20–cm sheet of AlloDerm Tissue Matrix (LifeCell). She continues to experience abdominal pain and visits the ER for that reason. In March 2009, she underwent repeat drainage of a pelvic collection via CT imaging. No further follow-up is available.

Could this catastrophic course have been avoided? What might have prevented it?

Adhesions are likely after any abdominal procedure

The biggest risk factor for laparoscopy-related intestinal injury is the presence of pelvic or abdominal adhesions.^1,2 Adhesions inevitably form after any intra-abdominal surgery, and new adhesions are likely with each successive intra-abdominal procedure. Even adhesiolysis leads to the formation of adhesions postoperatively.

 

Few reliable data suggest that adhesions cause pelvic pain, or that adhesiolysis relieves such pain.³ Furthermore, it may be impossible to predict with reasonable probability where adhesions may be located preoperatively or to know with certainty whether a portion of the intestine is adherent to the anterior abdominal wall directly below the usual subumbilical entry site. Because of the likelihood of adhesions in a patient who has undergone two or more laparotomies, it is risky to thrust a 10- to 12-mm trocar through the anterior abdominal wall below the navel.

A few variables influence the risk of injury

The trocar used in laparoscopic procedures plays a role in the risk of bowel injury. For example, relatively dull reusable devices may push nonfixed intestine away rather than penetrate the viscus. In contrast, razor-sharp disposable devices are more likely to cut into the underlying bowel.

Body habitus is also important. The obese woman is at greater risk for entry injuries, owing to physical aspects of the fatty anterior abdominal wall. When force is applied to the wall, it moves inward, toward the posterior wall, trapping intestine. In a thin woman, the abdominal wall is less elastic, so there is less excursion upon trocar entry.

Intestinal status is another variable to consider. A collapsed bowel is unlikely to be perforated by an entry trocar, whereas a thin, distended bowel is vulnerable to injury. Bowel status can be determined preoperatively using various modalities, including radiographic studies.

Careful surgical technique is imperative. Sharp dissection is always preferable to the blunt tearing of tissue, particularly in cases involving fibrous adhesions. Tearing a dense, unyielding adhesion is likely to remove a piece of intestinal wall because the tensile strength of the adhesion is typically greater than that of the viscus itself.

Thorough knowledge of pelvic anatomy is essential. It would be particularly egregious for a surgeon to mistake an adhesion for the normal peritoneal attachments of the left and sigmoid colon, or to resect the mesentery of the small bowel, believing it to be an adhesion.

Energy devices account for a significant number of intestinal injuries (FIGURE 1). Any surgeon who utilizes an energy device is obligated to protect the patient from a thermal injury—and the manufacturers of these instruments should provide reliable data on the safe use of the device, including information about the expected zone of conductive thermal spread based on power density and tissue type. As a general rule, avoid the use of monopolar electrosurgical devices for intra-abdominal dissection.

Adhesiolysis is a risky enterprise. Several studies have found a significant likelihood of bowel injury during lysis of adhesions.^4-6 In two studies by Baggish, 94% of adhesiolysis-related injuries involved moderate or severe adhesions.^5,6

FIGURE 1 Use of energy devices is risky near bowel
Energy devices account for a significant number of intestinal injuries. In this figure, the arrow indicates leakage of fecal matter from the bowel defect.

Is laparoscopy the wisest approach?

It is important to weigh the risks of laparoscopy against the potential benefits for the patient. Surgical experience and skill are perhaps the most important variables to consider when deciding on an operative approach. A high volume of laparoscopic operations—performed by a gynecologic surgeon—should translate into a lower risk of injury to intra-abdominal structures.⁷ That is, the greater the number of cases performed, the lower the risk of injury.

Garry and colleagues conducted two parallel randomized trials comparing 1) laparoscopic and abdominal hysterectomy and 2) laparoscopic and vaginal hysterectomy as part of the eVALuate study.⁸ Laparoscopic hysterectomy was associated with a significantly higher rate of major complications than abdominal hysterectomy and took longer to perform. No major differences in the rate of complications were found between laparoscopic and vaginal hysterectomy.

In a review of laparoscopy-related bowel injuries, Brosens and colleagues found significant variations in the complication rate, depending on the experience of the surgeon—a 0.2% rate of access injuries for surgeons who had performed fewer than 100 procedures versus 0.06% for those who had performed more than 100 cases, and a 0.3% rate of operative injuries for surgeons who had performed fewer than 100 procedures versus 0.04% for more experienced surgeons.⁷

A few precautions can improve the safety of laparoscopy

If adhesions are known or suspected, primary laparoscopic entry should be planned for a site other than the infra-umbilical area. Options include:

• entry via the left hypochondrium in the midclavicular line
• an open procedure.

However, open laparoscopic entry does not always avert intestinal injury.^9-11

If the anatomy is obscured once the abdomen has been entered safely, retroperitoneal dissection may be useful, particularly for exposure of the left colon. When it is unclear whether a structure to be incised is a loop of bowel or a distended, adherent oviduct, it is best to refrain from cutting it.

 

For adhesiolysis, traction and counter-traction are the techniques of choice. Dissection of intestine should always be parallel to the axis of the viscus. Remember, too, that the blood supply enters via the mesenteric margin of the intestine.

After any dissection involving the intestine, carefully inspect the bowel and describe that inspection in the operative report (FIGURE 2). If injury is suspected, consult a general surgeon and open the abdomen to permit thorough inspection of the intestines.

What the literature reveals about intestinal injury

Several published reports describe a large number of laparoscopic cases and the major attendant complications.^12-16 A number of studies have focused on gastrointestinal (GI) complications associated with laparoscopic procedures, providing site-specific data.

Many injuries occur during entry

Vilos reported on 40 bowel injuries, of which 55% occurred during primary trocar entry (19 closed and three open entries).¹⁷

In a report on 62 GI injuries in 56 patients, Chapron and colleagues found that one-third occurred during the approach phase of the laparoscopy; they advocated creation of a pneumoperitoneum rather than direct trocar insertion.¹⁸

In a report from the Netherlands, 24 of 29 GI injuries occurred during the approach.²

In a review of 63 GI complications related to diagnostic and operative laparoscopy, 75% of injuries were associated with primary trocar insertion.¹⁹

Optical access trocars do not appear to be protective against bowel injury. One study of 79 complications associated with these devices found 24 bowel injuries.²⁰

In addition, in two reports detailing 130 cases of small- and large-bowel perforations associated with laparoscopic procedures, Baggish found that 62 (77%) of small-bowel injuries and 20 (41%) of colonic injuries were entry-related.^5,6

Energy devices can be problematic

In the study by Chapron and colleagues of 62 GI injuries, six were secondary to the use of electrosurgical devices, four of them involving monopolar instruments.¹⁸

In a study from Scotland, 27 of 117 (23%) of bowel injuries during laparoscopic procedures were attributable to a thermal event.²¹

Baggish found that 43% of operative injuries among 130 intestinal perforations were energy-related.^5,6

Intraoperative diagnosis is optimal

Soderstrom reviewed 66 cases of laparoscopy-related bowel injuries and found three deaths attributable to a delay in diagnosis exceeding 72 hours.⁴

In a study by Vilos, the mean time for diagnosis of bowel injuries was 4 days (range, 0–23 days), with intraoperative diagnosis in only 35.7% of cases.¹⁷

In a Finnish nationwide analysis of laparoscopic complications, Harkki-Siren and Kurki found that small-bowel injuries were identified an average of 3.3 days after occurrence; when electrosurgery was involved in the injury, the average time to diagnosis was 4.8 days.²² As for large-bowel injuries, 44% were identified intraoperatively. In the remainder of cases, the average time from injury to diagnosis was 10.4 days for electrosurgical injuries and 1.3 days for injuries related to sharp dissection.

In the studies by Baggish, 82 of 130 (63%) intestinal injuries were diagnosed 48 hours or more after the operation.^5,6

Baggish also made the following observations:

• The most common symptoms of intestinal injury were (in order of frequency) abdominal pain, bloating, nausea and vomiting, and fever or chills (or both). The most common signs were abdominal tenderness, abdominal distension, diminished bowel sounds, and elevated or subnormal temperature.
• Sepsis was apparent (due to the onset of systemic inflammatory response syndrome) in the majority of small-bowel perforations and virtually all colonic perforations. Findings of tachycardia, tachypnea, elevated leukocyte count, and bandemia suggested sepsis syndrome.
• Radiologically observed free air was often misinterpreted by the radiologist as being consistent with residual gas from the initial laparoscopy. In reality, most—if not all—CO₂ gas is absorbed within 24 hours, particularly in obese women. Early CT imaging with oral contrast leads to the most expeditious, correct diagnosis, compared with flat and upright abdominal radiographs.
• Obese women did not exhibit rebound tenderness even though subsequent operative findings revealed extensive and severe peritonitis.
• When infection occurred, it usually was polymicrobial in nature. The most frequently cultured organisms include Escherichia coli, Enterococcus, alpha and beta Streptococcus, Staphylococcus, and Bacteroides.

Baggish concluded that earlier diagnosis could be achieved with careful inspection of the intestine at the conclusion of each operative procedure (FIGURE 2).

Similarly, Chapron and colleagues recommended meticulous inspection of all areas where bowel lysis has been performed. “When there is the slightest doubt, carry out tests for leakage (transanal injection of 200 mL methylene blue using a Foley catheter) in order not to overlook a rectosigmoid injury which would become apparent secondarily in a context of peritonitis,” they wrote. They also suggested that the patient be educated about the signs and symptoms of intestinal injury.¹⁸

 

Whenever a bowel injury is visualized intraoperatively, assume that it is transmural until it is proved otherwise.

FIGURE 2 Meticulous bowel inspection can identify perforation
It is vital to inspect the bowel after any dissection that involves the intestine, being especially alert for puncture wounds caused by a trocar and small tears associated with adhesiolysis.

SOURCE: Baggish MS, Karram MM. Atlas of Pelvic Anatomy and Gynecologic Surgery. 3rd ed. Philadelphia: Elsevier; 2011:1142.

How to avoid urinary tract injuries

Along with major vessel injury and intestinal perforation, bladder and ureteral injuries are the most common complications of laparoscopic surgery. Although urinary tract injuries are rarely fatal, they can cause a range of sequelae, including urinoma, vesicovaginal and ureterovaginal fistulas, hydroureter, hydronephrosis, renal damage, and kidney atrophy.

The incidence of ureteral injury during laparoscopy ranges from less than 0.1% to 1.0%, and the incidence of bladder injury ranges from less than 0.8% to 2.0%.^23-26 Investigators in Singapore described eight urologic injuries among 485 laparoscopic hysterectomies and identified several risk factors:

• previous cesarean delivery
• multiple fibroids
• severe endometriosis.²⁷

Another set of investigators found a history of laparotomy to be a risk factor for bladder injury during laparoscopic hysterectomy.²⁸

Rooney and colleagues studied the effect of previous cesarean delivery on the risk of injury during hysterectomy.²⁹ Among 5,092 hysterectomies—including 433 laparoscopic-assisted vaginal hysterectomies, 3,140 abdominal procedures, and 1,539 vaginal operations—the rate of bladder injury varied by approach. Cystotomy was observed in 0.76% of abdominal hysterectomies (33% had a previous cesarean delivery), 1.3% of vaginal procedures (21% had a previous cesarean), and 1.8% of laparoscopic operations (62.5% had a previous cesarean). The odds ratio for cystotomy during hysterectomy among women with a previous cesarean delivery was 1.26 for the abdominal approach, 3.00 for the vaginal route, and 7.50 for laparoscopic-assisted vaginal hysterectomy.²⁹

Two studies highlight common aspects of injury

In a recent report of 75 urinary tract injuries associated with laparoscopic surgery, Baggish identified a total of 33 injuries involving the bladder and 42 of ureteral origin. Twelve of the bladder injuries were associated with the approach, and 21 were related to the surgery. In contrast, only one of the 42 ureteral injuries was related to the approach.³⁰

Baggish also found that just under 50% of urinary tract injuries were related to the use of thermal energy, including all three vesicovaginal fistulas. Fourteen bladder lacerations occurred during separation of the bladder from the uterus during laparoscopic hysterectomy.³⁰

Common sites of injury were at the infundibulopelvic ligament, between the infundibulopelvic ligament and the uterine vessels, and at or below the uterine vessels.³⁰

None of the 42 ureteral injuries were diagnosed intraoperatively. In fact, 37 of these injuries were not correctly diagnosed until more than 48 hours after surgery. Two uterovaginal fistulas were also diagnosed in the late postoperative period.³⁰

Bladder injuries were identified via cystoscopy or cystometrogram or by the instillation of methylene blue into the bladder, with observation from above for leakage. Ureteral injuries were identified by IV pyelogram, retrograde pyelogram, or attempted passage of a stent. Every ureteral injury showed up as hydroureter and hydronephrosis via pyelography.³⁰

Grainger and colleagues reported five ureteral injuries associated with laparoscopic procedures.³¹ The principal symptoms were low back pain, abdominal pain, leukocytosis, and peritonitis. All five injuries were associated with endometriosis surgery, most commonly near the uterosacral ligaments.

Grainger and colleagues cited eight additional cases of injury. Three patients among the 13 total cases lost renal function, and two eventually required nephrectomy.³¹

How to prevent, identify, and manage urinary tract injuries

Thorough knowledge of anatomy and meticulous technique are imperative to prevent urinary tract injuries. Strategies include:

• Use sharp rather than blunt dissection.
• Know the risk factors for urinary tract injury, which include previous cesarean delivery or intra-abdominal surgery, presence of adhesions, and deep endometriosis.
• Be aware of the dangers posed by energy devices when they are used near the bladder and ureter. Even bipolar devices can cause thermal injury.
• Employ hydrodissection when there are bladder adhesions, and work nearer the uterus or vagina than the bladder, leaving a margin of tissue.
• When the ureter’s location is unclear relative to the operative site, do not hesitate to open the retroperitoneal space to observe the ureter. If necessary, dissect the ureter distally.
• Perform cystoscopy with IV indigo carmine injection at the conclusion of surgery to ensure that the ureter is not occluded.
• Be aware that peristalsis is not an indication of ureteral integrity. In fact, an obstructed ureter will pulsate more vigorously than a normal one.
• Consider preoperative ureteral catheterization, which may avert injury without increasing operative time, blood loss, and hospital stay,³² although the data are not definitive.³³
• Be vigilant. Early identification of injuries reduces morbidity. In the case of ureteral obstruction, immediate stenting will usually obviate the need for ureteral implantation and nephrostomy if the obstruction is not complete.
• Intervene early to cut an obstructing suture or relieve ureteral bowing. Doing so may eliminate the obstruction altogether in many cases.
• If a laceration is found in the bladder trigone or its vicinity, always perform ureteral catheterization to help prevent the inadvertent suturing of the intravesical ureter into the repair.
• After repair of a bladder laceration, perform cystoscopy with IV injection of indigo carmine to ensure ureteral integrity.
• Use only absorbable suture in bladder repairs. I recommend 2-0 chromic catgut for the first layer, which should encompass muscularis and mucosa. Place a second layer of sutures using 3-0 polyglactin 910 (Vicryl), imbricating the first layer.
• After completion of a bladder repair, instill a solution of diluted methylene blue (1 part methylene blue to 100 parts sterile water or saline) to distend the bladder, and carefully inspect the closure to ensure that it is watertight. Then place a Foley catheter for a minimum of 2 weeks. Four to 6 weeks after repair, perform a cystogram to ensure that healing is complete, with no leakage.
• Call a urologist if you are not well-versed in bladder repair, or if the ureter is injured (or injury is suspected).
• Watch for fistula formation, an inevitable outcome of untreated bladder and ureteral injury, which may occur early or late in the postoperative course.

 

Choose an approach wisely

Laparoscopy is a learned skill. Supervised practice generally leads to greater levels of proficiency, and repetition of the same operations improves dexterity and execution. However, laparoscopy is also an art—some people have the touch and some do not.

Although laparoscopic techniques offer many advantages, they also have shortcomings. The complications described here, and the strategies I have offered for preventing and managing them, should help gynecologic surgeons determine whether laparoscopy is the optimal route of operation, based on surgical experience, characteristics of the individual patient, and other variables.

We want to hear from you! Tell us what you think.

CASE: Adhesions complicate multiple surgeries

In early 2007, a 37-year-old woman with a history of hysterectomy, adhesiolysis, bilateral partial salpingectomy, and cholecystectomy underwent an attempted laparoscopic bilateral salpingo-oophorectomy (BSO) for pelvic pain. The operation was converted to laparotomy because of severe adhesions and required several hours to complete.

After the BSO, the patient developed hydronephrosis in her left kidney secondary to an inflammatory cyst. In March 2007, a urologist placed a ureteral stent to relieve the obstruction. One month later, the patient was referred to a gynecologic oncologist for chronic pelvic pain.

On October 29, 2007, the patient underwent operative laparoscopy for adhesiolysis and appendectomy. No retroperitoneal exploration was attempted at the time. According to the operative note, the 10-mm port incision was enlarged to 3 cm to enable the surgeon to inspect the descending colon. Postoperatively, the patient reported persistent abdominal pain and fever and was admitted to the hospital for observation. Although she had a documented temperature of 102°F on October 31, with tachypnea, tachycardia, and a white blood cell (WBC) count of 2.9 x 10³/μL, she was discharged home the same day.

The next morning, the patient returned to the hospital’s emergency room (ER) reporting worsening abdominal pain and shortness of breath. Her vital signs included a temperature of 95.8°F, heart rate of 135 bpm, respiration of 32 breaths/min, and blood pressure of 100/68 mm Hg. An examination revealed a tender, distended abdomen, and the patient exhibited guarding behavior upon palpation in all quadrants. Bowel sounds were hypoactive, and the WBC count was 4.2 x 10³/μL. No differential count was ordered. A computed tomography (CT) scan showed free air in the abdomen, pneumomediastinum, and subcutaneous emphysema of the abdominal wall and chest wall.

The next day, a differential WBC count revealed bands elevated at a 25% level. A cardiac consultant diagnosed heart failure and remarked that pneumomediastinum should not occur after abdominal surgery. In the evening, the gynecologic oncologist performed a laparotomy and observed enteric contents in the abdominal cavity, as well as a defect of approximately 2 mm in the lower portion of the rectosigmoid colon. According to the operative note, the gynecologic oncologist stapled off the area below the defect and performed a descending loop colostomy.

Postoperatively, the patient remained septic, and vegetable matter was recovered from one of the drains, so a surgical consultant was called. On November 9, a general surgeon performed an exploratory laparotomy and found necrosis, hemorrhage, acute inflammation of the colostomy, separation of the colostomy from its sutured position on the anterior abdominal wall, and mucosa at the end of the Hartman pouch, necessitating resection of this segment of the colon back to the rectum. Numerous intra-abdominal abscesses were also drained.

Two days later, the patient returned to the OR for further abscess drainage and creation of a left end colostomy. She was discharged 1 month later.

On January 4, 2008, she went to the ER for nausea and abdominal pain. Five days later, a plastic surgeon performed extensive skin grafting on the chronically open abdominal wound. On March 12, the patient returned to the ER because of abdominal pain and was admitted for nasogastric drainage and intravenous (IV) fluids. She returned to the ER again on April 26, reporting pain. A CT scan revealed a cystic mass in the pelvis, which was drained under CT guidance. In June and July, the patient was seen in the ER three times for pain, nausea, and vomiting.

In January 2009, she underwent another laparotomy for takedown of the colostomy, lysis of adhesions, and excision of a left 4-cm pelvic cyst (pathology later revealed the cyst to be ovarian tissue). She also underwent a left-sided myocutaneous flap reconstruction of an abdominal wall defect, and a right-sided myocutaneous flap with placement of a 16 x 20–cm sheet of AlloDerm Tissue Matrix (LifeCell). She continues to experience abdominal pain and visits the ER for that reason. In March 2009, she underwent repeat drainage of a pelvic collection via CT imaging. No further follow-up is available.

Could this catastrophic course have been avoided? What might have prevented it?

Adhesions are likely after any abdominal procedure

The biggest risk factor for laparoscopy-related intestinal injury is the presence of pelvic or abdominal adhesions.^1,2 Adhesions inevitably form after any intra-abdominal surgery, and new adhesions are likely with each successive intra-abdominal procedure. Even adhesiolysis leads to the formation of adhesions postoperatively.

 

Few reliable data suggest that adhesions cause pelvic pain, or that adhesiolysis relieves such pain.³ Furthermore, it may be impossible to predict with reasonable probability where adhesions may be located preoperatively or to know with certainty whether a portion of the intestine is adherent to the anterior abdominal wall directly below the usual subumbilical entry site. Because of the likelihood of adhesions in a patient who has undergone two or more laparotomies, it is risky to thrust a 10- to 12-mm trocar through the anterior abdominal wall below the navel.

A few variables influence the risk of injury

The trocar used in laparoscopic procedures plays a role in the risk of bowel injury. For example, relatively dull reusable devices may push nonfixed intestine away rather than penetrate the viscus. In contrast, razor-sharp disposable devices are more likely to cut into the underlying bowel.

Body habitus is also important. The obese woman is at greater risk for entry injuries, owing to physical aspects of the fatty anterior abdominal wall. When force is applied to the wall, it moves inward, toward the posterior wall, trapping intestine. In a thin woman, the abdominal wall is less elastic, so there is less excursion upon trocar entry.

Intestinal status is another variable to consider. A collapsed bowel is unlikely to be perforated by an entry trocar, whereas a thin, distended bowel is vulnerable to injury. Bowel status can be determined preoperatively using various modalities, including radiographic studies.

Careful surgical technique is imperative. Sharp dissection is always preferable to the blunt tearing of tissue, particularly in cases involving fibrous adhesions. Tearing a dense, unyielding adhesion is likely to remove a piece of intestinal wall because the tensile strength of the adhesion is typically greater than that of the viscus itself.

Thorough knowledge of pelvic anatomy is essential. It would be particularly egregious for a surgeon to mistake an adhesion for the normal peritoneal attachments of the left and sigmoid colon, or to resect the mesentery of the small bowel, believing it to be an adhesion.

Energy devices account for a significant number of intestinal injuries (FIGURE 1). Any surgeon who utilizes an energy device is obligated to protect the patient from a thermal injury—and the manufacturers of these instruments should provide reliable data on the safe use of the device, including information about the expected zone of conductive thermal spread based on power density and tissue type. As a general rule, avoid the use of monopolar electrosurgical devices for intra-abdominal dissection.

Adhesiolysis is a risky enterprise. Several studies have found a significant likelihood of bowel injury during lysis of adhesions.^4-6 In two studies by Baggish, 94% of adhesiolysis-related injuries involved moderate or severe adhesions.^5,6

FIGURE 1 Use of energy devices is risky near bowel
Energy devices account for a significant number of intestinal injuries. In this figure, the arrow indicates leakage of fecal matter from the bowel defect.

Is laparoscopy the wisest approach?

It is important to weigh the risks of laparoscopy against the potential benefits for the patient. Surgical experience and skill are perhaps the most important variables to consider when deciding on an operative approach. A high volume of laparoscopic operations—performed by a gynecologic surgeon—should translate into a lower risk of injury to intra-abdominal structures.⁷ That is, the greater the number of cases performed, the lower the risk of injury.

Garry and colleagues conducted two parallel randomized trials comparing 1) laparoscopic and abdominal hysterectomy and 2) laparoscopic and vaginal hysterectomy as part of the eVALuate study.⁸ Laparoscopic hysterectomy was associated with a significantly higher rate of major complications than abdominal hysterectomy and took longer to perform. No major differences in the rate of complications were found between laparoscopic and vaginal hysterectomy.

In a review of laparoscopy-related bowel injuries, Brosens and colleagues found significant variations in the complication rate, depending on the experience of the surgeon—a 0.2% rate of access injuries for surgeons who had performed fewer than 100 procedures versus 0.06% for those who had performed more than 100 cases, and a 0.3% rate of operative injuries for surgeons who had performed fewer than 100 procedures versus 0.04% for more experienced surgeons.⁷

A few precautions can improve the safety of laparoscopy

If adhesions are known or suspected, primary laparoscopic entry should be planned for a site other than the infra-umbilical area. Options include:

• entry via the left hypochondrium in the midclavicular line
• an open procedure.

However, open laparoscopic entry does not always avert intestinal injury.^9-11

If the anatomy is obscured once the abdomen has been entered safely, retroperitoneal dissection may be useful, particularly for exposure of the left colon. When it is unclear whether a structure to be incised is a loop of bowel or a distended, adherent oviduct, it is best to refrain from cutting it.

 

For adhesiolysis, traction and counter-traction are the techniques of choice. Dissection of intestine should always be parallel to the axis of the viscus. Remember, too, that the blood supply enters via the mesenteric margin of the intestine.

After any dissection involving the intestine, carefully inspect the bowel and describe that inspection in the operative report (FIGURE 2). If injury is suspected, consult a general surgeon and open the abdomen to permit thorough inspection of the intestines.

What the literature reveals about intestinal injury

Several published reports describe a large number of laparoscopic cases and the major attendant complications.^12-16 A number of studies have focused on gastrointestinal (GI) complications associated with laparoscopic procedures, providing site-specific data.

Many injuries occur during entry

Vilos reported on 40 bowel injuries, of which 55% occurred during primary trocar entry (19 closed and three open entries).¹⁷

In a report on 62 GI injuries in 56 patients, Chapron and colleagues found that one-third occurred during the approach phase of the laparoscopy; they advocated creation of a pneumoperitoneum rather than direct trocar insertion.¹⁸

In a report from the Netherlands, 24 of 29 GI injuries occurred during the approach.²

In a review of 63 GI complications related to diagnostic and operative laparoscopy, 75% of injuries were associated with primary trocar insertion.¹⁹

Optical access trocars do not appear to be protective against bowel injury. One study of 79 complications associated with these devices found 24 bowel injuries.²⁰

In addition, in two reports detailing 130 cases of small- and large-bowel perforations associated with laparoscopic procedures, Baggish found that 62 (77%) of small-bowel injuries and 20 (41%) of colonic injuries were entry-related.^5,6

Energy devices can be problematic

In the study by Chapron and colleagues of 62 GI injuries, six were secondary to the use of electrosurgical devices, four of them involving monopolar instruments.¹⁸

In a study from Scotland, 27 of 117 (23%) of bowel injuries during laparoscopic procedures were attributable to a thermal event.²¹

Baggish found that 43% of operative injuries among 130 intestinal perforations were energy-related.^5,6

Intraoperative diagnosis is optimal

Soderstrom reviewed 66 cases of laparoscopy-related bowel injuries and found three deaths attributable to a delay in diagnosis exceeding 72 hours.⁴

In a study by Vilos, the mean time for diagnosis of bowel injuries was 4 days (range, 0–23 days), with intraoperative diagnosis in only 35.7% of cases.¹⁷

In a Finnish nationwide analysis of laparoscopic complications, Harkki-Siren and Kurki found that small-bowel injuries were identified an average of 3.3 days after occurrence; when electrosurgery was involved in the injury, the average time to diagnosis was 4.8 days.²² As for large-bowel injuries, 44% were identified intraoperatively. In the remainder of cases, the average time from injury to diagnosis was 10.4 days for electrosurgical injuries and 1.3 days for injuries related to sharp dissection.

In the studies by Baggish, 82 of 130 (63%) intestinal injuries were diagnosed 48 hours or more after the operation.^5,6

Baggish also made the following observations:

• The most common symptoms of intestinal injury were (in order of frequency) abdominal pain, bloating, nausea and vomiting, and fever or chills (or both). The most common signs were abdominal tenderness, abdominal distension, diminished bowel sounds, and elevated or subnormal temperature.
• Sepsis was apparent (due to the onset of systemic inflammatory response syndrome) in the majority of small-bowel perforations and virtually all colonic perforations. Findings of tachycardia, tachypnea, elevated leukocyte count, and bandemia suggested sepsis syndrome.
• Radiologically observed free air was often misinterpreted by the radiologist as being consistent with residual gas from the initial laparoscopy. In reality, most—if not all—CO₂ gas is absorbed within 24 hours, particularly in obese women. Early CT imaging with oral contrast leads to the most expeditious, correct diagnosis, compared with flat and upright abdominal radiographs.
• Obese women did not exhibit rebound tenderness even though subsequent operative findings revealed extensive and severe peritonitis.
• When infection occurred, it usually was polymicrobial in nature. The most frequently cultured organisms include Escherichia coli, Enterococcus, alpha and beta Streptococcus, Staphylococcus, and Bacteroides.

Baggish concluded that earlier diagnosis could be achieved with careful inspection of the intestine at the conclusion of each operative procedure (FIGURE 2).

Similarly, Chapron and colleagues recommended meticulous inspection of all areas where bowel lysis has been performed. “When there is the slightest doubt, carry out tests for leakage (transanal injection of 200 mL methylene blue using a Foley catheter) in order not to overlook a rectosigmoid injury which would become apparent secondarily in a context of peritonitis,” they wrote. They also suggested that the patient be educated about the signs and symptoms of intestinal injury.¹⁸

 

Whenever a bowel injury is visualized intraoperatively, assume that it is transmural until it is proved otherwise.

FIGURE 2 Meticulous bowel inspection can identify perforation
It is vital to inspect the bowel after any dissection that involves the intestine, being especially alert for puncture wounds caused by a trocar and small tears associated with adhesiolysis.

SOURCE: Baggish MS, Karram MM. Atlas of Pelvic Anatomy and Gynecologic Surgery. 3rd ed. Philadelphia: Elsevier; 2011:1142.

How to avoid urinary tract injuries

Along with major vessel injury and intestinal perforation, bladder and ureteral injuries are the most common complications of laparoscopic surgery. Although urinary tract injuries are rarely fatal, they can cause a range of sequelae, including urinoma, vesicovaginal and ureterovaginal fistulas, hydroureter, hydronephrosis, renal damage, and kidney atrophy.

The incidence of ureteral injury during laparoscopy ranges from less than 0.1% to 1.0%, and the incidence of bladder injury ranges from less than 0.8% to 2.0%.^23-26 Investigators in Singapore described eight urologic injuries among 485 laparoscopic hysterectomies and identified several risk factors:

• previous cesarean delivery
• multiple fibroids
• severe endometriosis.²⁷

Another set of investigators found a history of laparotomy to be a risk factor for bladder injury during laparoscopic hysterectomy.²⁸

Rooney and colleagues studied the effect of previous cesarean delivery on the risk of injury during hysterectomy.²⁹ Among 5,092 hysterectomies—including 433 laparoscopic-assisted vaginal hysterectomies, 3,140 abdominal procedures, and 1,539 vaginal operations—the rate of bladder injury varied by approach. Cystotomy was observed in 0.76% of abdominal hysterectomies (33% had a previous cesarean delivery), 1.3% of vaginal procedures (21% had a previous cesarean), and 1.8% of laparoscopic operations (62.5% had a previous cesarean). The odds ratio for cystotomy during hysterectomy among women with a previous cesarean delivery was 1.26 for the abdominal approach, 3.00 for the vaginal route, and 7.50 for laparoscopic-assisted vaginal hysterectomy.²⁹

Two studies highlight common aspects of injury

In a recent report of 75 urinary tract injuries associated with laparoscopic surgery, Baggish identified a total of 33 injuries involving the bladder and 42 of ureteral origin. Twelve of the bladder injuries were associated with the approach, and 21 were related to the surgery. In contrast, only one of the 42 ureteral injuries was related to the approach.³⁰

Baggish also found that just under 50% of urinary tract injuries were related to the use of thermal energy, including all three vesicovaginal fistulas. Fourteen bladder lacerations occurred during separation of the bladder from the uterus during laparoscopic hysterectomy.³⁰

Common sites of injury were at the infundibulopelvic ligament, between the infundibulopelvic ligament and the uterine vessels, and at or below the uterine vessels.³⁰

None of the 42 ureteral injuries were diagnosed intraoperatively. In fact, 37 of these injuries were not correctly diagnosed until more than 48 hours after surgery. Two uterovaginal fistulas were also diagnosed in the late postoperative period.³⁰

Bladder injuries were identified via cystoscopy or cystometrogram or by the instillation of methylene blue into the bladder, with observation from above for leakage. Ureteral injuries were identified by IV pyelogram, retrograde pyelogram, or attempted passage of a stent. Every ureteral injury showed up as hydroureter and hydronephrosis via pyelography.³⁰

Grainger and colleagues reported five ureteral injuries associated with laparoscopic procedures.³¹ The principal symptoms were low back pain, abdominal pain, leukocytosis, and peritonitis. All five injuries were associated with endometriosis surgery, most commonly near the uterosacral ligaments.

Grainger and colleagues cited eight additional cases of injury. Three patients among the 13 total cases lost renal function, and two eventually required nephrectomy.³¹

How to prevent, identify, and manage urinary tract injuries

Thorough knowledge of anatomy and meticulous technique are imperative to prevent urinary tract injuries. Strategies include:

• Use sharp rather than blunt dissection.
• Know the risk factors for urinary tract injury, which include previous cesarean delivery or intra-abdominal surgery, presence of adhesions, and deep endometriosis.
• Be aware of the dangers posed by energy devices when they are used near the bladder and ureter. Even bipolar devices can cause thermal injury.
• Employ hydrodissection when there are bladder adhesions, and work nearer the uterus or vagina than the bladder, leaving a margin of tissue.
• When the ureter’s location is unclear relative to the operative site, do not hesitate to open the retroperitoneal space to observe the ureter. If necessary, dissect the ureter distally.
• Perform cystoscopy with IV indigo carmine injection at the conclusion of surgery to ensure that the ureter is not occluded.
• Be aware that peristalsis is not an indication of ureteral integrity. In fact, an obstructed ureter will pulsate more vigorously than a normal one.
• Consider preoperative ureteral catheterization, which may avert injury without increasing operative time, blood loss, and hospital stay,³² although the data are not definitive.³³
• Be vigilant. Early identification of injuries reduces morbidity. In the case of ureteral obstruction, immediate stenting will usually obviate the need for ureteral implantation and nephrostomy if the obstruction is not complete.
• Intervene early to cut an obstructing suture or relieve ureteral bowing. Doing so may eliminate the obstruction altogether in many cases.
• If a laceration is found in the bladder trigone or its vicinity, always perform ureteral catheterization to help prevent the inadvertent suturing of the intravesical ureter into the repair.
• After repair of a bladder laceration, perform cystoscopy with IV injection of indigo carmine to ensure ureteral integrity.
• Use only absorbable suture in bladder repairs. I recommend 2-0 chromic catgut for the first layer, which should encompass muscularis and mucosa. Place a second layer of sutures using 3-0 polyglactin 910 (Vicryl), imbricating the first layer.
• After completion of a bladder repair, instill a solution of diluted methylene blue (1 part methylene blue to 100 parts sterile water or saline) to distend the bladder, and carefully inspect the closure to ensure that it is watertight. Then place a Foley catheter for a minimum of 2 weeks. Four to 6 weeks after repair, perform a cystogram to ensure that healing is complete, with no leakage.
• Call a urologist if you are not well-versed in bladder repair, or if the ureter is injured (or injury is suspected).
• Watch for fistula formation, an inevitable outcome of untreated bladder and ureteral injury, which may occur early or late in the postoperative course.

 

Choose an approach wisely

Laparoscopy is a learned skill. Supervised practice generally leads to greater levels of proficiency, and repetition of the same operations improves dexterity and execution. However, laparoscopy is also an art—some people have the touch and some do not.

Although laparoscopic techniques offer many advantages, they also have shortcomings. The complications described here, and the strategies I have offered for preventing and managing them, should help gynecologic surgeons determine whether laparoscopy is the optimal route of operation, based on surgical experience, characteristics of the individual patient, and other variables.

We want to hear from you! Tell us what you think.

CASE: Adhesions complicate multiple surgeries

In early 2007, a 37-year-old woman with a history of hysterectomy, adhesiolysis, bilateral partial salpingectomy, and cholecystectomy underwent an attempted laparoscopic bilateral salpingo-oophorectomy (BSO) for pelvic pain. The operation was converted to laparotomy because of severe adhesions and required several hours to complete.

After the BSO, the patient developed hydronephrosis in her left kidney secondary to an inflammatory cyst. In March 2007, a urologist placed a ureteral stent to relieve the obstruction. One month later, the patient was referred to a gynecologic oncologist for chronic pelvic pain.

On October 29, 2007, the patient underwent operative laparoscopy for adhesiolysis and appendectomy. No retroperitoneal exploration was attempted at the time. According to the operative note, the 10-mm port incision was enlarged to 3 cm to enable the surgeon to inspect the descending colon. Postoperatively, the patient reported persistent abdominal pain and fever and was admitted to the hospital for observation. Although she had a documented temperature of 102°F on October 31, with tachypnea, tachycardia, and a white blood cell (WBC) count of 2.9 x 10³/μL, she was discharged home the same day.

The next morning, the patient returned to the hospital’s emergency room (ER) reporting worsening abdominal pain and shortness of breath. Her vital signs included a temperature of 95.8°F, heart rate of 135 bpm, respiration of 32 breaths/min, and blood pressure of 100/68 mm Hg. An examination revealed a tender, distended abdomen, and the patient exhibited guarding behavior upon palpation in all quadrants. Bowel sounds were hypoactive, and the WBC count was 4.2 x 10³/μL. No differential count was ordered. A computed tomography (CT) scan showed free air in the abdomen, pneumomediastinum, and subcutaneous emphysema of the abdominal wall and chest wall.

The next day, a differential WBC count revealed bands elevated at a 25% level. A cardiac consultant diagnosed heart failure and remarked that pneumomediastinum should not occur after abdominal surgery. In the evening, the gynecologic oncologist performed a laparotomy and observed enteric contents in the abdominal cavity, as well as a defect of approximately 2 mm in the lower portion of the rectosigmoid colon. According to the operative note, the gynecologic oncologist stapled off the area below the defect and performed a descending loop colostomy.

Postoperatively, the patient remained septic, and vegetable matter was recovered from one of the drains, so a surgical consultant was called. On November 9, a general surgeon performed an exploratory laparotomy and found necrosis, hemorrhage, acute inflammation of the colostomy, separation of the colostomy from its sutured position on the anterior abdominal wall, and mucosa at the end of the Hartman pouch, necessitating resection of this segment of the colon back to the rectum. Numerous intra-abdominal abscesses were also drained.

Two days later, the patient returned to the OR for further abscess drainage and creation of a left end colostomy. She was discharged 1 month later.

On January 4, 2008, she went to the ER for nausea and abdominal pain. Five days later, a plastic surgeon performed extensive skin grafting on the chronically open abdominal wound. On March 12, the patient returned to the ER because of abdominal pain and was admitted for nasogastric drainage and intravenous (IV) fluids. She returned to the ER again on April 26, reporting pain. A CT scan revealed a cystic mass in the pelvis, which was drained under CT guidance. In June and July, the patient was seen in the ER three times for pain, nausea, and vomiting.

In January 2009, she underwent another laparotomy for takedown of the colostomy, lysis of adhesions, and excision of a left 4-cm pelvic cyst (pathology later revealed the cyst to be ovarian tissue). She also underwent a left-sided myocutaneous flap reconstruction of an abdominal wall defect, and a right-sided myocutaneous flap with placement of a 16 x 20–cm sheet of AlloDerm Tissue Matrix (LifeCell). She continues to experience abdominal pain and visits the ER for that reason. In March 2009, she underwent repeat drainage of a pelvic collection via CT imaging. No further follow-up is available.

Could this catastrophic course have been avoided? What might have prevented it?

Adhesions are likely after any abdominal procedure

The biggest risk factor for laparoscopy-related intestinal injury is the presence of pelvic or abdominal adhesions.^1,2 Adhesions inevitably form after any intra-abdominal surgery, and new adhesions are likely with each successive intra-abdominal procedure. Even adhesiolysis leads to the formation of adhesions postoperatively.

 

Few reliable data suggest that adhesions cause pelvic pain, or that adhesiolysis relieves such pain.³ Furthermore, it may be impossible to predict with reasonable probability where adhesions may be located preoperatively or to know with certainty whether a portion of the intestine is adherent to the anterior abdominal wall directly below the usual subumbilical entry site. Because of the likelihood of adhesions in a patient who has undergone two or more laparotomies, it is risky to thrust a 10- to 12-mm trocar through the anterior abdominal wall below the navel.

A few variables influence the risk of injury

The trocar used in laparoscopic procedures plays a role in the risk of bowel injury. For example, relatively dull reusable devices may push nonfixed intestine away rather than penetrate the viscus. In contrast, razor-sharp disposable devices are more likely to cut into the underlying bowel.

Body habitus is also important. The obese woman is at greater risk for entry injuries, owing to physical aspects of the fatty anterior abdominal wall. When force is applied to the wall, it moves inward, toward the posterior wall, trapping intestine. In a thin woman, the abdominal wall is less elastic, so there is less excursion upon trocar entry.

Intestinal status is another variable to consider. A collapsed bowel is unlikely to be perforated by an entry trocar, whereas a thin, distended bowel is vulnerable to injury. Bowel status can be determined preoperatively using various modalities, including radiographic studies.

Careful surgical technique is imperative. Sharp dissection is always preferable to the blunt tearing of tissue, particularly in cases involving fibrous adhesions. Tearing a dense, unyielding adhesion is likely to remove a piece of intestinal wall because the tensile strength of the adhesion is typically greater than that of the viscus itself.

Thorough knowledge of pelvic anatomy is essential. It would be particularly egregious for a surgeon to mistake an adhesion for the normal peritoneal attachments of the left and sigmoid colon, or to resect the mesentery of the small bowel, believing it to be an adhesion.

Energy devices account for a significant number of intestinal injuries (FIGURE 1). Any surgeon who utilizes an energy device is obligated to protect the patient from a thermal injury—and the manufacturers of these instruments should provide reliable data on the safe use of the device, including information about the expected zone of conductive thermal spread based on power density and tissue type. As a general rule, avoid the use of monopolar electrosurgical devices for intra-abdominal dissection.

Adhesiolysis is a risky enterprise. Several studies have found a significant likelihood of bowel injury during lysis of adhesions.^4-6 In two studies by Baggish, 94% of adhesiolysis-related injuries involved moderate or severe adhesions.^5,6

FIGURE 1 Use of energy devices is risky near bowel
Energy devices account for a significant number of intestinal injuries. In this figure, the arrow indicates leakage of fecal matter from the bowel defect.

Is laparoscopy the wisest approach?

It is important to weigh the risks of laparoscopy against the potential benefits for the patient. Surgical experience and skill are perhaps the most important variables to consider when deciding on an operative approach. A high volume of laparoscopic operations—performed by a gynecologic surgeon—should translate into a lower risk of injury to intra-abdominal structures.⁷ That is, the greater the number of cases performed, the lower the risk of injury.

Garry and colleagues conducted two parallel randomized trials comparing 1) laparoscopic and abdominal hysterectomy and 2) laparoscopic and vaginal hysterectomy as part of the eVALuate study.⁸ Laparoscopic hysterectomy was associated with a significantly higher rate of major complications than abdominal hysterectomy and took longer to perform. No major differences in the rate of complications were found between laparoscopic and vaginal hysterectomy.

In a review of laparoscopy-related bowel injuries, Brosens and colleagues found significant variations in the complication rate, depending on the experience of the surgeon—a 0.2% rate of access injuries for surgeons who had performed fewer than 100 procedures versus 0.06% for those who had performed more than 100 cases, and a 0.3% rate of operative injuries for surgeons who had performed fewer than 100 procedures versus 0.04% for more experienced surgeons.⁷

A few precautions can improve the safety of laparoscopy

If adhesions are known or suspected, primary laparoscopic entry should be planned for a site other than the infra-umbilical area. Options include:

• entry via the left hypochondrium in the midclavicular line
• an open procedure.

However, open laparoscopic entry does not always avert intestinal injury.^9-11

If the anatomy is obscured once the abdomen has been entered safely, retroperitoneal dissection may be useful, particularly for exposure of the left colon. When it is unclear whether a structure to be incised is a loop of bowel or a distended, adherent oviduct, it is best to refrain from cutting it.

 

For adhesiolysis, traction and counter-traction are the techniques of choice. Dissection of intestine should always be parallel to the axis of the viscus. Remember, too, that the blood supply enters via the mesenteric margin of the intestine.

After any dissection involving the intestine, carefully inspect the bowel and describe that inspection in the operative report (FIGURE 2). If injury is suspected, consult a general surgeon and open the abdomen to permit thorough inspection of the intestines.

What the literature reveals about intestinal injury

Several published reports describe a large number of laparoscopic cases and the major attendant complications.^12-16 A number of studies have focused on gastrointestinal (GI) complications associated with laparoscopic procedures, providing site-specific data.

Many injuries occur during entry

Vilos reported on 40 bowel injuries, of which 55% occurred during primary trocar entry (19 closed and three open entries).¹⁷

In a report on 62 GI injuries in 56 patients, Chapron and colleagues found that one-third occurred during the approach phase of the laparoscopy; they advocated creation of a pneumoperitoneum rather than direct trocar insertion.¹⁸

In a report from the Netherlands, 24 of 29 GI injuries occurred during the approach.²

In a review of 63 GI complications related to diagnostic and operative laparoscopy, 75% of injuries were associated with primary trocar insertion.¹⁹

Optical access trocars do not appear to be protective against bowel injury. One study of 79 complications associated with these devices found 24 bowel injuries.²⁰

In addition, in two reports detailing 130 cases of small- and large-bowel perforations associated with laparoscopic procedures, Baggish found that 62 (77%) of small-bowel injuries and 20 (41%) of colonic injuries were entry-related.^5,6

Energy devices can be problematic

In the study by Chapron and colleagues of 62 GI injuries, six were secondary to the use of electrosurgical devices, four of them involving monopolar instruments.¹⁸

In a study from Scotland, 27 of 117 (23%) of bowel injuries during laparoscopic procedures were attributable to a thermal event.²¹

Baggish found that 43% of operative injuries among 130 intestinal perforations were energy-related.^5,6

Intraoperative diagnosis is optimal

Soderstrom reviewed 66 cases of laparoscopy-related bowel injuries and found three deaths attributable to a delay in diagnosis exceeding 72 hours.⁴

In a study by Vilos, the mean time for diagnosis of bowel injuries was 4 days (range, 0–23 days), with intraoperative diagnosis in only 35.7% of cases.¹⁷

In a Finnish nationwide analysis of laparoscopic complications, Harkki-Siren and Kurki found that small-bowel injuries were identified an average of 3.3 days after occurrence; when electrosurgery was involved in the injury, the average time to diagnosis was 4.8 days.²² As for large-bowel injuries, 44% were identified intraoperatively. In the remainder of cases, the average time from injury to diagnosis was 10.4 days for electrosurgical injuries and 1.3 days for injuries related to sharp dissection.

In the studies by Baggish, 82 of 130 (63%) intestinal injuries were diagnosed 48 hours or more after the operation.^5,6

Baggish also made the following observations:

• The most common symptoms of intestinal injury were (in order of frequency) abdominal pain, bloating, nausea and vomiting, and fever or chills (or both). The most common signs were abdominal tenderness, abdominal distension, diminished bowel sounds, and elevated or subnormal temperature.
• Sepsis was apparent (due to the onset of systemic inflammatory response syndrome) in the majority of small-bowel perforations and virtually all colonic perforations. Findings of tachycardia, tachypnea, elevated leukocyte count, and bandemia suggested sepsis syndrome.
• Radiologically observed free air was often misinterpreted by the radiologist as being consistent with residual gas from the initial laparoscopy. In reality, most—if not all—CO₂ gas is absorbed within 24 hours, particularly in obese women. Early CT imaging with oral contrast leads to the most expeditious, correct diagnosis, compared with flat and upright abdominal radiographs.
• Obese women did not exhibit rebound tenderness even though subsequent operative findings revealed extensive and severe peritonitis.
• When infection occurred, it usually was polymicrobial in nature. The most frequently cultured organisms include Escherichia coli, Enterococcus, alpha and beta Streptococcus, Staphylococcus, and Bacteroides.

Baggish concluded that earlier diagnosis could be achieved with careful inspection of the intestine at the conclusion of each operative procedure (FIGURE 2).

Similarly, Chapron and colleagues recommended meticulous inspection of all areas where bowel lysis has been performed. “When there is the slightest doubt, carry out tests for leakage (transanal injection of 200 mL methylene blue using a Foley catheter) in order not to overlook a rectosigmoid injury which would become apparent secondarily in a context of peritonitis,” they wrote. They also suggested that the patient be educated about the signs and symptoms of intestinal injury.¹⁸

 

Whenever a bowel injury is visualized intraoperatively, assume that it is transmural until it is proved otherwise.

FIGURE 2 Meticulous bowel inspection can identify perforation
It is vital to inspect the bowel after any dissection that involves the intestine, being especially alert for puncture wounds caused by a trocar and small tears associated with adhesiolysis.

SOURCE: Baggish MS, Karram MM. Atlas of Pelvic Anatomy and Gynecologic Surgery. 3rd ed. Philadelphia: Elsevier; 2011:1142.

How to avoid urinary tract injuries

Along with major vessel injury and intestinal perforation, bladder and ureteral injuries are the most common complications of laparoscopic surgery. Although urinary tract injuries are rarely fatal, they can cause a range of sequelae, including urinoma, vesicovaginal and ureterovaginal fistulas, hydroureter, hydronephrosis, renal damage, and kidney atrophy.

The incidence of ureteral injury during laparoscopy ranges from less than 0.1% to 1.0%, and the incidence of bladder injury ranges from less than 0.8% to 2.0%.^23-26 Investigators in Singapore described eight urologic injuries among 485 laparoscopic hysterectomies and identified several risk factors:

• previous cesarean delivery
• multiple fibroids
• severe endometriosis.²⁷

Another set of investigators found a history of laparotomy to be a risk factor for bladder injury during laparoscopic hysterectomy.²⁸

Rooney and colleagues studied the effect of previous cesarean delivery on the risk of injury during hysterectomy.²⁹ Among 5,092 hysterectomies—including 433 laparoscopic-assisted vaginal hysterectomies, 3,140 abdominal procedures, and 1,539 vaginal operations—the rate of bladder injury varied by approach. Cystotomy was observed in 0.76% of abdominal hysterectomies (33% had a previous cesarean delivery), 1.3% of vaginal procedures (21% had a previous cesarean), and 1.8% of laparoscopic operations (62.5% had a previous cesarean). The odds ratio for cystotomy during hysterectomy among women with a previous cesarean delivery was 1.26 for the abdominal approach, 3.00 for the vaginal route, and 7.50 for laparoscopic-assisted vaginal hysterectomy.²⁹

Two studies highlight common aspects of injury

In a recent report of 75 urinary tract injuries associated with laparoscopic surgery, Baggish identified a total of 33 injuries involving the bladder and 42 of ureteral origin. Twelve of the bladder injuries were associated with the approach, and 21 were related to the surgery. In contrast, only one of the 42 ureteral injuries was related to the approach.³⁰

Baggish also found that just under 50% of urinary tract injuries were related to the use of thermal energy, including all three vesicovaginal fistulas. Fourteen bladder lacerations occurred during separation of the bladder from the uterus during laparoscopic hysterectomy.³⁰

Common sites of injury were at the infundibulopelvic ligament, between the infundibulopelvic ligament and the uterine vessels, and at or below the uterine vessels.³⁰

None of the 42 ureteral injuries were diagnosed intraoperatively. In fact, 37 of these injuries were not correctly diagnosed until more than 48 hours after surgery. Two uterovaginal fistulas were also diagnosed in the late postoperative period.³⁰

Bladder injuries were identified via cystoscopy or cystometrogram or by the instillation of methylene blue into the bladder, with observation from above for leakage. Ureteral injuries were identified by IV pyelogram, retrograde pyelogram, or attempted passage of a stent. Every ureteral injury showed up as hydroureter and hydronephrosis via pyelography.³⁰

Grainger and colleagues reported five ureteral injuries associated with laparoscopic procedures.³¹ The principal symptoms were low back pain, abdominal pain, leukocytosis, and peritonitis. All five injuries were associated with endometriosis surgery, most commonly near the uterosacral ligaments.

Grainger and colleagues cited eight additional cases of injury. Three patients among the 13 total cases lost renal function, and two eventually required nephrectomy.³¹

How to prevent, identify, and manage urinary tract injuries

Thorough knowledge of anatomy and meticulous technique are imperative to prevent urinary tract injuries. Strategies include:

• Use sharp rather than blunt dissection.
• Know the risk factors for urinary tract injury, which include previous cesarean delivery or intra-abdominal surgery, presence of adhesions, and deep endometriosis.
• Be aware of the dangers posed by energy devices when they are used near the bladder and ureter. Even bipolar devices can cause thermal injury.
• Employ hydrodissection when there are bladder adhesions, and work nearer the uterus or vagina than the bladder, leaving a margin of tissue.
• When the ureter’s location is unclear relative to the operative site, do not hesitate to open the retroperitoneal space to observe the ureter. If necessary, dissect the ureter distally.
• Perform cystoscopy with IV indigo carmine injection at the conclusion of surgery to ensure that the ureter is not occluded.
• Be aware that peristalsis is not an indication of ureteral integrity. In fact, an obstructed ureter will pulsate more vigorously than a normal one.
• Consider preoperative ureteral catheterization, which may avert injury without increasing operative time, blood loss, and hospital stay,³² although the data are not definitive.³³
• Be vigilant. Early identification of injuries reduces morbidity. In the case of ureteral obstruction, immediate stenting will usually obviate the need for ureteral implantation and nephrostomy if the obstruction is not complete.
• Intervene early to cut an obstructing suture or relieve ureteral bowing. Doing so may eliminate the obstruction altogether in many cases.
• If a laceration is found in the bladder trigone or its vicinity, always perform ureteral catheterization to help prevent the inadvertent suturing of the intravesical ureter into the repair.
• After repair of a bladder laceration, perform cystoscopy with IV injection of indigo carmine to ensure ureteral integrity.
• Use only absorbable suture in bladder repairs. I recommend 2-0 chromic catgut for the first layer, which should encompass muscularis and mucosa. Place a second layer of sutures using 3-0 polyglactin 910 (Vicryl), imbricating the first layer.
• After completion of a bladder repair, instill a solution of diluted methylene blue (1 part methylene blue to 100 parts sterile water or saline) to distend the bladder, and carefully inspect the closure to ensure that it is watertight. Then place a Foley catheter for a minimum of 2 weeks. Four to 6 weeks after repair, perform a cystogram to ensure that healing is complete, with no leakage.
• Call a urologist if you are not well-versed in bladder repair, or if the ureter is injured (or injury is suspected).
• Watch for fistula formation, an inevitable outcome of untreated bladder and ureteral injury, which may occur early or late in the postoperative course.

 

Choose an approach wisely

Laparoscopy is a learned skill. Supervised practice generally leads to greater levels of proficiency, and repetition of the same operations improves dexterity and execution. However, laparoscopy is also an art—some people have the touch and some do not.

Although laparoscopic techniques offer many advantages, they also have shortcomings. The complications described here, and the strategies I have offered for preventing and managing them, should help gynecologic surgeons determine whether laparoscopy is the optimal route of operation, based on surgical experience, characteristics of the individual patient, and other variables.

We want to hear from you! Tell us what you think.

By age 50, almost 70% of white women and more than 80% of black women will have a uterine leiomyoma.¹ These benign, hormone-sensitive neoplasms¹ are asymptomatic in the majority of women, but they can cause infertility, abnormal uterine bleeding, and bulk symptoms.²

When symptomatic, fibroids are amenable to multiple management options, ranging from expectant management to medical therapy to uterine artery embolization to myomectomy to hysterectomy. Myomectomy remains the surgical option of choice for women with symptomatic fibroids who wish to retain their fertility. It is also an option for some women who may not desire fertility retention but who do wish to maintain their uterus.

Compared with traditional myomectomy by laparotomy, laparoscopic myomectomy offers the advantages of:

• less blood loss
• less postoperative pain
• less postoperative adhesions formation
• faster recovery
• better cosmesis.^3,4

Current technology makes performing laparoscopic myomectomy by either “straight-stick” or robotic assistance a viable option for most women.

In this article, we describe our technique in performing straight-stick laparoscopic myomectomy.

Preoperative evaluation: The first key to success

Laparoscopic myomectomy is an advanced, delicate, and challenging surgery. Preoperative evaluation is integral to its planning and a successful outcome.

Imaging

We recommend magnetic resonance imaging (MRI) as a standard order whenever a laparoscopic approach to myomectomy is being considered, for several reasons. First, MRI of the abdomen and pelvis with contrast allows for a precise map of the location of fibroids in relation to the myometrium and the uterine cavity. Reviewing the MRI results with the patient preoperatively gives both you and the patient a clearer picture of the challenges ahead. Patients tell us they appreciate these easier-to-understand images of their anatomy and, in cases when the decision is made to proceed abdominally, it is more clear to the patient why the decision is being made.

Surgically, the MRI helps compensate for the lack of tactile feedback when faced with deep intramural fibroids laparoscopically. The MRI also helps avoid operative surprises. Experience teaches us that, when relying on transvaginal ultrasound alone, adenomyotic regions can be identified mistakenly as fibroids. Preoperative MRI can help you avoid this discovery at the time of surgery.

A flexible office hysteroscopy serves as an adjunct to MRI for precise preoperative cavitary evaluation, especially when fibroids are present in close proximity to the endometrial cavity or the patient reports menorrhagia as a component of her symptomatology. When small submucosal fibroids exist in addition to larger fibroids, we frequently perform a combined hysteroscopic and laparoscopic approach to myomectomy.

Although bowel preparation does not diminish complications from bowel surgery or improve outcome,⁵ we generally use laxative suppositories the night prior to surgery to improve access to the posterior cul-de-sac and reduce bulk resulting from a sigmoid full of feces.

Preoperative laboratory evaluation should always include complete blood count, beta hCG, blood type testing, and antibody screen. In patients with known anemia or large intramural fibroids, we typically match the patient for 2 units of packed red blood cells. Additionally, if significant blood loss is anticipated, cell saver technology can be modified to accommodate a laparoscopic suction tip, allowing the patient’s own blood to be collected and readministered.

 

How to minimize blood loss

Blood loss during laparoscopic myomectomy generally is less than during laparotomy due to venous compression from pneumoperitoneum. However, blood loss remains a chief concern when performing laparoscopic myomectomy. A variety of techniques have been described to minimize blood loss, including injection of dilute vasopressin⁶ and tourniquet placement around uterine vessels.⁷

Injection. To temporarily minimize bleeding in the surgical field, we routinely utilize subserosal injection of dilute vasopressin (20 IU in 100 mL of normal saline) until visible vessels blanch. This practice is more effective than deep myoma or myometrial injection.

Tourniquet. We selectively use a laparoscopically placed tourniquet to compress uterine arteries at the mid-cervix during surgery. One approach is as follows (see VIDEO 1):

1. Open windows in bilateral broad ligaments lateral to the uterine pedicles and medial to the ureters.
2. Pass the end of a 14-16 French red rubber catheter through one of the low lateral port sites with the port removed.
3. Tag the trailing end of the tourniquet outside the abdomen and replace the port alongside the catheter.
4. Pass the end of the catheter down through the ipsilateral broad ligament window and under the posterior cervix.
5. Pass the end of the catheter up through the contralateral broad ligament window and over the anterior cervix.
6. Pass the end of the catheter through each of the broad ligament windows a second time and then out through the contralateral port site.
7. Pull the tourniquet tight from both port sites (which will occlude the uterine arteries). Place Kelly clamps on the catheter ends where they exit the port sites to maintain tension until the end of the uterine repair.

Lateral ports can still be utilized with the tourniquet in place.

Permanent occlusion. In women undergoing laparoscopic myomectomy who have completed child bearing, we advocate permanent uterine artery occlusion at the origin of the uterine arteries retroperitoneally. This can be performed in a number of ways— utilizing clips, suture, or transection. Uterine artery occlusion not only leads to less operative blood loss but preliminary studies also suggest it decreases the risk of fibroid recurrence.⁸

Surgical technique

After the patient is prepped and draped in low lithotomy position with her arms tucked at her sides, drain the bladder with an indwelling catheter. Insert a uterine manipulator, such as the VCare (Conmed Corporation), into the uterus.

Obtain umbilical entry for a 30° optic scope, and place the patient in steep Trendelenburg position. We use two 5-mm lateral ports and one 12-mm suprapubic port. The level of placement of the lateral ports is tailored to the size of the fibroids; it can be anywhere from the level of the anterior iliac spine to the level of the umbilicus for fibroids contained in the pelvis or in the abdomen, respectively.

Uterine incision

After vasopressin injection, tourniquet placement, or permanent uterine artery occlusion is performed as described above, we advocate a transverse uterine incision. We do so mainly because:

• The transverse incision runs parallel to the arcuate vessels of the myometrium, leading to less bleeding.
• We suture from the lateral ports so the transverse incision facilitates a more ergonomic repair.

Perform the uterine incision (we use the Harmonic Ace [Ethicon Endo-Surgery, Inc]) through the uterine serosa deep toward the myoma. Incision size should be appropriate to the diameter of the fibroid; smaller incisions result in unnecessary struggling during enucleation of the fibroid. Incision depth should reach the fibroid capsule, and this incision should be developed over the entire fibroid. Tunneling in the myometrium is undesirable and should be avoided because it increases myometrial injury as well as the risk of hematoma.

Fibroid enucleation

Once the initial uterine incision is complete, enucleate the fibroid using a combination of traction, countertraction, sharp, and blunt dissection (see VIDEO 2). Pearls to successful enucleation include:

• Maintain traction and countertraction when cutting tissue. This helps to identify appropriate planes and allows tissue to separate quickly, minimizing thermal energy spread.
• Replace the tenaculum or myoma screw regularly at the border of the myoma and myometrium. The ultrasonic scalpel blade can be drilled into the myoma in order to create traction on the myoma.
• Bluntly peel tissue from the myoma outward. Ideally all myometrium and vessels should stay with the uterus. A properly enucleated fibroid will be pearly in appearance and avascular.
• Be particularly careful when in contact with the endometrium. Even submucous fibroids can be enucleated regularly without entering the endometrial cavity.

Uterine repair

If the endometrial cavity is inadvertently entered, close the defect (we use a 2-0 monocryl or Vicryl suture). Next, imbricate the endometrium over with successive layers, taking special care not to pass a needle into the endometrial cavity. In cases in which significant endometrial disruption cannot be avoided, use a postoperative intrauterine balloon stent. This is placed postoperatively and left in place for 2 weeks. To stimulate endometrial proliferation, we prescribe oral estradiol 1 mg twice per day for 4 weeks. Following endometrial stimulation, we prescribe a 10-day progestin withdrawal and ask the patient to return to the office for a flexible diagnostic hysteroscopy following her first menses to ensure cavitary integrity.

 

Once fibroid enucleation is complete, perform a multilayer closure of the defect using an absorbable, unidirectional barbed suture (V-Loc, Covidien). Eliminate all dead space in the closure. The last two throws of each barbed suture should be in the direction of the prior two throws to secure the suture. Finally, cut the suture at the tissue edge without leaving any trailing tail or knot.

Why use a barbed suture? The advantages of using absorbable barbed suture include:

• elimination of knot tying
• shorter closure time
• better tension distribution throughout the wound.

Close the seromuscularis layer in a hemostatic baseball stitch fashion to minimize suture exposure and subsequent adhesions (FIGURE). Use of the suprapubic port for the needle retrieval device facilitates placement of the alternating “inside-out” baseball stitch (see VIDEO 3).

FIGURE Use of a hemostatic baseball stitch (with absorbable, unidirectional barbed suture) to close the seromuscularis layer of the uterus, thereby minimizing suture exposure and subsequent adhesions.

Morcellation

Mechanically morcellate the fibroids through the suprapubic port site. We use an electrical morcellator (Karl Storz Endoscopy). In cases of massive fibroids (>15 cm) we utilize cold- knife morcellation with a # 10 scalpel through an extended 3-cm suprapubic incision with a vertical fascial incision protected by a self-retaining wound retractor. It is important to be vigilant to remove all fibroid pieces as postoperative disseminated leiomyomatosis is well described.

Adhesion prevention

Myomectomy is notorious for creating dense and challenging postoperative adhesions. Given the high rate of repeat surgery for patients undergoing the procedure, anything you can do to limit the adhesion load will be appreciated by both your patient and her next surgeon. Without exception, the most important adhesion-prevention strategy is meticulous attention to tissue handling and hemostasis. In general, laparoscopy leads to fewer adhesions than laparotomy, but a bloody field and raw uterine serosa will create an environment ripe for adhesions regardless of surgical approach. If the operative field is dry, use commercial adhesion prevention aids according to manufacturers’ recommendations.

Concluding thoughts, from experience

Laparoscopic myomectomy is a challenging yet rewarding procedure. For essential points to our approach, see “Laparoscopic myomectomy: Key takeaways” on this page.

Other important things to keep in mind:

• Fibroid presentation is as varied as the women who have them—meticulous preoperative preparation is an absolute must.
• Utilize well-established approaches to preventing blood loss, removing fibroids, and repairing the uterine defects. The accomplished gynecologic laparoscopist will be successful in the majority of cases.
• Practice suturing in a box-trainer setting before taking on initial cases. Early cases should focus on straightforward subserosal fibroids and, as skills progress, more and more difficult cases will become reasonable.
• Do not place any hard and fast limit on either the number or size of fibroids you are willing to remove laparoscopically. Rather, rely on sound surgical judgment, an honest assessment of your limitations, and a healthy dose of caution as you approach every new patient. Never sacrifice the quality of your repair for a less invasive approach to surgery.

We want to hear from you! Tell us what you think.

By age 50, almost 70% of white women and more than 80% of black women will have a uterine leiomyoma.¹ These benign, hormone-sensitive neoplasms¹ are asymptomatic in the majority of women, but they can cause infertility, abnormal uterine bleeding, and bulk symptoms.²

When symptomatic, fibroids are amenable to multiple management options, ranging from expectant management to medical therapy to uterine artery embolization to myomectomy to hysterectomy. Myomectomy remains the surgical option of choice for women with symptomatic fibroids who wish to retain their fertility. It is also an option for some women who may not desire fertility retention but who do wish to maintain their uterus.

Compared with traditional myomectomy by laparotomy, laparoscopic myomectomy offers the advantages of:

• less blood loss
• less postoperative pain
• less postoperative adhesions formation
• faster recovery
• better cosmesis.^3,4

Current technology makes performing laparoscopic myomectomy by either “straight-stick” or robotic assistance a viable option for most women.

In this article, we describe our technique in performing straight-stick laparoscopic myomectomy.

Preoperative evaluation: The first key to success

Laparoscopic myomectomy is an advanced, delicate, and challenging surgery. Preoperative evaluation is integral to its planning and a successful outcome.

Imaging

We recommend magnetic resonance imaging (MRI) as a standard order whenever a laparoscopic approach to myomectomy is being considered, for several reasons. First, MRI of the abdomen and pelvis with contrast allows for a precise map of the location of fibroids in relation to the myometrium and the uterine cavity. Reviewing the MRI results with the patient preoperatively gives both you and the patient a clearer picture of the challenges ahead. Patients tell us they appreciate these easier-to-understand images of their anatomy and, in cases when the decision is made to proceed abdominally, it is more clear to the patient why the decision is being made.

Surgically, the MRI helps compensate for the lack of tactile feedback when faced with deep intramural fibroids laparoscopically. The MRI also helps avoid operative surprises. Experience teaches us that, when relying on transvaginal ultrasound alone, adenomyotic regions can be identified mistakenly as fibroids. Preoperative MRI can help you avoid this discovery at the time of surgery.

A flexible office hysteroscopy serves as an adjunct to MRI for precise preoperative cavitary evaluation, especially when fibroids are present in close proximity to the endometrial cavity or the patient reports menorrhagia as a component of her symptomatology. When small submucosal fibroids exist in addition to larger fibroids, we frequently perform a combined hysteroscopic and laparoscopic approach to myomectomy.

Although bowel preparation does not diminish complications from bowel surgery or improve outcome,⁵ we generally use laxative suppositories the night prior to surgery to improve access to the posterior cul-de-sac and reduce bulk resulting from a sigmoid full of feces.

Preoperative laboratory evaluation should always include complete blood count, beta hCG, blood type testing, and antibody screen. In patients with known anemia or large intramural fibroids, we typically match the patient for 2 units of packed red blood cells. Additionally, if significant blood loss is anticipated, cell saver technology can be modified to accommodate a laparoscopic suction tip, allowing the patient’s own blood to be collected and readministered.

 

How to minimize blood loss

Blood loss during laparoscopic myomectomy generally is less than during laparotomy due to venous compression from pneumoperitoneum. However, blood loss remains a chief concern when performing laparoscopic myomectomy. A variety of techniques have been described to minimize blood loss, including injection of dilute vasopressin⁶ and tourniquet placement around uterine vessels.⁷

Injection. To temporarily minimize bleeding in the surgical field, we routinely utilize subserosal injection of dilute vasopressin (20 IU in 100 mL of normal saline) until visible vessels blanch. This practice is more effective than deep myoma or myometrial injection.

Tourniquet. We selectively use a laparoscopically placed tourniquet to compress uterine arteries at the mid-cervix during surgery. One approach is as follows (see VIDEO 1):

1. Open windows in bilateral broad ligaments lateral to the uterine pedicles and medial to the ureters.
2. Pass the end of a 14-16 French red rubber catheter through one of the low lateral port sites with the port removed.
3. Tag the trailing end of the tourniquet outside the abdomen and replace the port alongside the catheter.
4. Pass the end of the catheter down through the ipsilateral broad ligament window and under the posterior cervix.
5. Pass the end of the catheter up through the contralateral broad ligament window and over the anterior cervix.
6. Pass the end of the catheter through each of the broad ligament windows a second time and then out through the contralateral port site.
7. Pull the tourniquet tight from both port sites (which will occlude the uterine arteries). Place Kelly clamps on the catheter ends where they exit the port sites to maintain tension until the end of the uterine repair.

Lateral ports can still be utilized with the tourniquet in place.

Permanent occlusion. In women undergoing laparoscopic myomectomy who have completed child bearing, we advocate permanent uterine artery occlusion at the origin of the uterine arteries retroperitoneally. This can be performed in a number of ways— utilizing clips, suture, or transection. Uterine artery occlusion not only leads to less operative blood loss but preliminary studies also suggest it decreases the risk of fibroid recurrence.⁸

Surgical technique

After the patient is prepped and draped in low lithotomy position with her arms tucked at her sides, drain the bladder with an indwelling catheter. Insert a uterine manipulator, such as the VCare (Conmed Corporation), into the uterus.

Obtain umbilical entry for a 30° optic scope, and place the patient in steep Trendelenburg position. We use two 5-mm lateral ports and one 12-mm suprapubic port. The level of placement of the lateral ports is tailored to the size of the fibroids; it can be anywhere from the level of the anterior iliac spine to the level of the umbilicus for fibroids contained in the pelvis or in the abdomen, respectively.

Uterine incision

After vasopressin injection, tourniquet placement, or permanent uterine artery occlusion is performed as described above, we advocate a transverse uterine incision. We do so mainly because:

• The transverse incision runs parallel to the arcuate vessels of the myometrium, leading to less bleeding.
• We suture from the lateral ports so the transverse incision facilitates a more ergonomic repair.

Perform the uterine incision (we use the Harmonic Ace [Ethicon Endo-Surgery, Inc]) through the uterine serosa deep toward the myoma. Incision size should be appropriate to the diameter of the fibroid; smaller incisions result in unnecessary struggling during enucleation of the fibroid. Incision depth should reach the fibroid capsule, and this incision should be developed over the entire fibroid. Tunneling in the myometrium is undesirable and should be avoided because it increases myometrial injury as well as the risk of hematoma.

Fibroid enucleation

Once the initial uterine incision is complete, enucleate the fibroid using a combination of traction, countertraction, sharp, and blunt dissection (see VIDEO 2). Pearls to successful enucleation include:

• Maintain traction and countertraction when cutting tissue. This helps to identify appropriate planes and allows tissue to separate quickly, minimizing thermal energy spread.
• Replace the tenaculum or myoma screw regularly at the border of the myoma and myometrium. The ultrasonic scalpel blade can be drilled into the myoma in order to create traction on the myoma.
• Bluntly peel tissue from the myoma outward. Ideally all myometrium and vessels should stay with the uterus. A properly enucleated fibroid will be pearly in appearance and avascular.
• Be particularly careful when in contact with the endometrium. Even submucous fibroids can be enucleated regularly without entering the endometrial cavity.

Uterine repair

If the endometrial cavity is inadvertently entered, close the defect (we use a 2-0 monocryl or Vicryl suture). Next, imbricate the endometrium over with successive layers, taking special care not to pass a needle into the endometrial cavity. In cases in which significant endometrial disruption cannot be avoided, use a postoperative intrauterine balloon stent. This is placed postoperatively and left in place for 2 weeks. To stimulate endometrial proliferation, we prescribe oral estradiol 1 mg twice per day for 4 weeks. Following endometrial stimulation, we prescribe a 10-day progestin withdrawal and ask the patient to return to the office for a flexible diagnostic hysteroscopy following her first menses to ensure cavitary integrity.

 

Once fibroid enucleation is complete, perform a multilayer closure of the defect using an absorbable, unidirectional barbed suture (V-Loc, Covidien). Eliminate all dead space in the closure. The last two throws of each barbed suture should be in the direction of the prior two throws to secure the suture. Finally, cut the suture at the tissue edge without leaving any trailing tail or knot.

Why use a barbed suture? The advantages of using absorbable barbed suture include:

• elimination of knot tying
• shorter closure time
• better tension distribution throughout the wound.

Close the seromuscularis layer in a hemostatic baseball stitch fashion to minimize suture exposure and subsequent adhesions (FIGURE). Use of the suprapubic port for the needle retrieval device facilitates placement of the alternating “inside-out” baseball stitch (see VIDEO 3).

FIGURE Use of a hemostatic baseball stitch (with absorbable, unidirectional barbed suture) to close the seromuscularis layer of the uterus, thereby minimizing suture exposure and subsequent adhesions.

Morcellation

Mechanically morcellate the fibroids through the suprapubic port site. We use an electrical morcellator (Karl Storz Endoscopy). In cases of massive fibroids (>15 cm) we utilize cold- knife morcellation with a # 10 scalpel through an extended 3-cm suprapubic incision with a vertical fascial incision protected by a self-retaining wound retractor. It is important to be vigilant to remove all fibroid pieces as postoperative disseminated leiomyomatosis is well described.

Adhesion prevention

Myomectomy is notorious for creating dense and challenging postoperative adhesions. Given the high rate of repeat surgery for patients undergoing the procedure, anything you can do to limit the adhesion load will be appreciated by both your patient and her next surgeon. Without exception, the most important adhesion-prevention strategy is meticulous attention to tissue handling and hemostasis. In general, laparoscopy leads to fewer adhesions than laparotomy, but a bloody field and raw uterine serosa will create an environment ripe for adhesions regardless of surgical approach. If the operative field is dry, use commercial adhesion prevention aids according to manufacturers’ recommendations.

Concluding thoughts, from experience

Laparoscopic myomectomy is a challenging yet rewarding procedure. For essential points to our approach, see “Laparoscopic myomectomy: Key takeaways” on this page.

Other important things to keep in mind:

• Fibroid presentation is as varied as the women who have them—meticulous preoperative preparation is an absolute must.
• Utilize well-established approaches to preventing blood loss, removing fibroids, and repairing the uterine defects. The accomplished gynecologic laparoscopist will be successful in the majority of cases.
• Practice suturing in a box-trainer setting before taking on initial cases. Early cases should focus on straightforward subserosal fibroids and, as skills progress, more and more difficult cases will become reasonable.
• Do not place any hard and fast limit on either the number or size of fibroids you are willing to remove laparoscopically. Rather, rely on sound surgical judgment, an honest assessment of your limitations, and a healthy dose of caution as you approach every new patient. Never sacrifice the quality of your repair for a less invasive approach to surgery.

We want to hear from you! Tell us what you think.

By age 50, almost 70% of white women and more than 80% of black women will have a uterine leiomyoma.¹ These benign, hormone-sensitive neoplasms¹ are asymptomatic in the majority of women, but they can cause infertility, abnormal uterine bleeding, and bulk symptoms.²

When symptomatic, fibroids are amenable to multiple management options, ranging from expectant management to medical therapy to uterine artery embolization to myomectomy to hysterectomy. Myomectomy remains the surgical option of choice for women with symptomatic fibroids who wish to retain their fertility. It is also an option for some women who may not desire fertility retention but who do wish to maintain their uterus.

Compared with traditional myomectomy by laparotomy, laparoscopic myomectomy offers the advantages of:

• less blood loss
• less postoperative pain
• less postoperative adhesions formation
• faster recovery
• better cosmesis.^3,4

Current technology makes performing laparoscopic myomectomy by either “straight-stick” or robotic assistance a viable option for most women.

In this article, we describe our technique in performing straight-stick laparoscopic myomectomy.

Preoperative evaluation: The first key to success

Laparoscopic myomectomy is an advanced, delicate, and challenging surgery. Preoperative evaluation is integral to its planning and a successful outcome.

Imaging

We recommend magnetic resonance imaging (MRI) as a standard order whenever a laparoscopic approach to myomectomy is being considered, for several reasons. First, MRI of the abdomen and pelvis with contrast allows for a precise map of the location of fibroids in relation to the myometrium and the uterine cavity. Reviewing the MRI results with the patient preoperatively gives both you and the patient a clearer picture of the challenges ahead. Patients tell us they appreciate these easier-to-understand images of their anatomy and, in cases when the decision is made to proceed abdominally, it is more clear to the patient why the decision is being made.

Surgically, the MRI helps compensate for the lack of tactile feedback when faced with deep intramural fibroids laparoscopically. The MRI also helps avoid operative surprises. Experience teaches us that, when relying on transvaginal ultrasound alone, adenomyotic regions can be identified mistakenly as fibroids. Preoperative MRI can help you avoid this discovery at the time of surgery.

A flexible office hysteroscopy serves as an adjunct to MRI for precise preoperative cavitary evaluation, especially when fibroids are present in close proximity to the endometrial cavity or the patient reports menorrhagia as a component of her symptomatology. When small submucosal fibroids exist in addition to larger fibroids, we frequently perform a combined hysteroscopic and laparoscopic approach to myomectomy.

Although bowel preparation does not diminish complications from bowel surgery or improve outcome,⁵ we generally use laxative suppositories the night prior to surgery to improve access to the posterior cul-de-sac and reduce bulk resulting from a sigmoid full of feces.

Preoperative laboratory evaluation should always include complete blood count, beta hCG, blood type testing, and antibody screen. In patients with known anemia or large intramural fibroids, we typically match the patient for 2 units of packed red blood cells. Additionally, if significant blood loss is anticipated, cell saver technology can be modified to accommodate a laparoscopic suction tip, allowing the patient’s own blood to be collected and readministered.

 

How to minimize blood loss

Blood loss during laparoscopic myomectomy generally is less than during laparotomy due to venous compression from pneumoperitoneum. However, blood loss remains a chief concern when performing laparoscopic myomectomy. A variety of techniques have been described to minimize blood loss, including injection of dilute vasopressin⁶ and tourniquet placement around uterine vessels.⁷

Injection. To temporarily minimize bleeding in the surgical field, we routinely utilize subserosal injection of dilute vasopressin (20 IU in 100 mL of normal saline) until visible vessels blanch. This practice is more effective than deep myoma or myometrial injection.

Tourniquet. We selectively use a laparoscopically placed tourniquet to compress uterine arteries at the mid-cervix during surgery. One approach is as follows (see VIDEO 1):

1. Open windows in bilateral broad ligaments lateral to the uterine pedicles and medial to the ureters.
2. Pass the end of a 14-16 French red rubber catheter through one of the low lateral port sites with the port removed.
3. Tag the trailing end of the tourniquet outside the abdomen and replace the port alongside the catheter.
4. Pass the end of the catheter down through the ipsilateral broad ligament window and under the posterior cervix.
5. Pass the end of the catheter up through the contralateral broad ligament window and over the anterior cervix.
6. Pass the end of the catheter through each of the broad ligament windows a second time and then out through the contralateral port site.
7. Pull the tourniquet tight from both port sites (which will occlude the uterine arteries). Place Kelly clamps on the catheter ends where they exit the port sites to maintain tension until the end of the uterine repair.

Lateral ports can still be utilized with the tourniquet in place.

Permanent occlusion. In women undergoing laparoscopic myomectomy who have completed child bearing, we advocate permanent uterine artery occlusion at the origin of the uterine arteries retroperitoneally. This can be performed in a number of ways— utilizing clips, suture, or transection. Uterine artery occlusion not only leads to less operative blood loss but preliminary studies also suggest it decreases the risk of fibroid recurrence.⁸

Surgical technique

After the patient is prepped and draped in low lithotomy position with her arms tucked at her sides, drain the bladder with an indwelling catheter. Insert a uterine manipulator, such as the VCare (Conmed Corporation), into the uterus.

Obtain umbilical entry for a 30° optic scope, and place the patient in steep Trendelenburg position. We use two 5-mm lateral ports and one 12-mm suprapubic port. The level of placement of the lateral ports is tailored to the size of the fibroids; it can be anywhere from the level of the anterior iliac spine to the level of the umbilicus for fibroids contained in the pelvis or in the abdomen, respectively.

Uterine incision

After vasopressin injection, tourniquet placement, or permanent uterine artery occlusion is performed as described above, we advocate a transverse uterine incision. We do so mainly because:

• The transverse incision runs parallel to the arcuate vessels of the myometrium, leading to less bleeding.
• We suture from the lateral ports so the transverse incision facilitates a more ergonomic repair.

Perform the uterine incision (we use the Harmonic Ace [Ethicon Endo-Surgery, Inc]) through the uterine serosa deep toward the myoma. Incision size should be appropriate to the diameter of the fibroid; smaller incisions result in unnecessary struggling during enucleation of the fibroid. Incision depth should reach the fibroid capsule, and this incision should be developed over the entire fibroid. Tunneling in the myometrium is undesirable and should be avoided because it increases myometrial injury as well as the risk of hematoma.

Fibroid enucleation

Once the initial uterine incision is complete, enucleate the fibroid using a combination of traction, countertraction, sharp, and blunt dissection (see VIDEO 2). Pearls to successful enucleation include:

• Maintain traction and countertraction when cutting tissue. This helps to identify appropriate planes and allows tissue to separate quickly, minimizing thermal energy spread.
• Replace the tenaculum or myoma screw regularly at the border of the myoma and myometrium. The ultrasonic scalpel blade can be drilled into the myoma in order to create traction on the myoma.
• Bluntly peel tissue from the myoma outward. Ideally all myometrium and vessels should stay with the uterus. A properly enucleated fibroid will be pearly in appearance and avascular.
• Be particularly careful when in contact with the endometrium. Even submucous fibroids can be enucleated regularly without entering the endometrial cavity.

Uterine repair

If the endometrial cavity is inadvertently entered, close the defect (we use a 2-0 monocryl or Vicryl suture). Next, imbricate the endometrium over with successive layers, taking special care not to pass a needle into the endometrial cavity. In cases in which significant endometrial disruption cannot be avoided, use a postoperative intrauterine balloon stent. This is placed postoperatively and left in place for 2 weeks. To stimulate endometrial proliferation, we prescribe oral estradiol 1 mg twice per day for 4 weeks. Following endometrial stimulation, we prescribe a 10-day progestin withdrawal and ask the patient to return to the office for a flexible diagnostic hysteroscopy following her first menses to ensure cavitary integrity.

 

Once fibroid enucleation is complete, perform a multilayer closure of the defect using an absorbable, unidirectional barbed suture (V-Loc, Covidien). Eliminate all dead space in the closure. The last two throws of each barbed suture should be in the direction of the prior two throws to secure the suture. Finally, cut the suture at the tissue edge without leaving any trailing tail or knot.

Why use a barbed suture? The advantages of using absorbable barbed suture include:

• elimination of knot tying
• shorter closure time
• better tension distribution throughout the wound.

Close the seromuscularis layer in a hemostatic baseball stitch fashion to minimize suture exposure and subsequent adhesions (FIGURE). Use of the suprapubic port for the needle retrieval device facilitates placement of the alternating “inside-out” baseball stitch (see VIDEO 3).

FIGURE Use of a hemostatic baseball stitch (with absorbable, unidirectional barbed suture) to close the seromuscularis layer of the uterus, thereby minimizing suture exposure and subsequent adhesions.

Morcellation

Mechanically morcellate the fibroids through the suprapubic port site. We use an electrical morcellator (Karl Storz Endoscopy). In cases of massive fibroids (>15 cm) we utilize cold- knife morcellation with a # 10 scalpel through an extended 3-cm suprapubic incision with a vertical fascial incision protected by a self-retaining wound retractor. It is important to be vigilant to remove all fibroid pieces as postoperative disseminated leiomyomatosis is well described.

Adhesion prevention

Myomectomy is notorious for creating dense and challenging postoperative adhesions. Given the high rate of repeat surgery for patients undergoing the procedure, anything you can do to limit the adhesion load will be appreciated by both your patient and her next surgeon. Without exception, the most important adhesion-prevention strategy is meticulous attention to tissue handling and hemostasis. In general, laparoscopy leads to fewer adhesions than laparotomy, but a bloody field and raw uterine serosa will create an environment ripe for adhesions regardless of surgical approach. If the operative field is dry, use commercial adhesion prevention aids according to manufacturers’ recommendations.

Concluding thoughts, from experience

Laparoscopic myomectomy is a challenging yet rewarding procedure. For essential points to our approach, see “Laparoscopic myomectomy: Key takeaways” on this page.

Other important things to keep in mind:

• Fibroid presentation is as varied as the women who have them—meticulous preoperative preparation is an absolute must.
• Utilize well-established approaches to preventing blood loss, removing fibroids, and repairing the uterine defects. The accomplished gynecologic laparoscopist will be successful in the majority of cases.
• Practice suturing in a box-trainer setting before taking on initial cases. Early cases should focus on straightforward subserosal fibroids and, as skills progress, more and more difficult cases will become reasonable.
• Do not place any hard and fast limit on either the number or size of fibroids you are willing to remove laparoscopically. Rather, rely on sound surgical judgment, an honest assessment of your limitations, and a healthy dose of caution as you approach every new patient. Never sacrifice the quality of your repair for a less invasive approach to surgery.

We want to hear from you! Tell us what you think.

CASE: Abdominal entry leads to life-threatening injury

A 50-year-old woman with a BMI of 25 kg/m², a strong family history of breast and ovarian cancer, and a confirmed BRCA mutation was scheduled for prophylactic bilateral salpingo-oophorectomy via robotic laparoscopy on November 26, 2009. At the time of the procedure, the gynecologic surgeon selected a site for the camera trocar that was several centimeters above the umbilicus. After making a transverse incision, he inserted a Veress needle and insufflated the abdomen with CO₂ gas until intra-abdominal pressure reached 17 mm Hg. He then thrust an 11-inch disposable trocar through the anterior abdominal wall, attached the camera to the laparoscope, confirmed proper intraperitoneal placement, and inserted two additional trocars under direct vision.

Shortly after these actions, the anesthesiologist reported that the patient’s blood pressure had dropped precipitously, along with end tidal CO₂. The surgeon examined the peritoneal cavity and discovered blood in the right paracolic gutter. The anesthesiologist advised the surgeon that he could no longer detect the patient’s blood pressure; electrocardiography revealed pulseless electrical activity.

The surgical team began chest compressions, evacuated the pneumoperitoneum, and removed all trocars. Blood was noted on the camera trocar, and the device was secured by the OR staff. The surgeon performed an emergent laparotomy, making the incision within 4 minutes of the beginning of CPR. Exploration revealed a large retroperitoneal hematoma above the area of the aortic bifurcation and inferior vena cava.

General and vascular surgeons were called. The general surgeon opened the retroperitoneum and found an extreme amount of clotted and unclotted blood. The vascular surgeon described the initial injury as a 1.5-cm laceration of the distal aorta, just above the bifurcation. A cell saver was requested and recorded blood loss of 12,000 mL.

The vascular surgeon clamped the aorta proximally; he also clamped both common iliac arteries. He then repaired the lacerations on the aorta using 5-0 Prolene suture (Ethicon). The aorta was significantly narrowed, however, so the surgeon decided to replace the distal aorta, which he then resected and repaired using a 14-mm Dacron graft (DuPont).

Further inspection revealed continuing retroperitoneal bleeding. The vascular surgeon found and repaired a laceration of the inferior mesenteric vein. He also clipped multiple small veins to stop bleeding.

When a hole in the transverse colon was identified, the general surgeon—who had left the operating table—rescrubbed to repair it. He also discovered an injury to the mesentery of the transverse colon and repaired both wounds, resecting the perforated segment. The divided, stapled colon was dropped back into the abdomen because the bowel was dusky. Despite an epinephrine drip, the patient was hypotensive and coagulopathic. The abdomen was packed and covered with sterile cassette film, with towels covering the open wound.

The patient was taken to the postanesthesia care unit in guarded condition and was subsequently transferred to the ICU, where her blood pressure dropped again. She was returned to the OR, where the packs were removed and a bleeding right common iliac artery was repaired using 5-0 Prolene suture. The next day, she underwent bilateral salpingo-oophorectomy with a transverse colon colostomy.

Because of the colon injury, the vascular surgeon believed that the Dacron graft had been contaminated. On December 1, the graft was taken down, a left femoral-vein autograft was harvested, and a reconstructive conduit was created for the terminal aorta. The patient underwent three additional procedures to place mesh into the abdominal wall. When the mesh became infected, it was removed.

The patient remained in the hospital for 1 month, after which she was transferred to a long-term care facility. She suffered permanent neurologic injuries because of prolonged hypoxia and continues to require supportive care.

How could this catastrophe have been avoided?

Traumatic injury to the great retroperitoneal vessels is an emergent and life-threatening event. During gynecologic laparoscopy, it is most likely to occur during entry into the anterior abdominal wall.

Most laparoscopic procedures require entry into the anterior abdominal wall for placement of a trocar and a sleeve that serves as a portal for insertion of the endoscope. Secondary ports provide entry points for manipulative and operative tools.

The most critical entry point is primary placement of the viewing device. Secondary trocars are always inserted under direct visualization; therefore, they carry a lower risk of inflicting injury to underlying viscera and vessels.

Practice safe entry

 

In the early days of laparoscopy, only one method of entry existed. Over time, however, several other techniques have been devised.

The initial method—still widely utilized—is known as the closed or blind technique. The surgeon creates a pneumoperitoneum with the use of a needle that is 18 gauge to 2.5 mm in diameter; the needle is placed through a subumbilical incision. Once intraperitoneal placement is confirmed, CO₂ gas is infused into the peritoneal cavity until the abdomen is tympanic to percussion (usually at pressures of 14 to 18 mm Hg).

Next, the surgeon aims the trocar toward the uterus at a 45° angle, maintaining the device in the midline. Entry is confirmed by opening the trocar’s trap-door valve and witnessing a rush of CO₂ gas.

Another entry technique—the open technique—is used almost universally by general surgeons. The procedure is a type of microlaparotomy. After making the subumbilical incision, the fascia of the abdominal wall is pierced and the peritoneum is grasped and opened bluntly or sharply. Once the edges of the peritoneum are secured, a blunt trocar (Hasson trocar) is inserted. Then the trocar is removed, leaving the sleeve in place to accept the laparoscope.

Another entry variation, called direct entry, employs no pneumoperitoneum. In this approach, the surgeon grabs the anterior abdominal wall, sharply elevating it, and directly thrusts the reusable or disposable trocar into the abdominal cavity.

An extensive review of entry techniques has been published elsewhere.¹

Many complications arise from entry techniques and devices

A survey of Australian gynecologists about entry techniques found that 73% of respondents used a Veress needle and pneumoperitoneum for entry and that 83% used a location other than the infraumbilical site when periumbilical adhesions were suspected. Twenty-one percent had experienced a major retroperitoneal vascular injury, but 33% lacked a plan to manage such injuries.²

In their review of entry techniques, Vilos and colleagues asserted that Veress-needle insertion should be accompanied by pneumoperitoneal pressures of 20 to 30 mm Hg rather than a predetermined volume of CO₂ gas.¹ They also recommended insertion in the left upper quadrant when periumbilical adhesions are suspected or when insufflation at the umbilicus fails three times.

Newer entry devices include the optical-view trocar and the radially expanding trocar. The first consists of a plastic, conically tipped instrument that is optically clear. At least hypothetically, this device permits the surgeon to view each layer of the abdominal wall as he or she thrusts the device under “direct vision” into the abdominal cavity.

The radially expanding trocar is inserted over a Veress needle into the abdominal cavity. Its initial diameter is only 3 mm; once the instrument is in place, however, a blunt plastic trocar and sleeve are pushed into the mesh-like, radially expanding tube until it reaches 11 to 12 mm in diameter. The blunt trocar is then removed, leaving the plastic sheath and mesh material in place to accept the laparoscope. One key advantage of this device is the mesh component, which resists slippage or movement as the laparoscope is moved in and out of the sheath.

Vilos and colleagues concluded that open entry was neither superior nor inferior to other entry techniques and that direct entry without pneumoperitoneum may be as safe as Veress-needle techniques and associated with a lower risk of gas embolism. They also reported that shielded trocars are not associated with fewer visceral or vascular injuries and that visual-entry trocars lack superiority, compared with other devices, for the prevention of visceral or vascular injuries.¹

Other review articles about entry techniques similarly found no objective evidence that any single technique is superior.³ However, data are conflicting on the safety of the optical trocar, compared with other trocars, with some data showing marginal advantages and others demonstrating no difference.^4-6

Follow a few key entry guidelines

In 1990, Yuzpe reported a mail-in survey of 800 practicing ObGyns in Canada on the topic of pneumoperitoneum and trocar injuries.⁷ Of the 407 physicians who responded, 16.7% reported that the pneumoperitoneum needle caused a visceral or major vessel injury, and 16.5% attributed the injury to the primary trocar. Among 109 vessel injuries, 31 were caused by the pneumoperitoneum needle, and 28 of 104 injuries were caused by the primary trocar.

To be safe, Veress needle and primary trocar entry require critical attention to the angle and direction of the thrust relative to the abdominal cavity (FIGURE, page 24). For example, if the Veress needle or the sharp tip of the trocar deviate to the right or left of the midline during entry into the abdomen, injury to the iliac vessels is a clear risk.

 

Most laparoscopic surgeons stand on the left-hand side of the patient and face her feet. Trocar deviation for a right-handed person tends to vector to the right, especially when a twisting motion is utilized. Correct alignment of the primary trocar is straight down the middle of the lower abdomen on a virtual or real line drawn from the center of the navel to the center of the symphysis.

An entry angle of 45° to 60° will carry the needle or trocar toward the bladder or uterus and away from the aorta and left common iliac vein. In contrast, a 90° thrust will aim the device dangerously toward the great vessels. A slightly upward and right-sided deviation from the subumbilical entry will place the needle and trocar in the direction of the inferior vena cava and right common iliac vessels. A 90° entry with deviation to the left will position the entry device at the inferior mesenteric vessels and the left common iliac vessels.

Primary abdominal entry
An entry angle of 45° to 60°, regardless of whether a needle or trocar is used, will carry the device toward the bladder or uterus and away from the aorta and left common iliac vein.In a review of access complications associated with laparoscopy, including major vascular injuries, Philips and Amaral listed variables responsible for large-vessel injury; they also documented the incidence of such injuries associated with laparoscopic cholecystectomy.⁸ They recommended that the patient be placed in the Trendelenburg position and that the needle or trocar be inserted at a 45° angle that stays within the midline; they also concluded that the trocar should be placed when pneumoperitoneal pressures exceed 20 mm Hg. They advised against direct insertion in patients with a history of pelvic surgery as well as in thin patients.

Place secondary trocars under direct visualization

Secondary trocars should always be placed under direct, visually controlled entry and, at least hypothetically, should never injure any great vessel. Nevertheless, secondary trocars do sometimes cause injury, most often as a result of extreme lateral entry near the inguinal ligament. The vessels at risk are the external iliac artery and vein.

Injuries are also invariably associated with adhesiolysis and anatomic problems. Precise knowledge of pelvic anatomy is not only a requisite for pelvic surgery in general but also for laparoscopic surgery, in which the operative view is less clear than it is in open procedures.

Know the risks associated with operative tools

Suturing and knot tying are not easy maneuvers during laparoscopic procedures and add significant operative time. Although they are performed more easily when robotics is utilized, few gynecologists are skilled practitioners. As a result, accessory instruments have been developed to prevent and control bleeding during laparoscopic operations. These devices include monopolar and bipolar instruments, lasers, ultrasonic tools, and stapling devices.

Avoid monopolar electrosurgery

This modality should be avoided whenever possible because the risk of injury is significantly higher than with bipolar electrosurgery. The key disadvantages of monopolar energy are high-frequency leaks; low-frequency currents; direct, indirect, and capacitative coupling; and return-electrode failures. None of these problems are common with bipolar techniques.

However, all electrosurgical devices carry a risk of thermal injury through direct tissue contact and conduction of heat to neighboring tissues and structures.

A full discussion of the physics and tissue actions of electrosurgical devices may be found elsewhere.⁹

CO₂ is the safest laser

A variety of lasers have been used in laparoscopic surgery. The neodymium–YAG, KTP-532, and CO₂ lasers have been used most frequently for gynecologic operations.

Because of its wavelength, the CO₂ laser is the safest device for intra-abdominal use. Advantages include precision and control. In addition, the CO₂ laser is absorbed by water very effectively. As a result, hydrodissection techniques can facilitate effective backstopping of the laser beam in strategic locations, thereby preventing injury to surrounding structures.

Laser energy is not conducted through tissue in the same way that electrosurgical energy is conducted. Therefore, the laser is ideal for vaporizing endometrial implants and cutting adhesions.

Beware of heat generated by the ultrasonic shears

This device, known more commonly as the Harmonic Scalpel (Ethicon), employs high-frequency sound waves to shear and coagulate tissue and prevent bleeding. It does not require conduction through tissues but does require contact with tissues. Because friction produces heat, these devices can become hot enough to inflict unintended burns on tissues that are inadvertently touched by the hot tip or by heat transmitted from the operative site by thermal conduction.

Stapler may inadvertently involve adjacent structures

This laparoscopic device has the advantage of not requiring or emitting energy other than the mechanical force of the operator’s hand. Disadvantages associated with the stapler center on the inadvertent inclusion of other structures within the jaws of the instrument. In addition, the staplers themselves tend to be large and somewhat unwieldy in close quarters, adding to the risk of stapling nearby viscera.

 

Further information on the physics and actions of lasers, ultrasonic shears, and staplers is available.^10,11

Obesity may increase the risk of major vessel injury

A recent study by Baggish found obesity to be a high-risk circumstance for major vessel injury.¹² In the study, 22 of 31 women who sustained injury were overweight or obese, with a BMI ranging from 26 to 30 kg/m².

Obesity increases the risk of major vessel injury because of the greater elasticity of the anterior abdominal wall. As force secondary to the downward thrust of the trocar is placed on the abdominal wall, it is pushed inward in the direction of the posterior wall. In contrast, thin women have rigid abdominal walls with minimal elasticity, so the force of the trocar thrust does not create significant displacement.

Baggish also found that disposable trocars accounted for 90% of major vascular injuries and that use of long trocars accounted for 43% of deaths.¹²

Injury and death are rare but real risks

In a multicenter study in France over 9 years, investigators reviewed 29,966 diagnostic and operative laparoscopic procedures and found a mortality rate of 3.33 deaths for every 100,000 laparoscopies and an overall complication rate of 4.64 complications for every 1,000 procedures.¹³ They found the complication rate to be significantly correlated with the complexity of the procedure (P = .0001). One in three complications (34.1%; n = 43) occurred during set-up, and one in four (28.6%) were not identified intraoperatively.¹³

The risk of great vessel injury associated with laparoscopy most frequently quoted is 0.5 injury for every 1,000 procedures.¹⁴ A multicenter study reported the prevalence of this complication to be 1.05 injuries per 1,000 procedures.¹⁵

The mortality rate associated with major vessel injury has been reported in several studies to range from 8% to 17%.^14-17

Two articles measured the distance from various points on the anterior abdominal wall to the great retroperitoneal vessels during laparoscopic operations; they also measured the force required for the trocar to penetrate the abdominal wall.^18,19 They found significant differences in the distance from the site of primary trocar insertion to the aorta and iliac vessels, depending on the BMI of the patient. In women with a BMI below 25 kg/m², the mean distance to the aorta was 11.21 cm. In women with a BMI of 25 to 30, it was 14.14 cm, and in women with a BMI over 30, it was 15.14 cm. They also found variations in the mean thickness of the abdominal wall, which was 3.48 cm, 3.85 cm, and 5.05 cm in women with a BMI of less than 25, 25–30, and more than 30, respectively.

As for the force required for entry, investigators found that disposable cutting trocars can traverse the anterior abdominal wall with less force and less time, compared with reusable trocars and optical viewing devices.^18,19

Another study measured the thickness of the abdominal wall and the distance to the great vessels by magnetic resonance imaging or computed tomography.²⁰ However, this study was not performed during laparoscopy with pneumoperitoneum in place.

As previously mentioned, Baggish reported on 31 cases of major-vessel injury associated with laparoscopic operations involving 49 major-vessel injuries. Twenty-eight injuries occurred as a result of entry techniques: 26 occurred during primary trocar insertion, and two were related to secondary trocar thrusts.¹² Four injuries and three deaths were associated with use of an 11-inch disposable trocar.

Of the injuries associated with primary trocar insertion, 10 occurred during direct insertion and 26 after creation of pneumoperitoneum. Open laparoscopy was performed in two cases.¹² The TABLE details the number of vessels injured and the sites of injury in this study.

Seven women (23%) died as a direct result of venous injury. Collateral injury to other structures was observed in 16 cases. Blood loss ranged from 1,000 mL to 7,000 mL.¹²

Sites of major vessel injury in one study of gynecologic laparoscopy

Site	Number of vascular injuries
Right iliac artery	14
Right iliac vein	12
Left iliac artery	3
Left iliac vein	9
Aorta	4
Vena cava	2
Mesenteric	2
Interior epigastric*	2
Other	1
Total injuries	49
Source: Baggish12

Avoid these common errors

The most common errors in gynecologic laparoscopy include:

• delayed diagnosis
• failure to act on a visible retroperitoneal hematoma
• failure to cross-match adequate supplies of blood and blood products
• failure to adequately transfuse blood and blood products
• clamping the large damaged vessel
• opening the abdomen via Pfannenstiel incision
• failure to call for a vascular surgeon in a timely manner.

Recommended interventions

When a major vascular injury occurs, a well-informed surgeon will take the following measures:

• call for a vascular surgeon immediately. (Baggish found that there was a substantial delay in getting a vascular surgeon to the operating table in four of 31 cases.¹²)
• open the abdomen via a midline incision
• use a sponge stick to apply direct pressure to the bleeding vessel
• obtain an emergency type and cross-match and order a minimum of 6 U of blood plus fresh frozen plasma
• obtain a baseline complete blood count, platelet count, fibrinogen level, and test for fibrin-split products
• advise the anesthesiologist to seek additional help
• call for additional OR nursing personnel
• assign one circulator to run stats and record critical data.^21-33

 

Prevention is the best strategy

As the opening case demonstrates, major vessel injury can occur without warning and cause cascading problems that can lead to permanent disability—even death. Because most serious vessel injuries occur during entry into the anterior abdominal wall, careful attention to entry techniques and the patient’s unique circumstances (obesity, presence of adhesions) can go a long way toward averting injury. Vigilance for the possibility of injury is also important throughout the procedure. When injury does occur, it is critical to call for help as soon as possible and to have safeguards in place to manage it.

We want to hear from you! Tell us what you think.

CASE: Abdominal entry leads to life-threatening injury

A 50-year-old woman with a BMI of 25 kg/m², a strong family history of breast and ovarian cancer, and a confirmed BRCA mutation was scheduled for prophylactic bilateral salpingo-oophorectomy via robotic laparoscopy on November 26, 2009. At the time of the procedure, the gynecologic surgeon selected a site for the camera trocar that was several centimeters above the umbilicus. After making a transverse incision, he inserted a Veress needle and insufflated the abdomen with CO₂ gas until intra-abdominal pressure reached 17 mm Hg. He then thrust an 11-inch disposable trocar through the anterior abdominal wall, attached the camera to the laparoscope, confirmed proper intraperitoneal placement, and inserted two additional trocars under direct vision.

Shortly after these actions, the anesthesiologist reported that the patient’s blood pressure had dropped precipitously, along with end tidal CO₂. The surgeon examined the peritoneal cavity and discovered blood in the right paracolic gutter. The anesthesiologist advised the surgeon that he could no longer detect the patient’s blood pressure; electrocardiography revealed pulseless electrical activity.

The surgical team began chest compressions, evacuated the pneumoperitoneum, and removed all trocars. Blood was noted on the camera trocar, and the device was secured by the OR staff. The surgeon performed an emergent laparotomy, making the incision within 4 minutes of the beginning of CPR. Exploration revealed a large retroperitoneal hematoma above the area of the aortic bifurcation and inferior vena cava.

General and vascular surgeons were called. The general surgeon opened the retroperitoneum and found an extreme amount of clotted and unclotted blood. The vascular surgeon described the initial injury as a 1.5-cm laceration of the distal aorta, just above the bifurcation. A cell saver was requested and recorded blood loss of 12,000 mL.

The vascular surgeon clamped the aorta proximally; he also clamped both common iliac arteries. He then repaired the lacerations on the aorta using 5-0 Prolene suture (Ethicon). The aorta was significantly narrowed, however, so the surgeon decided to replace the distal aorta, which he then resected and repaired using a 14-mm Dacron graft (DuPont).

Further inspection revealed continuing retroperitoneal bleeding. The vascular surgeon found and repaired a laceration of the inferior mesenteric vein. He also clipped multiple small veins to stop bleeding.

When a hole in the transverse colon was identified, the general surgeon—who had left the operating table—rescrubbed to repair it. He also discovered an injury to the mesentery of the transverse colon and repaired both wounds, resecting the perforated segment. The divided, stapled colon was dropped back into the abdomen because the bowel was dusky. Despite an epinephrine drip, the patient was hypotensive and coagulopathic. The abdomen was packed and covered with sterile cassette film, with towels covering the open wound.

The patient was taken to the postanesthesia care unit in guarded condition and was subsequently transferred to the ICU, where her blood pressure dropped again. She was returned to the OR, where the packs were removed and a bleeding right common iliac artery was repaired using 5-0 Prolene suture. The next day, she underwent bilateral salpingo-oophorectomy with a transverse colon colostomy.

Because of the colon injury, the vascular surgeon believed that the Dacron graft had been contaminated. On December 1, the graft was taken down, a left femoral-vein autograft was harvested, and a reconstructive conduit was created for the terminal aorta. The patient underwent three additional procedures to place mesh into the abdominal wall. When the mesh became infected, it was removed.

The patient remained in the hospital for 1 month, after which she was transferred to a long-term care facility. She suffered permanent neurologic injuries because of prolonged hypoxia and continues to require supportive care.

How could this catastrophe have been avoided?

Traumatic injury to the great retroperitoneal vessels is an emergent and life-threatening event. During gynecologic laparoscopy, it is most likely to occur during entry into the anterior abdominal wall.

Most laparoscopic procedures require entry into the anterior abdominal wall for placement of a trocar and a sleeve that serves as a portal for insertion of the endoscope. Secondary ports provide entry points for manipulative and operative tools.

The most critical entry point is primary placement of the viewing device. Secondary trocars are always inserted under direct visualization; therefore, they carry a lower risk of inflicting injury to underlying viscera and vessels.

Practice safe entry

 

In the early days of laparoscopy, only one method of entry existed. Over time, however, several other techniques have been devised.

The initial method—still widely utilized—is known as the closed or blind technique. The surgeon creates a pneumoperitoneum with the use of a needle that is 18 gauge to 2.5 mm in diameter; the needle is placed through a subumbilical incision. Once intraperitoneal placement is confirmed, CO₂ gas is infused into the peritoneal cavity until the abdomen is tympanic to percussion (usually at pressures of 14 to 18 mm Hg).

Next, the surgeon aims the trocar toward the uterus at a 45° angle, maintaining the device in the midline. Entry is confirmed by opening the trocar’s trap-door valve and witnessing a rush of CO₂ gas.

Another entry technique—the open technique—is used almost universally by general surgeons. The procedure is a type of microlaparotomy. After making the subumbilical incision, the fascia of the abdominal wall is pierced and the peritoneum is grasped and opened bluntly or sharply. Once the edges of the peritoneum are secured, a blunt trocar (Hasson trocar) is inserted. Then the trocar is removed, leaving the sleeve in place to accept the laparoscope.

Another entry variation, called direct entry, employs no pneumoperitoneum. In this approach, the surgeon grabs the anterior abdominal wall, sharply elevating it, and directly thrusts the reusable or disposable trocar into the abdominal cavity.

An extensive review of entry techniques has been published elsewhere.¹

Many complications arise from entry techniques and devices

A survey of Australian gynecologists about entry techniques found that 73% of respondents used a Veress needle and pneumoperitoneum for entry and that 83% used a location other than the infraumbilical site when periumbilical adhesions were suspected. Twenty-one percent had experienced a major retroperitoneal vascular injury, but 33% lacked a plan to manage such injuries.²

In their review of entry techniques, Vilos and colleagues asserted that Veress-needle insertion should be accompanied by pneumoperitoneal pressures of 20 to 30 mm Hg rather than a predetermined volume of CO₂ gas.¹ They also recommended insertion in the left upper quadrant when periumbilical adhesions are suspected or when insufflation at the umbilicus fails three times.

Newer entry devices include the optical-view trocar and the radially expanding trocar. The first consists of a plastic, conically tipped instrument that is optically clear. At least hypothetically, this device permits the surgeon to view each layer of the abdominal wall as he or she thrusts the device under “direct vision” into the abdominal cavity.

The radially expanding trocar is inserted over a Veress needle into the abdominal cavity. Its initial diameter is only 3 mm; once the instrument is in place, however, a blunt plastic trocar and sleeve are pushed into the mesh-like, radially expanding tube until it reaches 11 to 12 mm in diameter. The blunt trocar is then removed, leaving the plastic sheath and mesh material in place to accept the laparoscope. One key advantage of this device is the mesh component, which resists slippage or movement as the laparoscope is moved in and out of the sheath.

Vilos and colleagues concluded that open entry was neither superior nor inferior to other entry techniques and that direct entry without pneumoperitoneum may be as safe as Veress-needle techniques and associated with a lower risk of gas embolism. They also reported that shielded trocars are not associated with fewer visceral or vascular injuries and that visual-entry trocars lack superiority, compared with other devices, for the prevention of visceral or vascular injuries.¹

Other review articles about entry techniques similarly found no objective evidence that any single technique is superior.³ However, data are conflicting on the safety of the optical trocar, compared with other trocars, with some data showing marginal advantages and others demonstrating no difference.^4-6

Follow a few key entry guidelines

In 1990, Yuzpe reported a mail-in survey of 800 practicing ObGyns in Canada on the topic of pneumoperitoneum and trocar injuries.⁷ Of the 407 physicians who responded, 16.7% reported that the pneumoperitoneum needle caused a visceral or major vessel injury, and 16.5% attributed the injury to the primary trocar. Among 109 vessel injuries, 31 were caused by the pneumoperitoneum needle, and 28 of 104 injuries were caused by the primary trocar.

To be safe, Veress needle and primary trocar entry require critical attention to the angle and direction of the thrust relative to the abdominal cavity (FIGURE, page 24). For example, if the Veress needle or the sharp tip of the trocar deviate to the right or left of the midline during entry into the abdomen, injury to the iliac vessels is a clear risk.

 

Most laparoscopic surgeons stand on the left-hand side of the patient and face her feet. Trocar deviation for a right-handed person tends to vector to the right, especially when a twisting motion is utilized. Correct alignment of the primary trocar is straight down the middle of the lower abdomen on a virtual or real line drawn from the center of the navel to the center of the symphysis.

An entry angle of 45° to 60° will carry the needle or trocar toward the bladder or uterus and away from the aorta and left common iliac vein. In contrast, a 90° thrust will aim the device dangerously toward the great vessels. A slightly upward and right-sided deviation from the subumbilical entry will place the needle and trocar in the direction of the inferior vena cava and right common iliac vessels. A 90° entry with deviation to the left will position the entry device at the inferior mesenteric vessels and the left common iliac vessels.

Primary abdominal entry
An entry angle of 45° to 60°, regardless of whether a needle or trocar is used, will carry the device toward the bladder or uterus and away from the aorta and left common iliac vein.In a review of access complications associated with laparoscopy, including major vascular injuries, Philips and Amaral listed variables responsible for large-vessel injury; they also documented the incidence of such injuries associated with laparoscopic cholecystectomy.⁸ They recommended that the patient be placed in the Trendelenburg position and that the needle or trocar be inserted at a 45° angle that stays within the midline; they also concluded that the trocar should be placed when pneumoperitoneal pressures exceed 20 mm Hg. They advised against direct insertion in patients with a history of pelvic surgery as well as in thin patients.

Place secondary trocars under direct visualization

Secondary trocars should always be placed under direct, visually controlled entry and, at least hypothetically, should never injure any great vessel. Nevertheless, secondary trocars do sometimes cause injury, most often as a result of extreme lateral entry near the inguinal ligament. The vessels at risk are the external iliac artery and vein.

Injuries are also invariably associated with adhesiolysis and anatomic problems. Precise knowledge of pelvic anatomy is not only a requisite for pelvic surgery in general but also for laparoscopic surgery, in which the operative view is less clear than it is in open procedures.

Know the risks associated with operative tools

Suturing and knot tying are not easy maneuvers during laparoscopic procedures and add significant operative time. Although they are performed more easily when robotics is utilized, few gynecologists are skilled practitioners. As a result, accessory instruments have been developed to prevent and control bleeding during laparoscopic operations. These devices include monopolar and bipolar instruments, lasers, ultrasonic tools, and stapling devices.

Avoid monopolar electrosurgery

This modality should be avoided whenever possible because the risk of injury is significantly higher than with bipolar electrosurgery. The key disadvantages of monopolar energy are high-frequency leaks; low-frequency currents; direct, indirect, and capacitative coupling; and return-electrode failures. None of these problems are common with bipolar techniques.

However, all electrosurgical devices carry a risk of thermal injury through direct tissue contact and conduction of heat to neighboring tissues and structures.

A full discussion of the physics and tissue actions of electrosurgical devices may be found elsewhere.⁹

CO₂ is the safest laser

A variety of lasers have been used in laparoscopic surgery. The neodymium–YAG, KTP-532, and CO₂ lasers have been used most frequently for gynecologic operations.

Because of its wavelength, the CO₂ laser is the safest device for intra-abdominal use. Advantages include precision and control. In addition, the CO₂ laser is absorbed by water very effectively. As a result, hydrodissection techniques can facilitate effective backstopping of the laser beam in strategic locations, thereby preventing injury to surrounding structures.

Laser energy is not conducted through tissue in the same way that electrosurgical energy is conducted. Therefore, the laser is ideal for vaporizing endometrial implants and cutting adhesions.

Beware of heat generated by the ultrasonic shears

This device, known more commonly as the Harmonic Scalpel (Ethicon), employs high-frequency sound waves to shear and coagulate tissue and prevent bleeding. It does not require conduction through tissues but does require contact with tissues. Because friction produces heat, these devices can become hot enough to inflict unintended burns on tissues that are inadvertently touched by the hot tip or by heat transmitted from the operative site by thermal conduction.

Stapler may inadvertently involve adjacent structures

This laparoscopic device has the advantage of not requiring or emitting energy other than the mechanical force of the operator’s hand. Disadvantages associated with the stapler center on the inadvertent inclusion of other structures within the jaws of the instrument. In addition, the staplers themselves tend to be large and somewhat unwieldy in close quarters, adding to the risk of stapling nearby viscera.

 

Further information on the physics and actions of lasers, ultrasonic shears, and staplers is available.^10,11

Obesity may increase the risk of major vessel injury

A recent study by Baggish found obesity to be a high-risk circumstance for major vessel injury.¹² In the study, 22 of 31 women who sustained injury were overweight or obese, with a BMI ranging from 26 to 30 kg/m².

Obesity increases the risk of major vessel injury because of the greater elasticity of the anterior abdominal wall. As force secondary to the downward thrust of the trocar is placed on the abdominal wall, it is pushed inward in the direction of the posterior wall. In contrast, thin women have rigid abdominal walls with minimal elasticity, so the force of the trocar thrust does not create significant displacement.

Baggish also found that disposable trocars accounted for 90% of major vascular injuries and that use of long trocars accounted for 43% of deaths.¹²

Injury and death are rare but real risks

In a multicenter study in France over 9 years, investigators reviewed 29,966 diagnostic and operative laparoscopic procedures and found a mortality rate of 3.33 deaths for every 100,000 laparoscopies and an overall complication rate of 4.64 complications for every 1,000 procedures.¹³ They found the complication rate to be significantly correlated with the complexity of the procedure (P = .0001). One in three complications (34.1%; n = 43) occurred during set-up, and one in four (28.6%) were not identified intraoperatively.¹³

The risk of great vessel injury associated with laparoscopy most frequently quoted is 0.5 injury for every 1,000 procedures.¹⁴ A multicenter study reported the prevalence of this complication to be 1.05 injuries per 1,000 procedures.¹⁵

The mortality rate associated with major vessel injury has been reported in several studies to range from 8% to 17%.^14-17

Two articles measured the distance from various points on the anterior abdominal wall to the great retroperitoneal vessels during laparoscopic operations; they also measured the force required for the trocar to penetrate the abdominal wall.^18,19 They found significant differences in the distance from the site of primary trocar insertion to the aorta and iliac vessels, depending on the BMI of the patient. In women with a BMI below 25 kg/m², the mean distance to the aorta was 11.21 cm. In women with a BMI of 25 to 30, it was 14.14 cm, and in women with a BMI over 30, it was 15.14 cm. They also found variations in the mean thickness of the abdominal wall, which was 3.48 cm, 3.85 cm, and 5.05 cm in women with a BMI of less than 25, 25–30, and more than 30, respectively.

As for the force required for entry, investigators found that disposable cutting trocars can traverse the anterior abdominal wall with less force and less time, compared with reusable trocars and optical viewing devices.^18,19

Another study measured the thickness of the abdominal wall and the distance to the great vessels by magnetic resonance imaging or computed tomography.²⁰ However, this study was not performed during laparoscopy with pneumoperitoneum in place.

As previously mentioned, Baggish reported on 31 cases of major-vessel injury associated with laparoscopic operations involving 49 major-vessel injuries. Twenty-eight injuries occurred as a result of entry techniques: 26 occurred during primary trocar insertion, and two were related to secondary trocar thrusts.¹² Four injuries and three deaths were associated with use of an 11-inch disposable trocar.

Of the injuries associated with primary trocar insertion, 10 occurred during direct insertion and 26 after creation of pneumoperitoneum. Open laparoscopy was performed in two cases.¹² The TABLE details the number of vessels injured and the sites of injury in this study.

Seven women (23%) died as a direct result of venous injury. Collateral injury to other structures was observed in 16 cases. Blood loss ranged from 1,000 mL to 7,000 mL.¹²

Sites of major vessel injury in one study of gynecologic laparoscopy

Site	Number of vascular injuries
Right iliac artery	14
Right iliac vein	12
Left iliac artery	3
Left iliac vein	9
Aorta	4
Vena cava	2
Mesenteric	2
Interior epigastric*	2
Other	1
Total injuries	49
Source: Baggish12

Avoid these common errors

The most common errors in gynecologic laparoscopy include:

• delayed diagnosis
• failure to act on a visible retroperitoneal hematoma
• failure to cross-match adequate supplies of blood and blood products
• failure to adequately transfuse blood and blood products
• clamping the large damaged vessel
• opening the abdomen via Pfannenstiel incision
• failure to call for a vascular surgeon in a timely manner.

Recommended interventions

When a major vascular injury occurs, a well-informed surgeon will take the following measures:

• call for a vascular surgeon immediately. (Baggish found that there was a substantial delay in getting a vascular surgeon to the operating table in four of 31 cases.¹²)
• open the abdomen via a midline incision
• use a sponge stick to apply direct pressure to the bleeding vessel
• obtain an emergency type and cross-match and order a minimum of 6 U of blood plus fresh frozen plasma
• obtain a baseline complete blood count, platelet count, fibrinogen level, and test for fibrin-split products
• advise the anesthesiologist to seek additional help
• call for additional OR nursing personnel
• assign one circulator to run stats and record critical data.^21-33

 

Prevention is the best strategy

As the opening case demonstrates, major vessel injury can occur without warning and cause cascading problems that can lead to permanent disability—even death. Because most serious vessel injuries occur during entry into the anterior abdominal wall, careful attention to entry techniques and the patient’s unique circumstances (obesity, presence of adhesions) can go a long way toward averting injury. Vigilance for the possibility of injury is also important throughout the procedure. When injury does occur, it is critical to call for help as soon as possible and to have safeguards in place to manage it.

We want to hear from you! Tell us what you think.

CASE: Abdominal entry leads to life-threatening injury

A 50-year-old woman with a BMI of 25 kg/m², a strong family history of breast and ovarian cancer, and a confirmed BRCA mutation was scheduled for prophylactic bilateral salpingo-oophorectomy via robotic laparoscopy on November 26, 2009. At the time of the procedure, the gynecologic surgeon selected a site for the camera trocar that was several centimeters above the umbilicus. After making a transverse incision, he inserted a Veress needle and insufflated the abdomen with CO₂ gas until intra-abdominal pressure reached 17 mm Hg. He then thrust an 11-inch disposable trocar through the anterior abdominal wall, attached the camera to the laparoscope, confirmed proper intraperitoneal placement, and inserted two additional trocars under direct vision.

Shortly after these actions, the anesthesiologist reported that the patient’s blood pressure had dropped precipitously, along with end tidal CO₂. The surgeon examined the peritoneal cavity and discovered blood in the right paracolic gutter. The anesthesiologist advised the surgeon that he could no longer detect the patient’s blood pressure; electrocardiography revealed pulseless electrical activity.

The surgical team began chest compressions, evacuated the pneumoperitoneum, and removed all trocars. Blood was noted on the camera trocar, and the device was secured by the OR staff. The surgeon performed an emergent laparotomy, making the incision within 4 minutes of the beginning of CPR. Exploration revealed a large retroperitoneal hematoma above the area of the aortic bifurcation and inferior vena cava.

General and vascular surgeons were called. The general surgeon opened the retroperitoneum and found an extreme amount of clotted and unclotted blood. The vascular surgeon described the initial injury as a 1.5-cm laceration of the distal aorta, just above the bifurcation. A cell saver was requested and recorded blood loss of 12,000 mL.

The vascular surgeon clamped the aorta proximally; he also clamped both common iliac arteries. He then repaired the lacerations on the aorta using 5-0 Prolene suture (Ethicon). The aorta was significantly narrowed, however, so the surgeon decided to replace the distal aorta, which he then resected and repaired using a 14-mm Dacron graft (DuPont).

Further inspection revealed continuing retroperitoneal bleeding. The vascular surgeon found and repaired a laceration of the inferior mesenteric vein. He also clipped multiple small veins to stop bleeding.

When a hole in the transverse colon was identified, the general surgeon—who had left the operating table—rescrubbed to repair it. He also discovered an injury to the mesentery of the transverse colon and repaired both wounds, resecting the perforated segment. The divided, stapled colon was dropped back into the abdomen because the bowel was dusky. Despite an epinephrine drip, the patient was hypotensive and coagulopathic. The abdomen was packed and covered with sterile cassette film, with towels covering the open wound.

The patient was taken to the postanesthesia care unit in guarded condition and was subsequently transferred to the ICU, where her blood pressure dropped again. She was returned to the OR, where the packs were removed and a bleeding right common iliac artery was repaired using 5-0 Prolene suture. The next day, she underwent bilateral salpingo-oophorectomy with a transverse colon colostomy.

Because of the colon injury, the vascular surgeon believed that the Dacron graft had been contaminated. On December 1, the graft was taken down, a left femoral-vein autograft was harvested, and a reconstructive conduit was created for the terminal aorta. The patient underwent three additional procedures to place mesh into the abdominal wall. When the mesh became infected, it was removed.

The patient remained in the hospital for 1 month, after which she was transferred to a long-term care facility. She suffered permanent neurologic injuries because of prolonged hypoxia and continues to require supportive care.

How could this catastrophe have been avoided?

Traumatic injury to the great retroperitoneal vessels is an emergent and life-threatening event. During gynecologic laparoscopy, it is most likely to occur during entry into the anterior abdominal wall.

Most laparoscopic procedures require entry into the anterior abdominal wall for placement of a trocar and a sleeve that serves as a portal for insertion of the endoscope. Secondary ports provide entry points for manipulative and operative tools.

The most critical entry point is primary placement of the viewing device. Secondary trocars are always inserted under direct visualization; therefore, they carry a lower risk of inflicting injury to underlying viscera and vessels.

Practice safe entry

 

In the early days of laparoscopy, only one method of entry existed. Over time, however, several other techniques have been devised.

The initial method—still widely utilized—is known as the closed or blind technique. The surgeon creates a pneumoperitoneum with the use of a needle that is 18 gauge to 2.5 mm in diameter; the needle is placed through a subumbilical incision. Once intraperitoneal placement is confirmed, CO₂ gas is infused into the peritoneal cavity until the abdomen is tympanic to percussion (usually at pressures of 14 to 18 mm Hg).

Next, the surgeon aims the trocar toward the uterus at a 45° angle, maintaining the device in the midline. Entry is confirmed by opening the trocar’s trap-door valve and witnessing a rush of CO₂ gas.

Another entry technique—the open technique—is used almost universally by general surgeons. The procedure is a type of microlaparotomy. After making the subumbilical incision, the fascia of the abdominal wall is pierced and the peritoneum is grasped and opened bluntly or sharply. Once the edges of the peritoneum are secured, a blunt trocar (Hasson trocar) is inserted. Then the trocar is removed, leaving the sleeve in place to accept the laparoscope.

Another entry variation, called direct entry, employs no pneumoperitoneum. In this approach, the surgeon grabs the anterior abdominal wall, sharply elevating it, and directly thrusts the reusable or disposable trocar into the abdominal cavity.

An extensive review of entry techniques has been published elsewhere.¹

Many complications arise from entry techniques and devices

A survey of Australian gynecologists about entry techniques found that 73% of respondents used a Veress needle and pneumoperitoneum for entry and that 83% used a location other than the infraumbilical site when periumbilical adhesions were suspected. Twenty-one percent had experienced a major retroperitoneal vascular injury, but 33% lacked a plan to manage such injuries.²

In their review of entry techniques, Vilos and colleagues asserted that Veress-needle insertion should be accompanied by pneumoperitoneal pressures of 20 to 30 mm Hg rather than a predetermined volume of CO₂ gas.¹ They also recommended insertion in the left upper quadrant when periumbilical adhesions are suspected or when insufflation at the umbilicus fails three times.

Newer entry devices include the optical-view trocar and the radially expanding trocar. The first consists of a plastic, conically tipped instrument that is optically clear. At least hypothetically, this device permits the surgeon to view each layer of the abdominal wall as he or she thrusts the device under “direct vision” into the abdominal cavity.

The radially expanding trocar is inserted over a Veress needle into the abdominal cavity. Its initial diameter is only 3 mm; once the instrument is in place, however, a blunt plastic trocar and sleeve are pushed into the mesh-like, radially expanding tube until it reaches 11 to 12 mm in diameter. The blunt trocar is then removed, leaving the plastic sheath and mesh material in place to accept the laparoscope. One key advantage of this device is the mesh component, which resists slippage or movement as the laparoscope is moved in and out of the sheath.

Vilos and colleagues concluded that open entry was neither superior nor inferior to other entry techniques and that direct entry without pneumoperitoneum may be as safe as Veress-needle techniques and associated with a lower risk of gas embolism. They also reported that shielded trocars are not associated with fewer visceral or vascular injuries and that visual-entry trocars lack superiority, compared with other devices, for the prevention of visceral or vascular injuries.¹

Other review articles about entry techniques similarly found no objective evidence that any single technique is superior.³ However, data are conflicting on the safety of the optical trocar, compared with other trocars, with some data showing marginal advantages and others demonstrating no difference.^4-6

Follow a few key entry guidelines

In 1990, Yuzpe reported a mail-in survey of 800 practicing ObGyns in Canada on the topic of pneumoperitoneum and trocar injuries.⁷ Of the 407 physicians who responded, 16.7% reported that the pneumoperitoneum needle caused a visceral or major vessel injury, and 16.5% attributed the injury to the primary trocar. Among 109 vessel injuries, 31 were caused by the pneumoperitoneum needle, and 28 of 104 injuries were caused by the primary trocar.

To be safe, Veress needle and primary trocar entry require critical attention to the angle and direction of the thrust relative to the abdominal cavity (FIGURE, page 24). For example, if the Veress needle or the sharp tip of the trocar deviate to the right or left of the midline during entry into the abdomen, injury to the iliac vessels is a clear risk.

 

Most laparoscopic surgeons stand on the left-hand side of the patient and face her feet. Trocar deviation for a right-handed person tends to vector to the right, especially when a twisting motion is utilized. Correct alignment of the primary trocar is straight down the middle of the lower abdomen on a virtual or real line drawn from the center of the navel to the center of the symphysis.

An entry angle of 45° to 60° will carry the needle or trocar toward the bladder or uterus and away from the aorta and left common iliac vein. In contrast, a 90° thrust will aim the device dangerously toward the great vessels. A slightly upward and right-sided deviation from the subumbilical entry will place the needle and trocar in the direction of the inferior vena cava and right common iliac vessels. A 90° entry with deviation to the left will position the entry device at the inferior mesenteric vessels and the left common iliac vessels.

Primary abdominal entry
An entry angle of 45° to 60°, regardless of whether a needle or trocar is used, will carry the device toward the bladder or uterus and away from the aorta and left common iliac vein.In a review of access complications associated with laparoscopy, including major vascular injuries, Philips and Amaral listed variables responsible for large-vessel injury; they also documented the incidence of such injuries associated with laparoscopic cholecystectomy.⁸ They recommended that the patient be placed in the Trendelenburg position and that the needle or trocar be inserted at a 45° angle that stays within the midline; they also concluded that the trocar should be placed when pneumoperitoneal pressures exceed 20 mm Hg. They advised against direct insertion in patients with a history of pelvic surgery as well as in thin patients.

Place secondary trocars under direct visualization

Secondary trocars should always be placed under direct, visually controlled entry and, at least hypothetically, should never injure any great vessel. Nevertheless, secondary trocars do sometimes cause injury, most often as a result of extreme lateral entry near the inguinal ligament. The vessels at risk are the external iliac artery and vein.

Injuries are also invariably associated with adhesiolysis and anatomic problems. Precise knowledge of pelvic anatomy is not only a requisite for pelvic surgery in general but also for laparoscopic surgery, in which the operative view is less clear than it is in open procedures.

Know the risks associated with operative tools

Suturing and knot tying are not easy maneuvers during laparoscopic procedures and add significant operative time. Although they are performed more easily when robotics is utilized, few gynecologists are skilled practitioners. As a result, accessory instruments have been developed to prevent and control bleeding during laparoscopic operations. These devices include monopolar and bipolar instruments, lasers, ultrasonic tools, and stapling devices.

Avoid monopolar electrosurgery

This modality should be avoided whenever possible because the risk of injury is significantly higher than with bipolar electrosurgery. The key disadvantages of monopolar energy are high-frequency leaks; low-frequency currents; direct, indirect, and capacitative coupling; and return-electrode failures. None of these problems are common with bipolar techniques.

However, all electrosurgical devices carry a risk of thermal injury through direct tissue contact and conduction of heat to neighboring tissues and structures.

A full discussion of the physics and tissue actions of electrosurgical devices may be found elsewhere.⁹

CO₂ is the safest laser

A variety of lasers have been used in laparoscopic surgery. The neodymium–YAG, KTP-532, and CO₂ lasers have been used most frequently for gynecologic operations.

Because of its wavelength, the CO₂ laser is the safest device for intra-abdominal use. Advantages include precision and control. In addition, the CO₂ laser is absorbed by water very effectively. As a result, hydrodissection techniques can facilitate effective backstopping of the laser beam in strategic locations, thereby preventing injury to surrounding structures.

Laser energy is not conducted through tissue in the same way that electrosurgical energy is conducted. Therefore, the laser is ideal for vaporizing endometrial implants and cutting adhesions.

Beware of heat generated by the ultrasonic shears

This device, known more commonly as the Harmonic Scalpel (Ethicon), employs high-frequency sound waves to shear and coagulate tissue and prevent bleeding. It does not require conduction through tissues but does require contact with tissues. Because friction produces heat, these devices can become hot enough to inflict unintended burns on tissues that are inadvertently touched by the hot tip or by heat transmitted from the operative site by thermal conduction.

Stapler may inadvertently involve adjacent structures

This laparoscopic device has the advantage of not requiring or emitting energy other than the mechanical force of the operator’s hand. Disadvantages associated with the stapler center on the inadvertent inclusion of other structures within the jaws of the instrument. In addition, the staplers themselves tend to be large and somewhat unwieldy in close quarters, adding to the risk of stapling nearby viscera.

 

Further information on the physics and actions of lasers, ultrasonic shears, and staplers is available.^10,11

Obesity may increase the risk of major vessel injury

A recent study by Baggish found obesity to be a high-risk circumstance for major vessel injury.¹² In the study, 22 of 31 women who sustained injury were overweight or obese, with a BMI ranging from 26 to 30 kg/m².

Obesity increases the risk of major vessel injury because of the greater elasticity of the anterior abdominal wall. As force secondary to the downward thrust of the trocar is placed on the abdominal wall, it is pushed inward in the direction of the posterior wall. In contrast, thin women have rigid abdominal walls with minimal elasticity, so the force of the trocar thrust does not create significant displacement.

Baggish also found that disposable trocars accounted for 90% of major vascular injuries and that use of long trocars accounted for 43% of deaths.¹²

Injury and death are rare but real risks

In a multicenter study in France over 9 years, investigators reviewed 29,966 diagnostic and operative laparoscopic procedures and found a mortality rate of 3.33 deaths for every 100,000 laparoscopies and an overall complication rate of 4.64 complications for every 1,000 procedures.¹³ They found the complication rate to be significantly correlated with the complexity of the procedure (P = .0001). One in three complications (34.1%; n = 43) occurred during set-up, and one in four (28.6%) were not identified intraoperatively.¹³

The risk of great vessel injury associated with laparoscopy most frequently quoted is 0.5 injury for every 1,000 procedures.¹⁴ A multicenter study reported the prevalence of this complication to be 1.05 injuries per 1,000 procedures.¹⁵

The mortality rate associated with major vessel injury has been reported in several studies to range from 8% to 17%.^14-17

Two articles measured the distance from various points on the anterior abdominal wall to the great retroperitoneal vessels during laparoscopic operations; they also measured the force required for the trocar to penetrate the abdominal wall.^18,19 They found significant differences in the distance from the site of primary trocar insertion to the aorta and iliac vessels, depending on the BMI of the patient. In women with a BMI below 25 kg/m², the mean distance to the aorta was 11.21 cm. In women with a BMI of 25 to 30, it was 14.14 cm, and in women with a BMI over 30, it was 15.14 cm. They also found variations in the mean thickness of the abdominal wall, which was 3.48 cm, 3.85 cm, and 5.05 cm in women with a BMI of less than 25, 25–30, and more than 30, respectively.

As for the force required for entry, investigators found that disposable cutting trocars can traverse the anterior abdominal wall with less force and less time, compared with reusable trocars and optical viewing devices.^18,19

Another study measured the thickness of the abdominal wall and the distance to the great vessels by magnetic resonance imaging or computed tomography.²⁰ However, this study was not performed during laparoscopy with pneumoperitoneum in place.

As previously mentioned, Baggish reported on 31 cases of major-vessel injury associated with laparoscopic operations involving 49 major-vessel injuries. Twenty-eight injuries occurred as a result of entry techniques: 26 occurred during primary trocar insertion, and two were related to secondary trocar thrusts.¹² Four injuries and three deaths were associated with use of an 11-inch disposable trocar.

Of the injuries associated with primary trocar insertion, 10 occurred during direct insertion and 26 after creation of pneumoperitoneum. Open laparoscopy was performed in two cases.¹² The TABLE details the number of vessels injured and the sites of injury in this study.

Seven women (23%) died as a direct result of venous injury. Collateral injury to other structures was observed in 16 cases. Blood loss ranged from 1,000 mL to 7,000 mL.¹²

Sites of major vessel injury in one study of gynecologic laparoscopy

Site	Number of vascular injuries
Right iliac artery	14
Right iliac vein	12
Left iliac artery	3
Left iliac vein	9
Aorta	4
Vena cava	2
Mesenteric	2
Interior epigastric*	2
Other	1
Total injuries	49
Source: Baggish12

Avoid these common errors

The most common errors in gynecologic laparoscopy include:

• delayed diagnosis
• failure to act on a visible retroperitoneal hematoma
• failure to cross-match adequate supplies of blood and blood products
• failure to adequately transfuse blood and blood products
• clamping the large damaged vessel
• opening the abdomen via Pfannenstiel incision
• failure to call for a vascular surgeon in a timely manner.

Recommended interventions

When a major vascular injury occurs, a well-informed surgeon will take the following measures:

• call for a vascular surgeon immediately. (Baggish found that there was a substantial delay in getting a vascular surgeon to the operating table in four of 31 cases.¹²)
• open the abdomen via a midline incision
• use a sponge stick to apply direct pressure to the bleeding vessel
• obtain an emergency type and cross-match and order a minimum of 6 U of blood plus fresh frozen plasma
• obtain a baseline complete blood count, platelet count, fibrinogen level, and test for fibrin-split products
• advise the anesthesiologist to seek additional help
• call for additional OR nursing personnel
• assign one circulator to run stats and record critical data.^21-33

 

Prevention is the best strategy

As the opening case demonstrates, major vessel injury can occur without warning and cause cascading problems that can lead to permanent disability—even death. Because most serious vessel injuries occur during entry into the anterior abdominal wall, careful attention to entry techniques and the patient’s unique circumstances (obesity, presence of adhesions) can go a long way toward averting injury. Vigilance for the possibility of injury is also important throughout the procedure. When injury does occur, it is critical to call for help as soon as possible and to have safeguards in place to manage it.

We want to hear from you! Tell us what you think.

Placement of a suture around an incompetent cervix to prevent premature pregnancy loss was first described more than 50 years ago^1,2—but the few randomized studies that have been published (all of them in the past decade) devote very little attention to technique.^3-7

Are we to assume, then, that over more than 50 years, no modifications to technique have been devised?

Are we to assume as well that in the two largest randomized studies to date, which involved 266 cerclages inserted in 27 different medical centers over more than 4 years,^5,7 all cerclages were inserted in an identical manner using the same technique originated more than half a century ago?

In this article, we lay out five principles to achieve effective cerclage and describe a stepwise approach to technique. This technique is based on our experience with approximately 2,000 cerclages performed in a single medical center. We emphasize anatomic landmarks and surgical principles that are based on the published literature as well as our personal experience.

Five principles of effective cerclage

Place the cerclage as high as possible

In the original paper on cerclage, McDonald emphasized the need to place the suture as high as possible to be as close as possible to the level of the internal cervical os.²

Zilianti and colleagues elegantly described how—in the absence of cerclage—cervical tissue begins to change at the level of the internal os, forming a funnel that advances downward in the shape of the letters “Y,” “V,” and “U.”⁸ If we accept this notion, then the only way to prevent further shortening from the top down is by placing a high cerclage.

Studies have demonstrated improved pregnancy outcomes after placement of a high cervico-isthmic cerclage following failure of a “conventional” low cerclage.^9,10

Place the cerclage adjacent to the cervical stroma

Macroscopic and microscopic visualization of the cervix reveals the following main layers:

• epithelium/mucosa, which covers the deeper connective tissue known as cervical stroma
• cervical stroma, which may be divided into two zones: 1) a superficial, subepithelial zone that appears histologically as loose stromal bands and 2) a deeper, dense collagen layer.

It is the dense collagen layer of the cervical stroma that affords most of the resistance to forces of deformation, whereas the loose stromal layer and the epithelium above it slide easily over the deeper stroma. Including too great a proportion of these “slippery” components within the cerclage could increase the risk of displacement and failure.^11,12

Shirodkar was the first to suggest that the mucosa and submucosa be excluded from cerclage,¹ and a detailed submucosal cerclage insertion was described by Fahmy more than 30 years ago.¹³ We support his recommendation that cerclage placement be as close to the inner cervical stroma as possible and that it include as little as possible of the surrounding tissue.

Take three encircling cervical “bites”

In his original publication, McDonald described “five or six bites with the needle” to encircle the cervix.² Later authors usually described four encircling steps, but no reliable study has challenged the original dogma.

Although we lack science to favor one approach over another, common sense suggests that three bites (versus four or five) offer the following advantages. They:

• produce less penetrating injury
• require less manipulation of the cervix
• are simpler and quicker to perform
• offer less opportunity for the cerclage tape to get twisted (a flat tape provides for better distribution of the load)
• permit a small gap between the two final exit points of the tape (at 5 o’clock and 7 o’clock), which allows for easier cinching and tightening of the cerclage (FIGURE 1).

FIGURE 1 A small gap between the ends of the cerclage tape, which exit at 5 o’clock and 7 o’clock, allows for easier cinching and tightening.

Place the knot at 6 o’clock

Both Shirodkar¹ and McDonald² described placement of the knot (or approximation of the “ends”) at 12 o’clock, anteriorly. However, this approach can complicate removal if strong pressure is applied to the cerclage or if it is covered by tissue. Attempts to remove the cerclage can result in bladder injury.

For these reasons, we prefer the approach described by Caspi and colleagues, who placed the knot in the back of the cervix at 6 o’clock.¹⁴ In that location, the surgeon can reach as high as desired, and there is no risk of organ injury during removal.

 

That said, it should be noted that removal of a cerclage with a knot at 6 o’clock is more difficult than removal of one with a knot at 12 o’clock—but the convenience of the operator should be secondary to safety and efficacy of the cerclage.

Place a figure of 8 around the cerclage knot

Because of the proximity of the bladder anteriorly, there is a limit to how high one can place the cerclage anteriorly. However, in the back of the cervix, one can place the cerclage much higher without risk of injury. This approach sometimes will result in downward forces on the posterior part (where the knot is) and occasionally may cover the knot with tissue from the posterior vaginal fornix.

For these reasons, we propose securing the knot of the cerclage tape to the posterior surface of the cervical “core” by placing a figure of 8 using bright blue Prolene #1 (Ethicon) to prevent slippage and help call attention to the knot when the time for removal comes.

Stepwise surgical technique

1. Use a weighted speculum to retract the posterior-inferior vaginal wall. Have an assistant hold one or two right-angle retractors to retract the other aspects of the vaginal wall, including the bladder anteriorly, as needed.

2. Clamp the anterior and posterior lips of the cervix and tug them lightly—at all times—in an outward direction (FIGURE 2).

FIGURE 2 Clamping of the cervix
Clamp the anterior and posterior lips of the cervix and tug them lightly and steadily in an outward direction.

3. Retract and release the bladder several times using a right-angle retractor for more accurate identification of the cervico-vesical fold (FIGURE 3 and FIGURE 4). Note the distance from the external os to the cervico-vesical fold; it should be 2 cm or farther. (If it is less than 2 cm, another type of cerclage may be preferable.)

FIGURE 3 Anatomic landmarks
Cerclage is facilitated by orientation to the following landmarks; A. cervico-vesical fold; B. posterior fornix; C. cervical stroma; D. cervical mucosa.

FIGURE 4 Cervico-vesical fold
The black line indicates the location of the fold.

4. Identify the roof of the posterior fornix (FIGURE 3 and FIGURE 5).

FIGURE 5 Roof of the posterior fornix
This landmark is delineated in black.

5. Using Allis clamps bilaterally, clamp the soft tissue covering the cervical core (stroma), between the cervico-vesical junction anteriorly and the superior point of the posterior fornix posteriorly. This is a cardinal step because it separates the core from the mucosal/ submucosal elements (FIGURE 6). (Helpful hint: To achieve optimal placement of the lateral Allis clamps, place the open clamp ever so slightly to one side of the middle of the cervix. As you close the instrument, let the clamp slide off the cervical core until it is locked adjacent to it. This takes the soft tissue and supporting blood vessels out of the operative field.)

FIGURE 6 Anterolateral view
The pericervical mucosa (black arrow) after application of an Allis clamp.

6. Take three bites, 1 mm in depth, through the cervical core using a 5-mm Mersilene tape and a blunt-tipped needle (RS21; Ethicon). One bite should encompass 12:30 to 11:30 anteriorly. Another bite should go in at 3 o’clock and out at 5 o’clock, and another bite should go in at 9 o’clock and out at 7 o’clock (FIGURE 1). (Helpful hint: Ensure that the direction of the pull always is a direct extension of the passage through tissue in small steps and not an outward direction toward the operator. An instrument such as a curved Mayo clamp should be placed at the point of the needle’s exit to reduce the risk of injury. At the conclusion of the three bites, the Mersilene tape should be the same length on each side, exiting at 5 o’clock and 7 o’clock, as stated earlier [FIGURE 7].)

FIGURE 7 Ensure equal distribution of the tape
After taking three bites of tissue, ensure that the ends of the Mersilene tape are of equal length on each side.

7. Once the tape is of equal length on both sides, closely encircling three sides of the cervical core, empty the bladder with a catheter to ensure the presence of clear urine. Bloody urine could be an indication for cystoscopy to rule out bladder injury.

8. Cut the needles off of the tape and tie the cerclage in three ties, the first one being a surgical tie. After tying the first tie, ensure proper tension by pressing gently with the index finger up and down on the knot; if it is properly tensioned, it will not be displaced by this movement. (Helpful hint: There is no clear indication of how tight a cerclage should be tied. We suggest making the first tie as close as possible to the cervical core to create a visible, and palpable, depression in the soft tissue at the area of the knot [FIGURE 8]).

 

FIGURE 8 Tying the cerclage
Make the first tie as close as possible to the cervical core so that it creates a visible, and palpable, depression in the soft tissue at the area of the knot. Inset: Cerclage tie secured by a figure of 8.

9. Trim the ends of the tape to 3 cm to facilitate easy identification and manipulation at the time of removal. Place a figure of 8, using bright blue Prolene #1 (Ethicon), around the knot, securing it to the posterior surface of the cervical core (FIGURE 9). The tape should encircle the firm part of the cervix near the internal os, as shown by transvaginal ultrasonography in FIGURE 10. (Helpful hint: Place surgical gauze under pressure around the cervix to support hemostasis after removal of the clamps. Remove the gauze approximately 30 minutes after the procedure.)

FIGURE 9 Mark the cerclage
Place a figure of 8, using bright blue Prolene #1, around the knot of the cerclage, securing it to the posterior surface of the cervical core.

FIGURE 10 Final placement
The cerclage tape should encircle the firm part of the cervix near the internal os, as shown by transvaginal ultrasonography.

Technique is applicable to most cerclage procedures

One potential limitation of this technique is the fact that it is based on surgical experience in a single center, although it includes more than 2,000 operations performed at that center. Therefore, we lack data on the ease of teaching and reproducing this technique. Nevertheless, our approach incorporates various elements that previously were proposed to enhance the effectiveness of cerclage. It likely will be applicable to most cerclage procedures, with the exception of a few unique cases. These unique cases—most of them involving the failure of conventional cerclage—may require more elaborate technique.

As for data on the location of biomechanical stresses on cervical tissue during pregnancy, the literature indicates that the forces of maximum deformation begin internally at the level of the cervico-uterine junction.¹² If not successfully resisted, these forces will proceed down along the cervical canal and could lead to premature pregnancy loss.

Although the superiority of a high cerclage has not yet been proven clinically, it appears to be more effective than low placement because it is more likely to provide support at the right location.

As pregnancy progresses, the challenge to the cervix increases—not only because of increasing uterine volume but also because of greater uterine activity. Both raise the risk of cerclage slippage and displacement.¹⁵ To address these issues, several investigators proposed an approach that excludes the slippery mucosal layer.^1,13,14

The original Shirodkar cerclage and its modifications—but not the McDonald cerclage and its subsequent modifications—included an “anchor” suture attaching the cerclage band to the firm cervical stromal layer as a means to prevent downward slippage and displacement.¹ It remains to be seen whether this addition of a figure of 8 using nonabsorbable suture, as proposed here, is indeed effective.

We believe that, if a standardized way to perform effective cerclage can be agreed upon, we also might devise a better way to compare results based on proper patient selection.

We want to hear from you! Tell us what you think.

Placement of a suture around an incompetent cervix to prevent premature pregnancy loss was first described more than 50 years ago^1,2—but the few randomized studies that have been published (all of them in the past decade) devote very little attention to technique.^3-7

Are we to assume, then, that over more than 50 years, no modifications to technique have been devised?

Are we to assume as well that in the two largest randomized studies to date, which involved 266 cerclages inserted in 27 different medical centers over more than 4 years,^5,7 all cerclages were inserted in an identical manner using the same technique originated more than half a century ago?

In this article, we lay out five principles to achieve effective cerclage and describe a stepwise approach to technique. This technique is based on our experience with approximately 2,000 cerclages performed in a single medical center. We emphasize anatomic landmarks and surgical principles that are based on the published literature as well as our personal experience.

Five principles of effective cerclage

Place the cerclage as high as possible

In the original paper on cerclage, McDonald emphasized the need to place the suture as high as possible to be as close as possible to the level of the internal cervical os.²

Zilianti and colleagues elegantly described how—in the absence of cerclage—cervical tissue begins to change at the level of the internal os, forming a funnel that advances downward in the shape of the letters “Y,” “V,” and “U.”⁸ If we accept this notion, then the only way to prevent further shortening from the top down is by placing a high cerclage.

Studies have demonstrated improved pregnancy outcomes after placement of a high cervico-isthmic cerclage following failure of a “conventional” low cerclage.^9,10

Place the cerclage adjacent to the cervical stroma

Macroscopic and microscopic visualization of the cervix reveals the following main layers:

• epithelium/mucosa, which covers the deeper connective tissue known as cervical stroma
• cervical stroma, which may be divided into two zones: 1) a superficial, subepithelial zone that appears histologically as loose stromal bands and 2) a deeper, dense collagen layer.

It is the dense collagen layer of the cervical stroma that affords most of the resistance to forces of deformation, whereas the loose stromal layer and the epithelium above it slide easily over the deeper stroma. Including too great a proportion of these “slippery” components within the cerclage could increase the risk of displacement and failure.^11,12

Shirodkar was the first to suggest that the mucosa and submucosa be excluded from cerclage,¹ and a detailed submucosal cerclage insertion was described by Fahmy more than 30 years ago.¹³ We support his recommendation that cerclage placement be as close to the inner cervical stroma as possible and that it include as little as possible of the surrounding tissue.

Take three encircling cervical “bites”

In his original publication, McDonald described “five or six bites with the needle” to encircle the cervix.² Later authors usually described four encircling steps, but no reliable study has challenged the original dogma.

Although we lack science to favor one approach over another, common sense suggests that three bites (versus four or five) offer the following advantages. They:

• produce less penetrating injury
• require less manipulation of the cervix
• are simpler and quicker to perform
• offer less opportunity for the cerclage tape to get twisted (a flat tape provides for better distribution of the load)
• permit a small gap between the two final exit points of the tape (at 5 o’clock and 7 o’clock), which allows for easier cinching and tightening of the cerclage (FIGURE 1).

FIGURE 1 A small gap between the ends of the cerclage tape, which exit at 5 o’clock and 7 o’clock, allows for easier cinching and tightening.

Place the knot at 6 o’clock

Both Shirodkar¹ and McDonald² described placement of the knot (or approximation of the “ends”) at 12 o’clock, anteriorly. However, this approach can complicate removal if strong pressure is applied to the cerclage or if it is covered by tissue. Attempts to remove the cerclage can result in bladder injury.

For these reasons, we prefer the approach described by Caspi and colleagues, who placed the knot in the back of the cervix at 6 o’clock.¹⁴ In that location, the surgeon can reach as high as desired, and there is no risk of organ injury during removal.

 

That said, it should be noted that removal of a cerclage with a knot at 6 o’clock is more difficult than removal of one with a knot at 12 o’clock—but the convenience of the operator should be secondary to safety and efficacy of the cerclage.

Place a figure of 8 around the cerclage knot

Because of the proximity of the bladder anteriorly, there is a limit to how high one can place the cerclage anteriorly. However, in the back of the cervix, one can place the cerclage much higher without risk of injury. This approach sometimes will result in downward forces on the posterior part (where the knot is) and occasionally may cover the knot with tissue from the posterior vaginal fornix.

For these reasons, we propose securing the knot of the cerclage tape to the posterior surface of the cervical “core” by placing a figure of 8 using bright blue Prolene #1 (Ethicon) to prevent slippage and help call attention to the knot when the time for removal comes.

Stepwise surgical technique

1. Use a weighted speculum to retract the posterior-inferior vaginal wall. Have an assistant hold one or two right-angle retractors to retract the other aspects of the vaginal wall, including the bladder anteriorly, as needed.

2. Clamp the anterior and posterior lips of the cervix and tug them lightly—at all times—in an outward direction (FIGURE 2).

FIGURE 2 Clamping of the cervix
Clamp the anterior and posterior lips of the cervix and tug them lightly and steadily in an outward direction.

3. Retract and release the bladder several times using a right-angle retractor for more accurate identification of the cervico-vesical fold (FIGURE 3 and FIGURE 4). Note the distance from the external os to the cervico-vesical fold; it should be 2 cm or farther. (If it is less than 2 cm, another type of cerclage may be preferable.)

FIGURE 3 Anatomic landmarks
Cerclage is facilitated by orientation to the following landmarks; A. cervico-vesical fold; B. posterior fornix; C. cervical stroma; D. cervical mucosa.

FIGURE 4 Cervico-vesical fold
The black line indicates the location of the fold.

4. Identify the roof of the posterior fornix (FIGURE 3 and FIGURE 5).

FIGURE 5 Roof of the posterior fornix
This landmark is delineated in black.

5. Using Allis clamps bilaterally, clamp the soft tissue covering the cervical core (stroma), between the cervico-vesical junction anteriorly and the superior point of the posterior fornix posteriorly. This is a cardinal step because it separates the core from the mucosal/ submucosal elements (FIGURE 6). (Helpful hint: To achieve optimal placement of the lateral Allis clamps, place the open clamp ever so slightly to one side of the middle of the cervix. As you close the instrument, let the clamp slide off the cervical core until it is locked adjacent to it. This takes the soft tissue and supporting blood vessels out of the operative field.)

FIGURE 6 Anterolateral view
The pericervical mucosa (black arrow) after application of an Allis clamp.

6. Take three bites, 1 mm in depth, through the cervical core using a 5-mm Mersilene tape and a blunt-tipped needle (RS21; Ethicon). One bite should encompass 12:30 to 11:30 anteriorly. Another bite should go in at 3 o’clock and out at 5 o’clock, and another bite should go in at 9 o’clock and out at 7 o’clock (FIGURE 1). (Helpful hint: Ensure that the direction of the pull always is a direct extension of the passage through tissue in small steps and not an outward direction toward the operator. An instrument such as a curved Mayo clamp should be placed at the point of the needle’s exit to reduce the risk of injury. At the conclusion of the three bites, the Mersilene tape should be the same length on each side, exiting at 5 o’clock and 7 o’clock, as stated earlier [FIGURE 7].)

FIGURE 7 Ensure equal distribution of the tape
After taking three bites of tissue, ensure that the ends of the Mersilene tape are of equal length on each side.

7. Once the tape is of equal length on both sides, closely encircling three sides of the cervical core, empty the bladder with a catheter to ensure the presence of clear urine. Bloody urine could be an indication for cystoscopy to rule out bladder injury.

8. Cut the needles off of the tape and tie the cerclage in three ties, the first one being a surgical tie. After tying the first tie, ensure proper tension by pressing gently with the index finger up and down on the knot; if it is properly tensioned, it will not be displaced by this movement. (Helpful hint: There is no clear indication of how tight a cerclage should be tied. We suggest making the first tie as close as possible to the cervical core to create a visible, and palpable, depression in the soft tissue at the area of the knot [FIGURE 8]).

 

FIGURE 8 Tying the cerclage
Make the first tie as close as possible to the cervical core so that it creates a visible, and palpable, depression in the soft tissue at the area of the knot. Inset: Cerclage tie secured by a figure of 8.

9. Trim the ends of the tape to 3 cm to facilitate easy identification and manipulation at the time of removal. Place a figure of 8, using bright blue Prolene #1 (Ethicon), around the knot, securing it to the posterior surface of the cervical core (FIGURE 9). The tape should encircle the firm part of the cervix near the internal os, as shown by transvaginal ultrasonography in FIGURE 10. (Helpful hint: Place surgical gauze under pressure around the cervix to support hemostasis after removal of the clamps. Remove the gauze approximately 30 minutes after the procedure.)

FIGURE 9 Mark the cerclage
Place a figure of 8, using bright blue Prolene #1, around the knot of the cerclage, securing it to the posterior surface of the cervical core.

FIGURE 10 Final placement
The cerclage tape should encircle the firm part of the cervix near the internal os, as shown by transvaginal ultrasonography.

Technique is applicable to most cerclage procedures

One potential limitation of this technique is the fact that it is based on surgical experience in a single center, although it includes more than 2,000 operations performed at that center. Therefore, we lack data on the ease of teaching and reproducing this technique. Nevertheless, our approach incorporates various elements that previously were proposed to enhance the effectiveness of cerclage. It likely will be applicable to most cerclage procedures, with the exception of a few unique cases. These unique cases—most of them involving the failure of conventional cerclage—may require more elaborate technique.

As for data on the location of biomechanical stresses on cervical tissue during pregnancy, the literature indicates that the forces of maximum deformation begin internally at the level of the cervico-uterine junction.¹² If not successfully resisted, these forces will proceed down along the cervical canal and could lead to premature pregnancy loss.

Although the superiority of a high cerclage has not yet been proven clinically, it appears to be more effective than low placement because it is more likely to provide support at the right location.

As pregnancy progresses, the challenge to the cervix increases—not only because of increasing uterine volume but also because of greater uterine activity. Both raise the risk of cerclage slippage and displacement.¹⁵ To address these issues, several investigators proposed an approach that excludes the slippery mucosal layer.^1,13,14

The original Shirodkar cerclage and its modifications—but not the McDonald cerclage and its subsequent modifications—included an “anchor” suture attaching the cerclage band to the firm cervical stromal layer as a means to prevent downward slippage and displacement.¹ It remains to be seen whether this addition of a figure of 8 using nonabsorbable suture, as proposed here, is indeed effective.

We believe that, if a standardized way to perform effective cerclage can be agreed upon, we also might devise a better way to compare results based on proper patient selection.

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