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Tuesday, December 20, 2016

Dear readers,
At last did I reached the stage in life which is generally classified as retirement age- although I will not be involved in active clinical practise in Terneuzen, I do plan to be available for a group of gynaecologists worldwide: in Ketering The UK, in Tilburg and Hardewijk in the Netherlands, but also in far away places like Florida and Tennessee. All free services with no financial incentive.
I also an building a youtube channel and will spend again sometime here on this forum. Please feel free to contact me at nieuwoudt@gmail.com.

Monday, April 27, 2015

Tissue Guided Regenerative Surgery

Wednesday, February 11, 2015

What is Prolapse?

It is quite interesting to sit back and observe the chaos what at present is raging in the minds of those who choose to keep them busy with the females who have pelvic floor damage. The simple question asked will probably have different answers. What the author is going to do is to keep it simple and a little bit stupid -and stay with only the defining of what we are dealing with.

"Prolapse" is seen as a collapse of the vaginal wall when intra abdominal pressure increase - this will present itself as a ball that comes down the cavity and in extreme circumstances protrude through the vaginal opening. This is here that the confusion starts: it is seen by most authors as a "prolapse of pelvic organs", hence the name and classifications based on the supposed organ that will be in the ball. The words POP (Pelvic Organ Prolapse), cystocoele ("sac of the bladder"), rectocoele ("sac of the rectum") -this is sometimes even sub classified as high and low- and enterocoele (" sac of the intestines") is used by most. No reference is made to the underlying reason why the vaginal wall is collapsing- the structural support of the vaginal cavity, which is in essence a tunnel that ends blindly into the abdominal cavity and is subjected to varying degrees of pressures, has weak areas on specific spots and it is through these areas that herniation of abdominal contents protrude, pushing the vaginal skin ahead of it. A comparison with abdominal wall herniations, e.g. inguinal hernias, can be made.

 It is at this simple starting point that difference of opinions arise on how to treat this " prolapsed" wall:
If seen as a "organ prolapse" the avenue to treat that will be followed is to push, or pull, this out of the cavity - the so called "colphorrhaphies" is done whereby the protruding wall is folded onto itself with removal of extra skin/tissues, or the vaginal wall is strapped to the bone skeleton (sacro colpopexy or rectopexy): no attention is given to the underlying defects that lead to the protrusion or herniation -in a sense is this a symptomatic treatment at best.
If seen as a defect in the wall that leads to the protrusion, the treatment will be focused on finding these spots of weakness and the subsequent surgery will focus on strengthening these. The surgical approach will thus aim at diagnosing , and laying bare, the defects -the better this is done, the better the chances of correcting it can be done. The definitions of these defects will thus focus on an anatomical definition which will define the area where the weakness is and not on what the supposed contents of the hernial sac is -this will thus focus on treating the cause and origin of the protruding wall, rather that attacking the sac directly with an obvious more enduring result.

In this blog the last avenue of thinking is being explored and developed.

Wednesday, November 19, 2014

important patient information

video
1. This video from the IUGA archives (www.iuga.org) shows what pressure changes happen in the post operative field during normal daily activity: it also  -hopefully- will take away all the urban legends on what a patient is allowed to do and not to do post operatively. In Regenerative Surgery the patient is advised that mobility is an important adjuvant to wound healing.

Saturday, August 30, 2014

#D anatomy

https://youtu.be/P3BBAMWm2Eo

Monday, November 25, 2013

masterclass in vaginal surgery


Ik heb genoten van jouw workshop, alles was perfect : de ontvangst, het theoretisch gedeelte, de catering, het hotel cosy en comfortabel,  het diner, de organisatie in het operatiekwartier, de gemoedelijke sfeer, het contact met de andere deelnemers en last but not least jouw manier om de prolapsproblematiek te benaderen en de uitvoering ervan.  Ik ben wild enthousiast, zo wil ik het ook doen, of ik er ooit in slaag weet ik niet maar ik wil het proberen…..

I enjoyed your workshop- everything was perfect: the reception, the theoretical part, the catering, the hotel was cozy and comfortable, the dinner, the organization in the theatre, the relaxed admosphere, the contact with other colleques and las but not least the in which you approach prolapse and the way in which your surgical correction thereof is being done. I am wild enthousiastic- I want to operate also like that: if I will succeed will only be seen in the future.
C Beghin Gent Belgium

Thank you for taking the time out from your busy schedule for us and to show me (and share) your passion about regenerative tissue surgery principles as applied to pelvic floor reconstruction for the various defects. For some time now I have been questioning the 'conventional or traditional' incl. use of mesh surgeries for prolapse and considering (looking) for a viable alternative(s). Spending time next to you and watching the surgeries you have performed had shown me those 'missing' gaps in the alternative surgical techniques that I envisaged but was not sure of.

Dr Honest   Birmingham UK


This Master Class is about Regenerative Vaginal surgery: This is an alternative to conventional colphorrhaphies and Mesh kit surgery. It is bringing together the identification of the underlying pathology, the correction thereof and the utilization of regenerative native tissue protection techniques: the basic principles of tissue enginering and manipulation of wound healing is followed to enable the native tissue of the damaged vaginal wall to regenerate back to normal morphology and function. A full day of roundtable discussions and video directed theoretical presentations, is followed by live hands-on participation in theatre.
The next meeting is scheduled for7th and 8th May 2015.
contact: nieuwoudt@gmail.com

Thursday, July 18, 2013

Regenerative Vaginal Surgery





Diagnosis is not the end, but the beginning of practice.
                                                         Martin H. Fischer


During the Kelly1 and White2 era the only building blocks available to the surgeon were the tissues in front of him. Transfer of tissues from distant sites in the body - or from external sites - only became available late in the 20th century. These were called upon when the primary tissue was judged to be inadequate; be it in its healing capabilities or in tissue availability. This was replaced in due course by the primary utilization of the implant materials, ignoring the primary tissue as part of the “reconstructive” process. This lead to the madness - if one can call it that - of the synthetic Mesh “kits”. A halt is called due to complications that occurred.3. A true process of destructive surgery seemed to be the result of this “constructive” process. By simplifying techniques to lines and crosses drawn on the skin and utilization of “minimal invasive” needle techniques, incompetent vaginal surgeons were made to feel competent.4 The resulting complications led to a kneejerk response where all synthetics were to be banned from vaginal surgery - and a leap back to the previous comfort zone of the Kelly era...the conventional colphorrhapy is back! One might ask why was there a departure from these classic native tissue surgical procedures? Was it not the unpredictability of results and the poor results of redo surgery after these untested procedures?
The time has come to reach beyond these “classical” native tissue procedures.
One can treat a complicated problem simplistically or you can simplify a complicated problem. The secret of being a good physician is the ability to simplify a complicated problem. The simplistic manner in which prolapse is being seen and treated by most, lead to the perfect storm we are experiencing at present.5 Focus is being placed on reducing the symptom of a bulging vaginal wall, rather than looking for the origin of the defect that leads to the bulging wall. By attacking the bulge with conventional “native tissue” surgery, or by placing a bridge of implant tissue to do that, involves risks of permanent damage. The art of healing surely involves a diagnostic work-up looking for the origin of the disease that lead to the symptoms which brought the patient to the physician. By treating the origin of the disease the symptom will disappear!
Tissue engineering is an interdisciplinary field that applies the principles of engineering and life sciences toward the development of biological substitutes that restore, maintain, or improve tissue function - or even replace whole organs.6 7 Regenerative medicine holds the promise of regenerating damaged tissues and organs in the body by replacing damaged tissue and/or by stimulating the body's own repair mechanisms to heal previously irreparable tissues or organs.8 Regeneration puts the focus on either protecting or enhancing stem cell tissue engineering. With surgical repair of a wound or defect, continuity is established without regard to the exact replacement of lost or injured tissue. In contrast, regeneration is restoration with an exact copy; not only morphologic continuity, but also functionality.
The ultimate goal should be to improve the repair process with the addition of regeneration principles: this would be regenerative surgery. In regenerative surgery, wound healing is manipulated to increase the mass of healthy native tissue to bring the damaged area back to its original - or as near as possible - normal anatomical and physiological state. The focus here is on enhancing native tissue repair, rather than substituting native tissue, hence regenerative surgery – a manipulation of surgical wound healing in clinical practise since 1997.14 In plastic surgery, regenerative surgery is a recognized branch of regenerative medicine15 16 - as in other diciplines.17
This can be applied to vaginal wall prolapse surgery.
We are now entering what can be called the post mesh era. In this era one can return to the surgical techniques of the past, or improve them.
Native tissue is the primary building block in the reconstructive process. To do this, basic information is needed: what is the defect that led to the prolapsed vaginal wall? If one reconstructs, knowledge of the template of normality that you want to reproduce is essential. Accessibility of the support system in its entirety must be possible, which is best provided through the vaginal route. The origin of the defect that leads to the prolapse must be actively searched for and, when found, treated. To treat the defects in the vaginal wall support system, the existing native tissue and the template of normality in front of the surgeon are the best guides.
Native tissue surgery can be defined as the utilization of native tissue to enable the healing process to close the defective areas that led to the prolapsed vaginal wall, thereby reconstructing the normal support system of the vaginal wall. In defect specific surgery the primary underlying cause is treated resulting in the secondary effect, namely the prolapse being corrected.
Regenerative surgery has two legs to stand on: In the first instance is the replacement of healthy native tissue with unwanted collagen of scar tissue avoided by limiting the damage of the surgical onslaught with careful dissection and repair techniques. Secondly, new native tissue formation is supported by the utilization of biodegradable scaffolds to give temporary support to the repair with further limiting surgical trauma. This scaffold will aid in growth of resident-tissue stem cells. Regenerative medicine is combined with good, safe surgical practises.
Wound healing of the surgical insult to tissues will go through its phases of haemostasis, inflammation, proliferation and remodelling. Good surgical dissection techniques must be mastered in order to limit further tissue damage. The degree to which the regeneration process can lead to normal morphological and functioning tissues will depend on the degree to which the inflammatory stage is stimulated. By reducing the inflammatory stage of wound healing tissue, remodeling through regeneration is allowed with minimal scar tissue formation. Over this we have control.
A few rules will apply in regenerative surgery to enhance wound healing:
·      By respecting, during dissection, the tissue planes as well as the spaces between organs - thereby minimizing tissue trauma - and not putting strain or tension on the native tissue, the surgical insult is kept to its minimum.
·      Wound edges must be approximated but never under tension.
·      Foreign materials, infection, ischemia and tensioned tissue can prolong the inflammatory process with resultant increased scar tissue (collagen I) formation.
·      All these have an additional stimulatory effect on the proteolitic enzymes that break the extra cellular matrix protector, heparan sulfate, down.9
·      The use of biodegradable scaffolds and heparan sulfate analogues can be helpful as augmentation materials for regenerating normal healthy tissue.10

The process can be curtailed by either lack of tissue or poor quality of available tissue, necessitating the use of implanted tissue or materials. In the pelvis a third force is at play: variable tensions on the suture lines can lead to early breakdown of the repair or putting tension on the native tissue and thereby stimulating the inflammatory reaction. To counter this temporary splinting or support needs to be provided to keep the native tissue in place until proper strong collagen is being produced to strengthen the previous defective areas.6 In regenerative surgery new tissue can be remodelled under the guidance of a biodegradable synthetic scaffold or biodegradable xenografts. Regenerative surgery will involve technical protection of native tissue and splinting surgical sites of repair.

The first surgeon who attempts to repair the damage that lead to the collapse of the vaginal wall is the most important one. The surgical footprint left behind is not only paramount in the success of the primary surgery, but also may impede secondary surgical reconstructive attempts if the first procedure fails to give an optimal surgical outcome. This is especially true in vaginal surgery and in native tissue surgery. Removed organs and tissues cannot be replaced. The secondary procedure must not be an undo-redo process, but rather an add-on process. The minimal damage caused by following regenerative surgical principles will enhance this. Staged surgery can be a real option in some cases.
By performing defect-specific surgery the vaginal surgeon can approximate the tissue layers closing the defective areas. By manipulating the predictable tissue reactions during the process of wound healing the surgeon can decrease the formation of scar tissue and improve tissue quality and function using tissue regenerating surgical techniques.
Regenerative surgery puts the focus on the surgeon and his/her ability to do surgery on the do-no-harm principles. Guarnieri11 and Desarda12 with inguinal hernia repair done on the same basis as being describe here, already showed that one does not need synthetic materials for lasting effects. With proper knowledge and operative skills native tissue responses can be utilised to good effect. This is what regenerative surgery is all about.
The regenerative ability of a surgeon in tissue handling techniques ultimately will be his/her surgical legacy.

In a sense one could say that with regenerative vaginal surgery the vaginal surgeon is invited back into the vagina. Unfortunately, vaginal surgery is an art practise by many, but mastered by few.

A special thanks to Bianca Visschers and Gideon Nieuwoudt for help provided.








References:
1 Cooke TJ, Gousse AE A historical perspective on cystocele repair—from honey to pessaries to anterior colporrhaphy: lessons from the past.2008 J Urol. Jun;179(6):2126-30.
2 White GR. Cystocele. A radical cure by suturing lateral sulci of the vagina to white line of pelvic fascia. JAMA 1909;80(21) 1707-10.
4 Andri Nieuwoudt Int  Urogynecology J, Surgical Footprints. Then and now. 2008 vol 19 (9) 1187-1188
6 Boennelycke M, Gras S, Lose G Tissue engineering as a potential alternative or adjunct to surgical reconstraction in treating pelvic organ prolapse (2013) Int Urogynecol 24:741-747.
7 Langer R, Vacanti JP (May 1993). "Tissue engineering". Science 260 (5110): 920–6.
8 Mason C, Dunnill P (2008) A brief definition of regenerative medicine.Regen Med, 3(1), 1–5
9 Johan van Neck, Bastiaan Tuk, Denis Barritault and Miao Tong. The book Tissue Regeneration - From Basic Biology to Clinical Application, ISBN 978-953-51-0387-5. Heparan Sulfate Proteoglycan Mimetics Promote Tissue Regeneration: An Overview (2012) 4:69-92
10 Mouritsen L, Kronschnabl M, Lose G. Long-term results of vaginal repairs with and without xenograft reinforcement. Int Urogynecol J. 2010 Apr;21(4):467-73.
11 Guarnieri, Antonio; Moscatelli, Franco; Guarnieri, Francesco; Ravo, Biagio (1992). "A new technique for indirect inguinal hernia repair". The American Journal of Surgery 164 (1): 70–3.
12 Desarda, M. P. (2005). "Physiological repair of inguinal hernia: A new technique (study of 860 patients)". Hernia 10 (2) 143-6.
14 Whitman DH, Berry RL, Green DM  (1997) Platelet gel: an autologous alternative to fibrin glue with applications in oral and maxillofacial surgery..J Oral Maxillofac Surg. Nov;55(11):1294-9.
17Orlando G, Wood KJ, et al, (2012) Regenerative medicine as applied to general surgery. Ann Surg. 2012 May;255(5):867-80


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