Custom Search

Wednesday, November 09, 2005

What is the Surgical Options:

In the surgical repair of the damaged pelvis a few ground rules apply:
the most important of these is surely that no further damage must be done, especially if the surgical results are suboptimal - the so-called “ do no harm” effect.

The “standard” prolapse surgical techniques in common use in Europe, and elsewhere in the world, did not follow this ground rule. The main aim was to get rid of the bulge!
In this conquest, new anatomical structures were developed, present anatomical organs were mutilated, and new lines of pull directions were designed , taking over a new godlike role!
There was success in the conquest, but in others failures left the patient with a mutilated pelvis, with a resultant new attempt at rectifying the bulge with a repetition of the initial attack!
Tissue graph techniques were designed to supplement the defective area weakness, either from surrounding tissues ( incorporating muscle for instance in areas where it normally are not found) or from distant body areas. These gave poor results with , once again, mutilation of the prolapsed area.

Keeping the above “do no harm” effect in mind and hoping to obtain at least the same results in reconstructing the damaged pelvis, a paradigm shift is to my mind necessary.
Based on a solid knowledge of the anatomy of the pelvis, especially keeping in mind the functional anatomy, the pelvic reconstruction surgeon should be able to understand the damage present in the pelvis. Knowing what the pathogenesis were in damaging the pelvis, especially with childbirth, will also support the resultant rectifying surgery. Using proper surgical dissection techniques flow from this, with a resultant lesser risk for intra operative complications. Adhering to the basic surgical principles of hernia surgery will diminish failure rates. Do not use any technique that mutilate the pelvic organs, and remove redundant tissue, if really necessary, with care. The use of graphs must be highly individualized.
Pointers in decision making can be age of the patient, the type of defect and the area in the pelvis where the tissue needs to be used.

A protocol for the type of pelvic reconstructive surgery is possible. This pelvic organ reconstructive (POR) protocol will be dependant on the following options:

1. POR option A:
Site specific repair, the so-called vaginal paravaginal repair (VPVR), using only native tissue of the patient: repairing the damaged tissue directly.

2. POR option B:
Using of a second generation Xenograph to decrease the tension on the tissue surrounding the hernia.

3. POR option C:
Using a synthetic graph to decrease tension on the tissue surrounding the hernia.

In the folowing of the options from PORo A thru PORoB to PORo C, the risk, especially long-term, may be increasing ( “do no harm effect!”), but with possibly a better long-term success rate.

With the necessary individualisation based on above, the correct procedure can be done on the correct patient, with less harm to the patient, especially if the procedure did not give the optimal desired effect.

Only the future will give the answers.

extra reading

Please give your opinion on this!