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Friday, November 24, 2006

Surgical Options in Vaginal Prolapsed Pelvic Organ Reconstruction

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 “classical” prolapse surgical techniques in common use in Europe, and elsewhere in the world, do not follow this ground rule. The main aim is to get rid of the bulge!
In this conquest, new anatomical structures are developed, present anatomical organs are mutilated, and new lines of pull directions are designed. Thus 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! Let us call this option POR option A.

To improve results 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.

1. With the normal anatomy (and the functional anatomy) as a template the pelvic organ reconstruction surgeon can repair in the true sense of the word!

2. Knowing what the pathogenesis was in damaging the pelvis, especially with childbirth, will also support the resultant rectifying surgery.

3. Using proper surgical dissection techniques flow from this, with a resultant lesser risk for intra operative complications.

4. Adhering to the basic surgical principles of hernia surgery can diminish failure rates.

5. Do not use any technique that mutilate the pelvic organs, and remove redundant tissue, if really necessary, with care.

6. 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 B:
Site specific repair, the so-called vaginal paravaginal repair (VPVR), using only native tissue of the patient: repairing the damaged tissue directly.
A new approach is to augment or strengthen this with a Side Specific repair: the endopelvic fascia is sutured on both sides to the obturator fascia, following the ATFP as a guide.
2. POR option C:
Above is done and by using an overlay of a second generation Xenograph the tension is decreased on the tissue supporting the hernia repair
3. POR option D:
Using a synthetic graph to decrease tension on the tissue surrounding the hernia.
With this there is no PORoB done.
In the following of the options from PORo B thru PORoC to PORo D, the risk, especially long-term, may be increasing ( “do no harm effect!”), but with possibly a better long-term success rate.

The young patient can qualify for PORoB, or C, with the sexually inactive older lady, or possibly a patient with a faillure after previous surgery, for PORoD
With the necessary individualization 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

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For best viewing: click on bottom righthand side on Slideshare and then again in the new window on the bottom righthand side on full

We must dare to think 'unthinkable' thoughts. We must learn to explore all the options and possibilities that confront us in a complex and rapidly changing world. We must learn to welcome and not to fear the voices of dissent. We must dare to think about 'unthinkable things' because when things become unthinkable, thinking stops and action becomes mindless.
~ James William Fulbright


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