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Monday, July 16, 2007

Vaginal Side Specific Repair (VSSR)

"The reasonable man adapts himself to the world. The unreasonable one persists in trying to adapt the world to himself. Therefore, all progress depends on the unreasonable man.” (George Bernard Shaw)

Collapse of the vaginal support of the underlining organs is due to, at times interlinking, mechanical and biochemical factors. The mechanical damage to the support systems is usually associated with childbirth, with the biochemical factor an usually secondary occurrence years later when the surrounding collagen tissue undergoes degenerative changes.

The surgical approach of the pelvic organ reconstructive surgeon must be focused on surgical improvement of this collapse and do not only include repair of the mechanical damage but must also include improvement of the accompanying collagen weakness.

Understanding the pathogenesis of the damage childbirth causes help in creating the type of surgery necessary to rectify the wrong:
Damage of the anterior vaginal wall is due to the manoeuvres of the presenting part of the foetus as it encounters the resistance of the pelvic floor. This includes engagement, flexion (if it is a head) and internal rotation. The strain put on the supportive collagen tissue of the bladder is greatest on the side of the face; here is the greatest arch of rotation and movement. With the more common LOA position of the head it’s therefore not surprising to find the damage on the right -para-vaginally- in the vicinity of the ishial spines and on the transverse aspect just distal from the peri-cervical ring.

The focus of the vaginal repair done for the collapsed anterior wall must be to strengthen this weakened side supports of the bladder at or near the ischial spines and just proximal to the peri-cervical ring.

The existence of a "central" defect is questioned, as it is difficult to pathogenically explain its occurrence.

The traction direction on the side supports of a patient with prolapse is from lateral to medial; this direction of pull must be reversed.

Exactly this is done with the vaginal para-vaginal side specific repair (VSSR) by tying the torn side supports back onto the white line - focusing on the area at or near the ishial spines - plus re-attaching the inferior border of the vesico-vaginal “septum” onto the peri-cervical ring. (Compare this approach with the classical repairs where the focus of the repair is centrally, increasing the tension on the already weakened sides).

As a bonus the weakened surrounding collagen can be strengthened by bolstering the repair with a remodelling biomesh. This will act thus as a "band-aid" to the primary surgery.The resultant strengthening of the repair will come from the ingrowth of new collagen.
Compare this with the use of meshes where it is used to act as a primary support for the bladder - a bridging effect.

The Anterior VSSR in steps:

The procedure is preferably done under a spinal anaesthesia. The use of a Lone Star is essential for proper dissection and is indispensiable:- the traction - counter traction thus provided ensure success of the sharp dissection.

Vaginal paravaginal repair slideshow
if you click on "view" above,one can have a full screen presentation

1. The vaginal wall is incised with a knife between two Kocher tissue forceps after a mixture of water and adrenaline is injected. The cervix is stabilised onto the Lone Star retractor with a single hook fixed on the internal side of the anterior cervical lip.

2. With sharp dissection the vaginal skin is peeled off from the underlying vesico-vaginal tissue. This dissection is done with the scissors in a push and spread way directing towards the para-vesical space, as superficial to the vaginal skin as possible.

The veins that are exposed are cauterised with a high power cuatery (60+) thus creating a “flame thrower” effect.

3. When the lateral borders of the dissection field reach the inferior border of the pubic rami, the attention is directed to the central attachment of the bladder and the cervix, between the bladder pillars. This attachment is loosened with sharp dissection in the midline in the same fashion as one does with a vaginal hysterectomy before entering into the vesico-uterine cul de sac. A Maxon O suture on a HGU-46 taper needle ( Tyco serial number 6455-61)is placed on the dissected anterior surface of the cervix and the suture -with the needle still attached- is pulled and anchored onto the Lone Star retractor, pulling the uterus inferiorly. The hook is removed from the endocervix.

4. As the dissection proceed under the inferior pubic rami, progress is made by gentley sweeping the bladder from the sidewall of the pelvis with the surgeons’ finger, thus displacing the ureter and bladder centrally. This sweeping movement is on the sidewall on the inner aspect of the obturator fascia, directing the movement from above to below. The dissection is directed towards the Ischial spines and, when reached, one usually encounters the paravaginal defect running from the spines upwards along the white line towards the Symphasis pubis. If no weakening of the lateral attachments of the vesico-vaginal septum, or a defect, is found, one can follow the attachment of the said septum along the inferior border of the white line from ischial spines to symphasis pubis.

5. Through the window created between the bladder pillar below and the pubo-urethral ligaments above, one can identify the lateral aspect of the bladder if a defect is present, or is created.

The presence of fat is confirmation of this - the vaginal wall does not have fat! On the inner aspect of the obturator fascia the white line can usually clearly be felt, running from the ischial spines below to the inner surface of the symphisis pubis.

6. With a Boudijk (or Navratil Breisky) retractor (preferably a narrow one) the bladder is pulled medially. This enables one to place the lateral stitches on the obturator fascia.

7. A 10 x 20 swab is put into the para-vaginal space and removed directly before the stitches are placed- this provides local pressure and controls any venous bleeding.

8. Stitch A and B: The first two stitches (Maxon O on a HGU-46 taper needle) are placed near the ischial spine and one centimetre above the spine on the white line.

9. The double needle holder technique make the placing easier: beginning on the left side of the patient first (if right handed; begin on the right side if left-handed), to enable one to swing the needle from top to bottom as it pierces the obturator fascia, with the Boudijk or Breisky retractor pulling the bladder pillars medially and downwards - thus protecting the bladder and pulling the ureters out of harm’s way.

This placing is best guided by first feeling with the index finger of the free hand where the Ischial spine is and then directing in a blind fashion the needle towards this point. With the first stitch in place, the second can be placed by pulling the suture to the contra lateral side at a 45% angle upwards or downwards. This depends on whether the first placed stitch is near enough to the ischail spine so that the second one can either be placed inferior or superior to the first one.

By pulling on the stitch one can also feel the white line as it comes under tension.
10. The third stitch (Stitch C) is placed halfway between the symphisis pubis and the top of the above two stitches on the obturator fascia.

The last stitch (Stitch D) is put through the Pubo-urethral ligament (PUL). Placing of this is easier if the needle is on the needle holder in a “cat’s claw” fashion.

For both these superficial placed stitches it is recommended to use an O delayed absorbable material (example monofilament polyglyconate) also on a HGU-46 taper needle- TYCO. The author prefers to use Maxon O (serial number 6455-61)

• After placing of the stitches a 10x20 swab is again placed into the para-vesicle space.
• The needle is not removed from the suture material, neither is a knot thrown. It is useful to clamp the different stitches with different types of forceps on the outside to enable one to differentiate the sutures once placed from each other.

11. The side specific repair is done with stitches A an B:
• After removal of the swab a Boudijk (or Breisky) retractor is placed on the bladder pillars, pulling it downwards and away from the sidewall. With controlled removal and suction on the tip of the retractor, one can identify the area where the septum and lateral bladder wall meets -in this edge the needle of first stitch A and then stitch B is hooked from lateral to medial. This is put not deeper than 0.5 mm as the ureter is about 1cm from the edge in the bladder pillar. (This manoeuvre is easier if one grab the septal edge with a small kocher and pull it downwards).

• Tying Stitch A first and then Stitch B before doing the other side make the procedure easier on the contra lateral side.

• If needed a lateral plication can be done: with a medial bite of either stitch A or B the bladder can be plicated in a lateral to medial direction, bringing the bladder base under more tension. This type of secondary stitching can also control bleeders.

Once these four stitches are tied, the high transverse defect becomes apparent:

this can now be closed by tying the inferior border of the septum down onto the cervix, or onto the utero-sacrals if a hysterectomy was done (the “site” specific part of the repair)

12. If needed or deemed necessary, the repair can be bolstered with a suitable
remodelling biomesh material in the following way:
• A 10x7 piece of mesh is prepared.

• The mesh is secured to the side wall and onto the PUL and cervix by using the previously placed stitches (A,B,C,D and the cervical stitch).

By not tying the central stitch -cervical- and stitch B -on both sides- one can plicate the mesh sideways and around the cervix- thus creating a cervical ring- with these as they are tied secondary. The author did this to strengthen the central area. This plication also pull the biomesh into tension, which will enhance the secondary collagen reaction.

initially the author used Ti-Cron for all sutures, but the Ti-Cron tends to erode through the vaginal skin, and in one instance into the bladder: this was replaced by the use of Maxon. The key to success of this procedure lies in the use of the Lone Star retractor, the use of the HGU-46 needle and the double needle holder technique of side wall suture placing.

13. A trans urethral catheter is placed and the vagina is tightly packed. Both the vaginal plug and the catheter are removed after 24 or 48 hours.

This technique was initiated by Richard Reid in 2006 and modified in Ziekenhuis Zeeuws Vlaanderen in Terneuzen ,The Netherlands. Regular hands-on workshops are conducted in Ziekenhuis Zeeuws Vlaanderen by the author.
We are greatfull for the support given to us by Dr Reid. His vision led to a new mindset in treating the patient with POP.

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Tuesday, July 03, 2007