Custom Search

Wednesday, March 14, 2012

The mess of the meshes- is there a way forward?

The debate on the pro’s and cons of synthetic implants in the resent press needs to be look at in the right context. One can only make sense out of the perfect storm if you realize a few facts:

1. The prolapsed vaginal wall is a symptom of an underlying disease. In itself is it not a diagnosis. Treatment should be directed at the disease and not the symptom.

2. “ All cystocoels are not the same” – patients needs to be clustered in groups that can be compared with one another. The different defects in the vaginal wall support system must be identified and surgical procedures for each need to be compared accordingly. The same apply to tissue reaction of different age groups- to compare a 29 year olds’ response to surgery with that of an eighty year old is impossible.

3. Due to different factors uniquely to pelvic surgery (e.g. poor tissue quality, intra-abdominal pressure effects on suture lines, absent tissue, scar tissue formation, etc.) one needs to realize that not all pathology will be able to be corrected at one sitting alone. Suboptimal results can be expected in some patients. Staged surgery is a real possibility. The surgical footprint done in primary surgery must never have the potential of permanent irreversible damage.

4. The role of implants should be to play a supportive role in pelvic floor surgery and not a primarily role. This supportive role will lay down the requirements –be it temporary or permanent support- that need to be fulfilled by the material to be used.

5. Reconstructive surgery is reconstruction of normal anatomy, and not creation of new “ innovative” anatomy. There is a reason why ligaments run into specific directions in the pelvis. For the same reason is there not place in normal anatomy for ligaments to follow non-traction lines e.g. from the peri-cervical ring to the sacro- spinous ligament.

In this Eureka moment a paradigm shift of the mind allows the eyes to see what it had previously been blind to. The vaginal wall topography takes on a new meaning. The presence and absence of the rugae tells what lies beneath, the lateral sulci on the anterior wall predict what lies beneath, the position of the cervix in the vaginal apex has its’ own tale, and the dimples on the lateral fornixes where the cardinal ligaments takes its’ origin from the vaginal wall provide information about the integrity of the cardinal-utero-sacral ligament complex.

By looking beyond the prolapsed vaginal wall to the underlying defect, one realizes what needs to be done. Rectifying the wrong by treating the disease and not the symptom will involves doing defect specific surgery and not covering the prolapsed wall with a blanket.
This is reconstructive surgery and not surgery with a potential of destruction


Anonymous Laparoscopic Surgeons India said...

There are many drawback of Laparoscopic surgery also like restricted vision, the difficulty in handling of the instruments (new hand-eye coordination skills are needed), the lack of tactile perception and the limited working area are factors which add to the technical complexity of this surgical approach. For these reasons, minimal Access surgery has emerged as a highly competitive new sub-specialty within various fields of surgery. Surgical residents and junior consultant who wish to focus on this area of advanced surgery gain additional laparoscopic training after completing their basic surgical residency.

9:08 AM  
Blogger andri nieuwoudt said...

I agree- what I want to advocate is that the laparoscopic surgeon must come and join me looking upwards from the vaginal view at the defects. With this view he/she will be able to see more clearly what needs to be done. The vision of the laparoscopic surgeon will be markedly improved if he/she have the insight of the vaginal surgeon!

2:18 PM  
Anonymous Laparoscopic Surgeons India said...

Laparoscopic surgery includes operations within the abdominal or pelvic cavities, whereas keyhole surgery performed on the thoracic or chest cavity is called thoracoscopic surgery. Laparoscopic and thoracoscopic surgery belong to the broader field of endoscopy.

8:04 AM  
Blogger AmyG said...

It is troubling to me how many women I have met who have endured hip problems and dysplasia following mesh kit repairs of SUI and prolapse. When will surgeons realize there are other structures dependent on the natural design of the pelvic floor. Alterations of the pelvic floor lead to difficulty and improper articulation of the hips, spines and knees. Gynecologists and urologists need to start considering the frequent problems of the hips, knees and spines are not a coincidence following transvaginal mesh implants which most dismiss as the source of pain but rather the mesh is distorting proper alignment and articulations of major joint structures.

6:09 PM  

Post a Comment

<< Home