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:
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
5 Linda
Brubaker, Bob
Shull A perfect
storm International Urogynecology Journal
January
2012, Volume 23, Issue 1,
pp 3-4
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.
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
Labels: vaginal regenerative surgery
posted by andri nieuwoudt at 8:35 PM
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