FEATURE SURGERY
P
elvic organ prolapse is a frequent pathology among women and is due to a weakness of the apical, anterior and/or posterior walls of the vagina. We consider that 11% of women will need surgical treatment some time in their life. A third of these women will also need more than one procedure. The demand for correction of prolapse has increased significantly in the last decade. Many procedures have already been
described with a vaginal and/or abdominal access, with laparoscopic techniques or robotic assistance. The abdominal laparoscopic sacrocolpopexy is the procedure that appears to offer superior and more durable outcomes. Also, laparoscopic techniques are well known to reduce post- operative pain and be cosmetically pleasing. Laparo Endoscopic Single-site Surgery
(LESS) has been developed to reduce even more scars, pain, length of stay and recovery. This new approach consists in placing in the umbilicus natural scar a small device that allows the passage for a laparoscope and two or three working instruments. This single 25mm scar is finally totally hidden in the umbilicus and becomes invisible, but
«Laparo
Endoscopic Single- site Surgery (LESS) has been developed to reduce scars, pain, length of stay and recovery»
the surgeon gets a very restricted space to move his hands… Here is the challenge. The first urological LESS surgery was
reported in 2005, the first Nephrectomy in 2007 and then almost all of the urological procedures. Many specific laparoscopes, access devices, instruments (bended, articulated, extra long) have rapidly been developed to facilitate the operative steps. At first, reconstructive procedures (such as Sacrocolpopexy) did not seem to be feasible because the frequent clashing of the hands and instruments could not allow knot tying in good conditions. We have worked to get around this difficulty and like other teams we have developed and described many techniques that facilitate knot tying.
We performed our first LESS
sacrocolpopexy in October 2009 and 40 women have had surgery so far. In this first international experience, patients have not been selected, only three have been excluded because they were in a situation of multiple recurrences. Past history of pelvic surgery did not contra- indicate this procedure and did not influence operative time In our technique, we are using a standard
10mm/0° laparoscope and standard 5mm instruments. After the 25mm umbilical incision, the single port device is inserted and the insufflation begins. The first step consists in the promontory dissection. Then we place a posterior mesh into the recto vaginal space after exposition of
the two levator ani. An anterior mesh is used to reinforce the anterior vaginal wall. Bladder and vagina have been separated before. These two anterior and posterior meshes are then being fixed to the sacral promontory. All of the fixations of the meshes are made with intra or extra corporeal knot tying, but tackers may also be used. In case of difficulties a barbed wire represents also a good solution! At the end of the procedure, the scar is hidden in the umbilicus and we perform an anesthesic infiltration of the abdominal wall. The urinary catheter is removed 2 hours after the end of the procedure. The patient is discharged in the evening or the following day with very low pain rates. All efforts must be avoided for 8 weeks to limit the risk of recurrence.
Arab Health Issue 5 2011 45
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