Placement of retention sutures.

A retention suture using the buried technique has been developed. This retention suture encompasses fascia, muscle and subcutaneous tissue and remains extraperitoneally and just below the skin. Since the suture material is not in contact with the skin, complications, such as skin damage, stich abscesses and infection at exit points, are avoided. Severe postoperative pain related to retention sutures is minimized.     

A Modified Technique of Temporary Suspension of the Ovary to the Anterior Abdominal Wall

Study Objective

To demonstrate a modified technique of temporary suspension of the ovary to the fascia of the anterior abdominal wall after operative laparoscopy for advanced stage-endometriosis to reduce postoperative adhesion formation.

Does closure of Camper fascia reduce the incidence of post-cesarean superficial wound disruption?

OBJECTIVE: To determine whether closure of Camper fascia prevents the development of superficial wound disruption after cesarean delivery. METHODS: During a 1-year period, 438 women undergoing cesarean delivery were randomized into groups with and without approximation of Camper fascia with absorbable suture during closure of the abdominal incision. All women received routine postoperative care following our departmental guidelines. We reviewed charts after the puerperium to identify women with postoperative superficial wound disruption and to obtain demographic and delivery information for analysis. RESULTS: We found a significantly higher incidence of wound disruption in the group without the suture than in those in whom the tissue was approximated (P = .03). Four or more vaginal examinations and higher body mass index were also associated with a higher incidence of wound disruption (P = .05 and P = .04, respectively). Logistic regression correction for covariables that might influence the results of our main analysis revealed no effect of maternal age, parity, indications for cesarean delivery, duration of labor, duration of ruptured membranes, duration of surgery, use of internal monitoring, type of incision, use of antibiotic prophylaxis, surgeon's level of training, or maternal diabetes mellitus and/or hypertension. CONCLUSION: Approximation of Camper fascia with absorbable suture at closure of the abdominal incision during cesarean delivery appears to protect against postoperative superficial wound disruption and is therefore recommended.     

A comparison of barbed and smooth sutures for ovine cesarean delivery

Objective

To determine the adequacy of barbed and smooth sutures for closing the uterus and fascia in pregnant ewes.

Methods

Nine ewes that underwent cesarean delivery were randomized to each receive 2 different suture materials for both the uterus and the fascia. The sutures used were: barbed poliglecaprone 25, smooth poliglecaprone 25, braided polyglactin 910, and smooth chromic sutures on the uterus; and barbed polydioxanone (PDO), barbed poliglecaprone 25, braided polyglactin 910, and smooth chromic sutures on the fascia.

Results

In 4 of the ewes, the fascia suture line failed prematurely, leading to dehiscence prior to planned euthanasia and necropsy. The remaining 5 ewes were euthanized on days 2, 7, or 28. All suture materials (smooth and barbed) were adequate for uterine closures. Barbed PDO, smooth poliglecaprone 25, and braided polyglactin 910 were adequate for fascia closures, whereas both barbed poliglecaprone 25 and smooth chromic resulted in premature suture line ruptures and fascia dehiscence.

Conclusion

In a small pilot study, absorbable knotless barbed suture was adequate and equivalent to absorbable knotted smooth suture for closing the uterus following ovine cesarean delivery. On the rectus fascia, however, sutures—whether barbed or smooth—with lower tensile strength resulted in fascial dehiscence.     

Modified retropubic cystourethropexy

A variation of retropubic suspension of the urethrovesical junction was performed on 26 patients with urinary stress incontinence. Access to the retropubic space was through a low transverse muscle-splitting incision. Surgical technique consisted of securing a helical Prolene suture in the paraurethral fascia at each side of the bladder neck. Each suture was then passed through the abdominal wall fascia, exiting just above the symphysis pubis on either side of the midline, and tied to the opposite suture above the rectus fascia. The desired amount of elevation of the vesical neck was gauged by a Q-tip applicator inserted into the urethra just before the Prolene sutures were tied down. A cystotomy was performed to rule out any inadvertent penetration of the bladder by the nonabsorbable suture material, and the bladder was drained suprapubicly. The small number of cases and short follow-up times do not allow conclusions to be drawn at this time, but results to date have been encouraging.     

One layer closure of the abdominal wall

A one layer closure of the abdominal wall with a far-near, near-far suture has been used in 34 patients. This technique allows approximation of the fascia without pressure on the skin and leads to firm uncomplicated wound healing.     

Porcine dermal hammock for repair of anterior and posterior vaginal wall prolapse: 5-year outcome

STUDY OBJECTIVE: To estimate the long-term efficacy of acellular cross-linked porcine dermal implants for the substitution of prolapsed anterior and posterior endopelvic fascia. In addition, surgical techniques to improve outcome were examined. DESIGN: Prospective longitudinal study (Canadian Task Force classification II-2). SETTING: Private urogynecology clinic. PATIENTS: Patients were reviewed who had Pelvic Organ Prolapse Quantification stage 2 or greater anterior and/or posterior pelvic floor defects repaired with porcine dermis from March 2000 through August 2002 with at least 5 years of follow-up. INTERVENTIONS: Repairs consisted of endopelvic fascia implants side wall to side wall from the ischial spine to the vaginal introitus. Different techniques of dissection, wound closure, and tissue pliability were measured. MEASUREMENTS AND MAIN RESULTS: A total of 91 consecutive patients had endopelvic porcine dermal implants for pelvic organ prolapse. In all, 72 patients with a total of 82 defects had an objective cure rate of 81.6% and 86.4% at 5 years for anterior and posterior repairs, respectively. Concomitant anterior and posterior repairs had a 6 times higher objective failure rate. The method of dissection and mucosal wound closure significantly affected wound healing. Solid porcine implants had decreased tissue pliability. A significant improvement in quality-of-life questionnaires and high patient satisfaction occurred, shown by a visual analog scale. CONCLUSION: Complete replacement of the endopelvic fascia with porcine dermis had a better outcome than reported in many studies using classic plication or plication augmentation repairs. Porcine was well tolerated with high patient satisfaction and improved quality of life. Solid dermal implants resulted in thick scar plates, yet had a low occurrence of de novo dyspareunia and did not appear to adversely affect sexual activity.     

A prospective randomized trial using solvent dehydrated fascia lata for the prevention of recurrent anterior vaginal wall prolapse

OBJECTIVE: This study was undertaken to compare outcomes after anterior colporrhaphy with and without a solvent dehydrated cadaveric fascia lata graft. STUDY DESIGN: A total of 162 women were enrolled in a prospective, randomized trial that evaluated the impact of a solvent dehydrated cadaveric fascia lata patch on recurrent anterior vaginal prolapse. Subjects were randomly assigned to standard colporrhaphy with or without a patch. Before and after surgery, subjects were evaluated by both the Baden-Walker and pelvic organ prolapse quantification systems. "Failure" was defined as stage II anterior wall prolapse or worse. RESULTS: Of 154 women randomly assigned (76 patch: 78 no patch), all underwent surgery and 153 (99%) returned for follow-up. Sixteen women (21%) in the patch group and 23 (29%) in the control group experienced recurrent anterior vaginal wall prolapse (P = .229). Only 26% of all recurrences were symptomatic. Concomitant transvaginal Cooper's ligament sling procedures were associated with a dramatic decrease in recurrent prolapse (odds ratio [OR] 0.105 , P < .0001). CONCLUSION: Solvent dehydrated fascia lata as a barrier does not decrease recurrent prolapse after anterior colporrhaphy. Transvaginal bladder neck slings were associated with a significant reduction in the risk of recurrent anterior wall prolapse.     

Cesarean section by the Misgav Ladach+ with the abdominal opening surgery by the Joel Cohen method

The purpose of this study was to compare 90 Misgav-Ladach cesarean section by the Joel-Cohen method with 45 others with Pfannenstiel incision. The Misgav-Ladach technique involves the Joel-Cohen method, that is a superficial transverse cut in the cutis, a small midline incision in the fascia, then blunt preparation of deeper layers, including the peritoneum, followed by manual transverse traction applied to tear the recti muscles and subcutis. The uterus is also opened using the blunt preparation after a small cut in the midline. After the delivery of the fetus and placenta the uterus is lifted through the incision onto the draped abdominal wall. Then the uterus is closed with one layer of continuous vicryl suture. The abdomen is closed by a continuous suture of fascia, and widely spaced silk stitches of the skin. We sometimes use continuous suture of the skin. We do not close visceral and parietal peritoneum, recti muscles and subcutis. In our experience Misgav-Ladach method is 50% less time consuming, it reduces blood loss by about 250 ml. and allows for a much faster delivery of the fetus than Pfannenstiel method. The post operative outcome of the two methods is similar. Using the blunt preparation in the Joel-Cohen method causes less trauma and shortens convalescence time. We therefore recommend Misgav-Ladach method for cesarean section.     

Relative strength of a new suture technique for fascial closure

In an attempt to decrease the risk of fascial dehiscence, a new suture technique for fascial closure is proposed, referred to as the "secured" stitch. The secured interrupted stitch is performed by taking a double bite of fascia at each traditional site of fascial puncture. Relative strength of the secured interrupted stitch in comparison with the simple interrupted stitch is determined in samples of fresh bovine fascia. A significantly greater force is required to disrupt fascia repaired with the secured stitch compared with a simple interrupted repair. The secured stitch may afford a greater degree of protection from fascial dehiscence.     

Surgical management of difficult wounds of the groin

Coverage of large defects of the soft tissue of the groin present a challenging problem. Exposure of the femoral vessels or prosthetic grafts requires urgent coverage with well vascularized tissue. The medial and lateral femoral circumflex arteries supply the gracilis, sartorius, vastus lateralis, rectus femoris and tensor fascia lata muscles, permitting the use of these muscles or myocutaneous flaps for coverage of groin defects when the femoral artery is intact. With extensive wounds of the groin resulting from trauma, ablation of carcinoma and vascular reconstruction for atherosclerosis involving the femoral vessels, the aforementioned flaps cannot be used. The external iliac artery supplies the rectus abdominis muscle through the deep inferior epigastric artery and the interal oblique muscle through the deep circumflex iliac artery. These muscle flaps are available when the femoral vessels are not intact. If the ipsilateral iliofemoral vessels are not intact, branches of the contralateral iliac artery through deep inferior epigastric artery and deep circumflex iliac artery provide suitable flaps for covering the groin wound. We review our experience with the management of difficult groin wounds (n = 31) and present a systematic approach to reconstruction of the groin based on these anatomic facts.     

Microsurgical anastomosis of the rabbit oviduct using 9-0 monofilament polyglycolic acid suture.

As part of a larger study to determine which factors are important in fallopian tube reconstruction, 9-0 monofilament polyglycolic acid suture on a 145 micron-needle was used for rabbit oviduct microsurgical anastomosis. A 100% pregnancy rate in five rabbits with no disruption of the endosalpingial or muscular layers was noted. Of special note, the suture was totally resorbed, and no suture residuum or surrounging reaction was noted. The suture material appears to fulfill the criteria for an ideal suture described at the beginning of the paper. This is the first report of the use of a 9-0 monofilament polyglycolic acid suture.     

Assessment of tissue reaction at suture knots; an adaptation of Sewell's scoring system

From a theoretical point of view and from reported animal work the knot side should be considered the most relevant part of the suture loop for studying inflammatory foreign body reaction. In the present study a semi-quantitative histological assessment of inflammatory tissue reaction around the knots of implanted sutures is presented. To test the reliability of this method an animal model was used in which two suture materials with well-known differences in tissue reactivity were studied. Differences in tissue response around the knots between these materials proved to be highly significant statistically (tissue reactivity score (TRS) 44.17 vs. 58.71: p less than 0.001). No differences in TRS could be demonstrated between different localizations in the anterior abdominal wall of male Wistar rats. Implications of these findings with respect to future studies are discussed.     

Concomitant pericervical reconstruction with sacrospinous hysteropexy: Anatomical and functional results

ObjectivePericervical ring reconstruction through restoration of pubocervical and rectovaginal fascia is performed concomitantly with sacrospinous hysteropexy as a transvaginal native tissue procedure for vaginal apical prolapse.The main goal of this study was to assess subjective and objective outcomes of sacrospinous hysteropexy and additional pericervical ring reconstruction.Materials and methodsWe conducted a prospective and observational study. All participants underwent sacrospinous hysteropexy and pericervical ring reconstruction and perineorrhaphy. Surgical complications, anatomical and functional efficacy were assessed.Results108 cases were included in this study. The mean follow-up timeframe was 18.62 ± 1.22 months (minimum 12 and maximum 26 months). All parameters of subjective outcomes were improved significantly. The overall anatomic success rate was 92.59%. Mean operation time was 50.64 ± 20.8 min. No major intraoperative or postoperative complications were found. There was no statistically significant difference in demographic characteristics including age, BMI, gravidity, medical comorbidities, menopausal status, sexual activity, pretreatment prolapse severity scores between subjects with failure, and good anatomical outcome. Recurrence was mostly observed in patients with higher prolapse stages of anterior and apical compartments. Baseline POP-Q parameters Ba, C, D were significantly higher in cases with failure.ConclusionOur study disclosed sustainable anatomic and subjective outcomes of modified sacrospinous hysteropexy by means of additional pericervical ring reconstruction.     

Important anatomical structures used in paravaginal defect repair: cadaveric study

OBJECTIVE: To examine the variations and the anatomical characteristics of the tendinous arch of pelvic fascia (TAPF), the tendinous arch of levator ani (TALA) and the obturator fascia (Ofa) that are important structures in paravaginal defect repair and their relations with important neurovascular structures. STUDY DESIGN: We carried our study on 10 pelvic halves of five female cadavers fixed in 10% formaldehyde. RESULTS: TALA could show a very high location or a low location near to inferior edge of obturator internus. TAPF was not observed in four of the cases. It was examined as a quite weak structure in two of the cases. The location of obturator vessel-nerve bundle could show difference. Obturator artery (OA) and vein sometimes do not course parallel to obturator vein (OV) and make an inclination and extend to the obturator foramen (OF). The distance between TAPF and the pectineal ligament (PL) (Cooper ligament) was measured as 5 cm on average. The distance between TAPF and the entrance of obturator canal was measured as 3.2 cm on average. While the distance of pudendal vessel-nerve bundle from levator ani (LA) at the anterior border of the spine was 0 mm, 2 cm anteriorly it was measured as 4.4 mm on average. CONCLUSION: Since TAPF does not develop in every case, it is not a safe structure to be used in surgery. If TALA develop downward as a variation, it could be difficult to distinguish from TAPF. Since the obturator fascia is a thin membrane, it is not a strong structure for suture placement. The region that is 2 cm in front of the ischial spine (IS) is a dangerous zone for pudendal vessel-nerve bundle.     

Repair of vaginal vault prolapse with abdominal sacropexy

Ten women were treated for complete eversion of the vaginal vault with an abdominal sacropexy technique utilizing rectus fascia as graft material. The vault was suspended from the anterior sacral ligament by a strip of rectus fascia. Nine of ten patients had complete cure of the prolapse. All patients who remained sexually active have reported normal coital function. Abdominal sacropexy using rectus fascia is a safe, effective method for the long-term cure of vaginal vault prolapse.     

Biologic and synthetic graft use in pelvic surgery: a review

Urinary incontinence and pelvic organ prolapse are some of the most commonly treated conditions in postmenopausal women. Surgical cure rates vary greatly depending on surgical technique and the type of materials used, if any, to supplement the native tissue. Traditional colporrhaphy relies on adequate tissue for a successful repair. The main concern associated with traditional plication or needle suspension type repairs is that the use of intrinsic attenuated tissue may provide a weak, constricted, or an anatomically incorrect result. Graft use allows for a broader base of support and eliminates the need to rely on the existing weakened fascia and musculature. A review of the existing literature on success rates and complications with various synthetic and biologic graft materials yielded the following conclusions. The superiority of graft use over traditional suture suspensions for abdominal sacrocolpopexy and suburethral sling procedures has clearly been shown in the literature. Macroporous monofilament synthetic grafts and non-cross-linked biologic grafts appear to have the best integration into native tissues. Solvent dehydration and irradiation of biologic grafts may weaken the integrity of the material and may prevent proper tissue integration. Technical factors related to surgical technique may impact success rates, such as tension on suture line or failure to use vaginal packing. The perfect graft material has not yet been created. Suggestions for further research include more prospective, randomized trials comparing synthetic and biologic grafts, tension-free versus secured mesh, and absorbable versus nonabsorbable mesh. Target Audience: Obstetricians & Gynecologists, Family Physicians Learning Objectives: After completion of this article, the reader should be able to recall how common urinary incontinence is, explain the historical considerations for diagnosis and treatment, and summarize the updated methods of treatment based upon anatomical structures and pathophysiology.     

A trocarless,reusable, visual-access cannula for safer laparoscopy; An update

A new instrument for laparoscopic access consists of a trocarless, reusable, visual-access cannula with an external thread that ends in a blunt tip. The device has no sharp ends or moving parts. The cannula does not transect but radially stretches and elevates vessels, fascia, and muscle fibers, preserving the fascia's natural gridiron shutter mechanism at the access site. The outer thread stabilizes the cannula, and no fascial suture is necessary. In a prospective clinical trial between 1994 and 1997, the instrument was used in 203 patients requiring 234 access ports for diagnostic and operative laparoscopies. No device-related complications or failed attempts were recorded. The cannula caused less tissue trauma at access sites, and may decrease the frequency of hernias and postoperative access site pain.