- Email: [email protected]
Laparoscopic Uterosacral Suture Sacrohysteropexy: LUSSH Procedure
Accepted Manuscript Title: Laparoscopic Uterosacral Suture Sacro Hysteropexy: LUSSH Procedure Author: Haider Jan, Vishalli Ghai PII: DOI: Reference:
S1553-4650(18)30182-1 https://doi.org/10.1016/j.jmig.2018.03.025 JMIG 3475
To appear in:
The Journal of Minimally Invasive Gynecology
Received date: Accepted date:
14-3-2018 27-3-2018
Please cite this article as: Haider Jan, Vishalli Ghai, Laparoscopic Uterosacral Suture Sacro Hysteropexy: LUSSH Procedure, The Journal of Minimally Invasive Gynecology (2018), https://doi.org/10.1016/j.jmig.2018.03.025. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Laparoscopic Uterosacral Suture Sacro Hysteropexy: LUSSH Procedure
Haider Jan BSc, MBBS, MRCOG, Vishalli Ghai BMedSci MBBS MRCOG*,
Authors Mr Haider Jan, Consultant Gynaecologist, Department of Obstetrics and Gynaecology, Epsom & St Helier’s University Hospitals NHS Trust, Dorking Road, United Kingdom, KT18 7EG Miss Vishalli Ghai, Specialist Registrar, Department of Obstetrics and Gynaecology, Epsom & St Helier’s University Hospitals NHS Trust, Dorking Road, United Kingdom, KT18 7EG
Authors have no conflict of interest to report Institutional review board/Ethics committee ruled that approval was not required for this study.
Corresponding author: Miss Vishalli Ghai, Department of Obstetrics and Gynaecology, Epsom & St Helier’s University Hospitals NHS Trust, Dorking Road, United Kingdom, KT18 7EG. Email: [email protected]
Page 1 of 5
ABSTRACT Study Objective: To demonstrate mesh-free laparoscopic uterosacral suture sacro hysteropexy (LUSSH). Design: Technical video demonstrating LUSSH for uterine prolapse (Canadian Task force classification level III). Setting: University Hospital. Intervention: A 37-year old woman with grade 3 uterine-descent requesting uterinesparing surgery for symptomatic prolapse. The patient declined all mesh procedures. Conclusion: Laparoscopic sacrohysteropexy is a uterine preserving technique for uterine prolapse with high cure rates (92%) but a mesh erosion risk of up to 2.5%. [1,2] Complications have resulted in reclassification of transvaginal meshes as restricted use high-risk medical devices [3,4]. Sacrospinous hysteropexy and uterosacral ligament suspension are mesh free alternatives, but they have increased rates of anterior-compartment failures and a 20% recurrence rate in the latter [5,6]. Laparoscopic suture sacrohysteropexy has been described with reported success rates of 95% [7]. This video demonstrates a modified-technique offering a simple, robust and reproducible mesh free approach to uterine preserving prolapse surgery. We use two horizontal loop mattress sutures acting as a pulley to distribute the force evenly throughout the suture strand leading to a significantly stronger and more secure hold, reducing risk of avulsion [8]. The technique starts with careful dissection of the peritoneum from the sacral promontory to the cervix. Two permanent sutures are used taking bites at the anterior longitudinal ligament, the uterosacral, a loop
Page 2 of 5
mattress in the midline at the cervix, the uterosacral on the way back and finally at the sacral promontory. Damage to the uterine vessels is minimised by maintaining a central uterine position. The stitch is tied with caudal pressure on the uterus, applied via the uterine manipulator, approximating the cervix to the sacral promontory. The peritoneum is closed with dissolvable sutures burying the Ethibond to prevent exposure and bowel obstruction. Post-procedure, the uterus was well-supported with a vaginal length of 15 cm.
Word count: 297
KEYWORDS: Mesh-free; laparoscopic; sacrohysteropexy; suture sacrohysteropexy; uterine-preserving
References 1.
Nair R, Nikolopoulos KI, Claydon LS. Clinical outcomes in women undergoing laparoscopic hysteropexy: A systematic review. European Journal of Obstetrics and Gynecology. 2017;208:71-80. doi:10.1016/j.ejogrb.2016.11.019.
2.
Gutman RE, Rardin CR, Sokol ER, et al. Vaginal and laparoscopic mesh hysteropexy for uterovaginal prolapse: a parallel cohort study. Am J Obstet Gynecol. 2017;216(1):38.e138.e11. doi:10.1016/j.ajog.2016.08.035.
3.
National Institute for Health and Care Excellence. Transvaginal Mesh Repair of Anterior or Posterior Vaginal Wall Prolapse. 2017:1-9. Available at https://www.nice.org.uk/guidance/ipg599. Accessed October 4, 2018
4.
US Food and Drug Administration. FDA strengthens requirements for surgical mesh for the transvaginal repair of pelvic organ prolapse to address safety risks. Available at https://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm479732.htm. Accessed October 6, 2017.
5.
Dietz V, de Jong J, Huisman M, Schraffordt Koops S, Heintz P, van der Vaart H. The effectiveness of the sacrospinous hysteropexy for the primary treatment of uterovaginal prolapse. Int Urogynecol J Pelvic Floor Dysfunct. 2007;18(11):1271-1276. doi:10.1007/s00192-007-0336-6.
6.
Maher CF, Carey MP, Murray CJ. Laparoscopic suture hysteropexy for uterine prolapse. Obstet Gynecol. 2001;97(6):1010-1014.
7.
Krause HG, Goh JTW, Sloane K, Higgs P, Carey MP. Laparoscopic sacral suture
Page 3 of 5
hysteropexy for uterine prolapse. Int Urogynecol J. 2005;17(4):378-381. doi:10.1007/s00192-005-0019-0. 8.
Biddlestone J, Samuel M, Creagh T, Ahmad T. The double loop mattress suture. Wound Repair Regen. 2014;22(3):415-423. doi:10.1111/wrr.12159.
Page 4 of 5
JMIG-D-18-00233.jpg
Page 5 of 5
S1553-4650(18)30182-1 https://doi.org/10.1016/j.jmig.2018.03.025 JMIG 3475
To appear in:
The Journal of Minimally Invasive Gynecology
Received date: Accepted date:
14-3-2018 27-3-2018
Please cite this article as: Haider Jan, Vishalli Ghai, Laparoscopic Uterosacral Suture Sacro Hysteropexy: LUSSH Procedure, The Journal of Minimally Invasive Gynecology (2018), https://doi.org/10.1016/j.jmig.2018.03.025. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Laparoscopic Uterosacral Suture Sacro Hysteropexy: LUSSH Procedure
Haider Jan BSc, MBBS, MRCOG, Vishalli Ghai BMedSci MBBS MRCOG*,
Authors Mr Haider Jan, Consultant Gynaecologist, Department of Obstetrics and Gynaecology, Epsom & St Helier’s University Hospitals NHS Trust, Dorking Road, United Kingdom, KT18 7EG Miss Vishalli Ghai, Specialist Registrar, Department of Obstetrics and Gynaecology, Epsom & St Helier’s University Hospitals NHS Trust, Dorking Road, United Kingdom, KT18 7EG
Authors have no conflict of interest to report Institutional review board/Ethics committee ruled that approval was not required for this study.
Corresponding author: Miss Vishalli Ghai, Department of Obstetrics and Gynaecology, Epsom & St Helier’s University Hospitals NHS Trust, Dorking Road, United Kingdom, KT18 7EG. Email: [email protected]
Page 1 of 5
ABSTRACT Study Objective: To demonstrate mesh-free laparoscopic uterosacral suture sacro hysteropexy (LUSSH). Design: Technical video demonstrating LUSSH for uterine prolapse (Canadian Task force classification level III). Setting: University Hospital. Intervention: A 37-year old woman with grade 3 uterine-descent requesting uterinesparing surgery for symptomatic prolapse. The patient declined all mesh procedures. Conclusion: Laparoscopic sacrohysteropexy is a uterine preserving technique for uterine prolapse with high cure rates (92%) but a mesh erosion risk of up to 2.5%. [1,2] Complications have resulted in reclassification of transvaginal meshes as restricted use high-risk medical devices [3,4]. Sacrospinous hysteropexy and uterosacral ligament suspension are mesh free alternatives, but they have increased rates of anterior-compartment failures and a 20% recurrence rate in the latter [5,6]. Laparoscopic suture sacrohysteropexy has been described with reported success rates of 95% [7]. This video demonstrates a modified-technique offering a simple, robust and reproducible mesh free approach to uterine preserving prolapse surgery. We use two horizontal loop mattress sutures acting as a pulley to distribute the force evenly throughout the suture strand leading to a significantly stronger and more secure hold, reducing risk of avulsion [8]. The technique starts with careful dissection of the peritoneum from the sacral promontory to the cervix. Two permanent sutures are used taking bites at the anterior longitudinal ligament, the uterosacral, a loop
Page 2 of 5
mattress in the midline at the cervix, the uterosacral on the way back and finally at the sacral promontory. Damage to the uterine vessels is minimised by maintaining a central uterine position. The stitch is tied with caudal pressure on the uterus, applied via the uterine manipulator, approximating the cervix to the sacral promontory. The peritoneum is closed with dissolvable sutures burying the Ethibond to prevent exposure and bowel obstruction. Post-procedure, the uterus was well-supported with a vaginal length of 15 cm.
Word count: 297
KEYWORDS: Mesh-free; laparoscopic; sacrohysteropexy; suture sacrohysteropexy; uterine-preserving
References 1.
Nair R, Nikolopoulos KI, Claydon LS. Clinical outcomes in women undergoing laparoscopic hysteropexy: A systematic review. European Journal of Obstetrics and Gynecology. 2017;208:71-80. doi:10.1016/j.ejogrb.2016.11.019.
2.
Gutman RE, Rardin CR, Sokol ER, et al. Vaginal and laparoscopic mesh hysteropexy for uterovaginal prolapse: a parallel cohort study. Am J Obstet Gynecol. 2017;216(1):38.e138.e11. doi:10.1016/j.ajog.2016.08.035.
3.
National Institute for Health and Care Excellence. Transvaginal Mesh Repair of Anterior or Posterior Vaginal Wall Prolapse. 2017:1-9. Available at https://www.nice.org.uk/guidance/ipg599. Accessed October 4, 2018
4.
US Food and Drug Administration. FDA strengthens requirements for surgical mesh for the transvaginal repair of pelvic organ prolapse to address safety risks. Available at https://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm479732.htm. Accessed October 6, 2017.
5.
Dietz V, de Jong J, Huisman M, Schraffordt Koops S, Heintz P, van der Vaart H. The effectiveness of the sacrospinous hysteropexy for the primary treatment of uterovaginal prolapse. Int Urogynecol J Pelvic Floor Dysfunct. 2007;18(11):1271-1276. doi:10.1007/s00192-007-0336-6.
6.
Maher CF, Carey MP, Murray CJ. Laparoscopic suture hysteropexy for uterine prolapse. Obstet Gynecol. 2001;97(6):1010-1014.
7.
Krause HG, Goh JTW, Sloane K, Higgs P, Carey MP. Laparoscopic sacral suture
Page 3 of 5
hysteropexy for uterine prolapse. Int Urogynecol J. 2005;17(4):378-381. doi:10.1007/s00192-005-0019-0. 8.
Biddlestone J, Samuel M, Creagh T, Ahmad T. The double loop mattress suture. Wound Repair Regen. 2014;22(3):415-423. doi:10.1111/wrr.12159.
Page 4 of 5
JMIG-D-18-00233.jpg
Page 5 of 5