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Robotic Complete Excision of Sacrocolpopexy Mesh: Standardized Technique
Robotic Complete Excision of Sacrocolpopexy Mesh: Standardized Technique Elena Suarez-Salvador, MD, and Johnny Yi, MD From the Department of Gynecology, Mayo Clinic, Phoenix, Arizona (all authors).
ABSTRACT Study Objective: To describe a standardized technique for robotic complete excision of sacrocolpopexy mesh. Design: A step by step video demonstration of the technique. Setting: A tertiary care academic hospital. Patients: Three patients with persistent pain after sacrocolpopexy mesh insertion. Although exposure can usually be controlled with partial mesh removal, complete excision may be required for patients with persistent pain, exposure, or severe infection. Because of the inherent inflammation, fibrosis, and distortion of tissue planes with mesh augmentation, removal should be performed in a methodical fashion, preparing for possible visceral injury. Intervention: Robotic-assisted sacrocolpopexy mesh removal. Measurements and Main Results: This video (Video 1) presents a systematic, minimally invasive approach to sacrocolpopexy mesh removal, highlighting the technical and anatomic aspects that can facilitate the procedure. Retroperitoneal dissection along with identification of the anatomic landmarks, such as the sacral promontory, iliac vessels, right ureter, bladder, and rectum, are critical. Backfilling the bladder and the use of vaginal and rectal probes can also optimize difficult tissue planes. In each compartment, identifying the whole mesh before starting its removal may prevent leaving mesh fragments. The caudal to cranial and lateral to medial approach facilitates the extraction of the synthetic tissue. Removing the sacral mesh last allows the attachment to be used as a point of traction. Superior dissection of the mesh requires careful dissection and recognition of great vessels along with autonomic nervous structures such as the superior hypogastric plexus. Conclusion: Minimally invasive removal of sacrocolpopexy mesh can be standardized using this step by step approach. Journal of Minimally Invasive Gynecology (2019) 26, 1226−1226. © 2019 Published by Elsevier Inc. on behalf of AAGL. Keywords:
Sacrocolpopexy; Minimally invasive surgery; Robotic surgery; Mesh removal
Supplementary materials Supplementary material associated with this article can be found in the online version at https://doi.org/10.1016/j. jmig.2019.04.016.
The authors declare that they have no conflict of interest. Corresponding author: Elena Suarez-Salvador, MD, Department of Gynecology, Mayo Clinic, 5777 E Mayo Boulevard, Phoenix, AZ 85054. E-mail: [email protected]
Submitted March 28, 2019, Accepted for publication April 3, 2019. Available at www.sciencedirect.com and www.jmig.org
1553-4650/$ — see front matter © 2019 Published by Elsevier Inc. on behalf of AAGL. https://doi.org/10.1016/j.jmig.2019.04.016
ABSTRACT Study Objective: To describe a standardized technique for robotic complete excision of sacrocolpopexy mesh. Design: A step by step video demonstration of the technique. Setting: A tertiary care academic hospital. Patients: Three patients with persistent pain after sacrocolpopexy mesh insertion. Although exposure can usually be controlled with partial mesh removal, complete excision may be required for patients with persistent pain, exposure, or severe infection. Because of the inherent inflammation, fibrosis, and distortion of tissue planes with mesh augmentation, removal should be performed in a methodical fashion, preparing for possible visceral injury. Intervention: Robotic-assisted sacrocolpopexy mesh removal. Measurements and Main Results: This video (Video 1) presents a systematic, minimally invasive approach to sacrocolpopexy mesh removal, highlighting the technical and anatomic aspects that can facilitate the procedure. Retroperitoneal dissection along with identification of the anatomic landmarks, such as the sacral promontory, iliac vessels, right ureter, bladder, and rectum, are critical. Backfilling the bladder and the use of vaginal and rectal probes can also optimize difficult tissue planes. In each compartment, identifying the whole mesh before starting its removal may prevent leaving mesh fragments. The caudal to cranial and lateral to medial approach facilitates the extraction of the synthetic tissue. Removing the sacral mesh last allows the attachment to be used as a point of traction. Superior dissection of the mesh requires careful dissection and recognition of great vessels along with autonomic nervous structures such as the superior hypogastric plexus. Conclusion: Minimally invasive removal of sacrocolpopexy mesh can be standardized using this step by step approach. Journal of Minimally Invasive Gynecology (2019) 26, 1226−1226. © 2019 Published by Elsevier Inc. on behalf of AAGL. Keywords:
Sacrocolpopexy; Minimally invasive surgery; Robotic surgery; Mesh removal
Supplementary materials Supplementary material associated with this article can be found in the online version at https://doi.org/10.1016/j. jmig.2019.04.016.
The authors declare that they have no conflict of interest. Corresponding author: Elena Suarez-Salvador, MD, Department of Gynecology, Mayo Clinic, 5777 E Mayo Boulevard, Phoenix, AZ 85054. E-mail: [email protected]
Submitted March 28, 2019, Accepted for publication April 3, 2019. Available at www.sciencedirect.com and www.jmig.org
1553-4650/$ — see front matter © 2019 Published by Elsevier Inc. on behalf of AAGL. https://doi.org/10.1016/j.jmig.2019.04.016