I have a video here, I’m just going to start with that. This is an ELEVEST that was done about eight weeks ago. I’ll just describe the procedure as we go through it. The patient also had some mild endometriosis, which I excised. She didn’t have rectocele, but she had about a grade two uterine prolapse. This shows the trocar placement. I used three trocars: one for the scope and umbilicus and two 5’s laterally.
Here is the patient’s uterus. You can see it’s typical of a retroflexed uterus. It’s got a mottled appearance and is deep in the cul-de-sac. One of the keys is to use a good computer manipulator when you do the procedure. I use a RUMI uterine manipulator, but a Valtchev or Pelosi are also good too. You can appreciate how wide and open this cul-de-sac is. This is a relatively young patient. She’s 47, but she’s in excellent health. She’s a runner and exercise fanatic. She really didn’t want to have a hysterectomy.
This is her right ureter. I identify the ureters right off the start. Then I always do the urethrolysis to release the ureters. I open the peritoneum and release the ureters, so that I do not have to worry about where the ureters are for the rest of the case.
It’s interesting that the patients I have been receiving have actually been very athletically fit, healthy women that are active that are complaining of pelvic pressure, pain, and dyspareunia. It’s estimated that about 50% of adult women will have some clinically insignificant level of prolapse. It may be clinically insignificant, if all you have to offer them is a hysterectomy or having to live with it. So offering them a uterine suspension or something else to correct the defect is certainly an option that they appreciate.
Here again, I’m just releasing the uterosacral on the patient’s left side. This was where there was some endometriosis along the uterosacral on the sidewall that was excised. This is the right side. You can use whatever energy source that you want. These are just unipolar scissors. But certainly use a harmonic scalpel if you like, or bipolar scissors, laser, or whatever. It doesn’t matter.
You’ve go to understand that the camera adds at least two to four shakes for every movement there, so I really didn’t have too much caffeine that day. There is a 5-millimeter adaptor that allows the needle to go through the 5-millimeter trocar without losing pneumo. With the uterus well flexed with the uterine manipulator, we were able to identify where the uterosacral ligaments are. I’m actually passing the needle through with the suture. Karen and maybe Tom pass the needle without the suture, then grasp the suture and pull it through the hole, which probably is easier. But being from Minnesota, I like to suffer, so we like to make it harder on ourselves.
This is a first pass. I do it a little differently. I do a helical type stitch around the uterosacral ligaments here. So I’m going to take it, and pass it around again and create this helix around the uterosacral ligament. Others will reef in and out through the ligament, so you’re not wrapping the ligament itself. I really don’t think it makes a whole lot of difference. You can determine whatever technique works best for you. You can see that there’s no detachment here at the cervix, those uterosacral ligaments are well attached to the cervix. I work my way up towards the insertion point. Now as you use this needle, you can see there’s a fair amount of pressure that has to be applied. I think that’s always something that will get better as the instrumentation is refined a little bit. But you want to be careful as you pass this needle. Usually I use my finger as a sort of a stop on the outside along the trocar, so that I’m not going to make any sudden movement and go through. Potentially I think your risk would be with the rectum down below here. You don’t want to be gazing at the rectum. I try to aim as much as possible towards the middle of the pelvis. Maintain the ability to correct or stop the needle from going through too suddenly. Now, once I’ve gotten up to the cervical insertion, then I’m going back down and pulling it back through at the point where I started. This is at the point where I’ll tie. It’s just an extracorporeal knot. This is a 2-0 Ethibond suture that I’m using. You want to use a fair amount of pressure. But most time, with any kind of pelvic floor reconstruction, I think the tendency is always to overcorrect. The tendency is to always try to make things too good, too tight. You don’t want it to prolapse. So try not to create excessive tension there, but enough tension to maintain the level of support that you want.
So I’ve done the left side. Now I’m going to go do the right side. Basically the same technique. I use a little bit of a screwing motion to kind of corkscrew the needle through. The grasper is important, because you want to be able to try to stabilize that tissue as much as you can when you’re passing that needle. You want to have a good grasper and try to create some tension on the ligament itself, so that you’re not going to be pushing half-way across the pelvis. You get a real appreciation for just what this tissue is like. Obviously, if this was just nice, soft tissue, it wouldn’t take much to be pushing this needle through. But the fact that there is a lot of resistance in that tissue tells you that this is pretty solid tissue that we’re dealing with. The suture is going to reinforce that and create a stronger level of support for this patient. Coming up closer to the insertion point. Here again, with the proper traction on the uterus and traction on the ligament, you can really tent that tissue to make it easier to pass the suture through. Then as I go along, you want to continue to pull the suture down to give you some slack in order to be able to tie it and bring the suture out extracorporeally. So there’s the right side now.
So I’ve done both sides. As I looked at it, it looked pretty good, but I thought, I’m going to shorten just a little bit more. So I’m going to do a plication here up by the insertion. To do this you have to come at it from both sides, because it’s really tough for the angle to be able to pass the suture through both sides of this ligament from just one side of the abdomen. So what I’m doing is coming through with this suture on the right side first. Then after I’ve dropped the suture, I come back from the left side and pick it up and bring it through on the left side. I don’t do a marked plication where I do several layers and potentially constrict the posterior space here - just enough to shorten the uterosacral ligaments to reinforce the repair. Again, extracorporeal knots. So it’s relatively easy. You don’t have to do extracorporeal knots, but if you want to, you can. Think about how much time you have in the room.
So here is the completed uterosacral portion of the case. Now they are pulling on the uterus to see how much support and decensus there is. At this point I can see that she’s got very good support from that part of it.
Now I’m going to do the UPLIFT procedure for repositioning. In the first picture that you saw, the patient had a real retroflexed uterus. Dyspareunia was one of her main complaints. This is really a positing type operation. I’m not as dependent upon this for the support, but mainly to maintain this uterus in an anterior, neutral position. I always start with a needle and some Marcaine solution that I inject. I use that as a way of guiding me to the entrance point that I want to make with the UPLIFT needle. Then as I find that point, I make a skin nick. You do a near and far insertion. In other words, you want to be able to tie the suture over a fascial bridge. You want to make sure that you are leaving yourself a fascial bridge there to tie over. Once the suture is brought down the first time, it’s released. Then you come back and then take a different path again now. I always start with my first insertion and then the medial part of the stab wound. The second one lateral and trace my way back down through the round ligament again, exiting usually about one or two centimetres from the uterine fundus. Picking up the suture there and pulling it back. Truncating that ligament now. So at this point I remove the uterine manipulator.
I do it opposite of what Karen does. Karen does the UPLIFT portion of the procedure first, then does the uterosacrals. I do the uterosacrals, then do the UPLIFT. I remove the uterine manipulator to get an idea. I don’t want to create too much tension with this suture. I just want to position the uterus. I don’t want to overcorrect the situation.
So now this is the end of the case. The uterus is now up out of the cul-de-sac. It’s got strong ligament support in the back.
Well thank you.