A microlaparoscopic technique for Pomeroy tubal ligation.

OBJECTIVE: To evaluate the efficacy of performing Pomeroy tubal ligation using microlaparoscopic techniques. METHODS: Thirty-eight consecutive women desiring permanent sterilization underwent laparoscopic Pomeroy tubal ligation using small (2 or 5 mm) transumbilical laparoscopes and secondary midline sites (5 mm and 14 gauge). The procedures were performed under general anesthesia (n = 28) or local anesthesia with conscious sedation (n = 10). RESULTS: The mean operative time +/- standard deviation (SD) in minutes was 33.0 +/- 10.3. The mean recovery time +/- SD in minutes was 104.3 +/- 41.6. There were no operative complications, and no cases required conversion from the microlaparoscopic technique to a traditional method. CONCLUSION: The results of this study indicate that the Pomeroy tubal ligation may be performed using microlaparoscopic techniques. Furthermore, in selected cases, this technique can be performed under local anesthesia in an outpatient setting.

Anatomy of pelvic arteries adjacent to the sacrospinous ligament: importance of the coccygeal branch of the inferior gluteal artery.

OBJECTIVE: To describe the arterial vascular anatomy in the area of the sacrospinous ligament. METHODS: Cadaver pelvises were dissected to reveal the anatomy of the sacrospinous ligament with emphasis on vascular and neuroanatomy. Flexible rulers were used to measure the coccygeal branch in five hemipelvises. RESULTS: The pudendal vessels and nerve pass immediately medial and inferior to the ischial spine (within 0.5 cm of the spine) and behind the sacrospinous ligament. The pudendal artery lies anterior to the sacrotuberous ligament, which passes behind the ischial spine to its attachment at the posterior ischial tuberosity. The inferior gluteal artery originates from the posterior or the anterior branch of the internal iliac artery to pass behind the sciatic nerve and the sacrospinous ligament. There is a 3- to 5-mm window in which the inferior gluteal vessel is left uncovered above the top of the sacrospinous ligament and below the lower edge of the main body of the sciatic nerve plexus. The coccygeal branch of the inferior gluteal artery passes immediately behind the midportion of the sacrospinous ligament and pierces the sacrotuberous ligament in multiple sites. The main body of the inferior gluteal artery leaves the pelvis by passing posterior to the upper edge of the sacrospinous ligament and following the inferior portion of the sciatic nerve out of the greater sciatic foramen. CONCLUSION: Sutures placed through the sacrospinous ligament at least 2.5 cm from the ischial spine along the superior border of the sacrospinous ligament and without transgressing the entire thickness are in an area generally free of arterial vessels.

Uterosacral ligament: description of anatomic relationships to optimize surgical safety.

OBJECTIVE: To determine the optimal site in the uterosacral ligament for suspension of the vaginal vault with regard to adjacent anatomy and suspension strength. METHODS: Fifteen female cadavers were evaluated between December 1998 and September 1999. Eleven hemisected pelves were dissected to better define the uterosacral ligament and identify adjacent anatomy. Ureteral pressure profiles with and without relaxing incisions were done on four fresh specimens. Suture pullout strengths also were assessed in the uterosacral ligament. RESULTS: The uterosacral ligament was attached broadly to the first, second, and third sacral vertebrae, and variably to the fourth sacral vertebrae. The intermediate portion of the uterosacral ligament had fewer vital, subjacent structures. The mean +/- standard deviation distance from ureter to uterosacral ligament was 0.9 +/- 0.4, 2.3 +/- 0.9, and 4.1 +/- 0.6 cm in the cervical, intermediate, and sacral portions of the uterosacral ligament, respectively. The distance from the ischial spine to the ureter was 4.9 +/- 2.0 cm. The ischial spine was consistently beneath the intermediate portion but variable in location beneath the breadth of the ligament. Uterosacral ligament tension was transmitted to the ureter, most notably near the cervix. The cervical and intermediate portions of the uterosacral ligament supported more than 17 kg of weight before failure. CONCLUSION: Our findings suggest that the optimal site for fixation is the intermediate portion of the uterosacral ligament, 1 cm posterior to its most anterior palpable margin, with the ligament on tension.

Emerging clinical applications of electrical stimulation: opportunities for restoration of function.

Emerging clinical application of electrical stimulation in three systems is reviewed. In the bladder, stimulation of sacral posterior roots reduces reflex incontinence and significantly improves bladder capacity. With the combination of anterior and posterior root stimulation, bladder control can be achieved without the need for rhizotomy. Preliminary research demonstrates that bladder contractions may also be generated by stimulation of the urethral sensory branch of the pudendal nerve, even after acute spinal cord transection, while inhibition of the bladder and control of urge incontinence can be achieved by stimulation of the whole pudendal nerve. Spinal cord stimulation can modulate the activity of the intrinsic cardiac nervous system involved in the regulation of regional cardiac function and significantly reduce the pain associated with angina pectoris. Finally in the area of upper airway disorders, functional electrical stimulation has great potential for increasing life support as well as for quality of life in chronic ailments, particularly obstructive sleep apnea and dysphagia.

Variability of reported techniques for performance of the pubovaginal sling procedure.

The aim of this study was to determine the commonly used techniques for sling surgery. A questionnaire was distributed to the attendees at the 20th Annual Scientific Meeting of the American Urogynecologic Society. Techniques addressed included the type and length of the graft material, the fixation point, and the methods of sling tensioning. Type of training and monthly surgical volume was also determined. Sixty-five gynecologic and urologic surgeons responded to the survey, the majority of whom were fellowship-trained urogynecologists (68%). The median monthly operative experience was 8 anti-incontinence procedures, including 3.5 pubovaginal slings. There was wide inter-respondent variability in all techniques except fixation point. There was also large intra-respondent variability in sling technique: 42% reported the use of differing graft materials, 19% noted using differing graft lengths, and 19% employed variable tensioning methods. Type of training and operative experience did not predict surgical technique(s) or consistency. Our conclusion was that there is wide variability in the techniques of sling performance.

Prevalence of perioperative complications among women undergoing reconstructive pelvic surgery.

OBJECTIVE: The primary aim of this study was to report on the prevalence of perioperative complications associated with reconstructive pelvic surgery. A secondary aim was to identify risk factors predictive of perioperative complications in this population. STUDY DESIGN: A retrospective chart review was performed of 100 consecutive cases of reconstructive pelvic surgery. Statistical analysis included descriptive statistics and logistic regression. RESULTS: The prevalence of perioperative complications was 46%, including 13 intraoperative complications and 33 postoperative complications. The readmission rate for complications was 15%. The number of procedures per patient was an independent risk factor for intraoperative blood loss (P <.0038). Intraoperative estimated blood loss in turn was an independent risk factor for perioperative complications (P <.0001). CONCLUSIONS: Perioperative complications associated with reconstructive pelvic surgery were increased relative to those associated with general gynecologic surgery. The number of procedures per patient and associated blood loss appeared to contribute to the increase in perioperative complications.

Attachment of the rectovaginal septum to the pelvic sidewall.

OBJECTIVE: To describe the lateral attachment of the rectovaginal fascia to the pelvic sidewall. STUDY DESIGN: A descriptive study was performed with use of 10 embalmed female cadaveric pelves, each sectioned in the midsagittal plane. The lateral attachments of the pubocervical fascia and the rectovaginal fascia to the pelvic sidewall were examined. RESULTS: The rectovaginal fascia attaches to the pelvic sidewall along a well-defined line. It extends from the perineal body toward the arcus tendineus fasciae pelvis with which it converges approximately midway between the pubis and the ischial spine to form a y configuration. This point of convergence occurs an average of 4.8 cm from the ischial spine, 3.75 cm from the pubic symphysis, and 4.15 cm from the posterior fourchette. CONCLUSION: The rectovaginal fascia supports the posterior compartment analogous to the pubocervical fascia in the anterior compartment. Moreover, landmarks are identified that will aid suture placement during repair of posterior compartment defects.

Dynamic pelvic magnetic resonance imaging and cystocolpoproctography alter surgical management of pelvic floor disorders.

PURPOSE: Pelvic organ prolapse results in a spectrum of progressively disabling disorders. Despite attempts to standardize the clinical examination, a variety of imaging techniques are used. The purpose of this study was to evaluate dynamic pelvic magnetic resonance imaging and dynamic cystocolpoproctography in the surgical management of females with complex pelvic floor disorders. METHODS: Twenty-two patients were identified from The Johns Hopkins Pelvic Floor Disorders Center database who had symptoms of complex pelvic organ prolapse and underwent dynamic magnetic resonance, dynamic cystocolpoproctography, and subsequent multidisciplinary review and operative repair. RESULTS: The mean age of the study group was 58 +/- 13 years, and all patients were Caucasian. Constipation (95.5 percent), urinary incontinence (77.3 percent), complaints of incomplete fecal evacuation (59.1 percent), and bulging vaginal tissues (54.4 percent) were the most common complaints on presentation. All patients had multiple complaints with a median number of 4 symptoms (range, 2-8). Physical examination, dynamic magnetic resonance imaging, and dynamic cystocolpoproctography were concordant for rectocele, enterocele, cystocele, and perineal descent in only 41 percent of patients. Dynamic imaging lead to changes in the initial operative plan in 41 percent of patients. Dynamic magnetic resonance was the only modality that identified levator ani hernias. Dynamic cystocolpoproctography identified sigmoidoceles and internal rectal prolapse more often than physical examination or dynamic magnetic resonance. CONCLUSIONS: Levator ani hernias are often missed by physical examination and traditional fluoroscopic imaging. Dynamic magnetic resonance and cystocolpoproctography are complementary studies to the physical examination that may alter the surgical management of females with complex pelvic floor disorders.