Culligan lecture
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Transcript of Culligan lecture
![Page 1: Culligan lecture](https://reader034.fdocuments.net/reader034/viewer/2022042602/558484ead8b42a9f028b4c90/html5/thumbnails/1.jpg)
Robotic-Assisted Sacrocolpopexy
Patrick Culligan, MD, FACOG, FACS Director Atlantic Health Division of Urogynecology & Reconstructive Pelvic Surgery
Professor of Obstetrics Gynecology & Reproductive Science Mount Sinai School of Medicine
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Key Components of Sacrocolpopexy
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Sacrocolpopexy - History
Sacral Colpopexy first described by Lane in 1962
“Modern Version” described and refined by Addison in the 1980’s and 1990’s
Dubbed the “main abdominal approach to prolapse surgery” in a systematic review article 2004 (Nygaard et al)
That status solidified by a Cochrane review in 2005 (Maher et al)
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“Tried & True”
3 studies including greater than 200 patients & long-term follow-up: Sullivan et al Dis Colon Rectum 2001. Culligan et al. Am J Obstet Gynecol 2002. Lindeque et al. S Afr Med J 2002.
Objective Anatomic Success Rates
85 – 100%
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PATIENT SELECTION
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My progression to robotic surgery
Does the patient have a uterus?
YES vaginal hysterectomy +
additional vaginal procedures
NO OPEN Sacrocolpopexy
2002 – switched to laparoscopic Sacrocolpopexy
2005 First daVinci Sacrocolpopexy
Now I frequently combine supracervical hyst and daVinci sacrocolpopexy
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My Current Approach to Prolapse Surgery
What is the age and activity level of the patient?
“Younger” “Very Active”
“Older” “Less Active”
Laparoscopic Sacral Colpopexy (+ / - supracervical hyst)
Vaginal Mesh Placement
(probably no hysterectomy)
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Severe Uterovaginal Prolapse (before and after robotic sacrocolpopexy)
45 year old
G2 P2 Athletic Very active (physically , sexually, etc…)
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But.... Should this patient have a laparoscopic surgery?
78 year old
G5 P5
Significant co-morbidities
Not sexually active
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Patient Positioning: # 3 arm comes in from patient’s LEFT
Patient’s Skin Directly Against “Megadyne” Gel
Pad
Shoulder Pads
Use side-docking when patient does NOT have a uterus
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Port Placement - always the same...
Camera port - 12mm long bladed disposable Assistant port - 11 or 12 mm disposable (“Excel”) - size depends on whether you need to morcellate 4th arm port - WAY lateral and WAY high (a few cm lower than costal margin)
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Instrumentation
Monopolar shears Maryland Bipolar SutureCut
Large Needle Driver
PK Dissector
Tenaculum ProGrasp
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Comparison of Type-1 Polypropylene Mesh Products
Brand Name Pore Size (mm) Density (g/m2) Thickness (mm)
Alyte Y-mesh (CR Bard)
2.8 x x1.3 17.67 0.29
Restorelle Y (Coloplast)
1.8 x 1.8 18.96 0.31
IntePro Y-graft (AMS)
1.6 x 2.1 52.4 0.53
Gynemesh (Ethicon)
2.5 x 1.7 42.38 0.42
Polyform (Boston Scientific)
1.8 x 1.5 40.19 0.16
Novasilk (Coloplast)
1.5 x 1.7 18.66 0.25
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SACROCOLPOPEXY steps of the procedure
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First Steps
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Supracervical Hysterectomy Why supracervical as opposed to TOTAL hyst...?? Probably decreases incidence of mesh erosion Cuts down or eliminates need for vaginal instrumentation
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Anterior Dissection No Vaginal Instrumentation
Key Aspects: Have a specific goal in mind for each patient Create “fingers” by pushing most of tissue Use small amount of cautery when cutting these fingers
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Posterior Dissection - No vaginal or rectal instrumentation
Key Points: Get in “the room” Have a specific “length goal” in mind Keep scope right on top of the action Maintain traction / counter-traction with each move
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Posterior Dissection off to a bad start
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Suggested Vaginal Instrumentation
Lucite Dilators available from: Progressive Medical Instruments, Louisville, KY (800) 775-7644
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If there is no uterus / cervix to grab... Lucite Probe helps Side-docking helps
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If there is no uterus... Try to leave “dome” of peritoneum intact at apex....
Doing so may cut down mesh erosion risk
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Long, Wide Briesky retractor helps with posterior dissection
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Vasculature in Pre-Sacral Space
Middle Sacrals: Standard Hemostatic Measures Work Well
Lateral Sacral Plexus Be Afraid !
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Sacral Dissection Find “window of opportunity” at promontory Dissect at least 1/2 way down paracolic gutter Use minimal cautery Usually no need to cauterize middle sacral vessels.
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More Sacral Dissection
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Sacral Bleeding
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Sacral Bleeding
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Similar case...better result
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Mesh Placement
Plan specific lengths of the mesh - i.e. have a goal in mind
When using Y-Mesh, place a loose suture to fold anterior portion back out of your way
Start with Posterior mesh
In the Posterior compartment - It’s helpful to place sutures BETWEEN mesh and vaginal tissue – working your way from the perineum to the vaginal apex
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Mesh Preparation
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Posterior Mesh Placement
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Anterior Mesh Placement
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Peritoneal Closure: Step 1...Purse string
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Sacral Suturing Key Aspects: You only need to expose enough of the ligament to allow suture placement Usually minimal cautery needed Usually no need to change from zero degree to 30 degree scope
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Mesh Tensioning / Sacral Suturing
When setting mesh tension at the sacrum: No substitute for experienced hand Either you or your assistant should place hand in vagina
during tensioning step Goal - normal vaginal axis...not too tight...not too loose
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Peritoneal Closure: Step 2 - paracolic gutter to sacrum (after sacral suturing)
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Tricky Situations
Prior Abdominoplasty
Lung or Heart Disease
Prior abdominal prolapse repair
High BMI
Very small women
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OUR RESULTS
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A Double-Blind Randomized Trial Comparing Porcine Dermis & Polypropylene Mesh for
Laparoscopic Sacrocolpopexy
OBJECTIVE To compare objective and subjective outcomes ≥ 12 months after laparoscopic sacrocolpopexy using organic or synthetic graft material
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Methods
Randomization on the day of surgery
Surgery = Laparoscopic Sacrocolpopexy
Approximately 80% were robotic
All outcome measures collected by one research nurse
PATIENTS & RESEARCH NURSE were blinded as to their graft material throughout the study period
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Definitions of Cure
“POP-Q Cure” (both criteria required) All POP-Q points ≤ Stage 1 Point C -5 or better
“Clinical Cure” (all 3 criteria required) All POP-Q points < ZERO Point C -5 or better NO POP symptoms on PFDI / PFIQ
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Sample Size Calculation Based on “POP-Q Cure”
(aka NIH definition)
Culligan et al 2004
Randomized trial comparing cadaver fascia lata and synthetic mesh for OPEN sacrocolpopexy
91% “cure” for mesh versus 68% “cure” for fascia lata (23% difference)
With 57 patients per group we had 90% power to detect a difference of 23% (α = 0.05)
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Enrollment period 2005 - 2008 Patients eligible for study
N = 184
Patients declined enrollment N = 64
Patients randomized to receive either organic or synthetic mesh N = 120
Organic Group N = 57
Synthetic Group N = 62
Lost to follow-up N = 0
Lost to follow-up N = 4
One patient converted to vaginal case on OR table (organic group)
Completing 12 month trial N = 57 (organic)
Completing 12 month trial N = 58 (synthetic)
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12 Month “POP-Q Cure” (i.e. stage 0 or 1)
Porcine Dermis 80.4%
Synthetic Mesh 84.1%
p = 0.29
No Apical Failures
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12 month “Clinical Cure”
Porcine Dermis 84.2%
Synthetic Mesh 84%
p = 0.96
No Apical Failures
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Point C over time (pre-op to 12 months)
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Point Aa over time (pre-op to 12 months)
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Point Bp over time (pre-op to 12 months)
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Single-Arm Cohort Study
120 patients Robotic Sacrocolpopexy using Restorelle Y-Mesh
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Perioperative details (120 patients)
Mean operative time 140 minutes (range 80-225)
Defined as incision time to removal of trocars
Mean EBL 49 mL (range 5 - 300 mL)
No conversions to laparotomy
One cystotomy ; No Rectal Injuries
No Erosions
No Transfusions
All patients discharged on POD # 1
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“POP-Q Cure” 89% (i.e. stage 0 or 1)
“Clinical Cure” 95%
No Apical Failures
Text
Cure Rates at 12 Months
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Current Study (150 patients) Alyte Y-Mesh (CR Bard)
Our
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Interesting Situations
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Patient with prior (failed) anterior vaginal mesh “kit”
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“Gap Failure” (prior mesh kit)