INDICATIONS: The patient is a 46-year-old with a history of multiple mesh revision procedures in the past prior to being referred to me for definitive mesh removal. She underwent that mesh removal and a vaginal hysterectomy/colpopexy approximately 4-6 weeks ago. Due to her chronic pelvic pain, the patient desired to have all mesh removed from her abdomen, as well as an anti-incontinence procedure at a staged interval. The patient now re-presents for her abdominal approach removal of the mesh sling arms, as well as a Burch procedure to complete her treatment for her chronic pelvic pain and stress incontinence. The patient understands that given her history of a previous pubovaginal sling there is slightly increased risk for bladder injury and/or bleeding in the retropubic space during this procedure. Informed consent was obtained prior to going to the operating room.
DESCRIPTION OF PROCEDURE: The patient was taken to the operating room where general endotracheal anesthesia was found to be adequate. The patient was placed in the low lithotomy position and exam under anesthesia revealed the above listed findings. The patient's previous incision lines were noted to be healing well and intact. A Foley catheter was placed in the patient's bladder. The surgeon's gloves were changed and attention was turned to the suprapubic area where a low 6 cm transverse Cherney incision was made with a scalpel. The underlying connective tissue was taken down with Bovie electrocautery. The tendineus attachment of the rectus muscles was also taken down with Bovie electrocautery. The fascial incision was slightly extended bluntly and the preperitoneal dissection was taken down bluntly using a sponge stick and moist laparotomy sponges. The bladder was dissected from the pubic bone in order to expose the space of Retzius. The dissection was taken down to the level of the anterior vaginal wall bilaterally. The two sling arms were identified and excised from their abdominal wall attachments. The right sling arm was hydrodissected from the surrounding tissue and excised in its entirety. A small defect in the vaginal wall was closed with figure-of-eight stitch of 0 Vicryl suture. The left sling arm was then identified and was noted to be embedded within the left anterior bladder wall. The sling arm was circumferentially hydrodissected and excised down to its insertion point at the anterior vaginal wall. A small 2 cm cystotomy was noted in the inferior aspect of this dissection. The cystotomy was noted to ____ secondary to the erosion of this mesh sling arm into the bladder wall. The bladder mucosa was then reapproximated using a running stitch of 3-0 Monocryl suture. The overlying smooth muscle and connective tissue was reapproximated using 2-0 Vicryl suture in running fashion. Attention was turned to the perineum where a cystoscopy revealed excellent hemostasis and reapproximation of the bladder mucosa. Abdominally, the repair was noted to be watertight. The cystoscope was removed and a Foley catheter was replaced. The bladder repair was noted to be hemostatic and attention was turned to the periurethral tissue where a small area of the anterior vaginal wall was cleared off on either side of the urethra just distal to the bladder neck on either side. The excision site of the left mesh arm at the level of the vaginal wall was closed with a figure-of-eight stitch of 0 Vicryl suture. A small amount of bleeding was stopped with Bovie electrocautery. A Burch procedure was then performed using 0 Prolene suture. Two sutures were placed on either side of the urethra just lateral as one another and these sutures were taken through their ipsilateral Cooper's ligaments. The Foley catheter was removed and a plastic swab was advanced into the urethra and passed the bladder neck. The Burch colposuspension sutures were then tied down with excellent elevation of the vaginal wall to the inferior aspect of the pubic symphysis bilaterally. The plastic swab was noted to be in a slightly negative angle approximately less than 10 degrees. colonoscopy. The 4 Burch sutures were then tied and then further tied and secured into place. The Burch site was copiously irrigated. Excellent hemostasis was noted. A small segment of Gelfoam was advanced just inferior to the Burch sutures and all moist laparotomy sponges were removed from the patient's abdomen. One final cystoscopy revealed no further abnormalities within the bladder. The repair site was noted to be hemostatic. The Foley catheter was then maintained in the bladder. The surgeon's gloves were changed and attention was turned to the abdomen where the tendineus insertion of the rectus muscles was reapproximated using a looped #1 PDS suture in running fashion. Excellent reapproximation was noted. The subcutaneous tissue was then closed with multiple interrupted stitches of 3-0 Vicryl suture in a vertical fashion. The skin was then closed with subcuticular vertical stitches of 3-0 Vicryl suture and 4-0 Monocryl suture in running fashion. Excellent hemostasis was noted. The skin incision was then sealed with Dermabond. The patient tolerated the procedure well and was extubated without difficulty in the operating room. She was taken to the recovery room in stable condition.
DESCRIPTION OF PROCEDURE: The patient was taken to the operating room where general endotracheal anesthesia was found to be adequate. The patient was placed in the low lithotomy position and exam under anesthesia revealed the above listed findings. The patient's previous incision lines were noted to be healing well and intact. A Foley catheter was placed in the patient's bladder. The surgeon's gloves were changed and attention was turned to the suprapubic area where a low 6 cm transverse Cherney incision was made with a scalpel. The underlying connective tissue was taken down with Bovie electrocautery. The tendineus attachment of the rectus muscles was also taken down with Bovie electrocautery. The fascial incision was slightly extended bluntly and the preperitoneal dissection was taken down bluntly using a sponge stick and moist laparotomy sponges. The bladder was dissected from the pubic bone in order to expose the space of Retzius. The dissection was taken down to the level of the anterior vaginal wall bilaterally. The two sling arms were identified and excised from their abdominal wall attachments. The right sling arm was hydrodissected from the surrounding tissue and excised in its entirety. A small defect in the vaginal wall was closed with figure-of-eight stitch of 0 Vicryl suture. The left sling arm was then identified and was noted to be embedded within the left anterior bladder wall. The sling arm was circumferentially hydrodissected and excised down to its insertion point at the anterior vaginal wall. A small 2 cm cystotomy was noted in the inferior aspect of this dissection. The cystotomy was noted to ____ secondary to the erosion of this mesh sling arm into the bladder wall. The bladder mucosa was then reapproximated using a running stitch of 3-0 Monocryl suture. The overlying smooth muscle and connective tissue was reapproximated using 2-0 Vicryl suture in running fashion. Attention was turned to the perineum where a cystoscopy revealed excellent hemostasis and reapproximation of the bladder mucosa. Abdominally, the repair was noted to be watertight. The cystoscope was removed and a Foley catheter was replaced. The bladder repair was noted to be hemostatic and attention was turned to the periurethral tissue where a small area of the anterior vaginal wall was cleared off on either side of the urethra just distal to the bladder neck on either side. The excision site of the left mesh arm at the level of the vaginal wall was closed with a figure-of-eight stitch of 0 Vicryl suture. A small amount of bleeding was stopped with Bovie electrocautery. A Burch procedure was then performed using 0 Prolene suture. Two sutures were placed on either side of the urethra just lateral as one another and these sutures were taken through their ipsilateral Cooper's ligaments. The Foley catheter was removed and a plastic swab was advanced into the urethra and passed the bladder neck. The Burch colposuspension sutures were then tied down with excellent elevation of the vaginal wall to the inferior aspect of the pubic symphysis bilaterally. The plastic swab was noted to be in a slightly negative angle approximately less than 10 degrees. colonoscopy. The 4 Burch sutures were then tied and then further tied and secured into place. The Burch site was copiously irrigated. Excellent hemostasis was noted. A small segment of Gelfoam was advanced just inferior to the Burch sutures and all moist laparotomy sponges were removed from the patient's abdomen. One final cystoscopy revealed no further abnormalities within the bladder. The repair site was noted to be hemostatic. The Foley catheter was then maintained in the bladder. The surgeon's gloves were changed and attention was turned to the abdomen where the tendineus insertion of the rectus muscles was reapproximated using a looped #1 PDS suture in running fashion. Excellent reapproximation was noted. The subcutaneous tissue was then closed with multiple interrupted stitches of 3-0 Vicryl suture in a vertical fashion. The skin was then closed with subcuticular vertical stitches of 3-0 Vicryl suture and 4-0 Monocryl suture in running fashion. Excellent hemostasis was noted. The skin incision was then sealed with Dermabond. The patient tolerated the procedure well and was extubated without difficulty in the operating room. She was taken to the recovery room in stable condition.