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informed consent - pt taken to OR under general anesthesia. abdomen, perineum and vagina were all prepped and draped in the usual manner. Legs placed in Allen stirrups with SCD's on. Foley catheter was placed. The prolapse was examined and was noted to have a very high rectocele as well as quite a bit of narrowing of the vaginal apex and shortening of the vagina as well as a large anteriorr defect. the decision was made to correc all of these with the Pinnacle wrapping the tail around the apex and down the top of the posterior wall to close the high rectocele, the vaginal apex and anterior vagina to the level of the bladder neck were split in the midline. the pubvesical cervical fascia as well as the tissues at the vaginal apex and a small amount of rectvaginal fascia were dissected laterall to the pelvic sidewalls. the sacrospinous ligaments were accessed on the right and on the left as well as the arcus on the right an on th eleft. using the capio device the upper pinnacle arms were passed through the sacrospinous ligament 2 cm medial and inferior to the ischial spine on teh right and on the left. These were not tensioned. the second arm was passed through the arcus on the right and on the left just caudal to the ischial spine. the apex of the graft was wrapped around and tacked down to the posterior apex to ensure it would cover the rectocele. A second incision was then made between the mid urethra and the bladder neck and the dissection was carried laterally until the obturator membrane was palpable on the right and left. a skin incision was made on each side inferior to the adductor longus tendon lateral to the pubic bone. using the obtryx trocar the trocar was passed through the skin incision, the obturator foramen and out at the level of the mid urethra on the right and left. The sling was clipped to the ends of the trocar and brought back through the trocar path. Cystoscopy was performed. No damage to the bldder. Blue dye came from both ureteral orifices. the sling was tensioned to #9 Hegar dilator. the vagina closed with 2-0 Vicryl suture running stitch. the sheath was removed from the mesh and the mesh was trimmed off below the skin level. the skin incisions closed using indermil glue and the pinnacle was then tensioned to provide good support and yet not stricture the vagina. the vagina was closed using 2-0 Vicryl in a running stitch with no trimming. Vagina was packed usring a vaginal pack and premarin cream.
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