Name: transvaginal mesh insertion in the ovine model
Uploaded: 2017-07-27T12:30:00
Description: Watch this Scientific Journal Video about Transvaginal Mesh Insertion in the Ovine Model at JoVE.com

We thank Ivan Laermans, Rosita Kinart, Ann Lissens (Centre for Surgical Technologies, KU Leuven, Leuven, Belgium). Jo Verbinnen and Kristof Reyniers (Vesalius Institute of Anatomy, Faculty of Medicine, KU Leuven, Leuven, Belgium) provided technical support during the experiment. We thank Leen Mortier for the help with data and manuscript management. We thank FEG Textiltechniken for manufacturing prototype meshes, sterilizing them, and donating them unconditionally for research.

Ethical approval for this experiment was obtained from the Ethics Committee on Animal Experimentation of the KU Leuven (P065/2013). Animals were treated in accordance with current national guidelines on animal welfare.
1. Material and the Experimental Animal
<ol>
	<li>Surgery preparation
	<ol>
		<li>In the surgical theater cover a table with a sterile drape and prepare one sterile curved trocar (Figure 1, panel A), sterile surgical instruments, sutures, and sterile gauze. Perfor...

<ol>
	<li>Glazener, C., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Childbirth+and+prolapse:+Long-term+associations+with+the+symptoms+and+objective+measurement+of+pelvic+organ+prolapse.">Childbirth and prolapse: Long-term associations with the symptoms and objective measurement of pelvic organ prolapse.</a> BJOG An Int. J. Obstet. Gynaecol. 120 (2), 161-168 (2013).</li><li>Jia, X., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Efficacy+and+safety+of+using+mesh+or+grafts+in+surgery+for+anterior+and/or+posterior+vaginal+wall+prolapse:+systematic+review+and+meta-analysis.">Efficacy and safety of using mesh or grafts in surgery for anterior and/or posterior vaginal wall prolapse: systematic review and meta-analysis.</a> BJOG. 115 (11), 1350-1361 (2008).</li><li>Maher, C., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Transvaginal+mesh+or+grafts+compared+with+native+tissue+repair+for+vaginal+prolapse.">Transvaginal mesh or grafts compared with native tissue repair for vaginal prolapse.</a> Review. 2 (2), 10-13 (2016).</li><li>Nieminen, K., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Outcomes+after+anterior+vaginal+wall+repair+with+mesh:+a+randomized,+controlled+trial+with+a+3+year+follow-up.">Outcomes after anterior vaginal wall repair with mesh: a randomized, controlled trial with a 3 year follow-up.</a> Am. J. Obstet. Gynecol. 203 (3), e1-e8 (2010).</li><li>Abramowitch, S. D., Feola, A., Jallah, Z., Moalli, P. A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Tissue+mechanics,+animal+models,+and+pelvic+organ+prolapse:+a+review.">Tissue mechanics, animal models, and pelvic organ prolapse: a review.</a> Eur. J. Obstet. Gynecol. Reprod. Biol. 144, S146-S158 (2009).</li><li>Couri, B., Lenis, A., Borazjani, A., Paraiso, M. F. R., Damaser, M. S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Animal+models+of+female+pelvic+organ+prolapse:+lessons+learned.">Animal models of female pelvic organ prolapse: lessons learned.</a> Expert Rev. Obs. Gynecol. 7 (3), 249-260 (2012).</li><li>Deprest, J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+biology+behind+fascial+defects+and+the+use+of+implants+in+pelvic+organ+prolapse+repair.">The biology behind fascial defects and the use of implants in pelvic organ prolapse repair.</a> Int. Urogynecol. J. Pelvic Floor Dysfunct. 17, S16-S25 (2006).</li><li>Ozog, Y., Mazza, E., De Ridder, D., Deprest, J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Biomechanical+effects+of+polyglecaprone+fibers+in+a+polypropylene+mesh+after+abdominal+and+rectovaginal+implantation+in+a+rabbit.">Biomechanical effects of polyglecaprone fibers in a polypropylene mesh after abdominal and rectovaginal implantation in a rabbit.</a> Int. Urogynecol. J. 23 (10), 1397-1402 (2012).</li><li>Manodoro, S., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Graft-related+complications+and+biaxial+tensiometry+following+experimental+vaginal+implantation+of+flat+mesh+of+variable+dimensions.">Graft-related complications and biaxial tensiometry following experimental vaginal implantation of flat mesh of variable dimensions.</a> BJOG. 120 (2), 244-250 (2013).</li><li>Endo, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Cross-linked+xenogenic+collagen+implantation+in+the+sheep+model+for+vaginal+surgery.">Cross-linked xenogenic collagen implantation in the sheep model for vaginal surgery.</a> Gynecol. Surg. , 113-122 (2015).</li><li>Feola, A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Host+reaction+to+vaginally+inserted+collagen+containing+polypropylene+implants+in+sheep.">Host reaction to vaginally inserted collagen containing polypropylene implants in sheep.</a> Am. J. Obstet. Gynecol. 212 (4), e1-e474 (2015).</li><li>Barnhart, K. T., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Baseline+dimensions+of+the+human+vagina.">Baseline dimensions of the human vagina.</a> Hum. Reprod. 21 (6), 1618-1622 (2006).</li><li>Tayrac, R., Alves, A., Th&#233;rin, M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Collagen-coated+vs+noncoated+low-weight+polypropylene+meshes+in+a+sheep+model+for+vaginal+surgery.+A+pilot+study.">Collagen-coated vs noncoated low-weight polypropylene meshes in a sheep model for vaginal surgery. A pilot study.</a> Int. Urogynecol. J. Pelvic Floor Dysfunct. 18 (5), 513-520 (2007).</li><li>Sobiraj, A., Busse, G., I, H. B. O. S. E. D. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Ivastigation+into+the+blood+plasma+profiles+progesterone+in+sheep+sufferingform+vaignal+inversion+and+prolapse.">Ivastigation into the blood plasma profiles progesterone in sheep sufferingform vaignal inversion and prolapse.</a> Br. Vet. J. 142 (142), 218-223 (1986).</li><li>Reisenauer, C., Kirschniak, A., Drews, U., Wallwiener, D. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Anatomical+conditions+for+pelvic+floor+reconstruction+with+polypropylene+implant+and+its+application+for+the+treatment+of+vaginal+prolapse.">Anatomical conditions for pelvic floor reconstruction with polypropylene implant and its application for the treatment of vaginal prolapse.</a> Eur. J. Obstet. Gynecol. Reprod. Biol. 131, 214-225 (2007).</li><li>Carey, M., Slack, M., Higgs, P., Wynn-Williams, M., Cornish, A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Vaginal+surgery+for+pelvic+organ+prolapse+using+mesh+and+a+vaginal+support+device.">Vaginal surgery for pelvic organ prolapse using mesh and a vaginal support device.</a> BJOG An Int. J. Obstet. Gynaecol. 115 (3), 391-397 (2008).</li><li>Urbankova, I., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Comparative+anatomy+of+the+ovine+and+female+pelvis.">Comparative anatomy of the ovine and female pelvis.</a> Gynecol. Obstet. Invest. , (2016).</li><li>Maurer, M. M., R&#246;hrnbauer, B., Feola, a., Deprest, J., Mazza, E. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Mechanical+biocompatibility+of+prosthetic+meshes:+A+comprehensive+protocol+for+mechanical+characterization.">Mechanical biocompatibility of prosthetic meshes: A comprehensive protocol for mechanical characterization.</a> J. Mech. Behav. Biomed. Mater. 40, 42-58 (2014).</li><li>Leval, J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Novel+Surgical+Technique+for+the+Treatment+of+Female+Stress+Urinary+Incontinence.">Novel Surgical Technique for the Treatment of Female Stress Urinary Incontinence.</a> Transobturator Vaginal Tape Inside-Out. Eur. Urol. 44 (6), 724-730 (2003).</li><li>Reisenauer, C., Kirschniak, A., Drews, U., Wallwiener, D. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Transobturator+vaginal+tape+inside-out.">Transobturator vaginal tape inside-out.</a> Eur. J. Obstet. Gynecol. Reprod. Biol. 127 (1), 123-129 (2006).</li><li>Bafghi, A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Bowel+perforation+as+late+complication+of+tension-free+vaginal+tape.">Bowel perforation as late complication of tension-free vaginal tape.</a> J Gynecol Obs. Biol Reprod. 34 (6), 606-607 (2005).</li><li>Hinoul, P., Vanormelingen, L., Roovers, J. P., de Jonge, E., Smajda, S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Anatomical+variability+in+the+trajectory+of+the+inside-out+transobturator+vaginal+tape+technique+(TVT-O).">Anatomical variability in the trajectory of the inside-out transobturator vaginal tape technique (TVT-O).</a> Int. Urogynecol. J. Pelvic Floor Dysfunct. 18 (10), 1201-1206 (2007).</li><li>Schaller, O., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=.">.</a> Illustrated Veterinary Anatomical Nomenclature. , (2007).</li><li>. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Serious+Complications+Associated+with+Transvaginal+Placement+of+Surgical+Mesh+for+Pelvic+Organ+Prolapse.">Serious Complications Associated with Transvaginal Placement of Surgical Mesh for Pelvic Organ Prolapse.</a> FDA Safety Communication. , (2016).</li><li>Reinier, M., Groep, G. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Final+Opinion+on+the+use+of+meshes+in+urogynecological+surgery.">Final Opinion on the use of meshes in urogynecological surgery.</a> SCENIHR- European Commission. , (2016).</li></ol>

Here, we describe an experimental procedure in sheep, aimed to mimic vaginal dissection and transvaginal mesh insertion of an implant with or without anchoring arms. The subsequent steps and instruments were inspired by surgical procedures done for POP and stress urinary incontinence15,16,19,20. After initial anatomical dissections, there were still some problems during experimental mesh insert...

Pelvic organ prolapse is clinically diagnosed in half of women who had at least one vaginal delivery, but subjectively, it bothers half of women overall1. The mainstay of therapy is surgical reconstruction using either native tissue or implant materials, but each of these methods has its limitations, including recurrence or local complications2,3,4. The ideal implant has not yet been identified; hence, there is an ongoing demand for product innovation and for the development of a proper pipeline for preclinical experimentation prior to the introduction of new products and techniques to the market. One of the steps in this track is experimental evaluation on suitable animal models5,6. Ideally, they should mimic the anatomical, biomechanical, and biological environments. When it comes to the experimental evaluation of novel implants, they are typically tested first in smaller models, either for biocompatibility or for the reconstruction of abdominal wall defects. That type of experiments has been criticized, because the implants are not inserted into the area of interest (i.e., the vagina)7. Vaginal surgery models are more scarce, certainly when the goal of the experiment is to document the biomechanical characteristics of explants. For this reason, there was a move from rabbits to sheep8. Adult ewes are large-animal models with a reasonably sized and accessible vagina. They can be used for the mid-term evaluation of novel implants, and it is possible to reproduce vaginal exposures with certain materials9,10,11,12,13. Not only the dimensions and anatomy of the ovine vagina and pelvic floor are comparable to those in humans, but also the spontaneous occurrence of prolapse, which occurs in 15% of ewes. Prolapse risk factors are overlapping (i.e., multiparity, previous history of POP, increased intra-abdominal pressure induced by a higher bodyweight or when grazing on hills, and comparable effects of (phyto)estrogens)6,14. In Europe, sheep are the only reasonable alternative, as research on non-human primates has been nearly completely banned. Here, the model was taken one step further by mimicking the transvaginal insertion of implants using trocars and guides for the tension-free placement of meshes into the recto-vaginal septum. This was followed by fixing the implant using anchoring with arms through the ligaments of muscles, which can be considered equivalent to clinical practice15,16. So far, this technique has not been studied, though many believe that specific complications may occur due to the use of these longer strips and/or the piercing of anatomical structures.
In an earlier detailed anatomical study, the ovine pelvic floor was compared to the female pelvis17. When it comes to anchoring the implant, sheep do not have the sacrospinous ligament, yet they do have a very well-developed and broad sacrotuberous ligament. The pudendal nerve runs ventrally over it, making it unsafe to use this landmark as a suspension point. Conversely, the coccygeus muscle and its fascia, as well as the obturator membrane, are accessible through the rectovaginal space. Here, the access and position of the anatomical structures for the fixation of anchoring arms is proposed. The instruments that can be used to position the mesh are discussed. Finally, the relationship of the arms or trocars to adjacent anatomical structures, such as vessels and nerves, as well as potential intraoperative complications, are also described.

<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>Animals:&#160;</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>parous female sheep (45 - 65 kg)</td>
			<td>Zo&#246;technical Institute of the KU Leuven</td>
			<td>NA</td>
			<td>experimetnal animal</td>
		</tr>
		<tr>
			<td>Sterile clothing:&#160;</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>sterile drape 45 x 75 cm</td>
			<td>Lohmann &#38; Rauscher, Regensdorf, Germany</td>
			<td>33002</td>
			<td>other material</td>
		</tr>
		<tr>
			<td>sterile OR drape 150 x 180 cm</td>
			<td>Lohmann &#38; Rauscher, Regensdorf, Germany</td>
			<td>33009</td>
			<td>other material</td>
		</tr>
		<tr>
			<td>sterile glowes 2x</td>
			<td>Lohmann &#38; Rauscher, Regensdorf, Germany</td>
			<td>16652</td>
			<td>other material</td>
		</tr>
		<tr>
			<td>sterile surgical gown 2x</td>
			<td>Lohmann &#38; Rauscher, Regensdorf, Germany</td>
			<td>19342</td>
			<td>other material</td>
		</tr>
		<tr>
			<td>surgical head cap 2x</td>
			<td>Lohmann &#38; Rauscher, Regensdorf, Germany</td>
			<td>17427</td>
			<td>other material</td>
		</tr>
		<tr>
			<td>surgical face mask 2x</td>
			<td>Lohmann &#38; Rauscher, Regensdorf, Germany</td>
			<td>11983</td>
			<td>other material</td>
		</tr>
		<tr>
			<td>Other surgical material</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>implant</td>
			<td>FEG Textiltechnik GmbH, Aachen, Germany</td>
			<td>NA</td>
			<td>purposely designed implant</td>
		</tr>
		<tr>
			<td>3/0 polypropylene suture</td>
			<td>Prolene, Ethicon, Diegem, Belgium</td>
			<td>8762H</td>
			<td>suture material</td>
		</tr>
		<tr>
			<td>3/0 polygecaprone suture</td>
			<td>Vicryl, Ethicon</td>
			<td>J311H</td>
			<td>suture material</td>
		</tr>
		<tr>
			<td>gauze swabs 10 x 10 cm 10x, 12-ply</td>
			<td>Lohmann &#38; Rauscher, Regensdorf, Germany</td>
			<td>11574</td>
			<td>other material</td>
		</tr>
		<tr>
			<td>syringe 20 mL</td>
			<td>Becton Dickinsosn S.A., Madrid, Spain</td>
			<td>300613</td>
			<td>aqua-dissection</td>
		</tr>
		<tr>
			<td>needle 16 gauge</td>
			<td>Terumo, Leuven, Belgium</td>
			<td>NN-2238R</td>
			<td>aqua-dissection</td>
		</tr>
		<tr>
			<td>Surgical equipment:</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>blade no.22</td>
			<td>Fine science isntruments, Heidelberg, Germany</td>
			<td>10022-00</td>
			<td>surgical instruments</td>
		</tr>
		<tr>
			<td>Allis tissue forceps 1x</td>
			<td>Fine science isntruments, Heidelberg, Germany</td>
			<td>11091-15</td>
			<td>surgical instruments</td>
		</tr>
		<tr>
			<td>Standart pattern forceps 1x2 theeth 1x</td>
			<td>Fine science isntruments, Heidelberg, Germany</td>
			<td>11023-14</td>
			<td>surgical instruments</td>
		</tr>
		<tr>
			<td>Standart pattern forceps straight serrated 1x</td>
			<td>Fine science isntruments, Heidelberg, Germany</td>
			<td>11000-14</td>
			<td>surgical instruments</td>
		</tr>
		<tr>
			<td>Scalpel handle 1x</td>
			<td>Fine science isntruments, Heidelberg, Germany</td>
			<td>10004-13</td>
			<td>surgical instruments</td>
		</tr>
		<tr>
			<td>Halstead-Mosquito forceps 2x</td>
			<td>Fine science isntruments, Heidelberg, Germany</td>
			<td>13008-12</td>
			<td>surgical instruments</td>
		</tr>
		<tr>
			<td>Standart pattern scissors 1x</td>
			<td>Fine science isntruments, Heidelberg, Germany</td>
			<td>14001-14</td>
			<td>surgical instruments</td>
		</tr>
		<tr>
			<td>Metzenbaum scissors 1x</td>
			<td>Fine science isntruments, Heidelberg, Germany</td>
			<td>14016-18</td>
			<td>surgical instruments</td>
		</tr>
		<tr>
			<td>Crile Wood needle holder 1x</td>
			<td>Fine science isntruments, Heidelberg, Germany</td>
			<td>12003-15</td>
			<td>surgical instruments</td>
		</tr>
		<tr>
			<td>Kell forceps 1x</td>
			<td>Fine science isntruments, Heidelberg, Germany</td>
			<td>13018-14</td>
			<td>surgical instruments</td>
		</tr>
		<tr>
			<td>Long Starr Self-Retaining Retractor with eight 5mm sharp stay hooks</td>
			<td>Cooper Surgical, Tumbull, USA</td>
			<td>3704</td>
			<td>surgical instruments</td>
		</tr>
		<tr>
			<td>Heaney Simon Vaginal Retractor</td>
			<td>Medical supplies &#38; equipments co., Katy, Texas, USA</td>
			<td>403-129FSI</td>
			<td>surgical instruments</td>
		</tr>
		<tr>
			<td>Trocar (Insnare)</td>
			<td>Bard, West Sussex, United Kingdom</td>
			<td>NA</td>
			<td>any trocar on market for transvaginal mesh implantation</td>
		</tr>
		<tr>
			<td>Medication:</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>amoxilicilline clavulanate 1000mg / 300 mL (Ampiciline)</td>
			<td>GSK, Wavre, Belgium</td>
			<td>NA</td>
			<td>antibiotics</td>
		</tr>
		<tr>
			<td>buprenorfin 0.3 mg/mL + chlorocresol 1.35 mg/mL (Vetregesic)</td>
			<td>Ecuphar, Oostkamp, Belgium</td>
			<td>NA</td>
			<td>analgesia</td>
		</tr>
		<tr>
			<td>ketamin HCL 100mg/mL (Ketamine 1000)</td>
			<td>Ceva Sante Animale, Brussels, Belgium</td>
			<td>NA</td>
			<td>anesthesia</td>
		</tr>
		<tr>
			<td>isoflurane (IsoFlo)</td>
			<td>Abbott Laboratories Ltd, Maidenhead, Berkshire, UK</td>
			<td>NA</td>
			<td>anesthesia</td>
		</tr>
		<tr>
			<td>polyvidone iodium 7.5% (Braunol)</td>
			<td>B. Braun Medical, Machelen, Belgium</td>
			<td>NA</td>
			<td>local desinfection</td>
		</tr>
		<tr>
			<td>saline solution 500ml</td>
			<td>B. Braun Medical, Machelen, Belgium</td>
			<td>NA</td>
			<td>aqua-dissection</td>
		</tr>
		<tr>
			<td>Xxylazine HCl , 1 mL/50 kg&#160;</td>
			<td>Vexylan, Ceva Sante Animale, Belgium</td>
			<td>NA</td>
			<td>premedication</td>
		</tr>
		<tr>
			<td>atropine Sulfate 15 mg/ml (),</td>
			<td>Viatris, Belgium</td>
			<td>NA</td>
			<td>premedication</td>
		</tr>
	</tbody>
</table>

transvaginal mesh insertion in the ovine model

This protocol describes mesh insertion into the rectovaginal septum in sheep using a single vaginal incision technique, with and without the trocar-guided insertion of anchoring arms. Parous sheep underwent the dissection of the rectovaginal septum, followed by the insertion of an implant with or without four anchoring arms, both designed to fit the ovine anatomy. The anchoring arms were put in place using a trocar and an "outside-in" technique. The cranial arms were passed through the obturator, gracilis, and adductor magnus muscles. The caudal arms were fixed near the sacrotuberous ligament, through the coccygeus muscles. This technique allows for the mimicking of surgical procedures performed in women suffering from pelvic organ prolapse. The anatomical spaces and elements are easily identified. The most critical part of the procedure is the insertion of the cranial trocar, which can easily penetrate the peritoneal cavity or the surrounding pelvic organs. This can be avoided by a more extensive retroperitoneal dissection and by guiding the trocar more laterally. This approach is designed only for experimental testing of novel implants in large animal models, as trocar-guided insertion is currently not used clinically.

Management in a Longer Observation Setup
Following the surgical procedure, vaginal packing (a saline-solution-soaked gauze package inserted in the vagina immediately after the surgery) may be inserted for 24 h to secure the implant position. The sheep should be placed in a recovery cage and its respiratory function followed until full recovery. Later, it is possible to place the sheep in the stable and to allow ...

Watch this Scientific Journal Video about Transvaginal Mesh Insertion in the Ovine Model at JoVE.com

Transvaginal Mesh Insertion in the Ovine Model

This protocol describes mesh implantation in the ovine rectovaginal septum using a single vaginal incision technique, with and without the trocar-guided insertion of anchoring arms.

This protocol describes mesh insertion into the rectovaginal septum in sheep using a single vaginal incision technique, with and without the trocar-guided ...

The overall goal of this experimental surgical procedure is to use a single vaginal incision to implant mesh into the recto vaginal septum, with or without trocar guided insertion of the anchoring arms. The sheep is a useful model as the ovine pelvic floor experiences similar changes to those that occur during human childbirth, and as the sheep dimensions permit comparable surgical interventions. The main advantage of this technique is that it uses a widely available non primate large animal model that makes a clinically implemented surgical approach to transvaginal implantation.Though this method can provide insight into the surgical treatment of pelvic organ prolapse with implants it can also be applied to other surgical techniques, like native tissue repair. Visual demonstration of this method is critical, as it is difficult to teach these surgical techniques without being able to observe them. After confirming that the sheep is sleepy and lethargic, place the animal in the lithotomy position on the end of the surgical table and use ropes to secure the limbs with the hips in hyperflexion.Next, push transvaginally on the bladder to empty the organ and manually empty the rectum, followed by shaving of the perineum, the medial area of the thigh, and the tail folds. Disinfect the exposed skin with 7.5%povidone iodium and after donning the appropriate personal protective equipment cover the animal with a sterile drape, with an opening above the genital hiatus. Use allis forceps to grasp the dorsal vaginal wall three centimeters cranial to the hymenal ring.Then, use a 10 milliliter syringe loaded with a 22 gauge needle to inject saline three to four millimeters under the vaginal epithelium along the mid line of the recto vaginal septum 1.5 centimeters cranial to the hymenal ring. Aqua dissect the vaginal tissue by injecting the saline into the recto vaginal septum. Then use a scalpel to make a three centimeter long mid line incision on the vaginal epithelium starting caudal to the allis forceps and ending at the hymenal ring.Hold the incision open with a self retaining retractor over the perineum and four sharp stay hooks. Then use your index to bluntly dissect the recto vaginal fascia from the vaginal wall laterally toward the pelvic side walls and cranially up to the caudal aspect of the cul-de-sac. At this point, you can insert either the rectangular implant or continue with dissection to insert the implant with anchoring arms.When a suitable space has been created for the 30 by 40 millimeter flat mesh insert a vaginal retractor into the incision and use a simple interrupted three oh polypropylene suture on the left and right sides of the most cranial aspect of the dissected recto vaginal space to suture the left and right cranial corner of the implant. Trim the residual suture material and add one additional simple interrupted suture midway along the cranial aspect of the implant. Suture the lateral edges of the implant midway onto the surrounding connective tissue, with a simple interrupted three oh polypropylene suture.Suture the left and right caudal corners with simple interrupted three oh polypropylene sutures on the left and right sides of the most caudal aspect of the recto vaginal space. Then add one additional simple interrupted suture midway along the caudal aspect of the implant, and close the vaginal incisions with a running three oh polyglactin suture, which will be shown at the end of the video. This is another operation.Alternatively, one can continue the recto vaginal space cranial ventrally to reach the medial aspect of the obturator foramen and also dissect the space caudolaterally to reach the caudally located coccygeus muscle. With a number 24 blade, make four one centimeter wide incisions on the vulvar side cutting through the skin and superficial muscular fascia. Make two ventral incisions on the medial aspect of the thigh, approximately four centimeters cranial from the caudal border of the sciatic arch, and three centimeters lateral from the midline.Make two dorsal incisions at the insertion of the tail folds two centimeters medial to the tuber ischiadicum. Then place a curved trocar through one of the ventral incisions. Controlling the progression of the trocar with a finger inserted through the vaginal incision, pass the trocar through the abductor magnus muscle, the external obturator, and the medial aspect of the obturator foramen.Take special care when pushing the trocar, as pushing the trocar in the wrong direction may cause severe injury to the vessel or nerve both of which are located in the cranial aspect of the obturator foramen. Guide the tip of the trocar to the tendonous arc of the levator ani muscle, and expose the guiding wire in the vaginal wall incision. Load the wire with the corresponding ipsilateral cranial mesh arm and pull the loaded trocar through the tissues, keeping the mesh arm tension free.Then load the guide wire with the second cranial arm through the ventral incision on the other side of the animal and pull the trocar through the tissues, as just demonstrated. Now pass the trocar through the coccygeus muscle via one of the dorsal incisions just distal to the sacrotuberous ligament, and expose the guide wire through the vaginal incision. Grasp the dorsal arm of the mesh and pull the mesh out, keeping the arm tension free.Transfer the second arm of mesh to the other side of the animal as just demonstrated, and adjust the mesh position by flattening and applying tension to both arms, while keeping the mesh tension free. Using simple interrupted three oh polypropylene sutures in the middle of the caudal borders, secure the mesh to the surrounding connective tissue. Then cut the arms at the skin, and use simple interrupted three oh poliglecaprone sutures to close all of the skin incisions, followed by a running three oh poliglecaprone suture to close the vaginal incision.In this experimental animal, the cranial arms were passed through the caudal aspect of the obturator foramen. The entry point of the trocar was at the tendonous arc of the levator ani two to 2.5 centimeters caudal to the obturator canal and the obturator vessels and nerve. The gracilis muscle was moved medially to display the course of the cranial arm through the semi tendinosis and the abductor magnus muscles.The caudal arms were passed one centimeter to caudal to the caudal aspect of the broad sacrotuberous ligament, right through the coccygeus muscle. The central part of the mesh was placed flat with its cranial section stretching retroperitoneally under the caudal end of the cul-de-sac, and its caudal section down along the recto vaginal septum. Once mastered, this type of operation can be completed in 40 minutes.Before attempting this procedure, it is important to remember to become familiar with the ovine pelvic anatomy and to obtain surgical skills, such as blunt and sharp dissection and hemostatic techniques. Following this procedure other methods like native tissue repair can be performed. After its development this technique paved the way for researchers in the field of urogynecology to explore implant augmented pelvis organ prolapse repair in an ovine model for vaginal surgery.After watching this video you should have a good understanding of how to dissect the ovine recto vaginal septum to insert a flat rectangular implant and to use trocars to guide the insertion of an arm anchored implant. Don't forget that working with sharp objects, such as scalpels or needles may cause accidental injury or infection and that precautions such as paying full attention during the surgery should always be taken while performing this procedure.

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Research

JoVE Journal

Medicine

Ovine Lumbar Intervertebral Disc Degeneration Model Utilizing a Lateral Retroperitoneal Drill Bit Injury

Intervertebral disc degeneration is a significant contributor to the development of back pain and the leading cause of disability worldwide. Numerous animal models of intervertebral disc degeneration have been developed. The ideal animal model should closely mimic the human intervertebral disc with regard to morphology, biomechanical properties and the absence of notochordal cells. The sheep lumbar intervertebral disc model fulfils these criteria. We present an ovine model of intervertebral disc degeneration utilizing a drill bit injury through a lateral retroperitoneal approach. The lateral approach significantly reduces the incision and potential morbidity associated with the traditional anterior approach to the ovine spine. Utilization of a drill-bit method of injury affords the ability to produce a consistent and reproducible injury, of precise dimensions, that initiates a consistent degree of intervertebral disc degeneration. The focal nature of the annular and nucleus pulposus defect more closely mimics the clinical condition of focal intervertebral disc herniation. Sheep recover rapidly following this procedure and are typically mobile and eating within the hour. Intervertebral disc degeneration ensues and sheep undergo necropsy and subsequent analysis at periods from eight weeks. We believe that the drill bit injury model of intervertebral disc degeneration offers advantages over more conventional annular injury models.

Intervertebral disc degeneration is a significant contributor to back pain and a leading cause of disability worldwide. Numerous animal models of intervertebral disc degeneration exist. We demonstrate an ovine model of intervertebral disc degeneration, utilizing a drill bit, which achieves a consistent disc injury and reproducible level of disc degeneration.

Intervertebral disc degeneration is a significant contributor to the development of back pain and the leading cause of disability worldwide. Numerous ...

In Vitro Assays to Assess Blood-brain Barrier Mesh-like Vessel Formation and Disruption

Blood-brain barrier (BBB) coverage plays a central role in the homeostasis of the central nervous system (CNS). The BBB is dynamically maintained by astrocytes, pericytes and brain endothelial cells (BECs). Here, we detail methods to assess BBB coverage using single cultures of immortalized human BECs, single cultures of primary mouse BECs, and a humanized triple culture model (BECs, astrocytes and pericytes) of the BBB. To highlight the applicability of the assays to disease states, we describe the effect of oligomeric amyloid-&#946; (oA&#946;), which is an important contributor to Alzheimer&#39;s disease (AD) progression, on BBB coverage. Further, we utilize the epidermal growth factor (EGF) to illuminate the drug screening potential of the techniques. Our results show that single and triple cultured BECs form meshwork-like structures under basal conditions, and that oA&#946; disrupts this cell meshwork formation and degenerates the preformed mesh structures, but EGF blocks this disruption. Thus, the techniques described are important for dissecting fundamental and disease-relevant processes that modulate BBB coverage.

In Vitro Assays to Assess Blood-brain Barrier Mesh-like Vessel Formation and Disruption

Maintaining blood-brain barrier coverage is key for the homeostasis of the central nervous system. This protocol describes in vitro techniques to delineate the fundamental and pathological processes that modulate blood-brain barrier coverage.

Blood-brain barrier (BBB) coverage plays a central role in the homeostasis of the central nervous system (CNS). The BBB is dynamically maintained by ...

Isometric Contractility Measurement of the Mouse Mesenteric Artery Using Wire Myography

The wire myograph technique is used to assess the contractility of vascular smooth muscles in response to depolarization, GPCR agonists/inhibitors and drugs. It is widely used in many studies on the physiological functions of vascular smooth muscle, the pathogenesis of vascular diseases such as hypertension, and the development of smooth muscle relaxant drugs. The mouse is a widely used model animal with a large pool of disease models and genetically modified strains. We introduced this method to measure the isometric contraction of mouse mesenteric artery in detail. A 1.4-mm segment of mouse mesenteric resistance artery was isolated and mounted on a myograph chamber by passing two steel wires through its lumen. After equilibration and normalization steps, the vessel segment was potentiated by a high-K+ solution twice prior to the contraction assay. As an example of the application of this method in drug development, we measured the relaxant effect of a novel natural substance, neoliensinine, isolated from a Chinese herb, embryos of the lotus seed (Nelumbo nucifera Gaertn.) on mouse mesenteric arteries. The vessel segments mounted on the myograph chamber were stimulated with a high-K+ solution. When the force tension reached a stable sustained phase, cumulative doses of neoliensinine were added to the chamber. We found that neoliensinine had a dose-dependent relaxant effect on smooth muscle contraction, thus suggesting that it bears potential activity against hypertension. In addition, as the vessel segment can survive at least 4 hours after mounting and maintain contractility induced by the high-K+ solution for many times, we suggest that the wire myograph system may be used for the time-consuming process of drug screening.

The wire myograph technique is used to investigate vascular smooth muscle functions and screen new drugs. We report a detailed protocol for measuring the isometric contractility of the mouse mesenteric artery and for screening new relaxants of vascular smooth muscle.

The wire myograph technique is used to assess the contractility of vascular smooth muscles in response to depolarization, GPCR agonists/inhibitors and ...

Laparoscopic Repair of Para-Esophageal Hernia Using Absorbable Biosynthetic Mesh

Para-esophageal hernia repairs are challenging procedures and there is no consensus on the optimal approach to repair. Mesh reinforcement has been associated with lesser hernia recurrence when compared to the primary suture repair. The type of mesh that is most appropriate is still debatable. Synthetic and biosynthetic materials have been studied in the literature. It is well documented that a synthetic mesh is associated with esophageal erosion and migration into the stomach. Though there are limited long-term data on biosynthetic mesh, the short-term results are excellent and promising.
This paper illustrates how a biosynthetic prosthesis can be safely used with fibrin glue fixation and anterior Dor fundoplication to repair any para-esophageal defect. The absorbable biosynthetic mesh has been shown to produce good long-term patient satisfaction outcomes and low recurrence rates compared to conventional methods including repair with synthetic mesh. This technique also avoids the risk of esophageal erosion whilst strengthening the repair. Tacks that are still widely used to secure the mesh can be abandoned due to the associated risk of developing cardiac tamponade, or other disastrous consequences. This repair method, also, highlights how the prosthesis can be fashioned into a V-shape and easily placed in an onlay fashion behind the esophagus. The protocol demonstrates an alternative and safer method for mesh fixation using fibrin glue.

Presented here is a protocol of para-esophageal hernia repair. Use of absorbable biosynthetic mesh avoids the risk of erosion through the esophagus whilst reinforcing the repair. Glue fixation is preferred to avoid the risk of trauma such as bleeding or cardiac tamponade, which are associated with stitches or tacks.

Para-esophageal hernia repairs are challenging procedures and there is no consensus on the optimal approach to repair. Mesh reinforcement has been ...

The Lower Body Positive Pressure Treadmill for Knee Osteoarthritis Rehabilitation

Here, based on a clinician&rsquo;s point-of-view, we propose a two-model lower body positive pressure (LBPP) protocol (walking and squatting models) in addition to a clinical, functional assessment methodology, including details for further encouragement of the development of non-drug surgical intervention strategies in knee osteoarthritis patients. However, we only present the effect of LBPP training in improvement of pain and knee function in one patient through three-dimensional gait analysis. The exact, long-term effects of this approach should be explored in future studies.

Here, based on a clinician&#8217;s point-of-view, we propose a two-model lower body positive pressure (LBPP) protocol (walking and squatting models) in addition to a clinical, functional assessment methodology, including details for further encouragement of the development of non-drug surgical intervention strategies in knee osteoarthritis patients. However, we only present the effect of LBPP training in improvement of pain and knee function in one patient through three-dimensional gait analysis. The exact, long-term effects of this approach should be explored in future studies.

Here, based on a clinician&rsquo;s point-of-view, we propose a two-model lower body positive pressure (LBPP) protocol (walking and squatting models) in ...

Intravitreal Injections in the Ovine Eye

There are several methods for the delivery of therapeutic agents to the retina, including intravitreal (IVT), subretinal, suprachoroidal, periocular, or topical administration. IVT drug delivery involves an injection into the vitreous humor of the eye, a gelatinous substance that fills the posterior chamber of the eye and maintains the shape of the eye globe. Although the IVT route is less specifically targeted than subretinal delivery, it is much less invasive and is widely used in clinical settings for a range of ocular diseases. 
We previously demonstrated the efficacy of intravitreal delivery of an adeno-associated virus (AAV)-mediated gene therapy product (AAV9.CLN5) in sheep with a naturally occurring CLN5 form of neuronal ceroid lipofuscinosis (NCL). Affected sheep received IVT gene therapy in one eye, with the other untreated eye serving as an internal control. Retinal structure and function were maintained in the treated eye up to 15 months after treatment, while the untreated eye displayed progressively declining function and severe atrophy during postmortem examination. Based on the sheep studies, the CLN5 gene therapy product was cleared as a candidate investigational new drug (IND) by the United States Food and Drug Administration in September 2021. This paper details the surgical protocol for IVT delivery of a therapeutic viral vector to the ovine eye.

Intravitreal injections were performed in the sheep eye with the aim of delivering viral-mediated gene therapy to the retina.

There are several methods for the delivery of therapeutic agents to the retina, including intravitreal (IVT), subretinal, suprachoroidal, periocular, or ...

Laparoscopic Non-Mesh Cerclage Pectopexy for Pelvic Organ Prolapse

Pelvic organ prolapse (POP) is widespread among the female population and significantly impairs the patient's quality of life. It is important to restore apical support for treating POP. Sacrocolpopexy and pectopexy are indicated for apical prolapse. Using a synthetic mesh in these techniques increases success by enhancing apical support. However, the implantation of synthetic mesh is associated with mesh-related complications. In addition, the exorbitant cost of synthetic mesh and lack of universal access limit the popularity of these procedures. The current study develops a unique technique known as laparoscopic non-mesh cerclage pectopexy (LNMCP), in which permanent cervical cerclage sutures are embedded in the round ligament until the iliopectineal ligament. The iliopectineal ligament was sutured, resulting in a firm cervical suspension. The procedure was successfully performed in 16 cases in the hospital. The surgical duration was 67.8 min &plusmn; 15.5 min, and the blood loss was 73.1 mL &plusmn; 51.1 mL. No procedural complications were seen. LNMCP is associated with an objective success rate of 100% and a subjective success rate of 93.8%. LNMCP for patients with apical prolapse obviates the need for a mesh, thereby avoiding complications associated with mesh erosion and reducing medical costs. In addition, it is easy to perform even in resource-poor areas without access to synthetic mesh.

The present pilot study describes the development of laparoscopic non-mesh cerclage pectopexy to treat pelvic organ prolapse. The procedure can be used to prevent any complications associated with the use of mesh.

Pelvic organ prolapse (POP) is widespread among the female population and significantly impairs the patient's quality of life. It is important to restore ...

Neuronavigation and Laparoscopy Guided Ventriculoperitoneal Shunt Insertion for the Treatment of Hydrocephalus

Hydrocephalus is a common adult neurosurgical condition typically requiring treatment with a cerebrospinal fluid (CSF) shunt, of which the ventriculoperitoneal (VP) shunt is the most common type. Unfortunately, the failure rates of VP shunts are alarmingly high, with up to 50% of patients requiring revision surgery within 2 years. VP shunt failure may occur due to infection, or catheter mispositioning, migration, and occlusion. We undertook a joint neurosurgery and general surgery collaboration in a 7-year prospective non-randomized consecutive quality improvement cohort study to reduce the rates of ventriculoperitoneal (VP) shunt failures in 224 adult patients at a tertiary care institution. The initiative combined the use of electromagnetic stereotactic neuronavigation to guide the placement of the proximal catheter and laparoscopy to place the distal catheter under direct visualization. With laparoscopic assistance, the distal catheter was anchored through a small hole created in the falciform ligament and placed into the right retrohepatic space, free from the omentum, adhesions, or bowel that might obstruct the catheter tip. The surgeries were performed using a shunt infection prevention protocol to reduce the risk of shunt infections. Here, we present an intraoperative video of the surgical procedure. Compliance with shunt infection reduction strategies and the combined utilization of neuronavigation and laparoscopy techniques in adult VP shunt surgery resulted in a 44% reduction in the risk of overall shunt failure. The significant positive impact with regard to shunt-failure-free patient outcomes among patients who underwent VP shunt surgery using this strategy underscores the value associated with the use of these modern intraoperative techniques and cross-specialty collaboration during VP shunt surgery.

Patient outcomes of ventriculoperitoneal (VP) shunt surgery, the mainstay treatment for hydrocephalus in adults, are poor due to high shunt failure rates. We present intraoperative footage of VP shunt insertion using neuronavigation and laparoscopy guidance, with the goal to reduce the risks of proximal and distal shunt catheter failures, respectively.

Hydrocephalus is a common adult neurosurgical condition typically requiring treatment with a cerebrospinal fluid (CSF) shunt, of which the ...

Application of a New Mesh Fixation Method in Laparoscopic Incisional Hernia Repair

Laparoscopic incisional hernia repair using intraperitoneal onlay mesh (IPOM) is one of the most widely used minimally invasive methods for repairing incisional hernias. The laparoscopic IPOM involves implanting the mesh into the abdominal cavity through laparoscopy to repair an abdominal wall hernia. In the IPOM surgery, after the closure of the hernia ring, an anti-adhesion mesh is placed laparoscopically. The correct placement of this mesh is critical to the success of the method, and surgical skills are required to achieve perfect placement. If the mesh placement is not mastered properly, the operation and anesthesia time will be prolonged. In addition, improper placement of the mesh can lead to serious consequences, such as intestinal obstruction and mesh infection. A "contraposition and alignment" mesh fixation method is described in this study, which involves pre-marking the fixation position of the mesh to reduce the difficulty of mesh placement. A properly placed mesh is completely flat on the peritoneum, the edges are not curled or wrapped, and the mesh is adhered firmly such that there is no displacement after removing the pneumoperitoneum pressure. The "contraposition and alignment" mesh fixation technique offers the advantages of reliable placement of the mesh and fewer complications than other techniques, and it is easy to learn and master. It also allows for positioning the nail gun in advance based on the anatomy of the incisional hernia. This enables the use of the minimum number of nails possible while still ensuring good fixation, which can reduce the occurrence of complications and reduce the cost of surgery. Thus, the mesh fixation method described here is highly suitable for clinical applications based on the aforementioned advantages.

Presented here is a method for improving the mesh placement in laparoscopic incisional hernia repair, which can shorten the time required for mesh fixation and reduce the occurrence of postoperative chronic pain.

Laparoscopic incisional hernia repair using intraperitoneal onlay mesh (IPOM) is one of the most widely used minimally invasive methods for repairing ...

Chronic Ovine Model of Right Ventricular Failure and Functional Tricuspid Regurgitation

The pathophysiology of severe functional tricuspid regurgitation (FTR) associated with right ventricular dysfunction is poorly understood, leading to suboptimal clinical results. We set out to establish a chronic ovine model of FTR and right heart failure to investigate the mechanisms of FTR. Twenty adult male sheep (6-12 months old, 62 &#177; 7 kg) underwent a left thoracotomy and baseline echocardiography. A pulmonary artery band (PAB) was placed and cinched around the main pulmonary artery (PA) to at least double the systolic pulmonary artery pressure (SPAP), inducing right ventricular (RV) pressure overload and signs of RV dilatation. PAB acutely increased the SPAP from 21 &#177; 2 mmHg to 62 &#177; 2 mmHg. The animals were followed for 8 weeks, symptoms of heart failure were treated with diuretics, and surveillance echocardiography was used to assess for pleural and abdominal fluid collection. Three animals died during the follow-up period due to stroke, hemorrhage, and acute heart failure. After 2 months, a median sternotomy and epicardial echocardiography were performed. Of the surviving 17 animals, 3 developed mild tricuspid regurgitation, 3 developed moderate tricuspid regurgitation, and 11 developed severe tricuspid regurgitation. Eight weeks of pulmonary artery banding resulted in a stable chronic ovine model of right ventricular dysfunction and significant FTR. This large animal platform can be used to further investigate the structural and molecular basis of RV failure and functional tricuspid regurgitation.

Right ventricular failure and functional tricuspid regurgitation are associated with left-sided heart disease and pulmonary hypertension, which contribute significantly to morbidity and mortality in patients. Establishing a chronic ovine model to study right ventricular failure and functional tricuspid regurgitation will help in understanding their mechanisms, progression, and possible treatments.

The pathophysiology of severe functional tricuspid regurgitation (FTR) associated with right ventricular dysfunction is poorly understood, leading to ...