Name: laparoscopic non-mesh cerclage pectopexy for pelvic organ prolapse
Uploaded: 2022-09-13T14:20:00.000+00:00
Duration: 3 min 43 s
Description: Watch this Scientific Journal Video about Laparoscopic Non-Mesh Cerclage Pectopexy for Pelvic Organ Prolapse at JoVE.com

We thank all the patients who consented to participate in the pilot study and the staff who assisted us with our research.

The protocol using LNMCP was conducted after approval by the Institutional Review Board of The University of Hong Kong-Shenzhen Hospital on 1 March, 2021 (IRB Approval Number 2021-040). All human participants provided written informed consent for publication before undergoing the procedure. All women diagnosed with symptomatic POP and cystocele or uterine descent POP-Q stage 2 or higher were included in the study. Women with a history of prolapse surgery, established malignancy of the cervix or cervical dysplasia, language issues, intention to preserve fertility, contraindications for laparoscopic surgery, such as the risk of severe adhesions, and those not available for follow-up were excluded.
1. Patient preparation
<ol>
	<li>Discuss the benefits and risks associated with the procedure as well as the risk of complications such as uncontrolled bleeding warranting blood transfusion, conversion to laparotomy, postoperative infection, and the recurrence of POP.</li>
	<li>Perform surgery using general anesthesia and endotracheal intubation following a previous report7. Administer prophylactic antibiotics such as intravenous cefuroxime (1.5 g, see Table of Materials) to each patient 30 min before the induction of anesthesia.</li>
	<li>Start perioperative thrombosis prophylaxis in women using an enoxaparin sodium injection (4,000 AxaIU, see Table of Materials) according to hospital protocols.</li>
</ol>
2. Pre- LNMCP preparation
<ol>
	<li>Following skin sterilization, establish the ports (see Table of Materials) using standard techniques7: a 10 mm umbilical port, a 5 mm port on the right side, and two left-sided ports measuring 5 mm each on the left side of the lower abdomen.</li>
	<li>During the operation, carefully monitor the patient&#39;s vital signs with the help of an anesthesiologist. 
	NOTE: During the anesthesia, continually evaluate the patient&#39;s oxygenation, ventilation, circulation, and temperature.</li>
	<li>Maintain an intra-abdominal pressure of 12 mmHg and a gas flow rate of 20 L/min7.</li>
</ol>
3. LNMCP procedure
<ol>
	<li>Perform laparoscopic supracervical hysterectomy with bilateral salpingo-oophorectomy as previously described by Lyons et al.8.</li>
	<li>To perform cervical cerclage, suture, ligate, and attach a round ligament to the cervical stump using a permanent suture (size 2, see Table of Materials) in the uterine isthmus beginning at the 3 o&#39;clock position on the right side in a counterclockwise direction, performing peripheral movements with the needle around the cervix to complete one round until the starting position (Figure 1). Tighten and secure the stitch upon completion of the cervical cerclage (Figure 2).</li>
	<li>Embed the suture (size 2) in the round ligament until the iliopectineal ligament (Figure 3).</li>
	<li>Expose the iliopectineal ligament near the landmarks, including the round ligament and the obliterated umbilical artery. Incise the peritoneum to a length of approximately 8 cm along the inner edge of the round ligament toward the pelvic wall until the iliopectineal ligament is reached. Locate the posterior aspect of the iliopectineal ligament immediately below the external iliac vein.</li>
	<li>Insert the suture (size 2) through the iliopectineal ligament to ensure tension-free anchoring (Figure 4).</li>
	<li>Repeat steps 3.2-3.5 on the other side of the pelvis.</li>
	<li>Perform re-peritonealization with an absorbable suture (size 2-0, see Table of Materials).</li>
	<li>Perform anterior and/or posterior colporrhaphy and/or anti-incontinence surgery before LNMCP, if indicated9. 
	&#8203;NOTE: The postoperative pelvis and schematic shown in Figure 5 and Figure 6, respectively, illustrate the LNMCP technique.</li>
</ol>
4. Postoperative management
<ol>
	<li>Record the intraoperative and postoperative parameters, including blood loss based on vacuum drainage, the operation time of LNMCP, and perioperative complications.</li>
	<li>Document the primary outcomes, including objective and subjective success rates. 
	NOTE: An objective measure of surgical success is the absence of any prolapse extending beyond the hymen, an annoying bulge, or treatment for recurrent prolapse9. Subjective success is defined as Patient Global Impression (PGI) &#8804;2, based on the PGI Improvement Scale10.</li>
	<li>Prescribe low-dose vaginal estriol for at least 6 weeks post-surgery.</li>
	<li>Ask the patient to perform pelvic floor exercises starting 8 weeks after the surgery.</li>
	<li>Perform follow-up after the surgery at intervals of 6 weeks, 6 months, and again 1 year later. Conduct a gynecological examination of the patients, who should complete the PGI Improvement Scale questionnaire10.</li>
</ol>

<ol>
	<li>Brown, H. W., 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=International+urogynecology+consultation+chapter+1+committee+2:+Epidemiology+of+pelvic+organ+prolapse:+prevalence,+incidence,+natural+history,+and+service+needs.">International urogynecology consultation chapter 1 committee 2: Epidemiology of pelvic organ prolapse: prevalence, incidence, natural history, and service needs.</a> International Urogynecology Journal. 33 (2), 173-187 (2022).</li><li>Karmakar, D. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Commentary+to+&amp;#34;Defining+normal+apical+vaginal+support:+a+relook+at+the+POSST+study&amp;#34.">Commentary to &amp;#34;Defining normal apical vaginal support: a relook at the POSST study&amp;#34.</a> International Urogynecology Journal. 30 (1), 53-54 (2019).</li><li>Nygaard, I. E., 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=Abdominal+sacrocolpopexy:+A+comprehensive+review.">Abdominal sacrocolpopexy: A comprehensive review.</a> Obstetrics &amp; Gynecology. 104 (4), 805-823 (2004).</li><li>No&#233;, K. G., Schiermeier, S., Alkatout, I., Anapolski, M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Laparoscopic+pectopexy:+A+prospective,+randomized,+comparative+clinical+trial+of+standard+laparoscopic+sacral+colpocervicopexy+with+the+new+laparoscopic+pectopexy-postoperative+results+and+intermediate-term+follow-up+in+a+pilot+study.">Laparoscopic pectopexy: A prospective, randomized, comparative clinical trial of standard laparoscopic sacral colpocervicopexy with the new laparoscopic pectopexy-postoperative results and intermediate-term follow-up in a pilot study.</a> Journal of Endourology. 29 (2), 210-215 (2015).</li><li>Szymczak, P., Grzybowska, M. E., Wydra, D. G. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Comparison+of+laparoscopic+techniques+for+apical+organ+prolapse+repair+-+A+systematic+review+of+the+literature.">Comparison of laparoscopic techniques for apical organ prolapse repair - A systematic review of the literature.</a> Neurourology and Urodynamics. 38 (8), 2031-2050 (2019).</li><li>Rovner, E., de Tayrac, R., Kirschner-Hermanns, R., Veit-Rubin, N., Anding, R. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Is+polypropylene+mesh+material+fundamentally+safe+for+use+as+a+reconstructive+material+in+vaginal+surgery:+ICI-RS+2019.">Is polypropylene mesh material fundamentally safe for use as a reconstructive material in vaginal surgery: ICI-RS 2019.</a> Neurourology and Urodynamics. 39, 132-139 (2020).</li><li>Zeng, L., 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=Introduction+of+intracapsular+rotary-cut+procedures+(IRCP):+A+modified+hysteromyomectomy+procedures+facilitating+fertility+preservation.">Introduction of intracapsular rotary-cut procedures (IRCP): A modified hysteromyomectomy procedures facilitating fertility preservation.</a> Journal of Visualized Experiments. (143), e58410 (2019).</li><li>Lyons, T. L. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Laparoscopic+supracervical+hysterectomy.">Laparoscopic supracervical hysterectomy.</a> Obstetrics and Gynecology Clinics of North America. 27 (2), 441-450 (2000).</li><li>IJsselmuiden, M. v. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Hysteropexy+in+the+treatment+of+uterine+prolapse+stage+2+or+higher:+laparoscopic+sacrohysteropexy+versus+sacrospinous+hysteropexy-A+multicentre+randomised+controlled+trial+(LAVA+trial).">Hysteropexy in the treatment of uterine prolapse stage 2 or higher: laparoscopic sacrohysteropexy versus sacrospinous hysteropexy-A multicentre randomised controlled trial (LAVA trial).</a> BJOG. 127 (10), 1294 (2020).</li><li>Chatziioannidou, K., Veit-Rubin, N., Dallenbach, P. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Laparoscopic+lateral+suspension+for+anterior+and+apical+prolapse:+a+prospective+cohort+with+standardized+technique.">Laparoscopic lateral suspension for anterior and apical prolapse: a prospective cohort with standardized technique.</a> International Urogynecology Journal. 33 (2), 319-325 (2022).</li><li>Wu, J. M., Hundley, A. F., Fulton, R. G., Myers, E. R. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Forecasting+the+prevalence+of+pelvic+floor+disorders+in+U.S.+Women:+2010+to+2050.">Forecasting the prevalence of pelvic floor disorders in U.S. Women: 2010 to 2050.</a> Obstetrics &amp; Gynecology. 114 (6), 1278-1283 (2009).</li><li>Elliott, C. S., Yeh, J., Comiter, C. V., Chen, B., Sokol, E. R. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+predictive+value+of+a+cystocele+for+concomitant+vaginal+apical+prolapse.">The predictive value of a cystocele for concomitant vaginal apical prolapse.</a> The Journal of Urology. 189 (1), 200-203 (2013).</li><li>Obut, M., Oglak, S. C., Akgol, S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Comparison+of+the+quality+of+life+and+female+sexual+function+following+laparoscopic+pectopexy+and+laparoscopic+sacrohysteropexy+in+apical+prolapse+patients.">Comparison of the quality of life and female sexual function following laparoscopic pectopexy and laparoscopic sacrohysteropexy in apical prolapse patients.</a> Gynecology and Minimally Invasive Therapy. 10 (2), 96-103 (2021).</li><li>Petros, P. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+integral+system.">The integral system.</a> Central European Journal of Urology. 64 (3), 110-119 (2011).</li><li>Noe, K. G., Spuntrup, C., Anapolski, M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Laparoscopic+pectopexy:+A+randomised+comparative+clinical+trial+of+standard+laparoscopic+sacral+colpo-cervicopexy+to+the+new+laparoscopic+pectopexy.+Short-term+postoperative+results.">Laparoscopic pectopexy: A randomised comparative clinical trial of standard laparoscopic sacral colpo-cervicopexy to the new laparoscopic pectopexy. Short-term postoperative results.</a> Archives of Gynecology and Obstetrics. 287 (2), 275-280 (2013).</li><li>Kostov, 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=Corona+mortis,+aberrant+obturator+vessels,+accessory+obturator+vessels:+Clinical+applications+in+gynaecology.">Corona mortis, aberrant obturator vessels, accessory obturator vessels: Clinical applications in gynaecology.</a> Folia Morphologica. 80 (4), 776-785 (2021).</li></ol>

The authors declare that they have no conflicts of interest.

POP is highly prevalent among women, adversely affecting the quality of patients&#39; lives. The increase in the elderly population has contributed substantially to the rise in the number of women diagnosed with POP and individuals interested in a prophylactic intervention over the last 40 years11. Prolapse may involve cystocele associated with the anterior vaginal wall and rectocele affecting the posterior vaginal wall or the apex. POP mostly involves cystocele, and women who suffer from cystocele at or beyond the hymen mostly have apical defect concomitantly12. Therefore, interventions to restore apical support are critical in most surgical interventions for POP.
Several procedures are available to restore apical support. Laparoscopic sacrocolpopexy represents the mainstay of therapy for apical prolapse, with high success rates and long-term durability3. However, the mesh bridges the pelvic space carrying the sacrum and vagina, reducing and restricting the colon&#39;s movement, resulting in pain during defecation13. Laparoscopic pectopexy can replace sacrocolpopexy for the treatment of apical prolapse. The technique entails using the lateral components of the iliopectineal ligament to repair the prolapsed tissues. Pectopexy reduced the frequency of defecation disorders by ensuring that the pelvic space of the rectum is not decreased13.
However, both procedures use synthetic mesh for support, resulting in complications such as mesh perforation into the bladder, urinary tract, and bowel, infection, and pelvic pain5. In addition, synthetic mesh is expensive, which limits its application in areas with limited resources. Therefore, we have developed a non-mesh suspension procedure known as LNMCP.
LNMCP is based on the following key features:
Preservation of the cervix 
The cervix is a key structure in the pelvic suspensory system. It provides attachment for the cardinal and uterosacral ligaments. Cervical preservation is preferred to increase the stability of the fixation in the apical region14. During a supracervical hysterectomy, the preservation of a portion of the lower uterine segment results in the formation of a mushroom-shaped cervical stump and fixation of the cervical cerclage firmly on the cervix.
Identification of iliopectineal ligament 
The iliopectineal ligament is prepared starting with a surgical incision superficially adjacent to the round ligament, located next to the external iliac vessels and the obturator nerve anatomically15. The soft tissue in this area is removed to uncover the iliopectineal ligament without lacerating the corona mortis, an anastomosis between the external iliac and the obturator veins16.
Cervical cerclage 
The ring suture around the cervical isthmus ensures firm fixation of the cervical cerclage to the cervix and prevents tearing of the cervical stump.
Suture embedded in the round ligament 
The suspension creates significant tension between the cervical stump and the iliopectineal ligament. A naked suture with high tensile strength may damage the adjacent organs, such as the bowels and bladder. Therefore, a suture embedded in the surrounding ligament can prevent such complications.
A tension-free suspension 
The cervix is raised to POP-Q stage 0 to avoid overcorrection and ensure tension-free anchoring.
This&#160;pilot study presents a new procedure known as LNMCP using only sutures to treat apical prolapse. LNMCP showed excellent safety, efficacy, and feasibility. The current data indicate favorable outcomes, with the estimated blood loss, operative time, and objective and subjective parameters of success comparable to those obtained during laparoscopic pectopexy13. Further, LNMCP avoids using a synthetic mesh, thereby eliminating any risk of related complications and reducing the medical expenses for the patients. Thus, it is easy to perform even in areas with limited resources and without access to synthetic mesh.
However, this pilot study involves a small number of cases and reports short-term results, which is a limitation. Additional studies involving large case series and extensive follow-up are required to corroborate the encouraging results.

Pelvic organ prolapse (POP) is predominantly seen in women, especially those with multiple children. POP adversely and significantly affects the patient's quality of life1. Apical support is critical in ensuring the overall health of the pelvic organs. However, the loss of apical support is often disregarded. Once the cervix descends to &#8805;&#8722;3 cm or the vaginal cuff to &#8805;&#8722;4 cm, an apical defect must be considered2, and an apical support procedure needs to be performed to address POP.
Sacrocolpopexy is the gold standard treatment for apical prolapse3. However, sacrocolpopexy is associated with de novo defecation disorders due to outlet obstruction4. Pectopexy, a new technique for apical repair, is similar to sacrocolpopexy in terms of clinical efficacy, with minimal defecation disorders4. The use of synthetic mesh in sacrocolpopexy and pectopexy for apical support enhanced the success rates5.
However, the implantation of synthetic mesh was associated with complications such as perforation into the bladder, urinary tract, and bowel, resulting in infection and pain6. The production of transvaginal meshes for prolapse was banned by the United States Food and Drug Administration (FDA) in April 2019, suggesting imminent restrictions against using mesh in the abdominal repair of POP6. Therefore, alternative urogynecological management options are needed for such patients.
The present study reports the development of laparoscopic non-mesh cerclage pectopexy (LNMCP) for apical prolapse therapy without using a synthetic mesh, thereby eliminating the risk of mesh-related complications.

<table><tbody><tr><td>Cefuroxime&amp;nbsp;Sodium for Injection (1.5 g)</td><td>Guanzhou Baiyunshan Tianxin Pharmaceutical CO.LTD.</td><td>H20000015&amp;nbsp;</td><td></td></tr><tr><td>ENDOPATH XCEL Trocars</td><td>Johnson &amp;amp; Johnson MedTech</td><td>B12LP</td><td></td></tr><tr><td>Enoxaparin Sodium Injection (0.4 mL:4000AxaIU)</td><td>Sanofi Winthrop Industrie</td><td>H20170269</td><td></td></tr><tr><td>ETHIBOND EXCEL Polyester Suture</td><td>Johnson &amp;amp; Johnson MedTech</td><td>W4843</td><td>ETHIBOND EXCEL GRN 4X75CM M5</td></tr><tr><td>Laparoscopy</td><td>Stryker corporation</td><td>X 800</td><td></td></tr><tr><td>VICRYL (polyglactin 910) Suture</td><td>Johnson &amp;amp; Johnson MedTech</td><td>JV323</td><td>VICRYL VIO 75CM M3</td></tr></tbody></table>

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.

LNMCP was performed successfully in 16 patients during the past year. The calculated mean age was 58.5 years (SD 8.0). All women consented to visit the hospital for follow-up after a mean duration of 6.6 months (SD 3.8). The mean estimated blood loss was 73.1 mL (SD 51.1). The mean operation time was 67.8 min (SD 15.5). There were no complication. Only one patient complained of minor lower abdominal pain occasionally. The results revealed an objective success rate of 100% until the last follow-up, while the subjective success rate was 93.8% (Table 1).
<img alt="Figure 1" class="xfigimg" src="/files/ftp_upload/64388/64388fig01.jpg" /> 
Figure 1: Cervical cerclage. Peripheral stitches were made around the cervix. <a href="https://www.jove.com/files/ftp_upload/64388/64388fig01large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 2" class="xfigimg" src="/files/ftp_upload/64388/64388fig02.jpg" /> 
Figure 2: Completion of the cervical cerclage. The stitch was tightened and secured around the cervix, similar to the cerclage. <a href="https://www.jove.com/files/ftp_upload/64388/64388fig02large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 3" class="xfigimg" src="/files/ftp_upload/64388/64388fig03.jpg" /> 
Figure 3: Suture embedded in the round ligament. The suture was passed through and embedded in the round ligament until the iliopectineal ligament. <a href="https://www.jove.com/files/ftp_upload/64388/64388fig03large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 4" class="xfigimg" src="/files/ftp_upload/64388/64388fig04.jpg" /> 
Figure 4: Suture passed through the iliopectineal ligament. The suture was passed through the iliopectineal ligament to keep a tension-free suture anchoring. <a href="https://www.jove.com/files/ftp_upload/64388/64388fig04large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 5" class="xfigimg" src="/files/ftp_upload/64388/64388fig05.jpg" /> 
Figure 5: Postoperative pelvis. The cervix was raised to POP-Q stage 0 to avoid overcorrection and ensure tension-free anchoring. <a href="https://www.jove.com/files/ftp_upload/64388/64388fig05large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 6" class="xfigimg" src="/files/ftp_upload/64388/64388fig06.jpg" /> 
Figure 6: Schematic diagram describing the LNMCP technique. With cervical cerclage, embedding the suture in the round ligament, and fixing the suture on the iliopectineal ligament, LNMCP used only suture to treat apical prolapse and eliminated mesh-erosion complications. <a href="https://www.jove.com/files/ftp_upload/64388/64388fig06large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td></td>
			<td>Baseline demographic features of participants and the outcomes of LNMCP involving 16 cases</td>
		</tr>
		<tr>
			<td>Age&#160;</td>
			<td>58.5&#177;8.0 years</td>
		</tr>
		<tr>
			<td>BMI</td>
			<td>24.0&#177;3.3&#160;</td>
		</tr>
		<tr>
			<td>Parity</td>
			<td>2.1&#177;0.9</td>
		</tr>
		<tr>
			<td>POP-Q stage, range</td>
			<td>2--4</td>
		</tr>
		<tr>
			<td>Ba</td>
			<td>2.0&#177;2.1 cm</td>
		</tr>
		<tr>
			<td>Bp</td>
			<td>&#160;-1.5&#177;1.3 cm</td>
		</tr>
		<tr>
			<td>C</td>
			<td>2.1&#177;1.8 cm</td>
		</tr>
		<tr>
			<td>Operation time</td>
			<td>67.8&#177;15.5 min</td>
		</tr>
		<tr>
			<td>Estimated blood loss</td>
			<td>73.1&#177;51.1 ml</td>
		</tr>
		<tr>
			<td>Duration of follow-up</td>
			<td>6.6&#177;3.8 months</td>
		</tr>
		<tr>
			<td>complications</td>
			<td>None</td>
		</tr>
		<tr>
			<td>Objective success rate</td>
			<td>100%</td>
		</tr>
		<tr>
			<td>Subjective success rate (PGI&#8804; 2)</td>
			<td>93.80%</td>
		</tr>
	</tbody>
</table>
Table 1: Baseline demographic features of the participants and the outcomes of LNMCP involving 16 cases. Parameters include operation time, estimated blood loss, duration of follow-up, complications, and objective and subjective success rates. BMI = body mass index. POP-Q, Ba, Bp, and C refer to scores associated with pelvic organ prolapse measurement. PGI = Patient Global Impression.

Watch this Scientific Journal Video about Laparoscopic Non-Mesh Cerclage Pectopexy for Pelvic Organ Prolapse at JoVE.com

Laparoscopic Non-Mesh Cerclage Pectopexy for Pelvic Organ Prolapse

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 ...

laparoscopic-non-mesh-cerclage-pectopexy-for-pelvic-organ-prolapse

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JoVE Journal

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5.1K Views.  The University of Hong Kong-Shenzhen Hospital. 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.

Video: Laparoscopic Non-Mesh Cerclage Pectopexy for Pelvic Organ Prolapse

Intraoperative Gastroscopy for Tumor Localization in Laparoscopic Surgery for Gastric Adenocarcinoma

Determining resection margins for gastric cancer, which are not exposed to the serosal surface of the stomach, is the most important procedure during totally laparoscopic gastrectomy (TLG). The aim of this protocol is to introduce a procedure for intraoperative gastroscopy, in order to directly mark tumors during TLG for gastric cancer in the middle third of the stomach. Patients who were diagnosed with adenocarcinoma in the middle third of the stomach were enrolled in this case series. Before surgery, additional gastroscopy for tumor localization is not performed. Under general anesthesia, laparoscopic mobilization of the stomach is performed first. After the first portion of the duodenum is mobilized from the pancreas and clamped, the surgeon moves to the other side for the gastroscopic procedure. On the insertion of a gastroscope through the oral cavity into the stomach, 2 - 3 cc of indigo carmine is administered via an endoscopic injector into the gastric muscle layer at the proximal margin of the stomach. The location of stained serosa in the laparoscopic view is used to guide distal subtotal gastrectomy, however, total gastrectomy is performed if the tumor is too close to the esophagogastric junction. A specimen is sampled after distal gastrectomy to confirm sufficient length from resection margin to tumor before reconstruction. In our case series, all patients had tumor-free margins and required no additional resection. There was no morbidity related to the gastroscopic procedure, and the time required for the procedure has gradually decreased to about five minutes. Intraoperative gastroscopy for tumor localization is an accurate and tolerated method for gastric cancer patients undergoing totally laparoscopic distal gastrectomy.

In early gastric cancer, the aim of surgery is to precisely remove the distal stomach including the primary tumor. To do this, accurate localization of the tumor is crucial, especially in totally laparoscopic surgery. This protocol describes a procedure for intraoperative gastroscopy in totally laparoscopic subtotal gastrectomy.

Determining resection margins for gastric cancer, which are not exposed to the serosal surface of the stomach, is the most important procedure during ...

Generation of Organ-conditioned Media and Applications for Studying Organ-specific Influences on Breast Cancer Metastatic Behavior

Breast cancer preferentially metastasizes to the lymph node, bone, lung, brain and liver in breast cancer patients. Previous research efforts have focused on identifying factors inherent to breast cancer cells that are responsible for this observed metastatic pattern (termed organ tropism), however much less is known about factors present within specific organs that contribute to this process. This is in part because of a lack of in vitro model systems that accurately recapitulate the organ microenvironment. To address this, an ex vivo model system has been established that allows for the study of soluble factors present within different organ microenvironments. This model consists of generating conditioned media from organs (lymph node, bone, lung, and brain) isolated from normal athymic nude mice. The model system has been validated by demonstrating that different breast cancer cell lines display cell-line specific and organ-specific malignant behavior in response to organ-conditioned media that corresponds to their in vivo metastatic potential. This model system can be used to identify and evaluate specific organ-derived soluble factors that may play a role in the metastatic behavior of breast and other types of cancer cells, including influences on growth, migration, stem-like behavior, and gene expression, as well as the identification of potential new therapeutic targets for cancer. This is the first ex vivo model system that can be used to study organ-specific metastatic behavior in detail and evaluate the role of specific organ-derived soluble factors in driving the process of cancer metastasis.

This manuscript describes an ex vivo model system comprised of organ-conditioned media derived from the lymph node, bone, lung, and brain of mice. This model system can be used to identify and study organ-derived soluble factors and their effects on the organ tropism and metastatic behavior of cancer cells.

Breast cancer preferentially metastasizes to the lymph node, bone, lung, brain and liver in breast cancer patients. Previous research efforts have focused ...

Anogenital Distance and Perineal Measurements of the Pelvic Organ Prolapse (POP) Quantification System

Anogenital distance (AGD) is a sexually dimorphic attribute, twice longer in males than in females, and a marker of intrauterine hormonal environment. Interest in AGD measurements is increasing due to mounting evidence on their potential clinical implications. A parallel set of perineal measurements, the Pelvic Organ Prolapse Quantification System (POP-Q), include similar, but not exactly the same, landmarks: the perineal body (PB) and the genital hiatus (GH) lengths. However, clinical reproducibility of both perineal measurements and their usefulness to describe perineal anthropometry needs to be elucidated. To our knowledge, there is no publication in video format showing the methodology of these measurements. The main objective of this work is to show how to properly perform perineal anthropometry, including measurements of the AGD in its two variants [anoclitoral (AGDAC) and anofourchette (AGDAF)], genital hiatus (GH) and perineal body (PB). Moreover, we explored if there were differences in these measurements in women with and without Pelvic Organ Prolapse (POP). We research whether the anthropometric characteristics of the perineum, such as AGD (which is determined prenatally), may be altered in these women and be an independent etiological factor for pelvic floor dysfunction. We show two different ways of measuring perineal lengths, as they might be quite comparable. Our suggestion is that unifying perineal measurements could be useful for clinical and biomedical investigation. More studies are needed in order to compare GH and PB measurements and its AGD counterparts to analyze which procedures are more reproducible with less intra and interobserver variability.

Anogenital Distance and Perineal Measurements of the Pelvic Organ Prolapse POP Quantification System

This manuscript describes the procedures to perform anogenital distance (AGD) and perineal measurements standardized by the Pelvic Organ Prolapse Quantification System (POP-Q): perineal body (PB) and genital hiatus (GH). These measurements are compared in women with and without pelvic organ prolapse.

Anogenital distance (AGD) is a sexually dimorphic attribute, twice longer in males than in females, and a marker of intrauterine hormonal environment. ...

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 ...

Application of Straight-needle, Three-tailed, Knot-free, Peritoneal Sutures in Laparoscopic Transabdominal Preperitoneal Hernia Repair

Laparoscopic transabdominal preperitoneal hernia repair (TAPP) is one of the most widely used methods in inguinal hernia surgery. After the mesh is placed, the peritoneum must be resutured to avoid contact with the tissues and organs in the abdominal cavity. If the peritoneal suture time is too long, the operation and anesthesia time will be prolonged, increasing the burden on the patient. Moreover, improper suture methods cause serious consequences, such as intestinal obstruction and mesh infection.
The straight-needle suture method transforms the three-dimensional spatial configuration of the needle holder and the arc needle tip into a two-dimensional planar structure, which greatly reduces the difficulty of suturing. The three-tailed knot can be anchored at the beginning of the suture by its friction and button effect, which has an exact fixation effect. Thus, the suture does not easily slip, and the time to complete the suturing is shortened. Compared with the traditional suture method, the operator can suture the peritoneum more quickly, beginners can pass through the difficult learning curve faster, and skilled operators can also shorten the total operation time of TAPP to a certain extent. Thus, this suture method is extremely amenable to clinical application.

Here, we present a protocol to introduce a new peritoneal suture method. This method is called straight-needle, three-tailed, knot-free suture, and we will outline the manufacturing method and clinical application of this suture in detail.

Laparoscopic transabdominal preperitoneal hernia repair (TAPP) is one of the most widely used methods in inguinal hernia surgery. After the mesh is ...

Extraperitoneal Laparoscopic Modified Y-V Plasty for the Treatment of Refractory Bladder Neck Contracture

Bladder neck contracture (BNC) is a rare, late complication of transurethral resection of the prostate (TURP). Although the endoscopic procedure is the primary treatment for BNC, the recurrence rate remains high. Y-V plasty offers excellent surgical results for those individuals with refractory and recurrent BNC. Traditional open operations usually fail to provide satisfactory exposure to the operating field and lead to greater invasiveness. Interrupted sutures lead to prolonged operative time and increased anastomotic leakage. Laparoscopic modified Y-V plasty is performed through extraperitoneal access to the pelvis, which provides adequate exposure to the surgical view and avoids intra-abdominal injury. After incising the anterior bladder wall neck in a Y-shaped fashion, anastomosis is performed using two absorbable barbed sutures. The mucosa and submucosa layer of the bladder is closed to both sides with consecutive sutures in a V-shape before suturing serosa, and tunica muscularis are sutured to reinforce. The aforementioned procedures reduce leakage from the anastomosis and decrease operative time and patient trauma. Extraperitoneal laparoscopic modified Y-V plasty offers significant advantages over the open approach in terms of post-surgical recovery and invasiveness, making it a feasible and safe surgical option for patients with refractory BNC.

Here, we describe a modified surgical procedure for refractory bladder neck contracture that is associated with easy manipulation, optimum intraoperative exposure, and minimal invasiveness.

Bladder neck contracture (BNC) is a rare, late complication of transurethral resection of the prostate (TURP). Although the endoscopic procedure is the ...

Development of a Uterosacral Ligament Suspension Rat Model

Pelvic organ prolapse (POP) is a common pelvic floor disorder (PFD) with the potential to significantly impact a woman's quality of life. Approximately 10%-20% of women undergo pelvic floor repair surgery to treat prolapse in the United States. PFD cases result in an overall $26.3 billion annual cost in the United States alone. This multifactorial condition has a negative impact on the quality of life and yet the treatment options have only dwindled in the recent past. One common surgical option is uterosacral ligament suspension (USLS), which is typically performed by affixing the vaginal vault to the uterosacral ligament in the pelvis. This repair has a lower incidence of complications compared to those with mesh augmentation, but is notable for a relatively high failure rate of up to 40%. Considering the lack of standard animal models to study pelvic floor dysfunction, there is an urgent clinical need for innovation in this field with a focus on developing cost-effective and accessible animal models. In this manuscript, we describe a rat model of USLS involving a complete hysterectomy followed by fixation of the remaining vaginal vault to the uterosacral ligament. The goal of this model is to mimic the procedure performed on women to be able to use the model to then investigate reparative strategies that improve the mechanical integrity of the ligament attachment. Importantly, we also describe the development of an in situ tensile testing procedure to characterize interface integrity at chosen time points following surgical intervention. Overall, this model will be a useful tool for future studies that investigate treatment options for POP repair via USLS.

Pelvic organ prolapse affects millions of women worldwide and yet some common surgical interventions have failure rates as high as 40%. The lack of standard animal models to investigate this condition impedes progress. We propose the following protocol as a model for uterosacral ligament suspension and in vivo tensile testing.

Pelvic organ prolapse (POP) is a common pelvic floor disorder (PFD) with the potential to significantly impact a woman's quality of life. Approximately ...

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 ...

Surgical Closure of Equine Abdomen, Prevention, and Management of Incisional Complications

Although rarely fatal, complications of ventral midline laparotomy incision in equine patients increase hospitalization cost and duration and may jeopardize return to athletic function. Therefore, many techniques have been developed to reduce their occurrence and expedite their resolution when they occur. Our technique of celiotomy incision closure includes the use of tension sutures (vertical U mattress) of polyglactin 910 on the linea alba, which is then apposed by polyglactin 910 interrupted sutures or a simple continuous pattern suture with a stop midway before routine closure of the superficial layers. The celiotomy incision is protected by an elastic bandage during the immediate postoperative period. This technique has been associated with favorable results: 5.3% confirmed incisional infections after a single celiotomy and 26.7% after repeat celiotomy. The overall incisional complication (serous/sanguineous discharge, hematoma, infection, hernia formation, and complete wound breakdown) occurrence was 9.5% and 33.3% after single and repeat laparotomy, respectively. In cases considered more susceptible to infection (early relaparotomy or laparotomy incisions longer than 30 cm), negative pressure therapy was found easy to apply on closed incisions. No detrimental effects were observed. However, the potential prophylactic benefit of this therapy needs to be confirmed in a larger group. In infected laparotomy wounds requiring drainage, the use of negative pressure therapy seemed to have a positive effect on the formation of granulation tissue. However, there was no control group to allow statistical confirmation. Finally, one case of complete breakdown of the laparotomy incision was managed by stainless steel retention sutures, the application of negative pressure therapy, and a hernia belt. At re-evaluation 15 months post-surgery, several small hernias were detected, but the horse had returned to his previous level of sports performance and had not shown any episode of colic.

This paper describes a method of abdominal wall closure using tension and apposition sutures in horses undergoing ventral midline laparotomies. It also describes methods for prevention and management of postoperative incisional complications, such as bandaging, negative pressure therapy, and in case of wound breakdown, the application of retention sutures.

Although rarely fatal, complications of ventral midline laparotomy incision in equine patients increase hospitalization cost and duration and may ...

Uterine-Preserving Laparoscopic Cerclage Pectopexy 

Laparoscopic Non-Mesh Cerclage Pectopexy with Uterine Preservation for Pelvic Organ Prolapse

Pelvic organ prolapse (POP) affects millions of women globally and carries a significant socioeconomic burden. Adequate apical support is essential for treating POP. Recent research has increasingly validated the efficacy and safety of laparoscopic pectopexy (LP) for addressing apical POP. However, the cost of synthetic mesh and associated complications restrict the widespread use of this technique. Our team previously published a study describing a novel, non-mesh procedure called laparoscopic non-mesh cerclage pectopexy (LNMCP), demonstrating successful outcomes with satisfactory objective and subjective success rates. Many patients express a preference for retaining their uterus during prolapse surgery due to considerations related to sexuality, partnership, and body image. 
The present research introduces a novel approach known as laparoscopic non-mesh cerclage pectopexy with uterine preservation (LNMCPUP) for POP, wherein the uterus is suspended to the iliopectineal ligament through the round ligament using permanent cerclage sutures. We successfully performed this procedure in 14 cases at our hospital, six of whom still had menstruation, and the remaining eight were postmenopausal, with a mean operation time of 54.43 min (&plusmn; 10.18 min) and an average bleeding volume of 53.57 mL (&plusmn; 48.77 mL). The mean follow-up duration was 19.71 &plusmn; 15.87 months. The objective success rate of LNMCPUP was 100%, with a subjective success rate of 92.86%. No significant complications were observed during or after surgery. LNMCPUP integrates cervical cerclage and shortening of the round ligament, as well as LP without using mesh, thereby eliminating the risk of mesh erosion and lowering healthcare costs. Moreover, this novel technique is relatively easy to master, making it accessible even in rural and underdeveloped areas where synthetic mesh is unavailable. Therefore, it is worthwhile to adopt LNMCPUP in POP patients who desire the preservation of their uterus.

Author Spotlight: Advancing Pelvic Prolapse Treatment with a Non-Mesh Approach using Laparoscopic Pectopexy

Here we introduce a novel approach known as laparoscopic non-mesh cerclage pectopexy with uterine preservation for pelvic organ prolapse (LNMCPUP) for patients who wish to preserve their uterus. Permanent cerclage sutures are used to suspend the uterus to the iliopectineal ligament through the round ligament.

Pelvic organ prolapse (POP) affects millions of women globally and carries a significant socioeconomic burden. Adequate apical support is essential for ...