CAMPBELL

Hello, Professor Campbell, can you hear us?

Yes, I hear you.

Good afternoon from Rome. On behalf of Professor Palazzini, we thank you to participate and show us your procedure. Thanks very much.

Thank you very much. It's a privilege to transmit this case to you.

What is it about?

well we are in the we are in a position to give you an internal view now so um alan you can we

have further proctogram images if that's of interest so if you ask us at some point in the

case we can go back to the uh the radiology images yes yes maybe prof for interest of everybody in

the venue thanks okay so you have an internal image now yeah okay so yes internal image is

very clear the pelvis so what we what we have is we have a telescope set on the right hand side of

the abdomen we've got a 10 millimeter port um in the right suprapubic region and a five millimeter

port um just to the left of the umbilicus we've used protax to pitch the sigmoid colon up to keep

it out of our way so we have a nice view into the pelvis the small bowel is stacked up in the upper

abdomen and up here we have um hitched the uterus up with a single proline stitch so that's our

operative setup you can see the ureter vermiculating on the right hand side and you can see the sacral

promontory there so these are our various landmarks so we'll start the dissection by exposing

the sacral promontory to which we're going to fix our mesh and then we'll open up the rectovaginal

septum. So can I have the hook please now and some diathermy attached up. Okay so we just use a simple

monopolar diathermy dissection for these cases. We use a hook with a slight modification. It has a

suction channel, and we just remove that suction channel

so that we can evacuate smoke, particularly when we

get down to the pelvis.

So we're going to open up the peritoneum to accommodate a mesh.

There's our promontory, which is very clear here.

There's our ureter that we want to avoid. This is an unusually

slim patient for Dundee and for the United Kingdom.

them, but hopefully that will make some of the anatomy a bit clearer.

Prof, we were just commenting on how it's the view.

I can see the vermiculation of the ureter on the right side.

Yes.

It makes sense, right?

Yes, that's good.

Yeah.

We're not always as fortunate as to see it as clearly as that, but no, that's what's

going to help.

In the Congress case.

Well, to an extent, yes.

The benefit of this procedure is avoiding the posterior rectal dissection, which we

We know it denervates the rectum, so we'll make sure that we stay away,

we stay laterally, and don't go posterior and don't dig in underneath the rectum.

Our mesh is going to be attached onto the promontory here.

We don't need a great deal of space, we just need enough space

to be able to tack the mesh on at this point,

and then we'll open up a bit of space to accommodate our mesh.

Okay, and we're going to move fairly quickly down towards the rectovaginal region.

I think the next step is to open up the rectovaginal septum.

So at this point, we're going to place a vaginal retractor in.

We use a Kelly retractor, a bit of gel.

And for this case, we need two surgeons and we need an assistant who's going to sit between the patient's legs,

holding the vagina up and out of our way.

And that's very important.

We have Claire, a fifth-year medical student here in Dundee, who's going to perform that task for us.

We're just waiting for some lubricating gel before we put the retractor in.

She's a patient who's not had previous hysterectomy.

Many of these patients have, and she hasn't had previous gynecological surgery either, which many of them have.

Some of the more difficult cases have had previous rectifexia, previous STAR procedures.

procedures, but we're fortunate on a Friday afternoon not to be doing a case like that.

So I'm just going to place this retractor into the vagina, and you can see that that

will elongate the vagina and lift it upwards. And that's what Claire is going to do for

us now. So Claire, you're going to both keep the retractor pushed in. Now, hang on, let

me just take it in. If you look on the screen, what you're doing, when you push it in and

and push it, yeah, push in and up, so you see that movement, so you've got two movements,

pushing the retractor in at the bottom and pulling it back towards you, okay, this is

very clear, that's good, okay, so we're going to just, yeah, just like that for the moment,

now I'm just going to move this retractor a little bit more, yeah, that's it, yeah, just

just there. That's fine. So this is the critical part of the dissection, really, which is to

open up the rectovaginal septum. So we want to place traction on this and get into the

avascular plane that should exist between these two. Consultant colleague, Doron Zai,

will keep me right throughout this and tell me when I'm doing something wrong. You can

see the retractor just slipped a little bit there. You can see the wide pouch of Douglas

that these patients always have, particularly if they've

got a full rectal prolapse.

I think this lady has a degree of entrocele as well,

which we could demonstrate to you, perhaps,

on the proctogram at some stage in the case.

Yes, it would be interesting to see the pre-op images.

And I don't know, Dorn, if this lady had an exam

under anesthetic as well as part of her workup.

Sometimes we do an exam under anaesthesia if the proctogram is unclear or the patient's symptoms or examination with the aid of ultrasound in the outpatient setting hasn't helped.

This is all a Blundock session with the heel of the hook?

Yes, yes, just small, very small movements.

I don't think an energised device helps here really.

It's not the expense.

I think it really, I actually do all my pelvic dissection for cancer and with the hook.

I think it's still the most precise instrument.

I'm much more certain that I'm opening up a genuine plane and not creating a plane with ultrasound.

And you can see the rectum there.

What I will have handy is a pair of size 8 1⁄2 gloves so we can do an examination shortly.

But it is very, very small, slow movements, which I find the most useful.

Any comments, Doran, about progress?

How far do you go with your dissection of the rectum and of D?

We will be going down, as far as we can really, down to the intersyncteric plane.

This lady has a rectocele, and that rectocele will most likely extend right down.

down. So if we don't take our dissection, take our mesh down, she'll recur underneath

the mesh. So it's vital that we get the mesh right down to the intersphincteric plane.

In these women with short sphincters, the dissection will be just a couple of centimeters

or so from the anal verge. It will be very low down. So we just go fairly slowly. If

If we get bleeding, it will obscure the plane

and make this very much more difficult.

So it's better to go slow and avoid bleeding.

In some patients, it's surprisingly quickly

how soon you reach down to your point of dissection.

If you go too far, you start encountering bleeding.

So I think I might, just to gauge my progress,

I might do a rectal examination at this point.

Eight and a half blocks.

Is your system going to do this rectal exploration or yourself?

I'm going to do this myself, I think that's the best approach.

So I'm putting another glove on.

I can reach down and I'm going to just put my own finger into the rectum here now.

Okay, now that's fine.

I can now do a bimanual palpation with my hook and that's the tip of my finger there.

there. Now I will show you in a minute how far in. My finger is in as far as the first

joint of my finger. So my finger's in about two centimetres and I'm touching my own hook

here. So we are just about at the intersphinctaric plane. I don't think there's a great deal

more dissection to do. I can take my finger out and we can perhaps just show you where

and my finger, that's how far my finger is.

Yeah, a couple of centimeters, yes.

So I'm going to change my glove,

and I just have to ditch that down there for just now.

Okay, thank you.

So I think the length of dissection

is probably fairly reasonable.

We just need to tidy things up,

and what we need to do is be able to see

the rectal wall for placing our mesh.

Let's come in just a little bit.

it. So the purpose of dissection is to reach that point but make enough space to accommodate

the mesh. Okay, I'm just going to do a little bit more dissection perhaps here. We'll use

in addition, can we have a rectal sound? We'll use a sound or a dilator in the rectum to

guide our stitching. We're just creating a little space for ourselves really. You agree

Jorn would you go any further down to appreciate how meticulous you are in a

bloodless surgical field yes I mean if you get bleeding it just makes

everything take twice as long so I think if you if you rush and become impatient

you will take longer to do the case so I think you just learn by experience that

if you go slowly and avoid bleeding then you will be quicker in there also we've

come to realize that if you just do get a lot of bleeding it means you're probably in the wrong

place it means you're too lateral or that you've gone too far you're in the interesting teric plane

which will bleed if you if you go too far down into it okay so i think we will be able to plug

our mesh in on either side there do you have a mesh open now what kind of mesh are you going to

insert well that that's that's a very interesting question that causes a lot of debate

bait. We've been very clear in our approach to this and that we use no synthetic meshes

at all. We use a biological mesh. We use porcine dermis, permacol, and it's a specific mesh

which is just the right size. It's an 18 centimetres by 4 centimetres, one millimetre

thick mesh. There's a one and a half millimeter thick, but that is actually cumbersome to

use, difficult to stitch. The biologic mesh is more difficult to stitch, but I think there

you can see the intersphincteric interface there quite nicely. That white line running

across there, there's the rectal wall, that's the intersphincteric space, that's the lateral

wall of rectum there or inner rectum and we might just tidy up this lateral wall

on this side a tiny little bit thank you very much said professor Campbell that

the your mesh is a standard size this is a regardless of the size of

constitution and pelvis of the patient yes you're right I mean in no size no

mesh can fit everyone perfectly but we find almost always the time that is a

is a good size. The length, you know, doesn't matter quite so much. That's usually more

than long enough. The width, if it overlaps a little bit on either side, that's not going

to matter hugely. This is quite a small patient, so it might be slightly larger than necessary

for this lady, but that doesn't seem to matter. So I can see clearly where I'm going to place

my stitches on either side here. So I think the next step is to come back out, join up

our peritoneal and dissection just so that we can accommodate the mesh and I

find doing it in these two stages helps me it's once I've done the lower

dissection I can tell just exactly where I'm going to place the mesh I don't know

what you do Doran do you do it in two pieces in two stages yeah so we just we

don't want to do excessive dissection but just enough so we can close the

the peritoneum over the mesh.

So I wouldn't do any more at this stage.

We can always come back and dissect a little more

if we need to.

OK.

Can you give me a net cell now, and a grasper, please?

This is just a tampon we've used for many years in Dundee now.

It's much better than a swab.

It just absorbs any blood there.

there and just despite our care, there's a little bit of blood.

Looks like a tampon that you put for an abestacosis, isn't it?

That's exactly what it is.

We've stolen it from the ear, nose and throat surgeons.

It goes down the ten port nicely and there isn't a great deal of blood here

but if it fills up with blood, you can put a suction onto it.

You can suck it dry again and recycle it.

It's a very useful piece of equipment.

equipment. You can use it, sometimes we use it if the small bowel, just back up a little,

some of the small bowels and the way we can use it just as a barrier to stop the small bowel

falling down on top of it. So it's very useful. We use it for all our cancer patients and for

a great many laparoscopic procedures. Okay, so now we have our sacral promontory

here. That's where the mesh is going to attach. We have a peritoneal pocket to place our mesh into.

and we have our dissection completed down to the pelvic floor.

Now, to deal with an introseal, which this lady has,

we want to shorten the pouch of Douglas,

so I'm going to resect some of this excessive peritoneum here

so that when we close the peritoneum,

this pouch of Douglas will be higher and broader,

so there won't be this propensity for the small bowel

to come all the way down here and potentially impinge on the rectum

and interfere with its emptying.

So this is what we're doing as a component of this procedure

to address an enterocele.

Of course, this must be quite floppy,

and I'm sure it's not going to be under tension.

Yeah.

So we're going to just excise some of this peritoneum,

and this lady does have an enterocele.

I'm not sure if our images will make it documentable for you.

Do you think the next image on the screen shows the entraceal reasonably done?

I'm not sure.

What we can do is we can...

Is Alan here?

Yeah, okay.

While we get the mesh ready, we could show you the images of the entraceal.

But you can imagine if we excise this piece of peritoneum,

and then when we suture all of this together,

it will have obliterated the deep pouch of Douglas,

which is the problem with the entraceal.

So it'll be a mixture of this peritoneum, which we excise,

and the suturing up.

That's a reasonable excision, you think, Dorn?

Yes, the rectum's in danger here.

These rectums are floppy and you can pull them up

into your excision if you're careless at this point.

Another grasper, please.

Okay, so we're going to excise that portion of peritoneum

and just extract it.

That's good.

Okay, now, do you have the mesh ready?

Okay.

No, it's fine.

What we can do, maybe the best view we would have

have would be with your laparoscopic view, Dorn.

So what we'll do is we'll show you our mesh.

This is our 18 by 4 centimeter permacol mesh.

I can open it.

That's the mesh there, a marker pen.

So what I do with this is I mark it about 4 centimeters up,

which is there.

And I make a line across the mesh with a marker.

That's fine.

and you'll see why we do that just in a minute or two and so we're going to put

the mesh inside that goes down a little millimeter port really quite easily okay

so we'll go back inside okay and you can see that mesh extends up to the the

promontory very easily in this case the line is a good tip to have a good

the rotation so the mesh doesn't twist well there's that element of it and also

when we tack the mesh up we'll pull it up now if we tack the mesh right at the end here and then

pull it up and do this there'll be a space and that's the space into which a recurrent rectus

seal will come so what we're going to do is overlap deliberately we're going to place the

mesh like that so that when we pull up the mesh that mesh will then flop down and fill the space

is that clear yes very big yeah so that's what why we do that okay now i'll just line things up a

little bit here all right that's fine so let's have the first stitch please now we can take that

hook out of here so the next stage we just need a bit of coordination and we'll be following the

same pattern repeatedly so we work as a team you know at full length so that's

fine so we use a full length suture what are we using there's this ethic bond or

yeah so if the bond we're using today yeah so here's an ethic bond suture so

for suturing the mesh to the rectum we use a non-absorbable suture problems

that have arisen with this procedure in our view relate to using synthetic mesh

of the rectum. There's very little space down here, but what we need to do is make sure

that we are getting rectal wall. We're getting a good thickness of rectal wall. Some of these

sutures will be full thickness. Just pull back a little bit, Darren. Do you think we've

got a good bite there? Yeah. Okay. So we'll get a decent bite there. I'm not totally certain

It's gone into perirectal fat, so I'll actually take another bite.

Sometimes we place a rectal sound in just because we've got nice views in this thin patient.

This is a full thickness bite, eh?

It's a full thickness bite.

Now, everyone finds that of great concern, and we did also,

but the data on this procedure, which has been done many times now,

now, does reassure you that this doesn't matter.

I don't think all of these bites are entering the lumen.

So mesh, oh yeah, sorry.

Yes, I've distracted myself by not, yeah.

So many of these bites don't enter the lumen.

But counterintuitively, taking full thickness bites

of the rectum and placing a mesh doesn't

seem to matter as much as we at first thought it would do.

And that applies to the synthetic meshes as well.

Wow. Okay. So what we're going to do is take a bite at our marked line.

Yeah. Now this is where the biologic mesh is a little awkward

because getting a suture through it can be difficult.

I'm not doing a good job of it here.

You can sometimes try and aim for the holes, but it's a thick mesh

and it just doesn't take the suture particularly easily.

Often it's difficult to get the whole profile.

Yeah, it's difficult.

Sometimes it goes there quite nicely.

Okay, now, we have caused something of a problem here.

Let me just tidy this up.

Support the mesh in place.

These two sutures are always the most awkward.

Okay, all right.

Now, if you can cut that off right there.

Give me an artery clip now, not to push her.

can I have a light on this

just an external light on there

so because we're going to suture a lot

between the mesh

between closing the peritoneum

we're going to use an external knotting technique

just for speed of delivery really

and just because it is undoubtedly awkward

to suture right down

inside the pelvis okay so this is just expedient really this number of times

so I've lost the end of the suture grasp her please and just came out of my grasp

and said we just not quite got our coordination going there we put five

throws on and once we have a routine going this is relatively quick this is

This is the longest part then, because giving five throws each stitch takes quite a while.

It takes a while, yes. Can we have an endo-shear please, and a stitch that will...

I need a... yeah, that's fine.

Okay, good, next stitch please.

What distance in between the stitches?

Well, a centimeter or so.

We sort of gauge it patient by patient.

We don't have a set number of stitches,

but it's whatever you know seems to be right at the time so this time we go

through the mesh first of all if we can find a hole like that that makes it

easier yeah so you can see these are the

Quisit said dermis there are hair follicle holes so if you can find a hole

that's convenient and that makes it a little easier so and then this is going

going to, and there you are, there's our intersphincteric space, another full thickness bite of the

rectum, nice and low down, just support the mesh back into position, and up again, so

clip and cut, please, clip here, and cut, that's it, and we can hopefully get our routine

it's important to use a reusable, disposable scissors for this, because you get a very

good clean cut. Okay, next stitch, please. So this is just a series of sutures, so it'll

be a little bit repetitive. So, okay, so because I can see the rectal wall here, we're not

using a rectal sign. I don't know if you think we should, Dorn, or not. Yeah, so it's another

We can see if it's possible to do this in one bite, it's sometimes possible.

We try to have the mesh nice and flat, it doesn't really matter if it's a little folded

it up, that has no real bearing on the outcome. It just, as a surgeon, you want it to look

a little aesthetically more pleasing. So clip and cut again. I think the, another clip please.

The surgeons who do this in the UK are probably split between the groups who use a synthetic

mesh and those who use a biologic mesh such as this. Those who use a synthetic mesh feel

there's less likelihood of recurrence with a synthetic mesh, but it is accepted there

is an incidence of mesh erosion, and mesh erosion is an extremely serious problem, and

as I'm sure you're aware, the experience with gynecologic meshes has come under a great

deal of litigation, and I think we're much more comfortable just steering clear of synthetic

meshes altogether accepting that maybe in the long term the recurrence rate may

be higher but we feel more comfortable dealing with a recurrence of these

problems than with the really potentially devastating problem of mesh

erosion in case in how long will you have a recurrence with a biological mesh

and if it is a repeatable operation of course the same procedure yes yes it is

yes I think you can repeat this we we haven't yet had to repeat a ventral mesh

rectopexy we've we've performed ventral mesh rectopexy on patients previously

having had posterior rectopexy or posterior resection rectopexy which was

the previous approach we had to this so we have repeated it in those

circumstances but not yet unless have you repeated a ventral menstruate

defects you know we're not yeah but admit that's not long-term experience

yet he no longer in case would you expect and in erosion and what are the

was the clinical presentation a when would erosion occur yes you would

longer you would expect well the presentation can be varied the mesh can erode and migrate

into rectum or into vagina or elsewhere the the the time scale of that's a very good problem it

can be many years later so I think one of the sort of concerns that you might have with your

your non-biologic meshes is that in five, ten years' time, you may be dealing with

a great many problems with mesh erosion. And these will very likely be problems with

litigation. This is a benign condition. Particularly if you have migration mesh erosion into the

vagina, you can have dyspareunia. And if you're dealing with a population who are sexually

active starting with a benign disease they're going to be very upset and

that's what's happened in with the gynecological meshes in the United

States and litigation is now an absolutely huge issue in the

gynecological field and companies have withdrawn their meshes and have set

aside billions of dollars to settle potential litigation claims over the

the next few years. And our patients do ask about mesh, and we're able to reassure them

that we will be leaving no permanent mesh inside them. This mesh will be absorbed completely

and integrated into their own tissues.

Of course, there is a consent from the patient, and the patient is going to be put aware of

possible complications.

Do we discuss the complications beforehand?

Yes.

Yes, we do. I mean, the problems that these patients need to know about are potential for dyspareunia because we generally, it's not one component that we're dealing with here. We're dealing with an intracellular repair. Usually, we'll put some stitching into the back of the vagina, and that is a potential for dyspareunia.

so what I'm going to do at this stage is

because I have the mesh now to deliver traction

I can deliver traction now in a way I couldn't do before

and this allows me to get a deeper stitch now

so you see I'm pulling on the mesh

this is pulling the rectum up towards me

to allow me to get a nice distal stitch into position

so I think that's my routine

certainly with this procedure

is to put these four stitches in

and then get a stitch right down here.

Sorry, I've let go of the mesh.

Also, stretching at this point

makes it easier to go through with the needle.

Yes, it does.

So that's now my distal stitch.

And you can see we've gained a centimetre or so

of distal length just by that manoeuvre.

And I'm just going to bring this back through the mesh.

And then when we pull that up,

but we're still going to have an overlap down there at the bottom.

Okay, clip and cut again there.

Ah, okay.

Yeah.

So Luca, welcome.

We've been joined by our newly appointed fellow, Luca Bonomo,

who speaks Italian.

So if there is anyone who wants to ask a question

and have it explained in a way that I haven't done,

then you're very welcome to to do so thanks but anyway we have translators anyway ciao to luca

Luca, how are you? Where are you from?

I'm originally from Pescara, Abruzzese.

Mountain or sea?

Sea, sea, Abruzzese, Pescara.

Very good, good job.

with that distal stitch again.

You can see our intersphincteric septum very nicely there.

And that just lets us get a nice, full thickness

distal stitch.

I think the full thickness stitch is important,

because if the mesh is not convincingly applied

to the rectum, it's not going to hold.

So I think that distal stitch is necessary.

You're not going to have a headache because the mesh is not perfectly flattened, isn't it?

No, there's no problem with that at all. It's aesthetically you try to do that.

And we'll see in the end how well I succeed, but it makes no real difference.

The important thing is that the mesh is sitting without tension, but it's not bow-stringed because it's biological.

biological. Cuts and clips, please. Clip and cut, thank you.

Looks like a piece of skin, this mesh.

Yes, it is. Exactly, that's what it is. It's porcine pig dermis

that's been treated. This is a cross-linked mesh, so it will last

longer

before it has been absorbed.

Now, there are other meshes which are not

cross-linked and they will absorb faster however there's a real debate between

these manufacturers as to the speed of absorption versus the speed of tissue

incorporation so there's obviously a perfect there's a perfect length of time

and are in perfect balance between tissue incorporation and absorption and

and if you have the mesh absorbed

before there has been incorporation

then obviously that will be an unstable situation

so the cross-linked, this mesh will probably be around

for, if I understand correctly, about 12 months

I think is what they quote

if there's any infection

or bile spillage or so on

we know now it doesn't really work in these situations

but here in a stable, non-infected situation

situation. It's a problem. So aesthetically I'm upset now because my mesh has sort of

wrinkled, but I don't think that's really an issue. It's secure. The bites are good

quality. I'll give you that back. And that may straighten out a little bit when we pull

up.

Yeah. Okay. So let me just come back up and get the net cell just to tidy up a little

bit there. We'll get our planchette just to mop up some of that bleeding. And now this

is the point where we need to use some judgment and decide how many other sutures we put in.

Doran, what would your suggestion be for the next stitch? Would you tack it at this point?

Yeah. Okay. Yeah. Yeah, might do. I mean, we've got three sutures in, so six sutures

in total now. We have to consider what happens on the lateral side here, but that peritoneum

is going to close over there quite easily. Would we put another stitch onto the rectum

there? Feels like we should be putting a stitch there, do you think? Do you agree? So we're

debating about stitch placement. Yeah, so I think that looks as if that wants to go

go there. Okay. Okay, Luca, no, I appreciate that. Thank you very much. Okay, thank you, Luca.

what we'll need for the vaginal stitch is PDS, isn't it? Yeah. Okay, give you that back.

Another stitch, please. Okay, so the debate really is, I think, do we put another stitch

stitch on the other side or will we tack it at this point? I might be tempted to tack

it, I think. Yeah, yeah, okay. So, give you the stitch back. Let's just mop up a little

Okay, so we're going to tack our mesh into place on the promontory now. That's our promontory

there agree right there around the corner there okay so we're gonna yeah so we've got the mesh

okay so all right so this is now ready to tack and i think we want to look at the curve

we don't want this to be a straight line coming up we wanted to sit adjacent to the tissue so

that incorporation can occur but we want it to act to suspend rather than to pull up okay

Okay, so let me just sweep that aside a little bit.

Okay, so routinely five.

That's good.

The sticks are sitting right on the promontorium.

Yes, or just on the inferior border, a little bit inferior.

Just around, not up at the very top, but the nerve injury,

the nerves, if you're just distally and around the corner a little bit,

I think that's best.

test. So we've had one complication that we need to report, which is a discitis, presumably

related in some way to the tacks going into the disc. Okay, so next we have to really

figure out if we need any more sutures. Here, Dawn, I'm not totally certain if we do. Would

over to over to here okay so you would you would put another stitch where off to the right there

yeah actually that's i think she's i think she's quite small to be honest i i yeah i yeah i i think

i would i don't think i don't think i'll put any more sutures into the rectum in this case

so I think the next step would be whether we suture the back of vagina a little bit was that

the intention with this case or not the other argument for a suture up here is in terms of

of preventing anything sliding down behind again?

Yes, I think it would be nice to have a little bit of space.

So we're debating suturing anymore.

I think our plan would be not to suture anymore to the rectum.

I think there's sufficient fixation on the rectum now.

What we are going to do is place a suture between back wall

of the vagina and the mesh, which will both help to lift up

the vault or the uterus and also obliterate that space and prevent any

bowels sliding down into that into that gap okay so the PDS suture now no we're

not the V lock no just a Peter to PDS we give the camera slight clean as well so

so we're gonna clean our camera what was the reason on to put again they were

general tractor the sorry can you repeat the question what was the reason why did

the maneuver to put back again the vaginal retractor what reason yes yes it can slide

back i mean it's a difficult job for the assistant who has to stay still for a prolonged period so

the retractor can slip a little bit what we're going to do next is suture back of the vagina

to the mesh and we're debating the the need for that and the the need comes particularly

in patients who've got a uterine or vault

prolapse

but it is part

of the procedure as it was described really

by

Duhur

and what it does also is obliterate

that space and prevent

potentially recurrent enterosil

or loops of bowel going down

in between the vagina

and the rectum so it will be a

further reinforcement of the

enterosil repair

so that's going to be the next

step so we'll get a nice view of that using our 30 degree max on we do yeah so we yeah and I think

sorry we're just waiting for a suture to to come but you can see that that is more than enough

overlap down there you could say it's a little excessive I think probably a three centimeter in

this case would have done because she's so small okay that's fine yeah go away so so change of

suture material because we want to avoid an absorbable suture on the back of the vagina

a lot of the erosions that have occurred gynecologically have actually been suture

erosions rather than mesh erosions and those have come from uh non-absorbable

material for the for the suture okay so we're going to take a suture on the back

of the vagina oops needle is not being gripped well it's actually just slipped

and this is a throw-and-throw stitcher yes yeah but it's absorbable I think

that's very important important here it's back wall of the vagina now what we

we do now is we're going to drop the retractor and take the tension off now so we can see

where this is going to fit and that's going to just sit just about there, so I'll take

a bite of the mesh, again difficult just with this particular type of mesh, it's difficult

to get a nice bite but the disadvantage of the biologic mesh is just this difficulty

getting a stitch through it sometimes. That's it, so we'll take that out, we'll clean the

camera as well to give you a better view okay clip and cut and we'll have a second of these sutures

cut the other side other side yeah put others in there that's good okay we better stick with

to stitch with keep the wide view i think down two throws on that you can distract them two

two throws on that. How irritating is that? You see that? I think I was in the talking

and put two throws on it. That's quite a, okay, a lot of stitch there. There's not much

not as nice as PDS for this. PDS, you'd probably got that to slide down. We'll just make that

That actually doesn't run at all well. We should have that suture material on the tray

as they might not better in terms of number of throws. We'll probably get off at five

So, are you okay there?

Yeah.

So one more stitch on the back wall of the vagina.

Knot pusher now.

You've got to stay miles away from the knot.

It gets, come in nicely there.

Okay, it looks it's reasonably well fixed to the back of the vagina now.

Okay, not push her back. Okay, that's good. So next up will be the V-lock more or less. Okay, so I think we can pull back and let that drop down. And it's under a tiny bit of tension, I suppose, but it's not too bad. We can close that peritoneum fairly well there. Just hold that fairly gently there.

Can we just have a bit of irrigation attached to it and start the V-lock meantime?

Before we close the peritoneum, I probably would just V-lock it.

All right, okay, take the V-lock suture.

Yeah, I'll do it, yeah, that's fine.

Might as well, yeah.

Okay, so we're going to close the peritoneum next.

We're going to use this V-lock suture.

Yeah, yeah, good point. We'll get that out shortly.

So do you start laterally with this, or do you start in the middle?

Do you start in the middle? Okay, yeah, I'll give that a try.

Any drain, Professor Campbell?

So now we're going to close the peritoneum.

I think we've sutured the mesh to the back of the vagina,

and we've obliterated that space, and I think we're pretty much done.

done, just look down again, that's the mesh fixed to the promontory, just take the vaginal

retractor out just a little bit now, so you can see that's the fixation to the back of

the vagina, you can see that that vagina is going to be pulled up there, so now we're

just going to close the peritoneum over the mesh, and that will be the procedure done,

and when you come back and see this pouch of Douglas, just hang on to that, it's going

going to be much, much shorter and brought up much higher up towards the pelvic brim.

The new Pouch of Douglas will be across there. So we're going to use a continuous suture.

This is V-lock. It's just a convenient way to close the peritoneum. You can see the little

barbs on the suture for anyone in the audience who hasn't seen it, which means that once

Once you put it through the tissue, it locks.

You don't need to have an assistant continuously

placing tension for you.

So we can just close this peritoneum up.

I think it's the skin of seal, if I'm not mistaken,

the V-lock.

It's the skin of seal, I think.

Well, it was developed for plastic surgery to avoid knots.

So you could have these very fine suture materials

with no knot but it's started to find application in a lot of other in a lot

of other situations I think we we used it first in 2010 I think we didn't ever

report that but a lot of people started using it and since they are certainly in

the UK so it's a very useful it's actually very useful for bowel

bowel anastomosis as well. We've used it for suturing bowel, suturing bladder, any laparoscopic

suture. You see, once I pull this through and there's tension on it, it's locked. You

see, it holds itself automatically. So it's very useful for this type of continuous...

Also for intradermic suturing.

Yes, so it started for plastics, plastic surgery, skin suturing, cosmetic surgery, but all sorts

of uses now emerging for it.

Prof Campbell, if I remember correctly, you said you've done a series of five.

What is the follow-up so far?

A series of?

Five of these cases, if I'm not mistaken.

No, 70.

Oh, 70, sorry, but it is.

Yeah, 7-0.

Okay.

Doran, you know that.

We have a three-and-a-half-year follow-up, the longest follow-up.

I mean, what's the longest follow-up in the literature now, Doran, to yours?

Yeah, yeah.

Yeah, so there's approaching 10-year follow-up across Europe, experience-wise,

and our data seems to follow the good results that others have seen.

We've got our irrigation system attached at the moment,

so I'm just going to wash out the pelvis just before we finish that peritoneal closure.

So, yeah, we will remember to take the nettle out.

Yes, we're being reminded to.

so this would be typical of our indication

which is obstructive defecation

as opposed to full thickness rectal prolapse

and these patients

do seem to do very well with that indication

and I think we believe

this is because it addresses not

just rectal interception

or prolapse which is one component

it addresses the rectocele

it addresses the entrocele

it lifts up the pelvic

floor, it's lifting up the uterus

and the patients are very very

satisfied because it addresses a whole number of concerns and it seems to

address concerns which they didn't necessarily talk about initially. Their

sexual function seems to be better it just seems to address things much better

than a posterior rectopexy or a simple targeted intracellular repair. How long is the

hospice stay in average? Generally they go home the second day so two

nights. Some of them are ready to go the first day. But I think the impact is not so much

the surgery. They've got a mesh in. Sometimes their bladder function gets a little bit disrupted.

So we leave a urinary catheter in for several hours, maybe overnight. It depends on their

their age. This lady is fairly young and fit, so she may go home tomorrow, but the average

would be the second night. So it's very well tolerated. We've done a number of elderly

patients. I'm not quite sure how old the oldest would be, but patients into their 70s, 86,

86, yeah, 86, 82, so yeah, yeah, we have some young patients too, but it's very much a debate

now, if you have full thickness rectal prolapse in an elderly patient, you know, do you do

a perineal procedure, which might be somewhat easy to tolerate, but you know, if they're

going to live for the next five years, their recurrence from a perineal procedure is going

going to be very high, approaching 20%, whereas with this procedure the recurrence rate is

less than 5%. We've not yet had a recurrence of full thickness prolapse when doing it for

prolapse. So the results are very good. The functional outcome in rectal prolapse compared

to posterior rectoprexy is hugely better. You avoid all the problems with constipation

that these patients have, it seems to restore continence when that has been an initial problem

just as well. So we found it an extremely useful procedure which we're doing more and

that we need to do now is to push this mesh over to protect the tacks.

You leave the mesh folded at this stage on purpose?

Yeah, so that's deliberately to protect the protacks.

The protacks are pretty dangerous, these metal tacks.

They're the best thing for fixing onto the sacral promontory,

but otherwise they're quite vicious and sharp.

So we like to just fold that mesh over the top and have a double layer of protection on the protacks in case they were to push their way through the peritoneum.

So try to avoid using them.

Incisional hernias, we've tried to move to absorb attack or secure strap and stay away from the metal clips.

Oh, it's coming back out again.

Once you get a couple of stitches beyond it, it should be fine.

and there are 7,000 other surgeons connected on the web.

Yes, that's a fantastic meeting actually.

I think that's a great credit to the organizers.

It's been a pleasure to connect with you.

I think we're just about finished.

I think, one more stitch, and we will remember to take our tacks out, which we tacked up

the rectum with at the beginning, and we'll take the net-sew device out.

But I thought we'd finished, but I see another, just a small area here that I would like to

close a little bit further.

We just take it through the loop.

I'm not sure if that's necessary, but it just feels as if it's the right thing to do.

that's it so the nice thing about the v-lock is that you don't need to do any suturing it

will just hold itself there so if we look at our pouch of Douglas now it's very much

and reduced in size I'm just taking you don't yeah that's good we'll take our net so I take

down give you that back just check there's no bleeding from the stitch holes there

to do it are we still connected alan or was that yes yes oh sorry okay so just in terms of after

care we put all these patients on to stool softening medication for the next

four weeks and advise them to avoid strenuous lifting and they also have to

avoid vaginal intercourse for the four week period and we ask them just to stay

on the stool softening medication lactulose or something of that sort to

to avoid any straining at stool, which might potentially dislodge the mesh.

Also for pregnancy, how long do we advise to wait after the op?

12 months, we would advise.

And we do warn them that if they do become pregnant,

they may well have a recurrence,

because this is going to disrupt the whole support and ligamentous structure.

So, you know, the majority of patients are completed family, but we seem to have, you know, a steady number of patients who are within childbearing age and their symptoms are so bad that they opt to have this surgery regardless.

Okay, almost there.

Okay, so I think that's all the pro-tax.

I don't think that's too big a problem.

So I think that's our final view.

Ureters has dropped down there.

I can't really demonstrate it too easily,

but when we go down and do a rectal and vaginal examination,

we should find that the rectus heel has been addressed,

and we will expect that this patient will have fairly immediate improvement

in their obstructive defecation symptoms.

symptoms, patients usually feel that their pelvic floor feels more secure right from

the start. But I think we have completed the procedure. I don't know if there are any further

questions that anyone has.

No, I don't think so. On behalf of Professor Palazzini, we thank you very much for the

the high quality of your surgery, quality of the view,

and compliments to all your staff.

And ciao to Luca.

Thank you very much.

It's been a great pleasure.

Thank you.

Thanks a lot, Prof.

Have a good night.

Bye-bye.

You too.