Modified laparoscopic lateral suspension with a five-arm mesh in pelvic organ prolapse surgery

Background Laparoscopic lateral suspension (LLS) is a laparoscopic technique used to treat pelvic organ prolapse (POP) in apical and anterior compartment defect with the use of a synthetic T-shaped mesh graft. The posterior compartment is repaired using a second mesh or a procedure along with LLS, such as posterior colporrhaphy. The aim of this study was to evaluate the clinical results of LLS for POP using a five-arm mesh instead of a T-shaped mesh graft to repair the defect of the posterior compartment in addition to the apical and anterior compartments. Methods Data from 37 patients with a diagnosis of advanced-stage (≥ 3) POP undergoing LLS with the use of a five-arm mesh were retrospectively analysed. Pre-operative and post-operative examinations and, surgical outcomes were determined. The results of measurements and examinations, reoperation rates, erosion rates, lower urinary tract symptoms, and complications were analysed. The Prolapse Quality of Life Questionnaire (P-QOL) was also used. Results The median post-operative follow-up was 20 (13–34) months. There was a significant improvement in POP-Q scores in all treated compartments, with overall objective cure rates of 94.5% for the apical compartment, 86.4% for the anterior compartment, and 91.8% for the posterior compartment. The median operative time was 96 (76–112) minutes. The median length of hospitalization was 2 (1–3) days. A significant improvement in vaginal bulge, urinary urgency, incomplete voiding, urinary frequency, and constipation was observed after surgery. The sexuality among patients increased from 13 (35.1%) preoperatively to 22 (59.4%) post-operatively. De novo stress urinary incontinence developed in 7 (18.9%) patients. The P-QOL scores improved significantly after surgery. Conclusions In advanced-stage POP patients, the posterior compartment damage can also be repaired in LLS with the use of a single five-arm mesh without the need for an additional procedure, and the recurrence rate can be reduced.

Modified Laparoscopic Lateral Suspension with A 5 Arm Mesh in Pelvic Organ Prolapse Surgery.

Background: The LLS procedure is a laparoscopic technique used to treat pelvic organ prolapse (POP), performed with a T-shaped synthetic mesh graft. The posterior compartment is repaired by using a second mesh or a second procedure like posterior colporrhaphy in the LLS procedure. In laparoscopic lateral suspension (LLS) surgery, we want to repair the defect of the posterior compartment in addition to the apical and anterior compartment by using a 5-arm mesh instead of a T-shaped synthetic mesh graft. In this study, we aim to report clinical results of surgeries performed POP repair with a 5-arm mesh.Method: Data from 37 patients who underwent LLS surgery by using a 5-arm mesh with a diagnosis of advanced stage (≥ stage 3) POP and the defect of the posterior compartment were retrospectively analyzed. The postoperative examination included grading and measurement of the POP-Q stage. Surgical outcomes were reported in pursuance of the International Urogynecological Association recommendations. The results of measurements and examinations, the reoperation rates, the erosion rates, lower urinary tract symptoms (LUTS), and complications were recorded. A p-value of < 0.05 was considered to be statistically significant.Results: There was a significant improvement in POP-Q ≤ −1 score in all treated compartments with an overall objective cure rate of 95.3% for the apical compartment, 86.1% for the anterior compartment, and 91.1% for the posterior compartment. The mean operative time was 96.27±15.81 minutes. The mean length of hospitalization was 2±0.82 days. A significant improvement was observed in symptoms of the vaginal bulge, urinary urgency, incomplete voiding, urinary frequency after surgery. Also, an improvement occurred in defecation symptoms of patients after POP repair. While 13 of the patients (35.1%) were sexually active preoperatively, this rate was determined to be 59.4% (n=22) postoperatively. De novo stress urinary incontinence developed in 7 patients (18.9%) postoperatively. The POP-related quality-of-life score (PQOL) improved significantly after surgery.Conclusion: İn advanced stage POP patients undergoing laparoscopic lateral suspension procedure using a 5-arm mesh, damaged compartments including the posterior compartment can be repaired without the need for an additional procedure and the recurrence rate can be reduced.

Application of a Meshed Skin Graft in the Surgical Bed Immediately after Resection of Neurofibrosarcoma in the Distal Limb Region of a Dog

Background: Malignant peripheral nerve sheath tumors are neurogenic neoplasms that originate from cells that surround the axons of peripheral nerves. Surgery is the treatment of choice for peripheral nerve sheath tumors. They have a better prognosis when the lesion is in the extremity of a limb and the surgeon leaves wide peripheral margins after resection. However, this procedure makes local treatment a challenge due to difficult wound healing in this region. This report describes a successful case involving the use of a meshed skin graft immediately after resection of a neurofibrosarcoma in the distal region of the radius bone of a dog.Case: A 6-year-old Boxer bitch weighing 40 kg was admitted with a history of a round, firm, non-ulcerated skin nodule attached to the lateral side of the distal region of the right radius bone, which had been present for about 40 days. Fine needle aspiration cytology of the lesion showed the presence of mesenchymal cells, suggesting a sarcoma. Thus, the decision was made for an incisional biopsy to confirm the diagnosis and for the preparation of a subdermal pattern tubular flap for subsequent rotation and transposition to close the wound that would be formed after the complete removal of the lesion. After the 7th postoperative day, the diagnosis of low-grade neurofibrosarcoma was confirmed and due to the presence of necrotic onset in the middle portion of the tubular flap, further surgical intervention was scheduled for the resection of the tube flap, en bloc removal of the neoplastic lesion with peripheral margins of 2 cm, and wound closure with a free skin graft. A mesh skin graft was made with a portion of the right flank skin. The mesh graft was carefully implanted on the recipient bed using simple interrupted sutures with a 3-0 non-absorbable monofilament suture material. A dressing made with water-based sterile lubricating solution and gauze and a modified Robert Jones bandage were applied. The patient was treated with analgesic medication, antimicrobial therapy, and gastric protectors. The first bandage and dressing were changed after 48 h, and only warm physiological solution was used. Histopathological analysis confirmed the diagnosis of low-grade neurofibrosarcoma with free surgical margins. The dressing was changed every 72 h for up to 12 postoperative days, when the immobilization was removed, and wound cleaning could be completed at home using physiological solution and a dressing with nitrofurazone ointment. Granulation tissue was first seen at day 12, and at day 30 the wound was completely closed.Discussion: The primary closure of skin defects after the resection of tumors located in the distal portion of limbs is often not possible due to a lack of adjacent skin. Thus, grafts are commonly used to repair the skin in these areas using the technique presented in this report. In order to survive, skin grafts need a vascular bed capable of allowing new blood vessel connections with the implanted skin portion. There is no consensus in the literature on the best bed for graft implantations. In the case described in this study, a free mesh graft was implanted on a fresh wound without granulation tissue, which resulted in excellent clinical evolution and total survival of the graft. Excellent clinical results were achieved with the graft, since its survival and adherence to the recipient bed occurred without complications. The clinical result of this case suggests that the application of full-thickness mesh grafts to fresh wounds in distal limbs immediately after tumor resection is a good alternative when the surgical wound is too large (which prevents primary closure). Good preoperative planning associated with good surgical techniques and adequate postoperative management are essential for the success of the technique under these conditions.

Chronic abdominal pain after laparoscopic hernia repair due to mesh graft migration to the cecum: a case report

Background Hernia repair with mesh graft is one of the most common procedures in general surgery. Mesh graft repair is the treatment of choice for umbilical and periumbilical hernias to minimize recurrence. One of the rare but serious complications is mesh graft migration to viscus. These complications can occur months to years after repair and their diagnosis can be challenging as they may present as vague abdominal pain only. Case presentation A 74-year-old gentleman with multiple medical comorbidities was diagnosed with a para-umbilical hernia after which he underwent a laparoscopic hernia repair at our hospital using a mesh graft with no complications. On postoperative day 10, he presented to the emergency room (ER) complaining of colicky abdominal pain in the right iliac fossa for 1 day associated with diarrhea. A Computed Tomography (CT) scan of the abdomen and pelvis showed diffuse wall thickening of the cecum and terminal ileum with small free air worrisome for perforation. The decision was made in the ER to discharge him home on antibiotics. The patient then returned back multiple times to the ER for the same complaint along with bleeding per rectum for which he underwent further investigations. Months later, the patient presented again with the same symptoms. A CT scan revealed recurrence of a periumbilical hernia and thickening of the medial wall of the cecum with mesh graft material. The patient was then taken to surgery and intra-operative findings revealed migration of almost 50% of the mesh graft size to the cecum and part of the mesh graft was eroding the distal part of ileum just proximal to the ileocecal junction. Adhesolysis and limited right hemicolectomy with ileocolic anastomosis was done. The patient had an uneventful recovery after revisions surgery without any perioperative complications. He was discharged home on postoperative readmission day 5 and followed up at 2 weeks and 3 months without any delayed complications or subjective complaints. Conclusion It is important to consider mesh graft migration to viscus as a cause of persistent abdominal pain and bleeding per rectum irrespective of the time of presentation post hernia repair.

Autologous Dermis Graft Implantation: A Novel Approach to Reinforcement in Giant Hiatal Hernias

Objectives. Nonreinforced tensile repair of giant hiatal hernias is susceptible to recurrence, and the role of mesh graft implantation remains controversial. Creating a new and viable choice without the use of high-cost biological allografts is desirable. This study presents the application of dermis graft reinforcement, a cost-efficient, easily adaptable alternative, in graft reinforcement of giant hiatal hernia repairs. Methods. A 62-year-old female patient with recurrent giant hiatal hernia (9 × 11 cm) and upside down stomach, immediately following the Belsey repair done in another department, was selected for the pilot procedure. The standard three-stitch nonabsorbable reconstruction of diaphragmatic crura was undertaken via laparoscopic approach. A 12 × 6 cm dermis autograft was harvested from the loose abdominal skin. “U” figure onlay reinforcement of diaphragm closure was secured with titanium staples. The procedure was completed with a standard Dor fundoplication. One- and seven-month follow-ups were conducted. Results. No short-term postoperative complications were observed. One-month follow-up showed normal anatomical location of abdominal viscera on computed tomography imaging. High-resolution manometry showed normal lower esophageal sphincter pressure. Preoperative abdominal complaints were resolved. Procedural costs were lower than the average cost following mesh graft reinforcement. Conclusion. Dermis graft reinforcement is a cheap, easily adaptable procedure in the repair of giant hiatal hernias, even in the setting of laparoscopic reoperative procedure.