We can know whether we're in the proper location for injection by first observing the effect of the injection on the epithelium. When the injection is in the right place, the fluid will not lead to an intraepithelial wheal, nor will we see significant blanching. The injection is followed by a bold full-thickness incision just large enough for two fingers.
One of the main reasons these procedures are not for the busy generalist is that the dissection then needs to be carried fully down to the arcus tendineus and anteriorly to the SSL. You cannot leave extensive connective tissue covering the fixation point because doing so leads to an increased risk of visceral injury and won't allow the mesh to spread out over the plane. This is particularly important in a total repair.
Blunting of the apex is prevented by making the mesh traverse an adequate cephalad space.
Mesh will contract by an estimated 10%-20% in the year after surgery, so while it must be placed flat and smooth, it cannot be placed tightly.
I like to make the analogy of the “military-style bed”—straight and tight, with tucked corners—as opposed to a looser, imperfect “guy's dorm-room bed.” As surgeons, we have to learn to resist any desire for that military-style bed.
Surgeons have taken two approaches specific to a total mesh kit. Some surgeons who are concerned about the need to tunnel around the apex with mesh and potential blunting of the apex will split the system into two pieces, placing mesh in the anterior and posterior compartments separately.
The main disadvantage to this approach, again, is the resultant gap in support and the subsequent risk of sequential prolapse (prolapse of the uncovered portion). In addition, we've learned that keeping the mesh intact and wrapping the entire vagina does not result in blunting or shortening of the vagina.
Leaving the mesh intact does necessitate care, however. The bridge must not “bear down” on the apex and is adjusted with clamps or a long retractor to lay in the most cephalad space possible.
We also want to use a certain amount of finesse, taking care not to traumatize the sacrospinous ligament, arcus tendineus, or most importantly, the iliococcygeal, coccygeal, and obturator internus muscles.
The earliest employed techniques for mesh insertion involved multiple stitches encircling the ligaments and muscles. While using these techniques myself, I found that they often traumatized these deep anatomic structures, promoting buttock and vaginal pain.
Some of that trauma may still occur with deep trocar passes, especially in cases where passes are repeated. Securing mesh without either stitches or trocars may be an advantage in avoiding neurovascular structures. Second-generation mesh kits are characterized by their trocar-less delivery systems, in addition to having SSL fixation incorporated into the design for an anterior approach.
Reflections
The so-called total repair has been valuable only in the subset of patients at increased risk in both compartments. The evolution of mesh delivery may change that formula as the apex now can be addressed anteriorly.
It is clear to me that dogma and ideology are the most potent sources of bias in this time of change for prolapse repair. If we prove greater success rates with one approach, we must then find a way to objectify the differences between the types of complications. How many visceral injuries, for instance, are equivalent to a mesh exposure?
Equally noteworthy is the fact that the data regarding the impact of surgery on sexual function are substandard for all surgical approaches.
We do not have a validated questionnaire that accounts for the differing causes of pre-op versus post-op dyspareunia. We need qualitative study to find out how patients rate the experience of treating failure versus treating a sexual dysfunction.
There is no gold standard for prolapse repair because there are few standard patients. This complexity is the main reason why pelvic reconstruction is falling more to those who treat it regularly. I believe that if a surgeon is to be able to give the highest standard of care, he or she needs to be facile in open and laparoscopic abdominal approaches as well as transvaginal repairs with and without augmentation. The most successful hunters have multiple arrows in their quiver.
Three-dimensional pelvic anatomy simulations based on CT scans demonstrate the greater degree of vaginal support when a total procedure is performed rather than a single compartment repair. BOSTON SCIENTIFIC
The mid-sagittal hemisected cadaver pelvis improves surgical teaching in these technical and tactile procedures. The obturator internus and obturator vessels are easily viewed in relation to arcus tendineus fascia pelvis and sacrospinous ligament (SSL).