Surgical Procedure

The patient's legs are placed in low Allen stirrups and a three-way Foley is put in the bladder.

FIGURE2 ■ Obturator and Accessory Obturator Artery. (A) Normal Obturator artery, present 70 percent. A Obturator a.; B Obturator v.; C External Iliac a.; D External Iliac v.; E Inferior Epigastric a.; F Obturator branch anastomosing with pubic branch of the Inferior Epigastric a.; G Pubic a. branch, H Obturator nerve. (B) Accessory Obturator, present 25%. Five percent of patient have a combination of A and B. A, Obturator a, B, Obturator v.; C, External Iliac a.; D, External Iliac v.; E, Inferior Epigastric a.; F, Pubic branch of the Inferior Epigastric a.; G, Pubic a. branch supplying pubic ramus; H, Obturator nerve.

aAllen Medical, Garfield, OH. bCook OB/GYN, Spencer, IN. cEthicon, Inc., Sommerville, NJ. dEthicon EndoSurgery, Cincinnati, OH. eInlet Medical, Inc., Eden Prairie, MN.

The patient should be flat and not in Trendelenburg, which can bring the pelvic vessels closer to the abdominal wall.

The infraumbilical area is infiltrated with marcaine 25% (as are all of the trocar sites) and a stab incision is made. Preemptive anesthesia significantly decreases postoperative pain.

Veress needle or open Hasson technique is employed to achieve pneumoperitoneum (20). Once the abdominal pressure reaches 15 mmHg, the infraumbilical trocar is passed into the abdomen through the umbilical aponeurosis. The laparoscope, with video camera, is inserted. The left lateral port area is transilluminated to identify the superficial inferior epigastric vessels. A skin incision is made, and the 10-mm trocar, with a 5-mm reducer, is passed through the abdominal wall under direct vision. The same technique is used to place the right lateral and suprapubic 5-mm trocar. At this point, the patient can be placed in Trendelenburg in order to visualize the pelvis. After the initial abdominopelvic inspection is done, approximately 150 cc of methylene blue saline are instilled through the Foley catheter to delineate the borders of the bladder. The surgical landmarks for the initial peritoneal incision into the space of Retzius are the right and left obliterated umbilical arteries, slightly lateral and superior to the pubic tubercles. A transverse incision is made approximately 3 cm above the inferior aspect of the pubic bone from one obliterated vessel to the other. In the midline, care should be taken as the obliterated urachus, which can be vascular, is incised. It is important to remember that the patient is in Trendelenburg position and to not direct the dissection perpendicular to the pubic bone, but rather to dissect in an upward fashion. This will prevent inadvertent cystotomy. The pubic bone is identified under the retroperitoneal fat layer and can be followed into the space of Retzius. The correct plane is composed of fine areolar tissue and fat, which can be easily swept away with the spatula.

The Foley bulb is identified and care is taken to stay at least 2 cm lateral to the urethra. Adipose tissue is not removed from the anterior surface of the urethra. The surgeon's left hand is placed in the vagina to elevate the lateral paraurethral tissue, which greatly aids dissection. The rich venous plexus adherent to pubocervical fascia can be coagulated as necessary. On the sidewall, the arcus tendineus of fascia pelvis (arcus white line), along with the branching of the arcus tendineus of the levator ani, is identified. The obturator vessels and nerve are identified entering the obturator canal. The ischial spine is directly below the obturator canal. The Cooper's ligament is identified along the superior surface of the pelvic bone and cleaned off. The first absorbable 0 PDS suturef is placed 2 cm lateral to the midurethra as this tissue is elevated with the vaginal hand. A large purchase of tissue is taken. A figure-of-eight suture is not necessary, as demonstrated by Burch and Tanagho (1,3). The needle is passed up through the Cooper's ligament, and while the vaginal tissue is elevated, the suture is tied with an extracorporeal knot utilizing an open-ended knot pusher (Table 2).

The vaginal tissue should not be pulled all the way up to Cooper's ligament because this may result in overcorrection of the urethrovesical angle and posibly kink the ureter.

We leave approximately 2 cm of space between the suture and Cooper's ligament and a similar space between the urethra and pubic arch. The second suture is placed 2 cm lateral to the bladder neck and tied. Sutures are placed on the opposite side in similar fashion. At completion, the four sutures elevate the pubocervical fascia to form "dog ears," creating a hammock under the midurethra and bladder neck (Fig. 3). As the last two sutures are being placed, indigo carmine is given intravenously.

The final step is cystoscopy. It is essential that dye is seen coming from both ureteral orifices and that no sutures have penetrated the bladder wall. If the dye is not seen, the sutures must be removed from that side and replaced. We know of no reports of the ureter actually being caught in a Burch suture. The cause of ureteral obstruction is due to overelevation of the trigone, which crimps the ureter, preventing flow (21). After cystoscopy, the space of Retzius is closed with a continuous 0 PDS suture.

The Burch is always done last if there are concomitant procedures. The ure-throvesical angle can be affected by other repairs done after the Burch, secondary to changes in the pelvic axis. We usually do uterosacral vaginal colpopexies prior to the Burch to prevent prolapse in the posterior pelvic compartment in any patient demonstrating vaginal support weakness. The Burch has been combined with anterior and posterior support procedures, sacrocolpopexy (9), laparoscopic hysterectomy, external anal sphincteroplasty (12), and rectopexy.

The patient should be flat and not in Trendelenburg, which can bring the pelvic vessels closer to the abdominal wall.

The vaginal tissue should not be pulled all the way up to Cooper's ligament because this may result in overcorrection of the urethrovesical angle and possibly kink the ureter.

fEthicon, Inc., Sommerville, NJ.

TABLE2 ■ Laparoscopic Burch Colposuspensions with Sutures

Follow-up

Suture

Cure type

Major comp

Name (Ref.)

Study type

N

(mo)

Type

No.

of follow-up

%

lications (%)

Albala (5)

R

10

7

P

2

S

100

0

Liu (6)

R

107

3-27

P

4

O

97

7.4

Nezhat (7)

R

62

B-30

P

4

O

100

10

Radomski (36)

P

34

17

P

4

S

B5

11.B

Papasakelariou (32)

P

32

24

P

4

S

91

6.3

Saidi (22)

R

70

12.9

P

4

S

91

NR

Ross (B)

P

32

12

DA

4

O

94

6.3

Ross (39)

P

35

12

DA

4

O

91

Ross(9)

P

19

12

DA

4

O

93

Ross (10)

P

4B

24

DA

4

O

B9

Ross (12)

P

40

12

DA

4

O

B9

Ross (41)

P

B7

>60

DA

4

O

B4

Abbreviations: Study type: R, retrospective; P prospective; N, number of patients, suture type; P permanent; DA, delayed absorbable; Cure: S, subjective; O, objective.

In several experiences, this extraperitoneal dissection is reported as faster and cheaper than open or laparoscopic transperitoneal Burch, with comparable cure rates and high patient satisfaction.

Extraperitoneal laparoscopy can result in greater degrees of carbon dioxide absorption than transperitoneal surgery, increasing the chance of pneumomediastinum and pneumothorax.

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