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Continued from previous page...
(5) Urethral injury
Intra operative injuries to the urethra should be an
infrequent occurrence due to its easy identification
with a foley catheter in place. One must stay lateral in
all dissections around the proximal urethra and bladder
neck unless it is for diverticula or fistula at this
level. Similar to the bladder injury section above , if
one necessitates entry into the retropubic space, it
should be done at the level of bladder neck/proximal
urethra; yet lateral to these structures. Too medial an
entry can risk urethral injury however, this should
still occur infrequently. If injury does occur in the
course of dissection, immediate repair should be
undertaken in order to properly orient the anatomic
layers and prevent postoperative fistula, stricture or
diverticula formation. Interrupted or running suture of
fine absorbable material should be placed to re
approximate the periurethral fascia in such a way so as
to avoid overlapping suture lines. Large entries can
also be closed with the assistance of a fibrofatty
Martius flap graft prior to epithelial closure.
Injury to the urethra may be discovered in the
postoperative period. When a patient presents with
persistence incontinence despite restoration of normal
anatomy, the surgeon should also consider the
possibility of iatrogenic ureterovaginal, vesicovaginal
or urethrovaginal fistulae. This may occur as a result
of an unrecognized intra operative misadventure,
postoperative infection or ischemic necrosis of the
pelvic tissues especially in patients with poorly
estrogenized tissue or previous radiotherapy. Voiding
cystourethrogram is helpful in confirming this
diagnosis.
Sling erosions are occurring in a higher frequency with
increasing use of synthetic substances in vaginal sling
surgery. One must be cognizant of the issues related to
synthetics in that the body may reject the tissue and or
the sling may become infected. The symptoms may vary
from patient to patient; however is often pain with
voiding, frequency, vaginal discharge, and dyspareunia.
Proper management once sling erosion is identified
entails careful transvaginal excision of the sling and
suspending sutures as they may be infected. The sling
may have eroded into the urethral wall and accordingly,
may require urethral reconstruction with or without
interposition of flap for optimal repair. |
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(6) Ureteric Injuries
Ureteric injuries occur in 0.3 to 3% of patients
undergoing gynecological surgery, still over 2/3 of
these patients have the injury occur during the course
of transabdominal surgery, therefore, ureteric
complications of transvaginal surgery are fortunately
rare, the chances of ureteric injury increase if one has
had previous pelvic preoperative planning may allow one
to place a stent if there is a concern about possible
injury.
There exist several ways in which we prevent ureteric
injuries in the course of transvaginal surgery. During
sling surgery and entry into the retropubic space, as on
the bladder such that the chances of ureteric injury are
reduced. More commonly injury occur during suture
placement for re approximation of the perivesical fascia
in cystocoele repair. One can avoid the ureters by
grasping the perivesical fascia in bringing it medially
after reducing the trigone and elevating the base of the
bladder with an absorbable mesh. Horizontal mattress
suture placement through the perivesical fascia correct
the central defect. Intravenous administration of indigo
carmine dye ensures patency of the ureters if dye is
seen effluxing from orifice. Additionally, blood or lack
of dye efflux should alert one to the possibility of
ureteric injury. Usual management is repositioning of
the sutures and cystoscopic examination. A retrograde
ureteropyelogram remains the gold standard test both in
the immediate & delayed period. A Intravenous
Urogram(IVU) is also advised in all suspected cases. If
the injury is detected late, i.e. postoperatively,
proper drainage via endoscopic stent placement or
percutaneous nephrostomy tube drainage. If the ureter
fails to resume patency with these measures, operative
correction with a ureteric re implant is undertaken
after a prudent period of observation. |
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(7) Bowel/ Rectal Injury
Rectal and bowel injury should be an uncommon
complication, yet when injury does occur, one must
approach it seriously. Steps one can take to avoid intra
operative problems with the bowel include good
preoperative bowel preparation and proper intra
operative identification of the bowel to prevent its
injury. A routinely placement of betadine soaked rectal
pack to facilitate its identification by palpation.
helps to avoid this complication In the course of
rectocele repairs, one should stay very superficial in
the dissection of the vaginal wall off of the pre rectal
fascia. This dissection may also be facilititated by
injection of normal saline just beneath the vaginal wall
to help create the space/plane for dissection.
Enterocele repairs may be complicated by bowel injury as
well yet careful packing of the intra abdominal contents
by a laparotomy pack will reduce the incidence of
injury. In the case of bowel injury, one must decide on
the nature of the injury prior to decision of therapy.
In the event of a clean, small opening in the bowel,
transvaginal closure may be performed in a multilayer
watertight fashion. Interposition of fatty tissue or
other local tissue adjacent to the closure is wise, as
it may help prevent fistula formation postoperatively.
Large, extensive lacerations or those contaminated with
stool, may require colostomy fecal diversion after
termination of the vaginal procedure. Rarely the
placement of supra pubic catheters may lead to a bowel
fistula. |
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(8) Neurologic Injury / Postoperative Pain
Sacrospinous fixation can be complicated by nerve injury
as the pudendal nerve lies in proximity to the
sacrosspinous ligament. Clearly, one must maximize
exposure with use of the Breisky – Navratil retractors
and palpate the ligament prior to suture placement.
Additionally, the suture should be placed through the
ligament without lateral tissue incorporation to
decrease the chance of nerve injury. Rarely sciatic
nerve or obturator nerve injury can occur with lateral
or extensive retropubic dissection.
More commonly, one sees entrapment of the ilio inguinal
nerve branches that course immediately lateral to the
pubic bone on either side. This can cause quite
disabling, constant suprapubic pain. Therefore, in the
course of suprapubic suspension procedures, if the
dissection is carried out too far laterally or the
suspension sutures are tied over the ilio inguinal
nerve, pain may result from nerve entrapment. Ideally
one should stay more medial in the suspension suture
placement and immediately above the pubic bone as
opposed to laterally.
Proper patient positioning can help avoid complications
of peroneal palsy or femoral neuropathy. Gentle
positioning with use of padded lithotomy props and
avoidance of excessive pressure or tension to the lower
extremities can prevent problems. Recovery from these
injuries is usually spontaneous, but may take several
weeks to months. |
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