Kazuaki Nishimura

Laparoscopic fixation of the vaginal cuff to the uterosacral ligaments at the time of hysterectomy.

Introduction and HypothesisTransvaginal ipsilateral uterosacral ligament colpopexy for pelvic organ prolapse (POP), which was reported by Shull et al. (Shulls colpopexy) in 2000, is one of the most frequently performed non-mesh pelvic floor reconstructive surgical procedures. Despite its excellent anatomical outcomes, ureteral injury and difficulty in uterosacral ligament detection (especially in patients with severe POP) are typical issues with this procedure.MethodThis video demonstrates the procedure in a 58-year-old woman, gravida 2 para 2, with POP-Q stage II uterine prolapse and stage I cystocele. At the beginning of the operation, the bilateral uterosacral ligaments were confirmed and separated from the ureters after entering the retroperitoneal space. The inferior hypogastric nerve and pelvic nerve plexus were also separated from the uterosacral ligament. After total laparoscopic hysterectomy, three ipsilateral delayed absorbable monofilament sutures were placed between the uterosacral ligament and the vaginal cuff. Retroperitonealization was then performed using a continuous suture with closure of the Douglas pouch.ConclusionLaparoscopic Shull’s colpopexy for POP is a secure procedure with the advantages of laparoscopy (magnification and sharing the operative field). This may become one of the most useful operations for apical support as native tissue repair.

Novel technique for adhesion barrier insertion by using cut‐off surgical glove fingers in laparoscopic surgery

Laparoscopic surgery causes fewer postoperative adhesions than laparotomy and adhesion barriers are used to lessen the chance of adhesion. Sodium hyaluronate and carboxymethylcellulose (SH‐CMC), a bioresorbable membrane, is effective in preventing adhesions. However, its properties make it difficult to insert the film into the abdominal cavity and to place it into the target area during laparoscopic surgeries. Here we report a novel technique for applying SH‐CMC during laparoscopic surgeries by using cut‐off surgical glove fingers.

How to reduce the operative time of laparoscopic sacrocolpopexy

Objective: Laparoscopic sacrocolpopexy (LSC) has been reported to achieve lower recurrence rates, shorter recovery time, and less dyspareunia. However, as a pelvic organ prolapse (POP) surgery, LSC is problematic because it requires specific techniques and it takes a comparatively longer operative time. In this study, we present our surgical techniques of LSC and their effectiveness for shortening operative times and raising safety. Methods: Thirty-four women with stage 2 or greater POP who underwent LSC in our hospital between September 2014 and October 2015 were enrolled in this study. The notable points of our operative procedures are as follows: (1) fixing the sigmoid colon to the left lateral abdominal wall for a clearer visualization of the sacral promontory, (2) making a retroperitoneal tunnel (not opening the peritoneum) from the sacral promontory to the Douglas pouch, (3) dissection of the vaginal wall after transvaginal hydrodissection, (4) fixation of mesh to the vaginal wall by using absorbable tacks, and (5) limiting usage of posterior mesh for the patients with posterior vaginal wall descent. Results: The median operative time was 140 (range, 90–255) minutes, and blood loss was 50 (range, 10–1600) mL. The operative time decreased as the surgical techniques improved through experience. No major intra- or postoperative complications occurred. The mean follow-up period was 4 (range, 1 –14) months, and only one patient presented a recurrent grade 2 cystocele. Conclusion: Our unique procedures will help shorten operative times and reduce complications of LSC.

Objective diagnosis of arrested labor on transperineal ultrasound

Recent developments in transperineal ultrasound imaging of the pelvis have prompted trials to objectively evaluate labor progression for labor management. We evaluated the accuracy of transperineal ultrasound in diagnosing arrest of labor.

A case of severe pelvic organ prolapse with large vaginal mucosal defect underwent laparoscopic Shull^|^apos;s uterosacral ligament colposuspension

Pelvic organ prolapse (POP) patients present various clinical fi ndings. It is important to diagnose and repair the injured parts of the pelvic fl oor in each POP patient. The appropriate surgical procedure should be performed for each patient with considering their age, occupation, and life habits. We report a case that presented severe POP with large vaginal mucosal defect and underwent laparoscopic uterosacral colposuspension. She was 75 years old woman, gravid 4, para 1, with severe POP. She complained anuresis and had felt a sense of discomfort soon after the spontaneous delivery 30 years ago. Initially, TVM (tension-free vaginal mesh) operation was planned after curing the vaginal mucosal defect. The ring pessary insertion and estrogen/progesterone administration were performed. Unfortunately, anuresis and pyelonephritis occurred repeatedly and surgical treatment must be given emergently. We performed laparoscopic hysterectomy and vaginal vault suspension by using uterosacral ligaments (Shullʼs method). The advantages of this operation are low risk of ureter injury, fi rm colposuspension, completion with basic gynecologic laparoscopy, and no need for mesh. The patient discharged after 7 days after the operation without any complications and no recurrence has confi rmed for three months after the operation. This operation will be one of the useful POP procedure.