Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_190_библиотеки_им_акад_М_И_Перельмана

Placement of the sutures with the needle is done blindly and with a tactile feel for anatomic landmarks. Cystoscopy must be performed after each pass of the needle to ensure urinary tract integrity.

Before theadvent of the MIS, the traditional sling wasconsidered the domain of the urologist or specially trained urogynecologist. This “open” sling required opening the vaginal epitheliumunder the bladder neck, cutting the abdomen, and placing a sling or hammock under the bladder neck and urethra (Figure 14.2.9). Although many materials were used for the sling, the most com­mon material was autologous fascia or muscle. Fasciawas usually taken from the upper thigh (fascia lata) or the abdomen (rectus

By applying the principles of tension-free surgery, the sling is placed under the urethra, with a spacer temporarily interposed between sling and urethra. The sling is then pulled through the intervening tissue and not tied or secured to any tissue. This is the crucial step in the “tension-free” description.

The second-generation MIS used a transobturator approach instead of passing through the retropubic space.[26–28] Again, different proprietary products strive to achieve the same result with variations on material and on direction of place­ment.

In1998, Ulmstenet al. presented“A Multicenter Study of Tension­Free Vaginal Tape (TVT) for Surgical Treatment of StressUrinary Incontinence.”[29] It was noted by Ulmsten that “a long series of experiments proceeding the current TVT operation have shown that placing a sling under the midurethra without tension is the best way to provide a dynamic kinking of the organ, and hence to close the urethra in stress situations.”[30–32] This led to a patent by Dr. Ulmsten and subsequent sale of the device to Johnson & Johnson. The device is marketed under the name TVT (Figure

Local anesthesia with epinephrine is given to all patients regardless of whether the procedure is done under general anes­thesia or sedation. The epinephrine will greatly reduce blood loss by causing vasoconstriction. The local component will decrease pain sensation by numbing the pain receptors prior to incision. Vasopressin may also be substituted for the epinephrine compo­nent to achieve hemostasis.

A #14 surgical knife should be used to make small puncture incisions at the marked spots on the abdomen. The knife should then be used to cut a 3-cm vertical incision under the urethra starting just distal to the urethra vesical junction. Using a very sharp plastic surgical Metzenbaum or tenotomy scissors, flaps should be gently developed on the left and right sides of the mid­line incision. Injuries that occur with sharp dissection are almost always easier to repair than those created with blunt dissection or spreading. Care should be taken not to go too deep, as this may cause immediate entry into the urethra or bladder, or may contribute to delayed erosion in these structures. Superficial dis­section may lead to cutting through the vaginal epithelium. This is called a “button hole.” A button hole makes it easy to place the sling through the inside of the flap, out into the vagina, and then back into the flap. This will leave the patient with a small piece of exposed mesh in the vagina. Dissection should stop short of perforating into the retropubic space (Figure 14.2.11).

The TVT needle on one side is screwed tightly into the reusable TVT handle. Using a toothed forceps, the cut vaginal edge on the left side is lifted. Working in the left flap, the sur­geon should use his or her left hand to hold the TVT handle and position the tip of the needle into the flap. With the surgeon’s right hand, two fingers should be placed into the vagina, out­side the flap. The right hand should then cradle the curve of the TVT needle, aiming it at a 45