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Are meshes dangerous for pelvic floor repair ? Why FDA recommendations are unsatisfactory.

Are meshes dangerous for pelvic floor repair ? Why FDA recommendations are insufficient. SUMMARY OF RECOMMENDATIONS (for full data see article ) click to read full article For surgeons who do not currently perform transvaginal placement of surgical mesh for pelvic organ prolapse, but wish to begin performing this procedure: a. General knowledge should be documented either by completing a fellowship training program in Urogynecology, Female Pelvic Medicine and Reconstructive Surgery, or Female Urology or by completing adequate CME in pelvic anatomy and reconstructive pelvic surgery. b. Specific knowledge for a particular procedure should be obtained c. Skill may be documented by surgeons who have completed a Urogynecology, Female Pelvic Medicine and Reconstructive Surgery or Female Urology fellowship program via cases lists showing experience with transvaginal placement of surgical mesh for pelvic organ prolapse. Surgeons who do not have documentation of prior training with a specific transvaginal mesh prolapse procedure should be proctored on no fewer than 5 procedures or as many as is necessary to demonstrate that they can independently perform the specific procedure. d. Experience in treating women with pelvic floor disorders should be documented either by completing a fellowship training program in Urogynecology, Female Pelvic Medicine and Reconstructive Surgery or Female Urology or by demonstrating that they offer a full spectrum of surgical options for pelvic floor disorders and that surgery for pelvic floor disorders represents >50% of their surgical practice including a minimum of 30 surgical cases for pelvic organ prolapse annually. e. Demonstrate experience and privileges in nonmesh vaginal repair of prolapse including anterior colporrhaphy, posterior colporrhaphy, and vaginal colpopexy (eg, uterosacral or sacrospinous...

Robotic surgery in gynaecology and endometriosis

The discussion on robotic assisted surgery is continuing . Following our opinion statement on www.endometriosis.org John F Dulemba posted in World Endometriosis Research Foundation 7 January 07:43 PEOPLE. THE ROBOT IS JUST LAPAROSCOPY!!!!!!!!!!!!! PLEASE WATCH THIS MINUTE VIDEO….TO THE VERY END. YOU WILL SEE HOW PRECISE THE INSTRUMENTS CAN BE, AND I DO NOT THINK ANY STANDARD LAPAROSCOPISTS CAN BE AS PRECISE AS THE DOCTOR IN THIS VIDE!!!!!! When I wrote the comment below, the video has been withdrawn Nice video but misleading - obviously for specific movements a robot is superior to the human. Therefore I do expect that a robotic tubal reanastomosis will be superior to standard laparoscopy and come close to classic microsurgery. Unfortunately however , to the best of my knowledge, this superiority has never been demonstrated. No attemps were made even to demonstrate this in animal models. So doubt persists whether there is some uncertainty about outcome of such a trial. Failure indeed would killing a major indication - except tubal reanastomosis I doubt that superiority can be proven for any other gynaecological intervention (since it probably does not exist) - in addition robotic surgery can be potentially dangerous when performed by surgeons without sufficient training in laparoscopic surgery. (see blog http://www.gynsurgery.org/hysterectomy-myomectomy/robotic-surgery-is-not-superior-and-potentially-dangerous/) - finally, in this period of economic crisis, it is unclear who is willing to carry the associated huge cost : the surgeon ? the hospital ? (for marketing reasons) the patient ? (I doubt any patient is willing to pay today if correctly informed) I anyway want to stress my interest in robotic surgery as can be found in de development...

Small bowel herniation in trocar sites and early repeat laparoscopy

Small bowel herniation in trocar sites and early repeat laparoscopy RCTs have not been performed, nor will be performed , in order to document the incidence and the prevention of small bowel herniation in trocar sites. Indeed it is a rare complication and for obvious ethical reasons trials will not be performed. The evidence therefore can only be circumstantial.   We would try to summarise as follows our attitude. 1. The risk of small bowel herniation is believed to depend  on trocar diameter and on the surgical lesion caused by trocar insertion. 2. Unfortunately I am not aware of evidence that the risk of small bowel herniation is decreased by the use of conical trocars instead  of sharp triangular trocars or by the use of  the Termanian trocar. This could be expected given a smaller trauma as demonstrated years ago by Malcom Munro. 3. For the first intra publical trocar the risk seems so low that most of us will not suture the fascia. A plausible explanation could be that the insertion  is generally slightly oblique and that hte insertion thus closes by a flap valve mechanism.  For this reasons,  we only close the fascia of the first trocar insertion when either the patient is extremely thin or afther the incision has been enlarged for specimen retrieval. 4. For the secondary trocars which are inserted perpendicularly (in order to permit eventual backloading of sutures)  we do not close the fascia for 5 mm ports but always close them when 10mm or larger ports were used. 5. The biggest clinical challenge, however, is the diagnosis of a small bowel herniation since symptomatology is insidious.  For this reason, we advocate an early repeat laparoscopy whenever a patient does not improve...

Insufflators for laparoscopic surgery – loss of pneumoperitoneum

Published at the AAGL listserv. : Date: Fri, 17 Dec 2010 08:42:22 -0500 From: “Philippe R. Koninckx, Carlo De Cicco, Jasper Verguts, Roberta Corona and Anastasia Ussia” Subject: Loss of pneumoperitoneum through trocar Reading the comments regarding loss of pneumoperitoneum I do have the impression that many try to reinvent the wheel, or simply do not know that this issue was solved long time ago with the Thermoflator (Storz AG). In 1990, I patented through Leuven Research and Development and subsequently developed together with Storz AG the thermoflator based on a simple principle : as long as the internal diameter of the tubing and connexions is at least 7mm flow rates of 60 l/min are obtained with an insufflation pressure of 20 cm of water of 15mm of Hg. In contrast with all other insufflators based upon the Semm patent of the 80-ies, (intermittent insufflation with measurement of the intraperitoneal pressure during the pauses of insufflation ) this insufflator / the thermofaltor, has a series of advantages - It is safer since insufflation can be done at low pressure eg 15 mm of Hg. Thus abdominal overpression becomes impossible. With all other insufflators -to the best of my knowlege, unless patent infringement- insufflating intermittently at higher pressure, overpression in the abdomen is theoretically possible when a valve mechanism would occur permitting insufflation but preventing gas and pressure to flow back. With a minimal leak the measured pressure indeed will remain low. - It permits a continuous flow which is important for smoke evacuation (especially during CO2 laser surgery) : otherwise smoke is blown away intermittently. - A high flow...

Shiny Trinket

Shiny trinkets are shiny.