Perigee >>
The Inferior or Apical needle pass is the NEW pass. It allows the surgeon to attach the apical portion of the graft up to the white line near the ischial spine (this is the hardest area to get a good safe attachment of a graft) which is up near the top of the vagina. As you can imagine, this is a very difficult area to get to and the Perigee enables us to get a strong attachment safely which gives a very anatomic repair. The needle is passed through the inferior incision and then through the inferior, medial portion of the obturator foramen and membrane. Once in the obterator space, the surgeon can palpate the needle on the other side of the levators and he/she then walks the needle up as close to the ischial spine as possible and brings it through the sidewall, with direct finger guidance at all times. The fingers placed vaginally allow correct positioning of the needle and also protect the bladder when bringing the needle into the vagina. The apical arm of the graft is then attached to the needle and it is brought back out the groin incision. Although some vault support may be obtained, this procedure is NOT designed to give vault support and if a patient has vault prolapse, this must be repaired at the same time.
Perigee Figure: 1 |
Perigee Figure: 2 |
Graft in Position under Bladder: Once in place, the Perigee graft provides an entire new floor of support for the bladder from sidewall to sidewall. The skin of the vagina is closed over the graft, and the tissue ingrowth occurs very rapidly, making the graft become incorporated and part of the patients anatomy very quickly. The vaginal skin is left thicker during dissection and no extra skin is cut off (like typical repairs) therefore reducing the risk of the graft extruding through the skin. Most patients and their partners cannot tell there is a graft in place once healed.
Risks and Complications
As with any surgical procedure, risks do exist. One must always weigh the benefits of graft use (increased cure rate) with the risks associated. For example if a patient has had 2 previous surgeries and they have failed, it is very doubtful that repeating the same procedure again will work, therefore it is very easy to state that this particular patient needs a graft for her repair and the benefits far outweigh the small risks associated. For the most part, risks associated with graft use in pelvic floor surgery are relatively small, however, again, as with any surgical procedure, risks do exist. A graft is a foreign body and therefore risks do include infection, rejection or erosion of the graft (into the bladder or urethra). These type of complications are very rare and the graft materials utilized today have been shown to be very well tolerated with minimal risk of this (all typically less than 1%) and of course experience of the surgeon also has an impact on these risks. Other risks include: bleeding, pain in the vagina or groins, vaginal scarring or pain with intercourse (risk of any pelvic floor surgery).
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