Prevention of Vault Prolapse during Laparoscopic Hysterectomy Timothy Mckinney by Michael East
Michael East: Good afternoon where ever you are. This is Michael Yeast introducing Tim McKinney and we are at the ISGE Conference in Bari and it is 2008. I am going to ask Tim, who has just given an excellent talk about vault suspension. In particular, I am going to ask him how often he feels that this is necessary when performing hysterectomy. First, I am going to ask him to introduce himself in terms of where he comes from? Tim.
Dr Timothy McKinney: Okay. I have a center of excellence in laparoscopy as well as urogynecology and pelvic reconstruction surgery. I am the Director of Athena Womens Medical Health and Chief of Urogynecology at the University of Medicine and Dentistry, New Jersey as well as in Drexel University. Pretty complicated but….
Michael East: I think, that’s the end of the over, isn't it every one at a time. Anyway, tell me about how often do you think it's necessary to place vault suspension sutures at the time of hysterectomy?
Dr Timothy McKinney: I feel that if you have any kind of decent of the uterus that you need to address the level one defect and it is crazy to think that you are going to end up having the upper end of the vagina staying in place if there is prolapse at the time of the hysterectomy without addressing that kind of a defect. I tend to use a combination of the uterosacral ligaments from a natural approach as well as the iliococcygeal hitch type of stitches. I tend to use a combination vaginally of both permanent as well as absorbable because of the fact that I am trying to bury the permanent behind the vaginal wall so the bearings which is including the vaginal wall are the absorbable and I use usually a woven material of Ethibond just so it gets a little bit more of an inflammatory response at the upper end.
Michael East: Do you think that even if there isn't any discernible prolapse that we should be putting some sort of prophylactic stitch in place?
Dr Timothy McKinney: Well if you are disconnecting the vault support structures and absolutely you need to put something back together again. If you are performing say a laparoscopic hysterectomy supracervically and there is no prolapse, the whole concept behind doing a supracervical is to maintain all the support structures intact. There is, however, some data coming out showing that a supracervical hysterectomy may not always be preventative. I tend to put a simple stitch utilizing uterosacral ligaments anyway because I usually for my supracervical hysterectomies closed off like I always say in the lecture earlier taking the pubocervical fashion, the rectovaginal septum and covering over that cervical stump. That way you are combining it in, I also like to put in the uterosacral ligament at the same time.
Michael East: Are you ever placing mesh as a laparoscopic mesh, sacrocolpopexy, and if so how do you choose what procedure you are going to do?
Dr Timothy McKinney: Okay, the idea of the sacrocolpopexy has been around for years. It's the gold standard. I utilize it and particularly whenever I have a true apical defect and particularly the upper one-third of the level two as well as level one defects, I try to end up going for those and yes, I do it on a regular basis. I usually use polypropylene type of type one graft material. At this present time, I have been utilizing a new suture technique which is called the quill, it is basically a suture that does not require intracorporeal or extracorporeal knot tying because it has a property to it in which the middle of the suture from one side to the other have burs on it that work like fish hooks. So when your pads are sutured through, when you go to try to pull it back through, it will not move. So, you run it in one direction and then run it back in the opposite direction and it fixes that suture intact. It is fabulous for doing your running stitches for peritoneal closures as well as fixation of the graft through it, probably saves me about 20 minutes or half an hour on suturing technique.
Michael East: I am not intending to advertise, but can you just tell our viewers where you can acquire that?
Dr Timothy McKinney: It is a company; you got me on the spot here. It’s, I'll think of it, auto, something right there. It is not one of the major companies out there and it’s recently launched this year. I am sure, it will be bought up by somebody.
Michael East: ___________
Dr Timothy McKinney: Yeah I got to think of the name, the company that made quill.
Michael East: Okay.
Dr Timothy McKinney: Can’t remember. I am trying to think of it
Michael East: I’ll just give a local call. You are a local call away from me.
Michael East: Sorry, we don’t intend to advertise but because the quill is, it sounds like quite an interesting suture. We will actually put that on the video at the end. Thank you very much. Thank you, Tim
Dr Timothy McKinney: Thank you.