Modification in Blunt Dissection Technique during Transverse Perineal Support Operation

Francesco Cantarella

Surgical Technique

Modification in Blunt Dissection Technique during Transverse Perineal Support Operation

Francesco Cantarella^*
Department of Proctology and Pelvic Floor, Private Hospital in Forli, Italy

^*Corresponding author: Francesco Cantarella, Department of Proctology and Pelvic Floor, Private Hospital in Forli, Italy

Published: 17 Oct, 2018
Cite this article as: Cantarella F. Modification in Blunt Dissection Technique during Transverse Perineal Support Operation. World J Surg Surgical Res. 2018; 1: 1065.

Surgical Technique

Perineal Descent (PD) is characterized by the reduction of strength in perineal muscles with changes in force vectors during defecation. PD is frequent associated with other anatomical alterations in the obstructed defecation syndrome (ODS) [1]. Transverse Perineal Support (TPS), first described by Renzi et al. [2], is an interesting technique for perineal descent correction with the use of a biological mesh to reinforce the superficial transverse perinei muscle. TPS can be associated to other surgical procedures that aim at resect or suspend the prolapse. In the first technique described by Renzi the subcutaneous “pocket” for the mesh was created by finger blunt dissection. We realized that, although the space is superficial, the finger blunt dissection may create bleeding with post-operative haematoma formation. Considering the highly sensitive area even a mild haematoma can cause patient discomfort. So we ideate the use of minimal dissection with an arthroscopic trocar. The procedure is performed in lithotomy position under spinal anesthesia. The patient is prepped and draped in standard fashion. After bilateral skin incision at the level of ischial tuberosity we dissect by bipolar energy the subcutaneous layer until periostium of the ischio-pubic rami is reached. Two PDS 2/0 stay sutures are bilaterally passed in the periostium and left on kelly clamps. An arthroscopic trocar with a dissecting tip is advanced trough left skin incision while doing counter traction with allis clamp. Once the trocar reach the right skin incision the dissection tip is removed and a 0 prolene suture is passed in the provided hole and retrieved trough skin incision leaving the suture in the subcutaneous space. An 80 mm × 60 mm dermal porcine mesh (Tecnoss^® Protexa supplied by MV Medical Solutions S.r.l. Republic of San Marino) is rehydrated in a sterile saline solution for 30 min. Distance between the two ischial tuberosity and the high of perineal body are registered. The graft is fashioned on the recorded measurements. One end of the implant is passed with 0 prolene suture and withdrawn in place. Prothesis is secured to bony structures with bilateral “U” stitches. Skin incisions are closed in layers with vycril rapid 3/0. The arthroscopic trocar allows a minimal and linear dissection with less haematoma formation.

Figure 1

Figure 1
Patient in lithotomic position. Bilateral identification of ischial tuberosity. Skin marking of incisions.

Figure 2

Figure 2
Blunt dissection of perineal space with arthroscopic trocar. Distance between the two ischial tuberosity and the high of perineal body are registered.

Figure 3

Figure 3
An 80 mm × 60 mm dermal porcine mesh (Tecnoss® Protexa) is rehydrated in a sterile saline solution. The graft is fashioned on the recorded measurements.

Figure 4

Figure 4
A0 prolene suture is passed in the trocar provided hole and retrieved trough skin incision leaving the suture in the subcutaneous space.

Figure 5

Figure 5
One end of the implant is passed with 0 prolene suture and withdrawn in place. Prothesis is secured to bony structures with bilateral “U” stitches.

Figure 6

Figure 6
Skin incisions are closed in layers with vycril rapid 3/0.

Surgical Technique

Modification in Blunt Dissection Technique during Transverse Perineal Support Operation

Surgical Technique

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References