Excision Of Transvaginal Mesh Extrusion
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[Excision Of Transvaginal Mesh Extrusion]
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Excision of Transvaginal Mesh Extrusion
Mia A. Swartz, MD
Howard B. Goldman, MD
Principles of Mesh Excision
Excision of skin edges
Careful dissection of mesh from bladder and/or rectum
Excise any residual mesh at margin of dissection
Inspect bladder and/or rectum to ensure no residual mesh or perforations
Vaginal mesh extrusion is a potential complication of transvaginal mesh used for pelvic organ prolapse surgery. With proper management mesh that fails conservative treatment can still be managed with minimal morbidity to the patient. Several principles are important in the repair of mesh extrusion once it is recognized. First the edges must be excised and then undermined. This allows for complete removal of the mesh followed by a tension-free closure. Mesh should be completely excised with no remnants remaining where the incision will be closed. Care must be taken to inspect the bladder or rectum for signs of injury.
This 71-year old female underwent an anterior transvaginal mesh repair for anterior vaginal wall prolapse two years ago. Mesh extrusion was noted post-operatively and she failed conservative management with local hormonal cream. The two by one centimeter area of extruded mesh is identified. The vagina is completely inspected at this time to ensure there are no other areas of extrusion. Of note cystoscopy had been done previously in the office to exclude any intravesical mesh.
The patient is placed in the dorsolithotomy position and a Lone Star retractor is used for exposure. Fully decompression is used during the casee to minimize the chance of bladder injury during dissection. An incision line is marked out circumferentially approximately half a centimeter from the mesh edges, the selected incision line will allow for ample debridement of the vaginal skin edges. The area is then infiltrated with a mixture of lidocaine and epinephrine. An incision is then made. The Allis and Bonney pickups are used for retraction.
Using careful blunt and sharp dissection the edges are undermined for approximately one centimeter. Note that Blue hooks can be used for further retraction and exposure in the dissection bed. A Kittner is used for gentle blunt dissection to free mesh from the bladder.
The mesh in attached vaginal skin is grasped with an Allis and then trimmed away using heavy scissors. The wound that is inspected and some residual mesh is identified and ultimately trimmed away.
At this point, the exposed mesh has been completely excised and the vaginal wall edges have been debrided. The undermined edges will provide for a tension free closure.
The bladder was then distended to 300 CCs of fluid and there was no sign of injury. Of note, cystoscopy was also performed at this point to ensure that there was no bladder injury. A 2-0 absorbable running [marking] suture was used for closure.
In conclusion the principles of repair include wide mesh excision with generous vaginal skin flaps followed by a tension-free closure. Care should be taken to ensure the bladder and rectum are intact after complete excision is performed.
We believe that when mesh extrusion is recognized it can be managed with minimal morbidity to the patient.
Mesh identified and skin edges excised
Skin flaps developed
Mesh excised widely
Inspection of surgical area and cystoscopy to ensure bladder intact
When managed properly, mesh extrusion should result in minimal patient morbidity.
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