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Re: High uterosacral vaginal vault suspensions From: Glen Elrod (dr99645@yahoo.com) Mon Jun 30 12:38:14 2008 Messages sorted by: [ date ][ thread ][ subject ][ author ] Next message: Dean Huffman .: "Coding Question ..." Previous message: Lynn Montgomery: "Re: Butte" Maybe in reply to: rmodugno@aol.com: "High uterosacral vaginal vault suspensions" I'm not sure I'm the best at describing things, but I'm sure its better than my picture drawing (just ask my nurse that warns all my patients about my 'art work') Once the hyst is done you'll be left with all cuff with nothing tagged. A large goose neck speculum is in the vagina over a pedi lap sponge that packs the bowel away. We take Allis clamps at the 4 and 8 oclock position and grab the uterosacrals. We use generally 5 interrupted sutures of 0 Vicryl or equivalent starting just below the Allis clamps at 5 to 7 oclock, 4 to 8, 3 to 9, 2 to 10 until we get our 5 sutures in place. Each suture is tagged with matching instruments for identification later. Each suture goes from vaginal mucosa, grabs some support type tissue (US or cardinal) and peritoneum if possible. The last suture is placed most cepalad (ie the 2 to 10 area) and tied. The retractor in the anterior culdesac is removed and the small apex of cuff that is left is grasped with an Allis. The small portion is run with an 0 from 12 oclock until it meets the last suture tied. We tie the sutures in order and remove the speculum and packing as we get to the last. Similarly, the 6 oclock part of the cuff is grasped with an Allis and it is run from 6 to the last tied suture. Once that is done the 6 oclock part becomes the highest part of the cuff. I take either rings or spongestick and push it up in the vagina. Dan, I have seen the side to side, incorporating US at the corners and it seems more like a clothes line with the corners pulled up but the middle sagging. This closure seems to be more supportive across the entire cuff. I hope that helps. Glen >----- Original Message ---- From: "rchudacoff@mylinuxisp.com" <rchudacoff@mylinuxisp.com> To: Multiple recipients of list OB-GYN-L <ob-gyn-l@mail.obgyn.net> Sent: Friday, June 27, 2008 10:43:10 PM Subject: Re: High uterosacral vaginal vault suspensions I'm not sure I understand the procedure. Can you describe it in slightly more detail? Richard Chudacoff, MD, FACOG -sent from my Treo 650 -----Original Message----- From: Glen Elrod <dr99645@yahoo.com> Subj: Re: High uterosacral vaginal vault suspensions Date: Fri Jun 27, 2008 6:10 pm Size: 8K To: Multiple recipients of list OB-GYN-L <ob-gyn-l@mail.obgyn.net> Prior to moving here, I had routinely closed the cuff front to back, trying to incorporate the US at the angles. Here, I started to operate with a gyn that's dad was also a gynecologist and he has a unique closure that I hadn't seen before. Because he (and now I) use the Gyrus for all the vaginal pedicles, we don't have anything to tag going in. At the end of the hyst we use long Allis clamps to grasp the uterosacrals. We place 5 interrupted sutures starting just below the Allis clamp and going full thickness from peritoneum to vaginal mucosa. After the fifth one is placed it is tied. From that point, there is a small area anteriorly and posteriorly that is closed with a running suture of 0 vicryl. I wasn't sold on this closure until we did it during an LAVH and saw the great support at the cuff from the scope. Now that I've done some and seen them back for 6 week checkups, the cuff seems long, well supported and very anatomic. Glen >----- Original Message ---- From: Raymond Stephen <Stephen.Raymond@dhhs.tas.gov.au> To: Multiple recipients of list OB-GYN-L <ob-gyn-l@mail.obgyn.net> Sent: Saturday, June 21, 2008 4:59:05 PM Subject: Re: High uterosacral vaginal vault suspensions That is the way I was taught in the 70s and have done ever since. It seems I am the only one doing it here, and the registrars are impressed. I am sure it helps vault support. Steve From: ob-gyn-l@obgyn.net [mailto:ob-gyn-l@obgyn.net] On Behalf Of Charlie Chambers Sent: Sunday, 22 June 2008 8:11 AM To: Multiple recipients of list OB-GYN-L Subject: Re: High uterosacral vaginal vault suspensions With vag hyst my partner hangs on ties around/through the cardinal or the USL. At the time of closure, he ties them together in the midline w/ the corresponding ties that were tagged. He feels this gives the cuff additional support. What says the forum? **************************************************************************** Charlie Chambers Hood River, OR USA -- cchamber@alumni.rice.edu "...not because I regard fishing as being so terribly important but because I suspect that so many of the other concerns of men are equally unimportant-and not nearly so much fun." John Voelker ***************************************************************************** On Jun 21, 2008, at 2:39 PM, Dr. John Provatopoulos B.Sc. M.D.C.M. F.R.S.C. wrote: At Sat, 21 Jun 2008, rchudacoff@mylinuxisp.com wrote: Grab the US with a Babcock clamp as high as you think necessary (palpate the ureter to make sure you grab the right thing). Come laterally through the vaginal epithelium-US-cardinal ligament complex, throw two times above the Babcock (make sure you don't go through the Babcock clamp) and then come out posterior on the ipsilateral side. Hold with a hemostat. After you close the cuff tie down and watch the cuff elevate. I use O Vicryl but some use Ethibond. I just don't want the permanent suture in the vaginal. I have only pinched the ureters once. Cysto with Indigo Carmine might be a good idea for your first few cases Richard Chudacoff, MD, FACOG -sent from my Treo 650 Now do that vaginally, yes it can be done vaginally, not exactly as Richard described but the same general idea. -- Take care, John CONFIDENTIALITY NOTICE AND DISCLAIMER The information in this transmission may be confidential and/or protected by legal professional privilege, and is intended only for the person or persons to whom it is addressed. If you are not such a person, you are warned that any disclosure, copying or dissemination of the information is unauthorised. If you have received the transmission in error, please immediately contact this office by telephone, fax or email, to inform us of the error and to enable arrangements to be made for the destruction of the transmission, or its return at our cost. No liability is accepted for any unauthorised use of the information contained in this transmission. If the transmission contains advice, the advice is based on instructions in relation to, and is provided to the addressee in connection with, the matter mentioned above. Responsibility is not accepted for reliance upon it by any other person or for any other purpose. Next message: Dean Huffman .: "Coding Question ..." Previous message: Lynn Montgomery: "Re: Butte" Maybe in reply to: rmodugno@aol.com: "High uterosacral vaginal vault suspensions"

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