DR. LENROY BRYAN
OBSTETRICAN AND GYNAECOLOGIST
MBBS, DM( O&G) (UWI), MRCOG (LOND)
DMAS OCT 2019 BATCH. WORLD LAPAROSCOPY HOSPITAL INDIA 

Introduction
Urinary stress incontinence (USI) is the involuntary leakage of urine during increased abdominal pressures in the absence of detrusor activity. It affects 25 % to 35%  of the US female population(1-2). The generally accepted etiology is urethral hypermobility due to weakness of the underlying urethral support, although there can be a component of urethral sphincter weakness. Burch colposuspension, first described by John C Burch in 1961, was the recommended surgical treatment of choice with cure rates between 80% and 90%. Since the advent of vaginal mesh sling procedures,  Burch colposuspension procedures became less popular as these vaginal tapes had similar cure rates, had shorter operating times, and could be performed under sedation. In 2011 however, the Food and Drug Administration(FDA ) had a notification on serious complications on vaginal mesh (2-3). .In 2018 the use of vaginal mesh was halted across the UK amid safety concerns. With these negative publicities, there are renewed interests in performing Burch colposuspension as this avoids the unique complications associated with vaginal mesh procedures. The laparoscopic Burch colposuspension has a similar cure rate to the open procedure with the added advantage of less blood loss and earlier return to normal activity after the operation.

Pre-operative assessment 
-    Ensure there is a justified indication for surgery. This involves a thorough clinical evaluation and urodynamic investigation to exclude other causes of urinary incontinence
-    Anesthetist consult should be made to ensure the patient is optimized and fit for surgery
-    Informed consent must be obtained.



Equipment and safety checks
-    Ensure equipment is functional.
-    Ensure instruments are sterilized
-    Perform the WHO checklist
-    Ensure a laparotomy set is available should conversion to laparotomy becomes necessary
Anesthesia
-    This should be general anesthesia. Give perioperative antibiotics 30mins before the first skin incision
-    Clean and drape the abdomen.
Creation of pneumoperitoneum and placement of the primary port.
- Check the veress needle for spring action and patency
- Make a 2mm incision with No 11 surgical blade into the lower crease on the umbilicus
- Lift the abdominal wall area below the umbilicus and assess its full thickness
- Hold the veress needle like a dart at a level of 4cm plus the estimated thickness of the abdominal wall.
- Insert the  veress needle through the incision site such that the veress needle makes an angle of 900 with the abdominal wall and an angle of 450with the body of the patient
- Ensure two audible clicks are heard; one of the rectus sheaths is entered and another when the peritoneum is entered.
- Hold the veress needle at an angleof  450 to the patient’s body and perform confirmatory tests for successful peritoneum entry.

Perform the following tests:
1.     Irrigation Test: Injecting 5ml of normal saline, free flow confirms placement inside the peritoneal cavity
2.    Aspiration Test: There should not be any returning fluid, confirms placement inside the peritoneal cavity
3.    Hanging Drop Test: Drop of Normal Saline is placed at the hub of the Veress Needle, and the abdominal wall is lifted. The suction of this drop into the abdominal cavity confirms placement inside the peritoneal cavity
4.    Quadro-manometric Test
.
- Ensure that the gas tubing is attached to the insufflator and the insufflator is switched on. This will remove air from the gas tubing 
-  Pre-set pressure should be 15mmHg on the insufflator
- Attach the gas tubing to the veress needle and start the flow of CO2gas at 1 liter per minute
- Percuss over the right hypochondrium for of liver dullness after 200mls for C02
- Watch the insufflator reading of the flow of gas, actual pressure, and the total amount of gas used.
- The total amount of gas and actual pressure should raise parallel to each other
- When the actual pressure has reached pre-set pressure and amount of gas used is 1.5 liters, remove the veress needle from the abdomen and start preparation for Primary port site 
Insertion

Primary Port Insertion
- Use the primary port trocar to make an impression over the inferior crease of the umbilicus
- Increase the size of the umbilical incision to 11mm and dissect the subcutaneous tissue with an artery forceps using the Scandinavian technique
- Hold the 10mm port like a gun with index finger along the shaft, middle & ring finger wrapped around the gas vent and the port resting on to the thenar eminence of the palm and tip pointing towards the incision site
- Introduced the port through the incision in a rotating fashion pointing perpendicularly to the skin and 600 to the patient’s body.
- Once into the peritoneal cavity evident by an audible click and give-way sensation; direct the port at an angle towards the pelvis
- On removal of the trocar from the cannula, a whooshing sound of escaping gas is audible, which further confirms entry into the abdominal cavity. 
- The gas tubing should now be connected to the primary port.
- Focus the 300 telescopes and perform white balancing.
- Insert the 300  telescope into the primary port and visualize the intra-abdominal entry. 
- Immediately inspect the abdomen below the primary port site for any signs of injury

Patient position
-    15 degree Tredelenburg and  legs open.

Position of the surgical team
-    Primary Surgeon - Left side of the patient
-    Assistant Surgeon- Right side of the patient
-    Camera assistant - to the Right of the primary surgeon
-    Vaginal assistant- between the patient's legs
-    Scrub Nurse - by the left side of the Primary Surgeon
-    Anesthetist - at the head of the patient
-    Coaxial alignment- The primary surgeon, the target of dissection and monitor should form a straight line

Task Analysis
1.    Accessory Port placement- After pneumoperitoneum is created and the a 10mm umbilical port for the telescopeis placed, place  two contralateral 5mm ports infra-umbilically using the baseball diamond principle(on a 18cm arc) and the bladder neck as the target of dissection. Each port should be 7.5cm lateral to the Primary port
2.    Bladder preparation. Pass a 16F Foleys catheter into the bladder and anchor by distending the bulb. Instill 300mls methylene blue solution through the urinary catheter to distend the bladder. The catheter should be clamped to maintain bladder distension
3.    Patient position. Place the patient in the head down 15 degrees lithotomy position with the legs open
4.    Perform a diagnostic laparoscopy. This is to visualize important anatomical landmarks for dissection and identify the potential danger zones( trapezoid of disaster and the triangle of the dome). The median umbilical ligament,  medial umbilical ligaments and the delineated dome of the distended bladder should be clearly visualized
5.    Enter the space of Retzius.Grasp the peritoneum over the median umbilical ligament and make a transverse incision (using harmonic scalpel) in this peritoneum at a point 3 cm above the delineated dome of the distended bladder. The lower fold of the cut end of the peritoneum should be pulled down to expose the space of Retzius, and the incision extended laterally but not beyond the medial umbilical ligaments.
6.     Identify coopers ligament and tendinous arch of levator ani muscle (TALA). Use the atraumatic grasper/pledget to bluntly dissect the loose areolar tissue in the space of Retzius until the cooper’s ligaments are seen. The pneumoperitoneum will assist in this dissection as CO2 gets inside this space. The cooper’s ligament is identified as bright white structure (light house), which runs laterally on either side of the posterior surface of the superior pubic rami. Care must be taken not to extend the dissection too posterior laterally to avoid injury to obturator nerve and aberrant obturator vessels. The TALA is a white line below ( caudal)coopers ligament
7.    Exposure of the paravaginal fascia. Ask the vaginal assistant to insert a finger into each lateral fornix of the vagina at the level of the bladder neck- this can be identified by pulling gently on the catheter, so the bulb fits snuggly at the vesicourethral junction. Using the pledget, perform blunt dissection of the fibro-fatty tissue from lateral to medial on to the vaginal fingers until the shiny white surface of the paravaginal fascia is seen on either side, and the vesicourethral junction becomes obvious. Of note the dissection should be limited to 2cm lateral to the urethra to avoid injury to the  surrounding musculature
8.    Placement of a suprapubic port. A third accessory (5mm)port is now placed suprapubically to assist with longitudinal suturing of the paravaginal tissue since these muscle fibers run horizontally.
9.    Approximation of paravaginal tissue to coopers ligaments bilaterally. 
A.    Introduce 90cm of size 1.0 braided nonabsorbable suture (silk) through the 5mm accessory port.
B.    Ask the vaginal assistant to push the finger upwards in the lateral vaginal fornix at the level of the bladder neck, and the finger should be covered with a needle guard to avoid needle stick injury. 
C.    Place the needle holder through the suprapubic port and hold the needle. At the level of the bladder neck, take a longitudinal bite of the paravaginal tissue, this should be full thickness but avoiding the epithelium of the vagina. 
D.    Take a horizontal bite on the ipsilateral cooper’s ligament at a point 4 cm lateral to the pubic tubercle. 
E.    Pull both ends of the suture through the accessory port and make an extracorporal Weston knot 
F.    Pull tension on the suture and the knot will slip down without the need for a knot pusher
G.    With the assistant finger pushing the paravaginal tissue upwards, pull the tail end of the suture to lock the knot such that the paravaginal tissue suspended at the level of TALA. This should be loose as over-tightening increases the risk of urinary retention. Repeat this suturing on the opposite side of the paravaginal tissue at the level of the bladder neck.  Another pair of the suture is placed on either side of the bladder neck and approximated to the ipsilateral cooper’s ligament at a distance, 1.5cm from the first.
10.    Check for hemostasis. Any significant bleeding should be controlled only with bipolar coagulation to reduce the risk of electrosurgical injuries. There is no need to close the peritoneum over the space of Retzius as this will be approximated when the pneumoperitoneum resolves
11.    Check for Bladder injury. Extravasation of methylene blue would suggest bladder or urethral injury.
12.    Remove the ports. Under vision from the telescope, remove the 5mm ports under vision. Using a blunt tip trocar within the cannula to avoid bowel being sucked into the incision site on removal. Remove the primary port. 
13.    Skin closure. The skin incisions should be closed with a single bite of absorbable 3.0 vicryl/monocryl
14.    Postoperatively. Remove the bladder clamp and keep the urinary catheter insitu on free drainage for 48hrs. Advise the patient of symptoms and signs suggestive of urinary retention and detrusor instability.

References

1.    Markland AD, Richter HE, et al.Prevalence and Trends of Urinary Incontinence in Adults in the United States, 2001 to 2008.J Urol 2011;186(2):589–93.
2.    Sohlberg E, Elliott C, Burch Colposuspension.Urol Clin N Am 46 (2019) 53–59
3.    Drain A, Khan A, Ohmann E, et al. Use of concomitant Stress incontinence surgery at the time of pelvic organ prolapse surgery since the release of the 2011 notification on serious complications associated with transvaginal mesh. J Urol 2017;197(4):1092–8.
4.    Mishra RK. Textbook of laparoscopic surgery. 3rd ed.New Delhi.Jaypee Brothers medical publishers in 2013. Chapter 36.Laparoscopic management of stress incontinence. P408-4011.