06: Tips and tricks: a novel approach to complete trans-obturator sling mesh removal

Abstract

The purpose of this video is to demonstrate tips and tricks for removing the entirety of trans-obturator sling mesh when it cannot be found through bilateral groin dissections; we believe these techniques are especially useful in patients with poor wound healing, as they limit the extent of dissection necessary to remove the mesh completely. We demonstrate these techniques on a patient with severe scleroderma to show the utility of this approach in patients with poor wound healing. The first trick involves performing a minimally invasive bilateral groin dissection. Attempts to localize the mesh are performed by separating muscle fibers of the adductor brevis and the obturator externus with the nasal speculum rather than transecting the muscles. We then acknowledge that even with adequate groin dissection, finding the mesh can often be difficult. The second trick is to localize the mesh trans-vaginally and use a vessel loop to better delineate the borders of the mesh and facilitate a lateral dissection. The final trick involves using a novel technique of dividing the mesh in the midline, tagging the medial edge of the mesh with sutures, grasping these sutures with a clamp that is passed through the lateral groin dissection, and completely removing the mesh through the thigh incision by tugging on the clamp. This approach to trans-obturator sling mesh removal facilitates complete mesh removal through the groin incision with less extensive dissection, thus reducing postoperative pain and inflammation. We believe this technique is especially important for medically complex patients with a history of poor wound healing, as it maximizes the chances of complete mesh removal while avoiding a more extensive and morbid groin dissection.