1957 Robotic Assisted Mesh Removal: Posterior Vaginal Mesh Kit and Perivesical Mesh Invading Obturator Internus

Abstract

Video Objective This video depicts a surgical approach in a patient with both a complicated and unclear surgical history, with inability to obtain complete surgical record. It demonstrates a robotic assisted laparoscopic approach to removal of mesh in a patient with persistent pelvic pain with an unclear or unknown mesh location. Setting This is a 60 year old woman with a remote history of hysterectomy for benign indications. Per patient, she subsequently developed symptomatic prolapse for which she underwent a “bladder sling” and two “hernia repairs” which necessitated suprapubic catheter post-operatively. She then experienced worsening pelvic pain since that time, now years later, and with constant rectal pressure and more recent post-coital bleeding. The patient is adamant on complete mesh removal. This was performed as an ambulatory surgery within a hospital setting. Interventions Pelvic examination revealed noticeable tenderness of anterior vaginal wall, with no exposed mesh or bleeding. The video itself depicts a robotic assisted laparoscopic removal of bilateral posterior vaginal mesh kit and left perivesical mesh invading obturator internus. Careful surgical technique involving bladder dissection off vaginal cuff, ureterolysis, and dissection throughout the space of Retzius down to the obturator internus muscle is carried out with complete removal of multiple mesh components. Conclusion Avoiding transection of the mesh along with meticulous dissection aides in traction and greatest chance of complete removal. Maintenance of hemostasis is critical for adequate visualization, especially within the space of Retzius. Knowledge of pelvic anatomy is paramount, as scarring, fibrosis, and mesh migration can distort normal anatomical planes.