Pediatric Laparoscopy

Abstract

Laparoscopy should be considered only as a mode of abdominal access and not a change in the operative technique. Ideally the indications for a laparoscopic approach to retropubic colposuspension should be the same as an open (laparotomy) approach. This would include patients with GSUI and urethral hypermobility. The authors believe the laparoscopic Burch colposuspension can be substituted for an open Burch colposuspension in the majority of cases. Factors that might influence this decision include any history of previous pelvic or antiincontinence surgery, the patient’s age and weight, the need for concomitant surgery, contraindications to general anesthesia, and the surgeon’s experience. The surgeon’s decision to proceed with a laparoscopic approach should be based on an objective clinical assessment of the patient as well as the surgeon’s own surgical skills. Loss of the lateral vaginal attachment to the pelvic sidewall is called a paravaginal defect and usually results in a cystourethrocele and urethral hypermobility. If the patient demonstrates a cystocele secondary to a paravaginal defect diagnosed either pre-or intraoperatively, a paravaginal defect repair should be performed before the colposuspension. This approach combines the paravaginal repair with Burch colposuspension for treatment of anterior vaginal prolapse secondary to paravaginalondary to urethral hypermobility. The paravaginal defect repair also places the anterior vaginal wall in its correct anatomic position, i.e. at the level of the arcus tendineus fascia pelvi prior to the Burch sutures being placed. This helps minimize the chance of overcorrection of the bladder neck with the Burch sutures because the paravaginal repair limits how much the Burch sutures can be tightened and only allows the bladder neck to be elevated approximately 1-2 cm above the level of the base of the bladder. This adjustment and limitation helps reduce the risk of postoperative voiding dysfunction.