Thomas C. Gerber, MD, PhD

• Professor of Medicine and Radiology
• Mayo Clinic College of Medicine
• Rochester, Minnesota
• Consultant in Cardiology
• Mayo Clinic
• Jacksonville, Florida

Once acquired cholesterol quail egg cheap 10mg zetia with mastercard, the immunity lasts for rest of its life such as in measles and chickenpox cholesterol medication blood sugar generic 10 mg zetia. For other diseases cholesterol medication when to start zetia 10 mg overnight delivery, especially in intestinal diseases cholesterol oxidation eggs purchase zetia toronto, the immunity is short lasting cholesterol test mayo clinic buy 10 mg zetia overnight delivery. In syphilis cholesterol medication body odor purchase 10mg zetia with amex, malaria and few other diseases, a special type of immunity is observed known as infection immunity (premunition). Comparison of active and passive immunity Active Passive Obtained passively, no participation Conferred by ready-made antibody Produced actively by the host immune system Induced by infection (clinical and subclinical) Induced by immunogens, vaccines Durability Lag phase Immunological memory Negative phase Application to immune deficient subjects Protection is durable and effective Present Present, subsequent challenge is more effective May occur Not applicable Protection is transient and less effective No lag phase No immunological memory, hence no secondary response No negative phase Effective in immune deficient hosts 32 Textbook of Immunology Artificially acquired active immunity: this type of immunity results from vaccination or immunization. Vaccinations may be inactivated bacterial toxins (toxoids), killed microorganisms, live but attenuated microorganisms or parts of microorganisms such as capsules. Killed vaccines are generally less immunogenic than the live vaccines and the immunity lasts only for a short period. Killed (inactivated) Passive Immunity Passive immunity is resistance exhibited by the host, when ready-made antibodies or defensive cells are introduced into the body. This form of protection is passive, because the individuals own immune system does not make antibodies or defensive cells against the disease producing agents or toxins. Naturally acquired passive immunity: this type of immunity involves natural transfer of antibodies from mother to her infant and also from mother to fetus. Certain antibodies (IgA) are passed from the mother to her nursing infants in breast milk, especially in the first secretion called colostrum. During pregnancy, some of the maternal antibodies are also transferred through placenta to the fetus. If the mother is immune to diphtheria, rubella or polio, the newborn Bacterial products Bacterial products and killed bacteria 2. Artificially acquired passive immunity: this type of immunity involves the introduction of antibodies into the body. These antibodies come from animal or person, who is already immune to the disease. Convalescent sera from patients very recently recovered from measles, rubella, etc. At times, instead of whole lymphocytes, an extract of lymphocytes (transfer factor of Lawrence) may be introduced as a therapeutic procedure in certain disease, such as lepromatous leprosy, immunodeficiency diseases such as Wiskott-Aldrich syndrome, disseminated malignancy, etc. Local Immunity the mucosal immune system is composed of the lymphoid tissues that are associated with the mucosal surface of the gastrointestinal, respiratory and the urogenital tracts. The system involves production of mucosal-related Ig that is IgA (secretory immunoglobulin). The primary function of the mucosal immune system is to provide defense to the host at mucosal surface, locally. Optimal host defense at the mucosal surface depends on both intact mucosal immue responses and non-immunologic protective functions such as residential bacterial flora, mucosal motor activity (peristalsis; ciliary function), mucus secretion that create barrier between potential pathogens and epithelial surfaces and innate immunity factors (lactoferin, lactoperoxidase and lysozyme). The concept local immunity has gained importance in the treatment of infections, which are either localized or where it is operative in combating infection at the site of primary entry of pathogens. The Sabin vaccine (for poliomyelitis) is administered orally to promote local IgA Indication of Passive Immunization 1. Passive immunization may also be employed to suppress active immunity, when the latter may be injurious. The commonest example is the use of Rh immunoglobulin during delivery to prevent immune response to rhesus factor in Rhnegative women with Rh-positive babies. Ideally, it is employed to provide immediate protection to non-immune individual with a tetanus-prone wound. Herd Immunity Herd immunity refers to an overall immunity exhibited by a community, which is relevant in the control of epidemic diseases. However, if a significant number of unprotected individuals become infected, the infection could spread rapidly through the unprotected members of population. In the course of that rapid replication, new mutant forms might arise that could evade the immune response and produce diseases in vaccinated individuals as well. The response may involve exclusively the humoral or cellular limb of the immune system, but most commonly involves both. Different lymphocytes, each with different set of receptors, recognize different epitopes on the same antigen. Based upon the nature of immune responses they generate, the antigens/epitopes are divided into three broad functional categories: 1. Immunogens (Complete Antigens) Immunogens are antigens/epitopes that induce immune response either by producing antibody or sensitized lymphocytes, which in turn react specifically with immunogens, which produced them. Although all molecules that have the property of immunogenicity also have the property of antigenicity, 36 Textbook of Immunology the reverse is not true. Some small molecules called haptens are antigenic, but incapable by themselves of inducing specific immune response. Haptens (partial Antigens) Haptens are small molecular weight substances, which are antigenic, but incapable by themselves of inducing specific immune response. The drug is not immunogenic by itself, but some people develop hypersensitivity reaction to it. In these people, when penicillin combines with serum protein, the resulting combined molecules initiate an immune reaction. Tolerogens Tolerogens are antigens (usually self), which induce in normal condition, immune unresponsiveness. During development of immune repertoire, tolerance to self-molecules and cells develop first. Therefore, there is no immune response against the self-tissue in normal healthy state. Lipid and nucleic acid are less immunogenic than heteropolymer containing three or more different amino acids. However, when the hapten is combined with a larger carrier molecule, usually a serum protein, the hapten and its carrier together function as an antigen and can stimulate an immune response. Recognition of lipid by T cells, as a part of immune response to some pathogens (Mycobacterium tuberculosis, M. Foreignness (Difference from self) An important function of the immune system is to distinguish self (host) from non-self (foreign). Therefore, the more dissimilar a molecule from host molecules, the greater its immunogenicity. Dosage, Route and Timing of Antigen Administration also determine the immunogenicity. It is possible to enhance the immunogenicity of a substance by mixing it with an adjuvant. Adjuvants are substances that maintain the continuous stimulation of the immune responsive cells by slow release. Antigenic Determinants (Epitopes) An antigen may have one or more antigenic determinants (a determinant is roughly 5 amino acids or sugars in size). More the number of epitopes are there, they are antigenic not immunogenic (fails to activate T lymphocytes and B lymphocytes). On the other hand the innate immune system uses preformed receptors, which are mostly found on the genetic Constitution of the Host Two members of the same species of animals may respond differently to the same antigen, because of a different composition of immune response genes. These receptors recognize broad structural motifs that are highly conserved within the microbial species, but are generally absent in host. In forensic application in the identification of species of blood and seminal fluid. Isospecificity Isoantigens are found in some, but not in all members of a species. The best examples of isoantigens are human erythrocyte antigens based on which different individuals are classified into different blood groups. Using hapten (atoxyl) coupled with protein, it was seen that antigenic specificity is determined by a single chemical grouping even by a single acid radical. The importance of position (ortho, meta and para) of the antigenic determinants in antigen molecules is also responsible for antigenic specificity. T-independent antigens have repeating units that can cross-link several antigen receptors on the same B cell. These antigens stimulate the B cell to make antibodies without the aid of helper T cells. These isoantigens, besides being of clinical importance in blood transfusion and isoimmunization in pregnancy, they are also helpful in providing valuable evidence in disputed paternity. Histocompatibility antigens are those cellular determinants specific for each individual species. These are recognized by genetically different individual of the same species; when attempts are made to transfer or transplant cellular material from one individual to other. Heterogenetic specificity the same or closely related antigens may occur in different biological species, classes and kingdom. This is a lipid-carbohydrate complex widely distributed in human beings, animals, birds, plants and bacteria. Other heterophilic antigens, used in serological test, unrelated to causative agents are: 1. Sheep red cells used in the diagnosis of infectious mononucleosis caused by Epstein-Barr virus (Paul-Bunnell). Red cell antigen in the diagnosis of primary atypical pneumonia caused by Mycoplasma pneumoniae (cold agglutination test). Autospecificity Autologous or self-antigens are ordinarily non-antigenic, but in certain circumstances self-antigens behave as foreign antigens. Lens protein has no access to circulation as confined inside the capsule (sequestrated antigens). Spermatozoa are absent in embryonic life, but subsequently develop in adolescent life. When these antigens are released into the circulation (by injury to lens or damage to the testis) antibodies are produced against them. Organ specificity Some organs such as brain, kidney, lens protein of different species share a common antigen. Antigen Recognition Molecules 5 In order for the immune system to respond to non-self, i. Soluble molecules (secreted from plasma cells) present in serum and tissue fluids, which are structurally identical to the B cell antigen receptor, but lack transmembrane and intracytoplasmic portion. They have a domain structure built on three dimensional features known as immunoglobulin fold (Ig fold). Their structure and functions so presumed to be members belonging to one gene family known as Ig supergene family. Following injection of antigen into the animal, certain substances appeared in the serum and the tissue fluid called antibody, which reacted with the antigen specifically in an observable manner. Depending on the type of reaction, the antibodies were known as agglutinin, precipitin and complement-fixing antibodies and so on. Fractionation of immune sera by halfsaturation with ammonium sulfate separated serum protein into soluble albumins and insoluble globulins. Tiselius, in 1937 separated serum proteins by electrophoresis into albumin, alphaglobulin, beta-globulin and gamma-globulin. Sedimentation studies using ultracentrifuge disclosed the diversity of the antibody molecules. In 1964, a common terminology was evolved called Ig and was accepted internationally. Definition Immunoglobulins are proteins of animal origin, endowed with known antibody activity and for certain other proteins related to them by chemical structure. That means the Ig include, besides antibody globulin, the abnormal proteins found in myeloma, macroglobulinemia, cryoglobulinemia, etc. While Ig satisfies the structural and chemical concept, the antibody provides biological and functional concept. Based on the physicochemical, antigenic differences and the types of heavy chain Igs are classified into five types. All Igs are made up of light (molecular weight 25,000) and heavy polypeptide chains (molecular weight 50,000). Both types can occur in all classes of Ig (IgG, IgM, IgA, IgE and IgD), but any one Ig contains only one type of L chain. The amino-terminal portion of each L chain contains a part of antigen-binding site. The amino-terminal portion of each H chain participates in the antigen-binding site. The carboxy-terminal portion forms the fraction crystallizable (Fc) fragment, which has various biologic activities (complement activation, macrophage fixation, reactivity with rheumatoid factor and binding to cell-surface receptors). An individual antibody molecule consists of two H chains and L chains, covalently linked by disulfide bonds. Proteolytic cleavage of IgG by Porter, Edelman and their colleagues led to a better understanding of the detailed structure of the Ig molecule. Papain treatment produces monovalent antigen-binding fragment (Fab) and Fc fragments. Variable regions are for antigen-binding and the constant regions are responsible for other biologic functions. In the variable regions of both L and H chains, there are three extremely variable (hypervariable) amino acid sequences that form the antigen-binding site. Classes of Immunoglobulin There are five classes of immunoglobulins, according to their properties (Table 5. This class of Ig is not only found in the bloodstream, but also in extravascular spaces. It is also transported across the placenta and is therefore, responsible for passive immunity in the fetus and neonate.

Bladeless direct optical trocar insertion in laparoscopic procedures on the obese patient cholesterol test large small zetia 10mg otc. Laparoscopic Burch colposuspension: A minimum 2-year follow-up and comparison with open colposuspension cholesterol levels in fertilized eggs purchase zetia 10mg without prescription. Serious trocar accidents in laparoscopic surgery: A french survey of 103 lowering cholesterol by diet and exercise order zetia 10 mg on line,852 operations cholesterol in shrimp and eggs buy discount zetia online. Use of computed tomography in the diagnosis of bowel complications after gynecologic surgery cholesterol measurement chart purchase zetia australia. Burden of adhesions in abdominal and pelvic surgery: Systematic review and met-analysis cholesterol content in eggs during the laying period order 10 mg zetia otc. Abdominal sacral colpopexy or vaginal sacrospinous colpopexy for vaginal vault prolapse: A prospective randomized study. Promontofixation coelioscopique: Resultats a court terme et complications chez 83 patientes. Intraoperative and postoperative gastrointestinal complications associated with laparoscopic sacrocolpopexy. Gastrointestinal complications following abdominal sacrocolpopexy for advanced pelvic organ prolapse. Robotic compared with laparoscopic sacrocolpopexy: A randomized controlled trial [article]. Abdominal sacrocolpopexy for vault prolapse without burial of mesh: A case series. Implementation of laparoscopic sacrocolpopexy: Establishment of a learning curve and short-term outcomes. Uretral catheter placement for prevention of ureteral injury during laparoscopic hysterectomy. Lumbosacral osteomyelitis after robot-assisted total laparoscopic hysterectomy and sacral colpopexy. The development of robotic surgery was aided by the Defense Advanced Research Projects Agency, who funded research into the possibility of a remote surgery program for battlefield triage. The benefits for the surgeon include the potential for greater precision, lower error rates, shorter learning curves, and superior ergonomics than conventional laparoscopy. By December 2012, there were 2,585 da Vinci Surgical Systems installed in approximately 2,025 hospitals worldwide with approximately 450,000 robot-assisted procedures performed in 2012, an increase of approximately 25% compared to 2011 [6]. The general definition of technology assessment used was "a comprehensive form of policy research that examines the short- and long-term social consequences of the application or use of technology. This makes them an ideal tool and reference point for systematic reviews of new technology. They are a valuable tool for health care policy making and decision making by governments. They concluded that based on the evidence available, the robot-assisted surgery may have a significant impact on many clinical outcomes in patients undergoing hysterectomy. In general, robotic surgery can have an impact on reducing hospitalization costs, but the investment made in acquiring this technology is significant, and institutions that choose to adopt it should make efforts to monitor its costs and outcomes in order to maximize cost-effectiveness within their own center. To decrease costs, centers should maximize caseloads, consider keeping the robot operational for longer durations if possible, and use the technology for multiple indications, particularly those with greater potential 1524 impact on important patient outcomes and savings on institutional costs. One of the key advantages of using robotic technology for gynecological procedures is the reduction in surgeon fatigue and the ability to perform complex surgery with a minimal invasive technique. The EndoWrist instruments used during surgery combines 7 degrees of freedom, with 90 degrees of articulation to provide a range of motion superior to the human hand. It also combines intuitive motion and fingertip control with motion scaling and tremor reduction technology to provide instruments with greater capabilities, and improved surgical dexterity. The principle of robotic surgery is that the surgeon operates unscrubbed while seated at the console, from which they are able to view the operating field in three dimensions through a stereoscopic viewer. Furthermore, the conversion rates reduced with increased operator experience [15]. A study by Akladios assessing learning curves in robotic surgery highlighted that once the learning curve is complete, the 1-year cure 1525 rate was 98%; however, there was a 20% de novo dyspareunia rate [16]. Despite the large number of papers published on robot-assisted sacrocolpopexy, there are a limited number of randomized controlled trials comparing laparoscopic with robotic sacrocolpopexy with main end points of operation time, pain, functional activity symptoms, cost, anatomical support, and quality of life [18,19]. There were no functional differences between the two groups, while the robot-assisted approach was associated with an increased cost, increased operative time, and increased pain. This finding of increased pain postoperatively is at odds with other studies, which show either similar or reduced pain scores with robotic surgery [20]. They concluded that robotic sacrocolpopexy was associated with decreased length of hospital stay, a low complication rate, and high patient satisfaction [23]. They further stated that the robotic approach may assist the surgeon in dissecting over the sacral promontory [24]. Open sacrocolpopexy is generally associated with greater blood loss, longer hospital stay, delayed return of bowel function, increased postoperative pain, and increased wound complications [25]. A drawback with regard to laparoscopic sacrocolpopexy is the associated technical difficulty in placing sutures [26]. Ploumidis in a retrospective review of 94 cases undergoing robot-assisted sacrocolpopexy with specific regard to complications found one case in which a Clavien grade 3 postoperative complication occurred [27]. Subsequently, there was one case of mesh erosion during a follow-up period of 36 months. There were two cases of mesh erosion in the robot-assisted sacrocolpopexy group [28]. The data on 1488 robot-assisted sacrocolpopexies were collected from 27 studies, published from 2006 to 2013. The results revealed objective and subjective cure rates ranged from 84% to 100% and from 92% to 95%, respectively. Robot-Assisted Sacrocolpopexy: the Technique the robot-assisted sacrocolpopexy was first described in 2004 by DiMarco [30] as follows: the procedure combines the use of standard laparoscopy with the da Vinci robotic system. One camera port, two robotic ports, and two standard laparoscopic ports are placed. Standard laparoscopic dissection is used for initial anterior and posterior vaginal mobilization and exposure of the sacral promontory. The da Vinci robot is then docked and used to suture a silicone Y-shaped graft from the vagina to the sacral promontory. The culdoplasty, with plication of the uterosacral ligaments, is then performed, with the final step, retroperitonealization of the graft. However, over the last number of years with increased surgeon take-up of this technology, the procedure has been modified. In our current practice, the patient is placed in moderate to steep Trendelenburg, and the legs are then placed in the low lithotomy position. The robot is then docked, the camera arm attaching to the camera port, and the instrument arms subsequently attached and instruments introduced under direct vision. The assistant port is the left superolateral port to facilitate introduction of sutures and ports. The anterior and posterior vaginal walls are mobilized, and following this the sacral promontory is exposed, and a track created to allow the peritoneum to be closed over the mesh. The Y-shaped mesh is then attached from the anterior and posterior walls of the vagina to the anterior longitudinal ligament using permanent sutures. Overall robot-assisted sacrocolpopexy is associated with increased operative time compared to the laparoscopic approach [32]. Many publications include training operative times and the operative times for fellows/trainees. While we are aware the learning curves are short, the inclusion of these operative times presents a bias in the times reported. Therefore, to correctly comment on operative times publications should report openly on which times are included. The evidence available suggests comparable safety and efficacy when comparing robot-assisted to open sacrocolpopexy. The surgical technique used in open/laparoscopic/robot-assisted sacrocolpopexy varies depending on the surgeon across all stages of the procedure. Many papers fail to describe the technique used to perform the surgery, thus making comparison in terms of operation time and outcomes difficult. A consensus is required with regard to the optimal operative technique used to 1527 perform a sacrocolpopexy irrespective of approach used. Approaches including abdominal, vaginal, and laparoscopic are effective in the management of uterine prolapse where uterine preservation is required [33]. Successful pregnancies have been reported following laparoscopic hysteropexy; however, the long-term effects of pregnancy on the surgery are not yet fully appreciated [37]. Due to technical difficulties, the laparoscopic approaches have failed to achieve widespread adoption. A recently published case series found the robot-assisted approach to be a safe, feasible alternative to both the open and laparoscopic approach in adults [41]. Vesicovaginal Fistula Repair Another area of urogynecology where the robot-assisted approach has been used is vesicovaginal fistula repair. The robot technology allows a complicated laparoscopic procedure to be performed safely with good results. Traditionally, these fistulae are surgically managed via an open approach, as they are not accessible transvaginally. The robot aids in the complex dissection and reconstructive techniques required for this type of surgery (Video 103. Many colleges/boards responsible for the training of surgeons have implemented prerequisites that must be achieved to attain certification to perform surgery. Furthermore, surgeons are required to maintain and update their skills by achieving educational targets. The American Board of Surgeons requires a surgeon to achieve 90 hours of continued medical education credits every 3 years to maintain certification. To facilitate this, the Society of American Gastroenterologists and Endoscopic Surgeons has developed an online university that features journal club, online assessment program, and guidelines. Robot-assisted surgery has created new challenges to ensure proper training and avoid subjecting patients to unnecessary risk. Increased scrutiny of credentialing and medicolegal aspects of robotic surgery have reinforced the importance of training and have led to a number of papers outlining pathways to facilitate this [47,48]. The learning tools for robotic surgery include simulators, dual consoles, robotic courses, and proctoring. The length of the course varies from several hours to several days, sometimes even weeks in a 1528 mini-fellowship situation. They can be designed to target specific (or a subset of) technical skills needed to understand the basic functionality of a robotic system [47,52]. With various levels of difficulty, a continuum of inanimate exercises can guide surgeons of different abilities through their initial learning curves. Inanimate exercises for learning the fundamentals of laparoscopic surgery can be expanded to effectively target robot-specific skills [53]. In order to be useful training tools, inanimate exercises must challenge both specific technical skills of using a robotic surgical system and have validated metrics so that surgeons can accurately track their performance [54]. It is certain that the advent of excellent surgical simulators and structured inanimate exercises has provided tools for novice surgeons to acquire console skills in a safe and structured environment. This will enhance their operating performance and reduce aspects of the learning curve such as operating time; however, the lack of availability of in vivo training opportunities greatly limits the applicability of this method of surgical training [55]. Dual Console the introduction of the da Vinci Si Surgical System has given surgeons a second robotic console, facilitating collaboration between the proctor and trainee. The mentoring console has two collaborative modes: (1) the swap mode allows the mentor and trainee to operate simultaneously and actively swap control of the robotic arms. Live Surgery and Proctoring Live case observation remains an important component of a robotic training program [56] and allows the trainee to become familiar with the steps of a specific robotic procedure. Proctoring is defined as direct supervision by an expert during the initial phase of training and the learning curve [56]. It provides a safe environment during the introduction of a new technique and prevents surgeons from performing procedures before they have mastered the technique. The reality is that simulators, dual consoles, and robotic courses should play an important role in bridging the gap between early surgical skills and effective performance using the robot in a clinical setting without subjecting patients to unnecessary risk. Participants who acquire skills faster regain robotic skills faster after a training hiatus, but, on retraining, all participants can regain equivalent competence. One institution has incorporated a graduated program of resident and fellow console involvement based on level of training.

Laparoscopic promontory sacral colpopexy: Is the posterior grams of cholesterol in eggs generic zetia 10mg with visa, recto-vaginal cholesterol ratio blood test zetia 10mg with visa, mesh mandatory Porcine dermis compared with propylene mesh for laparoscopic sacral colpopexy: A randomized controlled trial cholesterol lowering foods fish oil zetia 10 mg without a prescription. Long-term results of robotic assisted laparoscopy: Sacrocolpopexy for the treatment of high grade vaginal vault prolapse cholesterol blood test values 10 mg zetia sale. Basic science and clinical studies coincide: Active treatment approach is needed after a sports injury cholesterol in shrimps good or bad buy generic zetia 10 mg line. Tension-free vaginal tape and laparoscopic mesh colposuspension in the treatment of stress urinary incontinence: Immediate outcome and complications-A randomised clinical trial increased cholesterol definition cheap 10mg zetia free shipping. Randomized prospective comparison of needle colposuspension versus endopelvic fascia plication for potential stress incontinence prophylaxis in women undergoing vaginal reconstruction for stage 3 or 4 pelvic organ prolapse. Laparoscopic sacrocolpopexy with Gynemesh as graft material-Experience and results. A comparison of laparoscopic and abdominal sacral colpopexy: Objective outcome and perioperative differences. Vaginal sacrospinous colpopexy and laparoscopic sacral colpopexy for vaginal vault prolapse. The absolute indication is fertility preservation in women who have not yet completed childbearing. However, this is a small group of patients; most women presenting requiring surgery for prolapse have no desire for further children, indeed the majority are postmenopausal. The latter is a contentious statement; clinical data is still sparse and will be discussed in this chapter. However, when there is loss of apical support, traditional vaginal hysterectomy will not correct defects. This is most readily apparent when women present with procidentia; it is self-evident that hysterectomy will not treat vaginal eversion. If hysterectomy is performed, additional vaginal suspension needs to be provided, usually either by sacrospinous fixation or sacrocolpopexy. Hysteropexy, in our view, offers a more logical approach, and furthermore avoids vaginal mesh, with the attendant extrusion risk it carries. While it has served the gynecologist well for many years, its continued use raises some significant questions. Vaginal hysterectomy fails to address the underlying deficiency in connective tissue pelvic floor support [1] that causes prolapse; indeed, the uterosacral ligaments are cut during the operation-it is hardly surprising that recurrent prolapse rates are so high, with rates of up to 40% described in the literature [2,3]. Recurrence can manifest with vaginal vault eversion, or more commonly recurrent enterocoele/cystocele. We know that cystocele commonly arises because of loss of apical type 1 vaginal support [4], and until apical support is established, it will recur. Up to one in four women may develop a vault hematoma following vaginal hysterectomy. This may be due to the wish to preserve fertility, or due to the belief that female identity is bound up in the female genital organs. It frequently arises after they have researched literature and the internet themselves and become aware that there are alternatives to hysterectomy. The overall rate of hysterectomy as treatment for menstrual dysfunction is also declining significantly. In 1888, Archibald Donald first described the Manchester repair as an alternative to vaginal hysterectomy for patients with uterine prolapse, although this may have been a more useful technique for patients with an elongated cervix rather than a true uterine descent. In 1934, Victor Bonney highlighted the passive role of the uterus in uterovaginal prolapse, telling us it was merely the symptom of underlying poor pelvic floor support [6]. Subsequent surgeons have developed techniques for uterine preservation via a vaginal, abdominal, or laparoscopic approach. His method involved a posterior colpotomy with division of the uterosacral ligaments from the cervix, plication across the midline, and reinsertion into the cervix. The cervix or uterosacral ligament is transfixed to the sacrospinous ligament using either permanent or delayed absorbable sutures. In 2001, Maher [9] reported a small comparison study between sacrospinous hysteropexy and vaginal hysterectomy with sacrospinous vault fixation, with no differences in objective or subjective outcomes at follow-up. Other studies have suggested that sacrospinous hysteropexy has a shorter operative time and reduced blood loss as compared to vaginal hysterectomy [10]. One study also reported less postoperative incidence of overactive bladder symptoms in the sacrospinous hysteropexy group [11]. Sacrospinous hysteropexy is the most studied vaginal technique for uterine preservation prolapse surgery; however, in general, the studies assessing it are of poor quality, with small numbers, of short follow-up periods, of lack of controls, and with limited functional outcome data. The technique of posterior vaginal slingplasty [13] was first described in 2001, using a mesh kit to create "neo-uterosacral ligaments. Abdominal Approach A number of methods for abdominal hysteropexy have been described, including transfixing the uterus to the anterior abdominal wall and ventral fixation to the pectineal ligaments. Most techniques use the sacral promontory as the fixation point, giving rise to the term abdominal sacrohysteropexy. Abdominal suture sacrohysteropexy [16] was described as early as 1957, with the uterine fundus being fixed to the sacral promontory with silk sutures. More recent techniques have utilized a variety of synthetic meshes to aid fixation. Leron and Stanton [18] followed up 13 women undergoing abdominal sacrohysteropexy and found it to be a safe and effective surgery for the management of uterine prolapse. Sacrohysteropexy was associated with a shorter operative time and hospital stay, with a reduction seen in intraoperative blood loss. It is difficult to interpret data reporting comparisons between abdominal sacrohysteropexy and hysterectomy due to variations used in surgical technique and differences in mesh type, size, shape, and attachment points. Laparoscopic Approach Laparoscopic abdominal surgery has, with very few exceptions, replaced laparotomy in many centers. The laparoscope confers better vision than laparotomy, allowing a magnified, high definition view. Furthermore, the long instruments allow better pelvic access, particularly behind the uterus, than laparotomy confers. A number of laparoscopic uterine suspension procedures have been described using different methods. Laparoscopic ventrosuspension proposes suturing the round ligaments to the rectus sheath. The round ligament is not however particularly robust, and perhaps as expected, it has been shown to have poor outcomes, with one case series of nine women reporting recurrent prolapse in all but one patient within 6 months [21]. While they reported good outcomes, all patients experienced significant pain or dragging 1501 sensations over the mesh attachment site. Recently, techniques have focused on using the sacral promontory as a point of fixation. The peritoneum is opened over the sacral promontory and the rectum is reflected laterally. A tunnel is created by blunt dissection underneath the peritoneum from the sacral promontory to the insertion of the uterosacral ligament complex into the cervix on either side. Mersilene tape on a needle is placed through the cervix, through the uterosacral ligaments, and through the peritoneal tunnels on each side before being tacked to the sacral promontory bilaterally to suspend the uterus. This technique aims for the sling to resemble newly created uterosacral ligaments. We therefore developed a method of complete cervical encirclage (The Oxford Hysteropexy, Price et al. Initial follow-up studies [28] show good outcomes with significant improvement (p < 0. The rest of this chapter looks at the technique of laparoscopic hysteropexy in more detail. Two strong attachment points are used; the cervix and the anterior longitudinal ligament overlying the sacral promontory. The theoretical advantage is that this type of repair, by augmenting weak connective tissue with prosthetic prolene, confers stronger apical support resulting in lower recurrence rates. It allows the patient to retain their fertility; and by avoiding vaginal surgery, there is a lower potential for dyspareunia and sexual dysfunction. A four-port laparoscopic technique is used with 10 mm umbilical, two 5 mm lateral, and a 12 mm suprapubic port inserted. After identifying the sacral promontory, the peritoneum is incised with bipolar graspers and monopolar scissors to identify a safe window of periosteum. A peritoneal relaxing incision is then used medial to the right ureter to retract it from the surgical site and extended into the pelvis, lateral to the rectum. The right uterosacral ligament is identified and the peritoneum is opened over this, where the uterosacral ligaments insert into the cervix. The vesicouterine peritoneum is incised to reflect the bladder away and bilateral avascular windows are created in the broad ligament, lateral to the uterine arteries, at the level of the internal os. This is transfixed to the anterior cervix using nondissolvable, nonabsorbable polyester 2-0 sutures 1502 (Ethibond). The mesh is attached to the sacral promontory under moderate tension using two to three 5 mm helical fasteners (Pro-Tack, Covidien). The technique has evolved over time; initially reperitonization was not performed, however after two patients undergoing subsequent laparoscopies were found to have bowel adhesions to the mesh, this adaptation was introduced. However, surgery can be complicated by unexpected anatomical anomalies and the surgeon should be aware of these to minimize risk. Less experienced laparoscopic surgeons would be well advised to consent patients for alternative options, such as vaginal surgery, should anatomical anomalies make laparoscopic surgery too challenging. The left common iliac vein can be particularly difficult to identify as it traverses the lumbar spine. Beware the boggy sacral promontory (called the pillow sign, on account of the similarity to pressing on a pillow); when the laparoscopic instruments palpate soft tissue rather than firm sacral promontory, you are either encountering periosteal fat, or low bifurcating great vessels; dissect carefully! Pelvic Sidewall There is usually a very safe window between the rectosigmoid medially and the ureter laterally that can be opened and used to bury the sacral mesh tail. Broad Ligament There is usually a large avascular window in the broad ligament lateral to the uterine artery that can be safely opened. One major advantage is the magnified image giving excellent intraoperative visualization of the pelvic anatomy. The other significant advantage is improved access to parts of the pelvis that are difficult to reach via an abdominal incision. In particular, access to the Pouch of Douglas is enhanced at laparoscopic hysteropexy, compared with laparotomy. General advantages of laparoscopic compared to open surgery are reduced hospital stay, reduced need for analgesia, quicker recovery, and minimal blood loss. The main disadvantage of laparoscopic surgery is the initial increase in operating time while the surgeon learns laparoscopic techniques. Focused training and use of skills labs and laparoscopic simulators can help to address this issue. As a new generation of surgeons develop, trained from the outset in laparoscopic techniques, such concerns will become obsolete. Many skilled laparoscopic surgeons, in fact, find that if they are in a situation where open surgery is required, the operating times are slower and visualization of the anatomy is poorer. One prospective observational study [28] has reported outcomes following laparoscopic sacrohysteropexy in 140 women. Eighty-nine percent of women felt their prolapse was "very much" or "much" better. Four percent of women experienced further apical prolapse of which half underwent further surgical intervention. This compares favorably with the risk of vault prolapse following vaginal hysterectomy [30]. One reason for recurrent apical prolapse was the initial mesh either being left too loose or stretching in vivo. This was simply treated by mesh plication (Prolene or Ethibond nonabsorbable sutures). The authors have now modified their technique and are using a more robust mesh, 5 cm in width compared with a previous 3 cm mesh that was more susceptible to stretch. The rate of serious complications was 4%, and comprised of bowel adhesions (prior to the modified reperitonization technique), broad ligament vascular injury and one pulmonary embolus. Ninety-two 1504 percent of women when asked would recommend the operation to a friend. As this is still a relatively new technique, more outcome data over a longer time frame is needed to enable comparison with more traditional approaches. However, this benefit is less relevant with current advances in minimally invasive treatment of abnormal uterine bleeding. The cervical screening program is reducing cervical cancer incidence, and endometrial cancer classically presents at an early stage with uterine bleeding. Therefore, hysterectomy, to prevent future malignancy, seems irrational and totally unnecessary. There may be some value in screening women listed for laparoscopic sacrohysteropexy with an ultrasound scan before surgery. It may therefore be the preferred approach for younger patients who may not have completed their family. Patients must however be counseled that data for pregnancy outcomes following the procedure are scarce, and the impact of the pregnancy on the surgery and indeed the effect of the surgery on the pregnancy are unknown. With the Oxford hysteropexy, the mesh encircles the cervix and vaginal birth is therefore not possible; in effect, the mesh acts as a cervical suture. There is also concern that uterine blood flow may be compromised as the mesh potentially surrounds the uterine arteries, although it is likely that a rich collateral supply is formed. Since introducing hysteropexy as our standard approach to uterine prolapse, the authors have been aware of three patients who have subsequently conceived. One patient has been followed through to delivery in conjunction with her obstetrician [33]. Uterine artery Doppler studies at 23 weeks of gestation showed no compromise to blood flow.

Cheap zetia 10 mg fast delivery. Importance of lipid rafts.