Prof. Dr. Recai PABUCCUThe operation starts with the placement of a 20 F foley catheter in the patient prepared in the dorsolithotomy position. 30 ml Indigo Carmen is injected into the bladder and the foley catheter is clamped. After the laparoscopic trocars are placed, a transverse incision is made on the parietal peritoneum approximately 1 cm. above the symphisis pubis
The parietal peritoneum is dissected from the front wall of the abdomen towards the pubic bone, and the retropubic space is entered. This cavity is dissected with laparoscopic scissors. The symphisis pubis, obturator foramen, obturator neuromuscular cluster and arcus tendineus are the anatomical boundaries. The paravaginal fatty tissue in this area should be extracted as much as possible, causing scar formation and fibrosis in the paravaginal area. Then, the bladder is moved towards the medial. An assistant puts a finger in the vagina and separates the lateral superior sulcus of the vagina. This sulcus is sutured to the ‘arcus tendineus’ with permanent sutures such as 2.0 prolene. Full layer sutures are placed along the lateral sulcus of the vagina. During the operation, to prevent damage to the paraurethral vascular plexus, this plexus should be passed under and tied. Otherwise heavy bleeding may occur. To avoid bleeding, the first paravaginal suspension suture is placed near the ischial spine. Additional sutures are placed along the vaginal sulcus and fascia. The last suture should be placed as near the pubic ramus as possible. It is important that the pudental nerves and blood vessels are not damaged during the first suture. To this end, the ischial spines should be defined with the help of vaginal palpation and laparoscopy. The first suture is usually placed about 1 – 1.5 cm towards the ventral, along the white line. If cystourethrocele is also present, Burch sutures are placed. Then the retropubic space is irrigated with Ringer lactate. After the hemostasis of the area, peritonization is carried out with an absorbable suture such as 2.0 catgut. Lastly, a cystoscopy is carried out to evaluate if there are any sutures in the bladder, and the operation is concluded.
