title: Effect of operative technique on mesh exposure in laparoscopic sacrocolpopexy.
abstract: OBJECTIVE
  To determine if opening the vaginal cuff during laparoscopic sacrocolpopexy influences the rate of mesh exposure.
  
  
  METHODS
  A total of 390 medical records were retrospectively reviewed for demographic information, operative technique, and relevant outcomes.
  
  
  RESULTS
  Eleven mesh exposures (2.8%) and 14 suture extrusions (3.6%) were found, none involving visceral organs. Mesh exposure was more common when the vaginal cuff was opened, either during hysterectomy or when allowing transvaginal attachment of mesh in patients with a prior hysterectomy (4.9% vs 0.5%; relative risk [RR], 9.0, P = 0.012). In cases where concomitant hysterectomy was performed, a higher mesh exposure rate was seen in open-cuff hysterectomy (total vaginal hysterectomy/laparoscopically assisted vaginal hysterectomy) compared to supracervical hysterectomy (4.9% [9/185] vs 0% [0/92]; P = 0.032). Mesh exposure was more common when the mesh was sutured laparoscopically compared with transvaginally in patients undergoing open-cuff hysterectomy (14.3% [5/35] vs 2.7% [4/150]; RR, 5.4; P = 0.013). Permanent suture extrusion was significantly associated with laparoscopic versus transvaginal suturing of mesh (5.6% vs 0.6%; RR, 8.8; P = 0.010). Five patients underwent reoperation for mesh exposure, whereas most suture extrusions were asymptomatic; and all were managed nonsurgically.
  
  
  CONCLUSIONS
  We found that preserving the integrity of the vaginal cuff led to a lower incidence of mesh exposure in patients undergoing laparoscopic sacrocolpopexy. When hysterectomy is indicated, a supracervical technique should be strongly considered as the mesh exposure rate was significantly lower. If removal of the cervix is indicated, the risk for mesh exposure remains low and should not preclude total hysterectomy, though transvaginal mesh attachment may be preferable.
authors.affiliation: Department of Obstetrics and Gynecology, Walter Reed National Military Medical Center, Bethesda, MD, USA. homegrown95@yahoo.com
authors.forename: William B
authors.initials: WB
authors.lastname: Warner
authors.forename: Sonali
authors.initials: S
authors.lastname: Vora
authors.forename: Eric A
authors.initials: EA
authors.lastname: Hurtado
authors.forename: Jeffrey A
authors.initials: JA
authors.lastname: Welgoss
authors.forename: Nicolette S
authors.initials: NS
authors.lastname: Horbach
authors.forename: Walter S
authors.initials: WS
authors.lastname: von Pechmann
mesh_terms: D000368:Aged; D005260:Female; D006801:Humans; D007045:Hysterectomy, Vaginal / Q000295:instrumentation / Q000379:methods / Q000592:standards; D015994:Incidence; D010535:Laparoscopy / Q000295:instrumentation / Q000379:methods / Q000592:standards; D008875:Middle Aged; D010043:Outcome and Process Assessment, Health Care / Q000706:statistics & numerical data; D011183:Postoperative Complications / Q000453:epidemiology / Q000209:etiology / Q000628:therapy; D012086:Reoperation / Q000706:statistics & numerical data; D013526:Surgical Mesh / Q000009:adverse effects*; D013536:Suture Techniques / Q000009:adverse effects / Q000592:standards; D016896:Treatment Outcome