Synthetic materials. Synthetic graft materials of various designs and substances also have been used as sling material. Monofilament, large-pore weave grafts (Type 1 mesh) are recommended for implantation in the vagina. Although good efficacy can be achieved with synthetic mesh, the material also may increase the risk of serious complications, such as infection, vaginal extrusion, and genitourinary erosion, and is not recommended for use beneath the proximal urethra or bladder neck.
The autologous pubovaginal sling supports the proximal urethra and bladder neck to achieve continence by providing a direct compressive force on the urethra and bladder outlet, or by reestablishing a reinforcing platform or hammock against which the urethra is compressed during increased abdominal pressure.
How to harvest rectus fascia and create a sling
1. Choose anesthesia and perioperative antibiotics
Pubovaginal sling procedures are generally carried out under general anesthesia, but spinal or epidural anesthesia also is possible. Full-patient paralysis is not warranted but may facilitate closure of the rectus fascia after fascial harvesting.
Perioperative antibiotics usually are given to ensure appropriate coverage against skin and vaginal flora (for example, a cephalosporin or fluoroquinolone). In fact, perioperative antibiotics have become a mandated quality of care measure in the United States.
2. Position the patient for optimal access
Place the patient in the low lithotomy position with her legs in stirrups. The abdomen and perineum should be sterilely prepared and draped to provide access to the vagina and lower abdomen.
After the bladder is drained with a Foley catheter, place a weighted vaginal speculum and use either lateral labial retraction sutures or a self-retaining retractor system to facilitate vaginal exposure.
3. Make an abdominal incision
Make an 8- to 10-cm Pfannenstiel incision approximately 3 to 5 cm above the pubic bone, carry the dissection down to the level of the rectus fascia using a combination of electrocautery and blunt dissection, and sweep the fat and subcutaneous tissue clear of the rectus tissue (FIGURE 1).
FIGURE 1 Skin incision
Before initiating the operation, delineate the location of the transverse skin incision, which should measure 8 to 10 cm and be situated about 4 cm above the symphysis pubis. A vertical incision is also feasible, although it usually is less aesthetic.
4. Harvest the fascia
The rectus abdominis fascia can be harvested in a transverse or vertical orientation. A fascial segment at least 8 cm in length and 1.5 to 2 cm in width is recommended.
Delineate the fascial segment to be resected using a surgical marking pen or electrocautery, then incise the tissue sharply with a scalpel, scissors, or electrocautery along the drawn lines.
Virgin fascia is preferred, but the presence of fibrotic rectus fascia does not prohibit its use. If you are resecting the fascia close and parallel to the symphysis pubis, leave at least 0.5 to 1.0 cm attached to facilitate closure of the defect created in the fascia. Small Army/Navy retractors permit aggressive retraction of skin edges, making it possible to use a smaller skin incision (FIGURE 2).
FIGURE 2 Resect the fascial strip
After choosing the optimal location for excision, mark the area using electrocautery or a surgical marking pen. Then resect the strip using a scalpel or electrocautery. The strip should measure 8 to 10 cm in length and 1 to 2 cm in width. If the skin incision is small, Army/Navy retractors may enhance exposure.
5. Close the fascial defect
Use heavy-gauge (#1 or #0) delayed, absorbable suture in a running fashion. It may be necessary to mobilize the rectus abdominis fascial edges to ensure appropriate tension-free approximation. It is important that anesthesia be sufficient to ensure muscular relaxation and paralysis during closure.
6. Prepare the fascial sling
Affix a single #1 permanent (for example, polypropylene or polyester) suture to each end of the fascial segment by passing the needle through the undersurface of the sling and then back through the top of the sling. If necessary, defat the sling (FIGURE 3).
FIGURE 3 Attach suspensory sutures
A. Mark the midline of the fascial sling with a pen and gently grasp it using a hemostat. B. Attach a polyester suture to each end of the fascial sling after stripping it of any adipose tissue. Ensure that the initial entry and exit points of the polyester sutures are on the same side of the strip that originally abutted the rectus muscles.
7. Dissect the vagina
Use injectable-grade saline or a local analgesic, such as 1% lidocaine, to hydrodissect the subepithelial tissues of the distal portion of the anterior vaginal wall. Make a midline or inverted “U” incision into the vagina (FIGURE 4).