Thomas Lyons, MD

Good morning. Thank you very much for showing  up at this time of morning. I’m astounded at the number of people here,  the buzz. It’s terrific. I think Karen emphasized the importance of  pelvic floor support. I view this particular product as an aid to  predominantly prophylactic support of the vault post hysterectomy, to  some degree post supracervical hysterectomy, and finally for those  individuals who do have some vault support problems, who are not having a  hysterectomy. I think it is a problem. It’s something that we all see.  But it’s an area that we don’t understand the real problem, because the  knowledge may not available to us. We’re trying to recreate anatomy that  may or may not be recreatable per se. 
 
 I think the most important literature that has come along regarding  vault support, post hysterectomy are three studies out of the Mayo  Clinic conducted over the last 50 years or so. They are really very good  studies. They are ongoing case control studies. The Mayo Clinic was  able to study patients that had hysterectomies over long periods of time  with good access to follow-up. Basically, what they found was that from  1950 to 1957 those individuals who underwent hysterectomy had an  incidence of vault support problems of 25%. 
 
 At that point in time, McCall, in association with a number of other  physicians at the Mayo, instituted the McCall’s or high McCall’s  culdoplasty. What we’re seeing here is the so-called Avesta procedure.  It’s not something that’s new. It is in essence an attempt, as we do  many, many times in laparoscopy to recreate a procedure that has tried  and true data, so we can do it in a fashion that’s less morbid for the  patient. When McCall introduced his high McCall’s culdoplasty, which in  essence is a shortening in the uterosacral ligamental structure, in a  second 7-year period, the incidence of vault support problems dropped  from that 25% to 6%. Finally, in another longer study from 1976 to 1987,  the incidence was found to be 5%. We’ve got a procedure that has data.  It’s tried and true.  All of the procedures done at the Mayo were  performed using absorbable sutures. We don’t use them anymore, so we may  even be able to reduce that number down to something less than the 5%  number that they arrived at. I think that’s the important thing, and one  of the things I wanted to drive home with regard to this procedure this  morning. 
 The techniques as you’ve seen now. A couple of people are applying the  technique. In the Mayo procedure, multiple sutures are used. The key is  you’re trying to actually advance the vagina or the posterior vaginal  vault over the uterosacral ligaments. What we’re seeing and what we’re  actually doing in this procedure is actually shortening that uterosacral  and in so doing, advancing the vagina. If you want to get more complex  and make your repairs more effective, you have to go down further. We  talked about that in the lab the other day. It’s something we can  discuss: how you can get down further on the uterosacral ligaments or  distal on the uterosacral ligaments and how you might be able to make  your support sutures better.
 
 As stated, the Mayo procedures were all done with absorbable sutures.  We’re recommending nonabsorbable sutures. I think the easiest one to  work with is  braided Teflon or Ethibond. You can have a little trouble  if you use Gore-Tex or those types of suture in that they will not  reepithelialize over as rapidly as Ethibond does. If you’ve got Ethibond  on tension, you will get reepithelialization within 48 hours even if  you are intravaginal with the suture.
 
 Again, I think the key is to pay attention to the normal vaginal axis  without trying to “over correct”. We also recommend that urethrolysis be  performed - as you saw Jim (Presthus MD) do very nicely in his  procedure - or that you make a relaxing incision in the peritoneum over  the uterosacral ligaments. That does two things for you. One, it allows  you to know where the ureter is. Secondly, when you tie those sutures  up, if you haven’t made that incision, sometimes you can get urethral  kinking. That can be of course be a problem.
 
 You’ve seen the trocar sites. The basis is you have to have these two  lateral sites. For doing hysterectomy, I routinely have a larger site  (10–12) midline. So we’re normally using a four-trocar position. You can  of course do the procedure with two 5 mm trocars, as you’ll see in the  video. But once again you need to place trocars laterally, because it  seems to be the safest and easiest way to get these needles through  those tissues. 

Again, recognition of the uterosacral complex can be quite simple.  But after the uterus and cervix are removed or after a cervical  procedure, it can sometimes be quite daunting to recognize the  uterosacrals. That’s the reason we recommend opening this peritoneum and  making sure you know where ureter is. Sometimes, and almost always when  I do the procedure, I’ll have my assistant pushing the cervix or  pulling the cervix upward toward the anterior abdominal wall to further  demonstrate these ligamented structures. Again this is what you saw Jim  doing. We’ll pick out the peritoneal surface and make an incision. This  allows the ureter to fall out a little laterally. We’ll take this  incision down to the uterosacral, and this allows us to work  aggressively with the uterosacral ligament and not have to worry about  that. Again all of our patients undergoing LSH or LH - the vast majority  of my patients undergo LSH - have prophylactic support performed. At  this point in time in our series, no recurrent prolapse has been seen-  specifically in those patients who are having prophylactic procedures  performed. In patients who have vaginal prolapse for other reasons, I  think there can be individuals in whom you can’t get adequately get  sufficient uterosacral tissue to work with. Morbidity with the procedure  is basically is nil. We don’t see anybody who has real problems with  this as long as you don’t have a kinked ureter. Again you can obviate  that by proceeding as we have stated.
 
 Let’s look at the video, and then we’ll come back to a couple of slides. 
 
 This is a patient who has a fairly large uterus. You can see it’s  somewhere in the neighborhood of 16–18 weeks. In this particular case,  the patient has had a supracervical hysterectomy. I find that it’s  easiest to work with the grasper on the opposite side. That allows you  to penetrate the ligament much more effectively in general. As Jim says,  he takes the suture through with the device. I find it is much easer to  penetrate these ligamental structures with the bare needle. Again  holding the tissue very tightly, so it’s also demonstrating the ligament  clearly and using a backstop for the insertion of the needle, I then  just simply pulling the suture through and through. 

These patients do not have prolapse at the time. This is a  prophylactic procedure. The vast majority of our patients don’t already  have significant prolapse. Of course patients who already have  significant prolapse require multiple defect repair, site-specific type  repair. This is simply vault support. Vault support, is of course  considered one of the significant morbidities of hysterectomy in  general. So, we want these patients to have good vault support post  hysterectomy, and that’s predominantly where I’m using this procedure. 
 
 See the cervix is closed. See how the uterosacral arches are  demonstrated. We tighten this down nicely. If you have someone who has  significant vault prolapse, you’ll want get the furthest most suture  down further and further in the vagina to do better and better vault  support for that patient. 
 
 This patient has nice demonstrable uterosacrals. Again, this is just a  good prophylactic procedure for this patient. It’s something that I was  trained to do whenever I did hysterectomy, and that I want to continue  to do with laparoscopic hysterectomy. That’s my expensive scissors. It’s  a YAG laser.
 
 Again from the opposite side. I agree totally with Jim, that you have to  be prepared to do this procedure from each side. Grasping the ligament,  demonstrating the ligament clearly to you. We’re using the midline  trocar to just push this through. Pushing with the opposite grasper can  sometimes be very helpful as far as getting through this tissue.
 
 I think there are going to be improvements in this device from the  standpoint of the amount of pressure that is required to move the needle  through the tissue. It’s something we’re working on. But you can  certainly easily enough get it done in this case. I like to put this as  high on the uterosacral as possible. That’s going to give you the  maximum amount of shortening on the ligament and it will be quite  effective in that regard.
 
 Now, we’re putting the final pass in up near the insertion of the  ligament. As I’ve said, if you want to do a better and better vault  support, what you want to do is open the peritoneum here and slide up.  We’re going to the vaginal cul-de-sac and place the needle there. It’s  easily done and quite easily done in total laparoscopic hysterectomy. I  think the key when you look at this is that you get a very anatomically  sound basis. The vagina is in the correct axis. All you’ve done is  anatomically shorten these ligaments, which in essence is going to  improve this patient’s support. You’re using a permanent suture, so that  should be something that’s going to last in that patient indefinitely.
 
 Let’s go back to the slides, hopefully.
 
 Again, a couple of things just to remember: There can certainly be  failures and complications with this. You have to remember the axis. One  of the things you don’t want to do is to try and go higher and higher  towards the sacral promontory. That’s not where you belong, and you will  get into trouble in that regard. 

The nice part about this is too, if the patient has an enterocele  defect, that defect needs to be repaired. Continuity of the anterior and  posterior support to the fascia has to first be established, then do  the vault support. This is a vault support procedure. This is not an  enterocele corrective procedure. You don’t have to worry about foreign  material there. Each of these patients has, or can have stress  incontinence, if they have significant prolapse. If you have corrected  the prolapse, maybe your problems will be solved. Other defect repairs  may be indicated. Unlike sacral culpopexy, you will not run into sacral  radiculopathy. Almost everybody that has sacral culpopexy has a problem -  for a short period of time admittedly. But it always worries you. It’s a  simple procedure. It’s been done before. It’s proven. That’s the most  important factor here. It’s very important to remember that the goal of  pelvic, of any kind of pelvic floor support surgery you’re doing, is to  try to restore the anatomy. We don’t want to try to make something that  wasn’t there before. We just want to restore the anatomy back to where  it was. Thereby, you’re optimizing the function of those tissues. Now we  can do this in a minimally invasive manner. You are going to reduce the  patient’s morbidity.
 
 Thank you very much.

Articles

Good morning. Thank you very much for showing up at this time of morning. I’m astounded at the number of people here, the buzz. It’s terrific. I think Karen emphasized the importance of pelvic floor support.

Avesta Vault Suspension

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AAGL 27th Annual Meeting - Atlanta, GA - November, 1998

QnA on THL Procedure

   “This is the last speaker and I’m pleased now to introduce Tom Lyons  who’s Clinic Professor at Emory University in Atlanta and is Director of  the Center for Women’s Care and Reproductive Medicine.  I’m so pleased  to have Tom participate in our work because I have a high regard for  what he has been doing in introducing and evaluating new techniques such  as supracervical hysterectomy, and he has been assisting us in running  our courses on laparoscopy – Tom.”
     
     

  “Thank you,  Ivo, and I appreciate the invitation to be here.  I think that at the  very least, all of us here should be very appreciative and congratulate  with vigor Dr. Gordts and Dr. Brosens and the people at Leuven.  I think  this work is absolutely fantastic, and they deserve a round of  applause.  To follow them, unfortunately, is me so I really want to give  you our experience and I want to actually tell you my experiences which  is probably going to be similar to yours in that you see this very  impressive work and you see these pictures and videos which I felt were  terribly impressive and immediately begin to think of the ways that you  can possibly use them to help your practice and to help in women’s  healthcare. 
     
     In my opinion, and not being a reproductive endocrinologist although  I do a lot of work with endometriosis, etc., I began to look at  slightly different directions than Dr. Gordts and the people at Leuven.   But again, my experience is still the same, in that we are visualizing a  space in the female pelvis that is really the area where most of the  pelvic pathology resides.  Certainly statistically that is true, and we  are visualizing this with such good accuracy that we’re actually seeing  things now that we’ve not been able to see before, and actually, we’re  now having to sort of re-categorize and re-catalogue some of our prior  thoughts.  Some of the things we’ve seen, some of these very fine  adhesions, we now have biopsied and have found are positive for  endometriosis.  We would not have thought that before and you can’t even  see them in laparoscopy so I think it’s pretty exciting.  What I want  to do is show you a video that gives you our experience the way we’ve  approached this.  It is a bare minimum compared to the lovely video that  you just saw with Dr. Gordts but I do want to go ahead and start this  video, and I’ll talk as we go through this about the things that we can  see on the video. 
     
     Our experiences really started as of the middle of summer, I went  over and visited with Dr. Gordts and his colleagues in April and then  after working through IRV approval and some other things, we began doing  cases around the first of July.  We started our experience - you see us  putting the equipment together here - using it in patients who are  going to have laparoscopy done.  Most of these were patients who were  having procedures performed be that hysterectomy or other procedures  done laparoscopically.  They were being done under general anesthetic  originally, we have done some patients under local at this time and find  that it’s a very do-able procedure under local but again, our  procedures were originally done in patients who we were anticipating  other laparoscopic procedures to follow.  You see this presented quite  clearly, this is the obturator and dilator and the Veress needle set up.   You see our patients are more elegantly draped because we’re about to  do operative laparoscopy on them, but again, it’s a very simple, easy  procedure.  We do place the patients in a pretty steep Trendelenburg as  much Trendelenburg as we’re comfortable with, and again, I think that  helps a little bit.  The angle of the Veress needle is further downward  into the pelvis then you would anticipate.  This is what the needle  looks like coming through under laparoscopy.  We did only a few patients  where we actually had the laparoscope in place when we placed the  needle in the cul-de-sac but we did do that a few times just to become  more comfortable.  It’s a single procedure and I find that I actually  slide the dilator in over the Veress needle with one hand, and I don’t  find it very difficult to do.  Once we assure ourselves that we are in  the abdominal cavity and the peritoneal cavity, we remove the speculum,  and actually, we can even remove the tenaculum if necessary. 
     
     These have been done both on patients with uteruses and without.  I  found that usually I’m further end down then I anticipate when I go in  so I usually have to back out.  Again, what’s on this video is just a  series of pathology that we were able to visualize.  Unfortunately,  since I’m closer than you are, I can barely see this but here you see  some filmy adhesions on this area here.  This is the small bowel that  has been bound down into the pelvis and adhesions are quite clearly  seen.  It’s not hard to visualize at all, I think that, again, the  colors are quite nice.  Actually, it’s not quite as clear on this large  screen as it is in the video in surgery itself.  Again, the pelvic side  wall and you can see both the white sclerotic changes that are  consistent with endometriosis and also you’ll see a little bit of  carbonization in certain cases - this is either carbonization or it may  very well be endometriosis.  In this particular case, it was  endometriosis.  Sometimes you’ll see the same type of pattern in  patients who have had prior laser therapy or ablative therapy with  carbonization left.  But, again, these dense adhesions are quite common  and excellent visualization of the pelvic sidewall.  Systemic evaluation  was seen.  With the fimbriated ends, everyone in the room always sort  of takes a deep breath and sighs when you see this because it really is  gorgeous stuff.  The amazing thing is these very, very fine adhesions  that you see on the ovary, here’s the left     fimbria. 
     
     Of course, salpingoscopy is not the easiest thing to do, it’s easily  done by Dr. Gordts but it’s not always easy unless the tube is really  facing you perfectly but if you can slide into this it can be quite  rewarding.  In this case, the ovary itself is smooth and sclerotic just  what a normal ovary should look like but because of the hydroflotation  you can begin to see some of these very fine adhesive disease.  Again,  most of the patients who we were doing you see these little fine  adhesions on the sidewall.  Most of the patients we were doing were  actually patients who had had pelvic pain and endometriosis was the  prior diagnosis and probably the best for the majority of the patients.   We have not only a 30-degree lens but also a 70-degree lens and  sometimes the 70-degree lens can be helpful in seeing some areas that  are difficult on the sidewall.  See these very fine adhesions on the  ovary, these are invisible at laparoscopy; I will assure you that when  we put the laparoscope in these patients, you can’t see these adhesions.   This is, I believe, the 70-degree lens where you can, again, get a  better appreciation of some of the sidewall structures.  Same thing here  but particularly I find that the cul-de-sac is very easily seen with a  70-degree lens as you’re coming out.  Trying to slide into the fallopian  tube from the side, again, when you look in the abdomen, you will see  plenty of fluid, and this is our laparoscope’s end. 
     
     You’ll also see the site at which we entered the abdominal cavity,  and usually there’s no bleeding.  There’s a typical endometriosis lesion  on the left, on the pelvic sidewall.  Abnormal vascularity is, I think,  better seen because you don’t see the compression of the capillary  structures as you would see it with CO2 at laparoscopy.  We’ve also had  two patients who had obliterated cul-de-sacs and we were successful in  performing the procedure.  I don’t recommend it but it certainly is a  contraindication that you don’t always know.  We’ll slip up and probably  see the appendix here, and the omentum, omental structures down the  center.  Here is a dense vascular adhesion in the ovary to the pelvic  sidewall.  This is an amalgam of different pathologies.  This is again  the sclerotic and/or different changes that you’ll see with  endometriotic lesions.  Most of the pathology that I have is  endometriosis for obvious reasons since these are mostly patients with  pelvic pain.  Again, classic endometriotic changes and abnormal  vasculature surround all of this.  All these patients, of course, had  excisional therapy after these procedures were performed and the  pathology that we obtained a specimen was consistent with what you’d  expect with this visualization.  That was the cul-de-sac.  Again, it’s  not very difficult to obtain a perspective, the first couple of times  that you do it, it just takes a little while to get used to the  visualization and then once you’re comfortable with it, you really tour  around quite easily. 
     
     Tubal from the fimbria, again, you see these fine adhesions on the  ovary; this is of course a normal fimbria.  We see corpora lutea, some  classic endometriotic adhesions superficial on the ovary associated  possibly with some abnormal vascularity.  And now right back to the  cul-de-sac, you’re looking at the uterosacral ligament, little bit of  structures, etc. in the cul-de-sac, left ovary, fallopian tube, etc.   But I think it’s patently obvious that you can see better underwater as  the advertisement says.  I think there’s no question that we really are  seeing more things in this procedure then we have seen before but I  think with that there’s a challenge to us to be able to re-catalogue  these abnormalities because we’re really going to have to go through a  whole new atlas of changes.  We certainly see ureteral activity on the  pelvic sidewall, all of these things that you anticipate seeing.  This  is the ureter, this movement over here, I don’t know if you can see it  clearly.  There’s the ureteral peristalsis.  This is the appendix lying  here.  And again, we obviously work with really one set of equipment  which sort of travels with us.  We can do this at several different  places; it’s not a difficult procedure to perform.  Lateral sidewall  endometriosis, you see this plane lesions that have been cauterized  before.  Here’s the tip of the appendix, you see in the right upper  pelvis, more filmy adhesive disease on the ovary.  Again, these  adhesions when biopsied were, in fact, endometriosis, and some cases  endosalpingiosis. 
     
     In our experience, and I’ll just tell you briefly, we’ve done  twenty-five cases at this time and we’ve had no significant  complications whatsoever, no bleeding.  I think we probably did enter  the bowel in our first one or two cases but no sequela with that and to  this date, I think the procedure has been quite informative to us.  My  feeling is that one of the areas that this procedure can be helpful to  our patients is that it may be a way to do effective screening in  high-risk patients for ovarian cancer.  That’s one of the areas that  we’re going to be looking at over the next several months.  Again, I’ve  been very happy to be associated with working with this.  I really want  to thank Dr. Gordts, Dr. Brosens, and the group in Belgium because I  think it is going to be something that’s important to our patients.  I  appreciate you having me here and we’ll be answering some questions  later.  Thank you.”   

OBGYN.net Conference CoverageFrom American Association of Gynecological LaparoscopistsAtlanta, Georgia, November, 1998

Thomas Lyons, MD

Articles

Avesta Vault Suspension

QnA on THL Procedure

The Benefits of the THL Procedure in Diagnosing Endometriosis