| Pelvic organ prolapse(POP)is a common chronic disease in middle-aged and older women.Its symptoms include cystocele,urethrocele,rectocele,uterine prolapse or vaginal vault prolapse,which affects patients’ daily lives and negatively affects these peoples’ mental health.With the progress of the aging process and the increasing life expectancy,the incidence rate of POP is increasing accordingly.It is estimated that the number of women who will have POP will increase by about 50%by 2050.The prevalence rate of POP in China is expected to be about 30%-50%,of which 10%-20%of women may need surgical treatment,which will bring a huge burden to the family and society.Therefore,it is imperative to pay attention to and understand POP.POP is a common reason for admission to hospitals in older women and indicates laparoscopic surgery.Sacrocolpopexy is still considered the gold standard surgery for the POP treatment,but due to the specificity of anchor site anatomy and long learning curve,the surgery is difficult for obese patients,with high risks and the risk of side injuries.To solve this problem,laparoscopic pectopexy was developed in 2011 and has shown some advantages recently.Regardless of the operation type,the optimization of surgical techniques is expected to reduce the operation time and avoid complications,thus ensuring the medical safety of patients.The proficiency and precision of the operation cannot be separated from the deep understanding of the local anatomical structure and characteristics.Despite the continuous innovation and development of pelvic floor reconstruction surgery in recent years,including robotic surgery,NOTES surgery via natural cavity,and standard laparoscopic surgery,rich experience has been accumulated.However,the choice of the apical fixation point,suture material,and suture method remains a specific problem facing clinicians and continues to concern.Located in the posterior pubic space,the iliopectineal ligament extends from the pubic tuberosity to the sacrum along the iliopectineal line.Due to its dense and smooth fibrous tissue and easy to reflect light,the iliopectineal ligament has been described as a bright pelvic lighthouse that cannot be ignored.It is often used as an indicator and anchor point for reconstructive surgery in orthopedics,hernia surgery,urology,etc.However,the iliopectineal ligament has received little attention in gynecology,and the applied anatomical studies in Chinese women have not been reported.The purpose of this study is to understand the anatomical and biomechanical characteristics of iliopectineal ligament in Chinese female cadavers,to analyze and evaluate its ultimate load,and to find the most appropriate suture needle and suture material.In addition,the local anatomical characteristics of the iliopectineal ligament were observed under laparoscopy to guide the safer implementation of the operation.Randomized controlled trials were also conducted to determine the clinical value of laparoscopic pectopexy.Part one:Biomechanical study of iliopsopubic ligamentObjective:To study the applied anatomy and biomechanical characteristics of the iliopectineal ligament and its reliability and safety as anchors.Materials and Methods:Four formalin-preserved cadaver specimens,two complete pelvises,and four pairs of incised hemipelvis were selected.1.Disassociating Retzius space exposed the external iliac vessel region and the obturator region,exposed the obturator nerve and the obturator vessel,and observed the anatomical relationship between the external iliac vessel and its branches and branches,especially the accessory obturator vein and the iliopectineal ligament;The origins and terminations of the iliopectineal ligament were observed,and the distance between the midpoint of the iliopectineal ligament and the pubic tubercle and the external iliac vein was measured.The surgical suture area was observed and recorded to see whether the external iliac vessels crossed the iliopectineal ligament and merged into the obturator vessels.2.The thickness and ultimate load of different parts of the iliopectineal ligament and anterior longitudinal sacral ligament were measured.To understand the tension resistance of two kinds of ligaments at different suture depths,different suture sites,and different types of suture needles after penetrating the tissue.Results:The average age of female cadavers was 68.8±6.21(y).The entire length of the iliopectineal ligament was 6.57±0.41 cm on the left side and 6.47±0.50 cm on the right side.The pubic tuberosity to the midpoint of the iliopectineal ligament was 3.10±0.30 cm to the left and 3.20±0.60 cm to the right.The mean distance from the midpoint of the left pubic ligament to the left external iliac vein was 1.16±0.33 cm,and the mean distance from the midpoint of the right pubic ligament to the right external iliac vein was 1.35±0.41 cm.Variation of external iliac blood vessels branch was observed,both sides are visible external iliac venous collateral branch accessory obturator vein,including 9 at the left iliopectineal on the ligament(90%)with 1 m AOV across,1(10%)had two AOV across,on the right side see seven(70%)had 1 AOV across,2(20%)had two AOV across,1(10%)iliopectineal ligament thickness is uniform,suture depth is only 1 mm,minimum tension value is 23.6 N full-thickness suture and the maximum tensile resistance can reach 238.9 N,at this time the action of external force iliopectineal ligament full-thickness separated from iliopectinealbrim.The maximum tensile force of the anterior longitudinal ligament was 209.3N at the sacral promontory,but the tensile force and thickness decreased in descending order.The ligaments at the S2 level were weak,and the minimum tensile force was 19.10N.There was no significant difference in the maximum tensile strength between the two groups(P>0.05),but the S2 level was significantly lower than the tensile strength at the second suture site of the iliopectineal ligament.The tensile strength of the iliopectineal ligament and anterior longitudinal sacral ligament at different anchors was significantly different(P<0.01).Conclusion:The iliopectineal ligament is challenging,with superficial anatomical position and accessible to exposure.The ultimate load is similar to that of the anterior longitudinal ligament.The accessory obturator vein crossing accompanies it,attention should be paid to avoid injury and lead to bleeding.The iliopectineal ligament can be used as an ideal anchor point to reduce the incidence of iatrogenic vascular injury.Part two:Clinical anatomy of iliopectineal ligamentObjective:To observe the pelvic external iliac vascular area in Chinese women by laparoscopy,to understand the anatomical characteristics of the external iliac vascular area in the Retzius space,to understand the relationship and variation between the iliopectineal ligament and the branches and subordinate branches of the external iliac artery and-vein,and to confirm the surgical approach and the safe area of anchors for laparosopic pectopexy.Methods:A retrospective analysis in October 2018 to July 2020 in The First Affiliated hospital of USTC cervical cancer group-patients with stage Ia2-Ibl line of radical hysterectomy and Lymphadenectomy and Ⅱ-Ⅳ pelvic organ prolapse(anterior vaginal wall,uterus,vagina after vaginal wall surfaces is accepted laparoscopic iliac ligament fixation surgery videos,comply with the discharge standard,and successful completion of the standardization of operation according to standard procedure,clear operation field,external iliac blood vessels exposed area is good,convenient for observation.The intraoperative natural space was observed,and the number,shape,and variation of the left and right accessory obturator veins were recorded and counted.Results:All 40 cases were successfully operated,and all the 20 cases had laparoscopic pectopexy.The accessory obturator veins are common on both sides of the iliopectineal ligaments,and all the accessory obturator veins originate from the external iliac vein.80%of the accessory obturator veins were from the right side,67.5%were one vessel,10%were two parallel vessels,and 2.5%were two crosses vessels.67.5%of the accessory obturator veins originated from the left side,all of which were one vessel.Two patients with intraoperative video showed 2 large CMOR,1 on the left and 1 on the right,all of which were in the group undergoing laparoscopic pectopexy.Conclusion:The observation and study of the external iliac vessel area by laparoscopy are critical to ensure the safety of this operation.Attention should be paid to avoid the injury of the accessory obturator vein or the dead crown,and the entry into the Retzuis space between the round ligament and the occulture umbilical artery is safe and convenient.Part three:Randomised controlled trial of laparoscopic pectopexyObjective:To investigate the difference of short-term efficacy between laparoscopic pectopexy and laparoscopic sacral colpopexy in patients with pelvic organ prolapse(POP).Methods:Clinical data of patients with pelvic prolapse with POP-Q score Ⅱ or above admitted to our center from January 2018 to December 2019 were prospectively included in a 1:1 randomized control group.The patients were evaluated for preoperative standardized diagnosis and treatment.The subjects underwent laparoscopic iliopectineal ligament fixatilaparoscopic pectopexy(LP group)and laparoscopic sacral colopexy(LSC group).For patients complicated with anterior and posterior vaginal wall bulge,urinary incontinence,or benign gynecological diseases requiring surgical treatment,the above procedures were performed based on the two surgeries.Outpatient follow-up,gynecological examination and subjective questionnaire were performed at 3,6,and 12 months after surgery.The surgical indexes,subjective and objective cure rates,perioperative complications,and short-term efficacy of the two surgical methods were compared.Results:A total of 116 patients were included,and the 12-month postoperative information was not automatically considered as missing medical records,and the patients lost to follow-up were excluded from the study before the analysis of statistical results.A total of 111 patients were included in the study,including 56 in the LP group and 55 in the LSC group,with a follow-up rate of 95.7%.There were no significant differences between the two groups in age,body mass index,a number of deliveries,menopause or not and duration of menopause,degree of prolapse,complications,and other aspects.There were no significant differences in operative time,intraoperative blood loss,days of the indwelling catheter,and residual urine volume between 2 groups(P>0.05),and there were no significant differences in postoperative complication rate between 2 groups(P>0.05).Postoperative POP-Q indicator points(Aa,Ba,C,Ap,Bp)were all the better than those before surgery(P<0.05)and returned to the normal range with satisfactory anatomical reduction.According to the POP-Q lowest point as the objective basis for the determination,1 case of recurrence was found in the study group,and the recurrence was mainly presented as anterior vaginal wall enlargement.The objective cure rate of the study group was 98.21%(55/56).There were 2 cases of recurrence,1 case of anterior vaginal bulge and 1 case of posterior vaginal bulge in the control group,.The objective cure rate of the control group was 96.36%(53/55).There was no significant difference in PFDI-20,PFIQ-7,and PISQ-12 scores between groups after the operation(P>0.05).Postoperative PFDI-20 and PFIQ-7 scores in both groups were significantly lower than those before operation(P<0.05),and the effect was stable.There was no significant change in PISQ-12 among sexually active patients.Moreover,the effect is stable.There were no complications such as apical prolapse and mesh exposure in the two groups during the follow-up period.In the study group,there were 2 patients with urinary incontinence and 1 patient with constipation,and the subjective effective rate was 94.64%(53/56).In the control group,there was 1 patient with urinary incontinence and 1 patient with constipation,and the effective subjective rate was 96.36%(53/55).Conclusion:Both of the two methods have achieved satisfactory anatomical reduction.Compared with sacrovaginal fixation,pectopexy is easy to separate and locate,with fewer complications and a short learning period,which is conducive to promotion and clinical application and can become a new choice for POP treatment.Innovations1.Take the lead in the biomechanical study of the iliopectineal ligament in the pelvis on the cadavers of Chinese women.The maximum load force and anatomical position of the iliopectineal ligament were determined,and the average length and thickness of the iliopectineal ligament were measured,providing a specific basis for the ideal anchor point.2.The relationship between the vascular variation in the external iliac vessel area of the posterior pubic space and the iliopectineal ligament,especially the relationship with the ideal anchor site,was observed under fine laparoscopic anatomy of gynecology to provide a basis for the safety of surgery.3.Laparoscopic iliopectineal ligament fixation and laparoscopic sacral fixation were randomly divided into two groups for a controlled study,to understand the short-term subjective and objective cure rates and complications of the two groups and to provide a basis for the evaluation of the application of this surgery in the treatment of pelvic organ prolapse.Limitations1.The use of embalmed cadavers without fresh frozen cadavers may have a particular influence on the biomechanical parameters of the iliopectineal ligament.2.The sample size for observing anatomic variation should be further expanded.3.Controlled clinical studies also need long-term follow-up for evidence support. |
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