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Surgeons Respond to Pelvic Reconstruction Column : The Master Class


 

As editor of the Master Class columns on gynecology, I was very proud to have C.Y. Liu, M.D., present an excellent two-part discourse on pelvic floor prolapse in the October 1, 2004, and November 1, 2004, issues of OB.GYN. NEWS.

I subsequently received a letter to the editor from Marvin H. Terry Grody, M.D. In my mind, Dr. Grody has raised compelling issues, especially in regard to the importance of the perineal body in pelvic floor prolapse. Because of this, I have asked Dr. Liu and a panel of experts to discuss Dr. Grody's concerns.

I trust you will find this discussion both interesting and informative.

Dear Editors:

In the Oct. 1, 2004, issue of Ob.Gyn. News, there appeared Part 1 of a two-part series entitled “Laparoscopic Pelvic Reconstructive Surgery.” The author, C.Y. Liu, M.D., who is a well-reputed and skilled laparoscopic surgeon, acceptably covered the issues of defects of the pelvic supportive and suspensory mechanisms and their effects on associated organs. But from the viewpoint of a vaginal and pelvic reconstructive surgeon, he embodied a major misconception in his statement, “The perineal membrane and perineal body are not very crucial for pelvic organ support.”

He is not only dead wrong, but he is giving misinformation that could be seriously destructive to surgery performed by a myriad of minimally experienced young surgeons whom experts in the field are trying tenaciously to convince otherwise.

Before I go further into this matter, I must first suppress my emotionally charged conviction (shared by many others) that the average gynecologic surgeon will not achieve anywhere near the degree of success working through a telescope that has been thrust through the abdominal wall as she or he could attain much more directly with less time and expense—and probably less risk—by using alternative approaches.

Contrary to Dr. Liu's disregard of any contributive importance of the perineal body (PB), pelvic reconstructive surgeons universally consider a disrupted PB to be a critical obstacle to the achievement of durably effective success in pelvic anatomical and functional restoration. Over a period of 4 decades starting in the 1960s, David H. Nichols, M.D.—whom most of us view as one of the most renowned vaginal surgeons—firmly and repeatedly established the mandatory requirements of restitution of the normal vaginal axis in the correction of the anatomically defective pelvic floor.

For reference, a full description of the normal vaginal axis and its vital role in good pelvic support can be found in my chapter on colpoperineorrhaphy in the ninth edition of TeLinde's Operative Gynecology (Philadelphia: Lippincott Williams & Wilkins, 2003, p. 966-85).

The PB is a key element in the structural composition of the normal vaginal axis. If significant defects in the PB are ignored and not completely repaired to natural configuration in this commonly coexistent lesion in pelvic floor anatomical failure, then no matter how wonderful the surgeon feels about his or her effort in correcting the other defects, the operation is almost certainly doomed to fail in time. Such inevitability relates to the interdependence of all the elements of the connective tissue network running through the pelvis. An ignored, significantly defective PB can become the weak link that will blow the entire chain of support.

Even if we uncover the rare gynecologic surgeon possessed of laparoscopic skill equivalent to that of Dr. Liu, if the patient does not undergo a full perineorrhaphy from the vaginal approach as the last part of the total operation, then that surgeon must be considered stupid.

Finally, I must question the wisdom of publishing this laparoscopy series that focuses on a surgical approach that will unquestionably be within the province of only a highly-specialized, well-trained, innately gifted few when other easier, safer, very effective, and far less costly and time-consuming procedures can be ably pursued by a significantly larger segment of qualified operating practitioners.

Given today's world of astounding technological feats, will such a truly perverse printed exposure stimulate adventurous young gynecologic surgeons who think they are much better than they really are into imprudent undertakings beyond their true capabilities, leading to serious injury to their patients? Goodness knows what difficulties we already find in our cluttered residency programs in getting basic maneuvers (like vaginal hysterectomy) across, let alone highly sophisticated, industry-driven, potentially dangerous operative challenges performed through a spyglass.

If there are critics abroad who think I am wrong, let them please tell me.

Rather than repudiating Dr. Grody's opinion about laparoscopic surgery, I will only respond to his point about the importance of the perineal membrane and PB to pelvic organ support.

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