Promedon Calistair S Instructions D'utilisation page 7

NOTE: Lower extremity nerve injury and compartment syndrome
may occur with lithotomy positioning of the patient. Limit the risk by
avoiding excessive hip flexion and hip abduction and reducing the
operation time.
Surgical Steps
1. Full thickness vaginal wall dissection
Place two Allis clamps vertically on the vaginal wall for the midline incision.
Milk the bladder away from the vaginal wall with the thumb and index
finger to develop the vesicovaginal space. Perform a hydrodissection with
injectable saline prior to fist incision to create a space between the vaginal
wall and the underlying structures. Perform a midline incision of the anterior
vaginal wall with the scalpel. Perform a full thickness vaginal wall dissection
for entry of the vesicovaginal space. by sharp and blunt preparation.
NOTE: Limit the use of electrocautery to prevent the disruption of
blood flow.
NOTE: A partial-thickness dissection may disrupt the blood supply to
the vaginal mucosa and increases the risk of mesh exposure.
2. Mesh implantation
Develop the rectovaginal space by sharp and blunt dissection as appropriate.
Subsequently, enter the pararectal space using blunt finger dissection
to identify the ischial spine with the index finger. The ischial spine and
sacrospinous ligament are identified by palpation. The surrounding tissue
of the sacrospinous ligament is wiped away carefully from the ischial spine
along the ligament using the index finger. Perform this step bilaterally.
NOTE: The final position of the anchor is recommended to be approx.
2 cm medially from the ischial spine in the sacrospinous ligament.
Surrounding tissue should be minimised at the intended position of
the anchor.
The TAS is put on the Retractable Insertion Guide (RIG) (Ref: DPN-MNL).
Then, the protection sheet is pulled over.
NOTE: The protection tube closes with the tip of the Retractable
Insertion Guide to prevent it from becoming stuck or injuring
surrounding tissue due to the anchor's barbed hooks.
The TAS is fixed to the right sacrospinous ligament by the left hand. Firstly,
the right index finger identifies the sacrospinous spine and ligament. The
rectum is gently pulled medially. The right hand remains in this position in
order to guide the TAS to the sacrospinous ligament. The RIG is subsequently
pushed forward with the left hand along the right hand for guidance to
the sacrospinous ligament. The final position for the TAS should be located
approximately 2 cm medially from the ischial spine on the sacrospinous
ligament. Hold the RIG firmly and straight when pushing the RIG on the
sacrospinous ligament at its final position. Release the TAS at the intended
position. The TAS is released by pushing the RIG's switch down.
Perform the procedure accordingly on the contralateral site by using the
left hand for guidance and the right hand for pushing. The sutures are left
hanging out of the introitus until needed.
NOTE: Rectal examination may be required in case of suspected
bowel perforation.
NOTE: Ensure that the TAS are firmly attached to sacrospinous
ligament by gently pulling on the TAS suture.
Perform a sharp and blunt dissection towards the obturatum foramen
horizontally to the bladder neck on the right side. For this purpose, put the
left index finger in the angle between the labium majus and minus pudendi,
slightly below the commissura labiorum anterior, on the right side and take
the corresponding clamp in the same hand. The sharp and blunt dissection is
performed by the right hand. The instruments and directions are palpated by
the index finger of the left hand. Perform the dissection of the contralateral
side accordingly by putting the right index finger in the angle while using
the left hand for dissection.
Put the anchor of the Anterior Attachment Arm (AAA) on the RIG (Ref:
DPN-MNC).
The RIG is guided by the right hand to the right internal obturator muscle
by pushing the RIG parallel to the obturator membrane into the bulge of
the Internal obturator muscle. For this purpose, the left index finger is put
in the angle between the labium majus and minus pudendi, slightly below
the commissura labiorum anterior, on the right side. The RIG is palpated
and guided in this position by the left index finger, while the RIG is pushed
by the right hand parallel to the obturator membrane. The anchor is fixed
into the internal obturator muscle. Release the RIG by pulling the switch of
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