Instruments and Techniques Laparoscopic Removal of Mesh Used in Pelvic Floor Surgery Su-Yen Khong, MRCOG*, and Alan Lam, FRCOG, FRANZOG From the Centre for Advanced Reproductive Endosurgery, St. Leonards, New South Wales, Australia (both authors). ABSTRACT Various meshes are being used widely in clinical practice for pelvic reconstructive surgery despite the lack of evidence of their long-term safety and efficacy. Management of complications such as mesh erosion and dysparuenia can be challenging. Most mesh-related complications can probably be managed successfully via the transvaginal route; however, this may be impossible if surgical access is poor. This case report demonstrates the successful laparoscopic removal of mesh after several failed attempts via the vaginal route. Journal of Minimally Invasive Gynecology (2009) 16, 592–594 Ó 2009 AAGL. All rights reserved. Keywords: Mesh; Complication; Vaginal prolapse; Laparoscopy In an attempt to improve primary surgical outcomes, syn- thetic and biological meshes have been introduced to reduce recurrence rate while maintaining vaginal capacity and coital function [1]. Despite the lack of level 1 evidence to elucidate its long-term safety and efficacy, meshes for pelvic recon- structive surgery are currently being used widely in clinical practice [2,3]. Serious mesh-related complications have been reported including mesh erosion, infection, dyspareu- nia, and even trauma to bowel, bladder, and blood vessels [4–6]. Management of these complications can be challeng- ing. This case report demonstrates the successful laparo- scopic removal of mesh after several failed attempts via the vaginal route. Case Report A 67-year-old woman, para 3, reported persistent right buttock pain, sciatica pain in her left leg, back pain and bowel dysfunction. She had a complex medical history of chronic back pain and bilateral sciatica secondary to degenerative spi- nal disease, total abdominal hysterectomy because of myo- mas, and 7 vaginal repairs including 2 vaginal fascia repairs preceding the hysterectomy in 2002 and posterior re- pair and bilateral sacrospinous fixation using polypropylene mesh in 2004. A second anterior repair was performed in 2005 using nonabsorbable polyester sutures (SURGIDAC; Covidien, Mansfield, Massachusetts) to attach the vaginal vault to the sacrospinous ligaments combined with insertion of a polypropylene mesh (TiMesh; Medtronic, Inc, Minneap- olis, Minnesota) via the transobturator route. Six weeks later, a second sacrospinous fixation procedure was performed be- cause of recurrent enterocele. A strip of porcine dermis im- plant (Pelvicol; C. R. Bard, Inc, Covington, Georgia) was laid across the vaginal vault and posterior vaginal wall and was then secured to the sacrospinous ligaments with polyes- ter sutures (Ethibond; Ethicon, Inc, Somerville, New Jersey). In May 2006, a small area of mesh was found to have eroded into the vaginal vault and was subsequently excised via the transvaginal route with the patient under general anesthesia. In July 2006, the patient sought an opinion from another urogynecologist because of persistent backache, right groin and suprapubic pain, frequency of defecation, tenesmus, and dyspareunia. Examination revealed that the vaginal walls were well supported. However, there was substantial tender- ness along the posterior wall and the vault over the area of the sacrospinous ligaments. Colonoscopy and gastroscopy were performed, and ruled out any gastrointestinal disease. After unsuccessful pain management using hydrotherapy, physio- therapy, and regional anaesthetic agents, the patient was ad- mitted for mesh removal, again via the transvaginal route. Despite prolonged attempts and with great difficulty owing to limited access, only a portion of the Pelvicol implant at- tached to the sacrospinous ligaments with Ethibond sutures could be removed from the posterior wall and vault. Evidence of chronic inflammation with intense induration and scarring The authors have no commercial, proprietary, or financial interest in the products or companies described in this article. Corresponding author: Su-Yen Khong, MRCOG, Centre for Advanced Re- productive Endosurgery, AMA Building, Ste 408, Level 4, 69 Christie Street, St. Leonards NSW 2065, Australia. E-mail: su-yen@sydneycare.com.au Submitted February 13, 2009. Accepted for publication May 12, 2009. Available at www.sciencedirect.com and www.jmig.org 1553-4650/$ - see front matter Ó 2009 AAGL. All rights reserved. doi:10.1016/j.jmig.2009.05.005