5 TYPES OF APPROACHES:TOT – TransObturatorTape ( IN OUT technique)TOT – TransObturatorTape ( OUT IN technique)
6 Step 1 out-in TOT PROCEDURE (most common) 2 cm anterior vaginal wall incisionPeriurethral scissor dissection.Step 1
7 Step 2 out-in TOT PROCEDURE Area of groin incision located 1 cm inferior to the AdductorLongus Tendinous insertion,at the level of clitoris.Step 2
8 Step 3 out-in TOT PROCEDURE To guide the needle, the finger is placed in the vaginal incision.The needle is placed in the groinincision and then passed throughit.Step 3
9 Step 4 out-in TOT PROCEDURE The needle passed through the groin incision, through the Obturator membrane and muscles and brought into the vaginal incision.Step 4
10 Step 5 out-in TOT PROCEDURE Once the needle is brought into the vaginal incision, it is connected to the tip of the mesh inserting the threads in the needle’s hole.Step 5
11 Step 6 out-in TOT PROCEDURE The needle with the attached thread of the mesh is then brought back through the groin incision.Step 6
12 Step 7 out-in TOT PROCEDURE The needle and the mesh is passed on the opposite side.Tape is then adjusted with anintra-operative cough test andadjusted until no leakage occurs.Step 7
13 Step 8 out-in TOT PROCEDURE Excess mesh is cut off at the groin incisions andthese are closed withsteri-strips.Vaginal incision is closed.Step 8
14 TOT PROCEDURE IN-OUTExactly the same as TOT OUT-IN procedure but the introduction of the needle is made from the vaginal incision to the groin incision, instead of the contrary.The needle used for this technique are semi-circular.
15 TVT PROCEDUREThe needles are passed from the vaginal incision lateral to the urethra, following the posterior wall of the pubis, and crossing the fascia and the rectus muscle until the needle appears at the lower abdominal wall.The sling is adjusted and the excess mesh cut of.