MBBS, MS (Gold Medalist) FIMSA Dip Yoga (Gold Medalist) FCLS POPSTARR Brij B. Agarwal MBBS, MS (Gold Medalist) FIMSA Dip Yoga (Gold Medalist) FCLS Vice Chairman, Professor & Senior Consultant, Department of Laparoscopic & General Surgery, GRIPMER  & Sir Ganga Ram Hospital, New Delhi, India. International Advisor, SLS America Secretary, Association of Surgeons of India, Delhi Associate Editor, Indian Journal of Surgery Vice President, International Society of Colo-Proctology Chairman, Delhi State, International Medical Sciences Academy Brij B Agarwal, SELSICON, August 8, 2015, Cochin

Brij B. Agarwal Nothing To Disclose Brij B Agarwal, SELSICON, August 8, 2015, Cochin

What is POPSTARR? POPSTARR is pelvic organ prolapse surgery with STARR STARR i.e. Stapled Transanal Resection Rectopexy is a procedure for posterior compartment pelvic repair. Brij B Agarwal, SELSICON, August 8, 2015, Cochin

Pelvic Floor Dysfunction Pelvic floor has three compartments Anterior deals with urinary symptoms Middle deals with urogenital symptoms Posterior deals with defecatory disorders Posterior compartment is dealt with STARR POPSTARR addresses anterior and middle compartments. Brij B Agarwal, SELSICON, August 8, 2015, Cochin

Principles of POPSTARR The pelvic floor reconstruction is prosthesis based (mesh). The sling of mesh aims at Repositioning the sagging viscera by lifting it up cranially and towards anterior abdominal wall. The sling is anchored anteriorly and not posteriorly, hence avoiding any neurogenic & other sequelae of sacral fixation. The uterosacral ligaments are used as pulley for middle compartment The anterior cervix is used as pulley for anterior compartment The V-shaped sling is completely extra-peritoneal Brij B Agarwal, SELSICON, August 8, 2015, Cochin

The Position of the Patient Brij B Agarwal, SELSICON, August 8, 2015, Cochin

Port Positions Brij B Agarwal, SELSICON, August 8, 2015, Cochin

Mesh sling fashioning Brij B Agarwal, SELSICON, August 8, 2015, Cochin

Diagnostic lap and uterosacrals Brij B Agarwal, SELSICON, August 8, 2015, Cochin

Extraperitoneal uterosacral tunneling Brij B Agarwal, SELSICON, August 8, 2015, Cochin

Left sling placement Brij B Agarwal, SELSICON, August 8, 2015, Cochin

Right sling placement Brij B Agarwal, SELSICON, August 8, 2015, Cochin

Final Appearance Brij B Agarwal, SELSICON, August 8, 2015, Cochin

Postoperative Brij B Agarwal, SELSICON, August 8, 2015, Cochin

Index Case (June 2010) A 60 years’ lady presented with chief complaint of constipation refractory to medical management for last > 10 years. Her clinical presentation was consistent with ODS (Score 21). MR Defecography- full-thickness internal rectal prolapse + intra- rectal intussusception + deep enterocele+ > 5 cms. rectocele+ Large cystocele. She was not a suitable case for STARR due to enterocele. Brij B Agarwal, SELSICON, August 8, 2015, Cochin

Outcome Last seen at At 42 month follow up, the lady was free of ODS (Score <5) MR Defecography at 12 months showed absence of enterocele / cystocele / rectocele but the intra-rectal intussusception was still seen < 30% of pre-op Brij B Agarwal, SELSICON, August 8, 2015, Cochin

Thanks for your kind attention and patient listening Thank You Pooja Pant, Ramneek Kaur, Nayan Agarwal & Krishna Adit Agarwal Brij B Agarwal, SELSICON, August 8, 2015, Cochin