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Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_190_библиотеки_им_акад_М_И_Перельмана

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Investa
suture
Laparoscopic Uterine Suspension, Sacrocolpopexy, Vault Suspension — 397
Creating round ligament bridge
1st exit point
1-2 cm
2nd exit point
Retrieve suture and tie
across fascial bridge
TM
Fascial bridge
E
UPLIFT Procedure
MetraTie
F
Figure 14.3.1.4. (continued)(D) The second pass exits 1 to 2 cm from the first exit point near the uterus. (E) The suture ends are retrieved and tied to create a fascial bridge. (F) The round ligament is shortened and strengthened, repositioning the uterus. (A–F courtesy of Inlet Medical, Inc.)
TM
knot
pusher
junction of the ligament and the uterus. Care was taken to avoid adjacent vessels, especially engorged varicose veins, which may lie close to the ligaments and may result in hemorrhage. To com­plete a full circle, a third suture was placed on the upper part of the right uterosacral ligament and a fourth suture was placed on the lower part of the ligament opposite the previous sutures. Finally, the suture was carried out of the body and used to per­form extracorporeal knot tying. When the knot was tied down, the upper and lower sites were brought closer and the ligaments were plicated together bilaterally, yielding an effective shortening and tightening of the ligaments. Therefore, the upper and lower
Round ligament
shortened, thickened
and strengthened
sutures should be separated as far apart as possible to achieve better ligament shortening.
The modified Gilliam suspension of the round ligaments was then performed. The accessory cannula in the lower abdomen was removed, the skin incision was extended to 1 to 2 cm, and the underlying rectus fascia was exposed. A grasping forceps was pushed intothepelviccavitytograsptheroundligamentatapoint about 2 to 3 cm lateral to its insertion on the uterus. This point could be adjusted and changed slightly to ensure proper tension and ideal degree of uterine suspension. Improper traction on the fallopian tubes was avoided. The round ligament was withdrawn
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shortened a little in some women, but only around 1.0 cm and without symptoms.
This procedure restores the normal relationship between the uterus and intra-abdominal pressure. As the uterus is completely fixed into an anteverted andanteflexed position, intra-abdominal pressure falls on the posterior surface of the uterus and to some degree prevents conversion of the uterine position.
Margossian et al.[24]reported on a technique of laparoscopic uterosacral ligament plication and shortening for pelvic organ prolapse.Theauthorspointedoutpelvicorganprolapsecanoccur when pelvic support structures are subjected to increased intra­abdominal pressure. Commonly, thereis an intrinsic defect ofthe pelvic floor. The clinical manifestation of pelvic organ prolapse reflects this specific fascial defect.
The procedure these authors described is as follows:
Figure 14.3.1.5. Anteverted uterus has a normal, uniform color fol­lowing the UPLIFT procedure. (Courtesy of Dr. James E. Carter.)
into the incision and sutured to and through the anterior rectus fascia in a figure-of-eight manner with size 0 Vicryl (Ethicon Inc., Somerville, NJ). The same procedures were repeated on the opposite side.
Operating time was 24.1 ± 4.7 minutes, with blood loss of 30 mL or less in all cases. No intraoperative or postoperative complications occurred. At the first clinic visit 1 week later, all patients felt only slight lower abdominal traction and could walk freely without discomfort.
All the patients had an anteverted, anteflexed uterus without failure, and all declared they experiencedmarkedimprovement of deep dyspareunia, with a mean follow-up of 3.3 ± 1.0 years. The technique lengthened the vagina a little in most patients. Average vaginal lengths before and after surgery were 5.9 ± 0.7 cm and
7.0 ± 0.3 cm, respectively. In 2 years of follow-up, vaginal length
Uterus
After inserting the laparoscope, we carefully identify the ureters. An incision is made in the peritoneum medial to the ureters. In this way,whentheuterosacralligamentsare plicated, there is no kinking of the ureters. We used per­manent sutures to plicate and shorten the uterosacral lig­aments. The plication sutures are placed in the uterosacral ligament at its insertion into the cervix and through the posterior wall of the vagina and then tied with an extra­corporeal knot-tying technique. Additional sutures are placed betweenthe uterosacral ligaments to close the cul­de-sac. To shorten the uterosacral ligament, a suture is placed near its insertion in the sacrum and then through its insertion on the uterus. This isrepeated ontheopposite side. Only after both sutures are placed are they tied. The uterosacral ligament in between the sutures is allowed to fold medially.
Results obtained with the procedure were not reported.
More recently, a technique using the ELEVEST device has
been describe[25–27] (Figure 14.3.1.6A-F). It involves uterine
Uterus
Suture passer
A
Figure 14.3.1.6. (A) ELEVEST procedure. While traction is used to hold the uterosacral ligament taut, the first suture is placed in the posterior one third of the ligament. (Courtesy of Inlet Medical, Inc.) (B) The suture is released, and the suture passer is removed from the uterosacral ligament. The suture is passed through the uterosacral ligament at the uterosacral ligament cervical junction. (Courtesy of Inlet Medical, Inc.) (Continued )
Grasper
Bowel
Uterosacral ligament
Uterosacral ligament
Grasper
Bowel
B
Laparoscopic Uterine Suspension, Sacrocolpopexy, Vault Suspension — 399
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Suture passer
Uterus
Suture passer
Grasper
Bowel
C
Uterus
Uterosacral ligament
D
Uterus
Uterosacral ligament
Grasper
Bowel
Uterus
Uterosacral ligament
Bowel
EF
Figure 14.3.1.6. (Continued )(C) The suture is grasped again with the jaws of the suture passer. A second pass is made through the uterosacral ligament. (D) Three or four passes are made with the suture, with the last pass placed near the cervix. A second suture may be passed to reinforce the repair. (E) An extracorporeal knot is tied and tightened down to the level of the uterosacral ligament, thereby shortening and strengthening the ligament. (F) The procedure is completed with suture placement. (Figures courtesy of Inlet Medical, Inc.)
hysteropexy with round ligament suspension using specialized needlepoint suture passer that does not require a laparoscopic
with long-term follow-up of up to 3.3 ± 1.0 years, and is a valid option for women who desire uterine preservation.
Bowel
Uterosacral ligament
needle driver suturing technique. There were no major compli­cations in thesesmall series. Although 1 patientrequireda second operation to remove one of the round ligament sutures due to pain and 1 patient had recurrent prolapse [26], follow-up at 37 weeks for 21 patients [26] and at 18 months for 1 patient [27] revealed satisfactory results.
CONCLUSION
Treatment ofuterine descensus by uterine suspensionbya combi­nation of round ligament and uterosacral ligament plication and shortening has been demonstrated in a number of series, some
REFERENCES
1. Rasian F, Lynch CB, Rix J. Symptoms relieved by endoscopic ven­tral suspension. Gynecol Endosc. 1995;4:101–104.
2. Massouda D, Ling FW, Muram D, et al. Laparoscopic uterine sus­pension with Falope rings. JReprodMed. 1987;32:859–861.
3. Candy JW. Modified Gilliam uterine suspension using laparo­scopic visualization. Obstet Gynecol. 1976;47:242–243.
4. Mann WJ, Stenger VG. Uterine suspension through the laparo­scope. Obstet Gynecol. 1978;51:563–566.
5. Yoong FE. Laparoscopic ventrosuspension: a review of 72 cases. Am J Obstet Gynecol. 1990;163:1151–1153.
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6. Perry CP, Sarria C. Minimal incision Pereyra needle uterine sus­pension. J Laparosc Surg. 1991;1:151–155.
7. Ivey JL. Laparoscopic uterine suspension as an adjunctive pro­cedure at the time of laser laparoscopy for the treatment of endometriosis. JReprodMed. 1992;37:757–765.
8. Gordon SF. Laparoscopic uterine suspension. JReprodMed. 1992;37:615–616.
9. Koh L, Tang F, Huang M. Preliminary experience in pelviscopic uterine suspension using Webster–Baldy and Franke’s method. Acta Obstet Gynecol Scand. 1996;75:575–578.
10. Nezhat CR, Nezhat FR, Luciano AA, et al. Uterine Surgery in Oper- ative Gynecologic LaparoscopyPrinciples and Techniques.NewYork: McGraw-Hill; 1995.
11. Daniell JF, Lalonde CJ. Advanced laparoscopic procedures for pelvic pain and dysmenorrhea. Baillieres Clin Obstet Gynaecol. 1995;9:795–808.
12. Metzger DA. Uterine suspension. In: Steege JF, Metzger DA, Levy BS, eds. Chronic Pelvic Pain: An Integrated Approach. Philadelphia: Saunders; 1998.
13. Ortega I. Uterine suspension for deep dyspareunia using Carter­Thomason needle point suture passer. Presented at: The Inter­national Society of Gynecologic Endoscopists World Conference; March 15–18, 1998; Sun City, South Africa.
14. Halperin R, Padoa A, Schneider D, Bukovsky I, Pansky M. Long­term followup (5–20 years) after uterine ventrosuspension for chronic pelvic pain and deep dyspareunia. Gynecol Obstet Invest . 2003;55:216–219.
15. Ou CS, Liu YH, Joki JA, Rowbotham R. Laparoscopic uterine sus­pension by round ligament plication. JReprodMed. 2002;47:211–
216.
16. Batioglu S, Zeyneloglu HB.Laparoscopicplication and suspension of the round ligament for chronic pelvic pain and dyspareunia. J Am Assoc Gynecol Laparosc. 2000;7:547–551.
17. Gargiulo T, Leo L, Gomel V. Laparoscopic uterine suspension using 3-stitch technique. J Am Assoc Gynecol Laparosc. 2000;7:233–
236.
18. Smith DB, Kelsey JF, Sherman RL, et al. Laparoscopic uterine sus­pension. JReprodMed. 1977;18:98.
19. Steptoe PC. Laparoscopy and Gynecology. London: Livingstone;
1967.
20. Carter JE. Carter-Thomason uterine suspension and position­ing by ligament investment, fixation, and truncation (UPLIFT). JReprodMed. 1999;44:417–422.
21. Perry CP, Presthus J, Nieves A. Laparoscopic uterine suspension for pain relief: a multicenter study. JReproMed. 2005;50:567–570.
22. Maher CF,CareyMP, MurrayCJ.Laparoscopicsuturehysteropexy for uterine prolapse. Obstet Gynecol. 2001;97:1010–1014.
23. Yen CF, Wang CJ, Lin SL, Lee CL, Soong YK. Combined laparo­scopic uterosacral and round ligament procedures for treatment of symptomatic uterine retroversion and mild uterine descensus. J Am Assoc Gynecol Laparosc. 2002;9:359–366.
24. Margossian H, Walters MD, Falcone T. Laparoscopic manage­ment of pelvic organ prolapse. Eur J Obstet Gynecol Reprod Biol. 1999;85:57–62.
25. Presthus J. Uterine prolapse: a new technique for uterine preser­vation. Video presented at: Annual Meeting of the Society of Laparoendoscopic Surgeons; May 16, 2003; New York, NY.
26. Sobolewski C, Glazerman L, Abbott K, Presthus J, Schwartz M. ELEVEST: a new technique for laparoscopic treatment of uterine prolapse without hysterectomy. Poster presented at: Annual Meet­ing of the American Association of Gynecologic Laparoscopists; November 16–22, 2003; Las Vegas, NV.
27. Abbott KR. A new technique for laparoscopic uterine prolapse repair: 18-month followup. Internet communication, Athena Gynecology Medical Group, San Carlos, CA, 2003.
PART 2: LAPAROSCOPIC VAGINAL VAULT
SUSPENSION
Laparoscopicvaginal vault suspensionisperformed to treat apical
enterocelesandvaultdescensusandtorepositionthevaginalvault after hysterectomy.[1]
To properly perform pelvic vault reconstruction, specifically apical enterocele repair and vaginal vault suspension, a paradigm shift in theunderstanding of the anatomy of thepelvis is required. Defects in pelvic support are now viewed as defects in the actual fascia, which can beunderstoodtoconstitutea“hernia.” Richard­son [2] described the anatomic defects in the apical enterocele. Ross [3] elegantly reviewed apical vault repair, which is the cor­nerstone of pelvic vault reconstruction.
Vaginal prolapse occurs when the upper one third of the vagina that is suspended by the cardinal–uterosacral ligament complex breaks free of its attachments to the sacrum via the uterosacral ligament. Additionally, the middle one third of the vagina, which is maintained by lateral attachments, is frequently broken free. Lateral defects are often found in the anterior quad­rant of these patients and can be unilateral or bilateral. These are paravaginal defects or detachments of the pubocervical fascia from its lateral attachment to the fascia of the obturator internus muscle at the level of the arcus tendineus fascia of the pelvis. The arcus tendineus pelvic fascia is the tendinous aponeurosis of the obturator internusmuscle anteriorly and the levator ani complex posteriorly.[4–7] All pelvic support defects must be addressed to ensure the integrity of the vagina and to correct associated stress incontinenceifit exists. This section focuses on laparoscopic tech­niques for reconstruction of the vaginal apex with correction of vaginal vault prolapse.
ANATOMY
The apex of the vagina after hysterectomy is formed by the con­nection of the pubocervical fascia to the rectovaginal (Denonvil­liers’) septum (rectovaginal fascia). The rectovaginal fascia is a distinct fibrous tissue layer between the vagina and rec­tum in a diaphragm-like configuration. The principle attach­ments are located peripherally; cranially to the cul-de-sac peri­toneum, the uterosacral ligaments, and the base of the cardinal ligaments; caudally to the perineal body; and laterally to the fas­cial covering of the levator ani muscles. The rectovaginal fas­cia merges in the cul-de-sac with the fibers of the uterosacral ligaments. It merges into the more lateral fibers of the cardinal– uterosacral complex in the area lateral to the upper vagina. An enterocele may occur if the pubocervical fascia separates from the rectovaginal fascia in the midline (Figure 14.3.2.1). [2–8]
Pelvic support defects are similar to hernias. They are not associated with protrusions of peritoneal sacs containing intra­abdominal contents with the exception of enteroceles such as those described here. However, pelvic support defects do exhibit disruptions in the continuity of their supporting connective tissues as is the case with midline cystoceles and in rectocele defects.[9] These disruptionsin supporting connective tissues are also seen in paravaginal defects. These defects can be made vis­ible in preoperative and intraoperative inspection. They behave
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Figure 14.3.2.1. Vaginal vault suspension and enterocele repair. A beginning enterocele. Notice the separation of the pubocervical fascia at the anterior wall from the rectovaginal fascia of the posterior vagi­nal wall. From Carter JE.[9] Reprinted with permission of A. Cullen Richardson, MD.
just as other hernias and either remain stable or increase in size. Failure to accurately identify and properly repair each of these defects may result in failure of the operation. Therefore, oper­ative repair of pelvic floor support defects must address each anatomic defect posteriorly, laterally, and anteriorly as described by Richardson [2,6–8] and Shull.[10]
Clinical evaluation of women with pelvic floor defects is performed using the techniques described by Shull.[11] The effectiveness of addressing fascial defects for rectocele has been demonstrated.[8,12,13] The effectiveness of a defect-specific approach to the paravaginal area involving reattachment of the pubocervical fascia laterally to the fascia of the obturator inter­nus muscle at the level of the arcus tendineus fascia of the pelvis
has been demonstrated by Shull [10], Richardson et al. [6,7] and Liu.[14] Therefore, transverse, midline, and lateral ligament defects in the anterior vaginal wall must be addressed when per­forming laparoscopic vaginal vault suspension and enterocele repair as described by Richardson.[6,7]
Ross [3] described apical vault repair as the cornerstone of pelvic floor reconstruction. The techniques available for api­cal vault repair, including laparoscopic vaginal vault suspension using the uterosacral ligaments, have been described by several authors.[9,15–17] Laparoscopic vaginal vault support may also be provided by laparoscopic sacrocolpopexy with or without the use of mesh.[18,19]
TECHNIQUE AND RESULTS
Uterosacral Ligament Suspension
There are two laparoscopic techniques to treat vaginal vault prolapse: uterosacral ligament suspension and sacrocolpopexy. This section concentrates on laparoscopic uterosacral ligament suspension.
After general endotracheal anesthesia has been induced, careful pelvic exam is performed. The abdomen is insufflated with CO
, and trocars are selected and placed depending on
2
the surgeon’s preferences regarding suturing techniques and instrumentation.[1,9,17] The patient is placed in Trendelenburg position, and the bowel is swept out of the pelvis. Using a rectal sizer placed in the vaginal vault, the vault is inverted so that the peritoneal lining overlying the separated rectovaginal and pub­ocervical fascia is visible in the pelvic cavity (Figure 14.3.2.2). The uterosacral ligaments are identified bilaterally, with care also taken to identify the course of the ureters anterolateral to the uterosacral ligaments.The uterosacral ligaments are examined as they enter the sacrum. The unbroken portion of the uterosacral ligament is tagged with suture bilaterally and used for reattach­ment of the vaginal apex (Figure 14.3.2.3). The peritoneum over­lying thebreak between thepubocervical andrectovaginal fasciae is opened. The pubocervical fascia is identified ventrally between the vagina and the bladder by sharp dissection. The rectovagi­nal fascia is identified posteriorly (Figure 14.3.2.4). Redundant
A
Figure 14.3.2.2. The vaginal vault is inverted using the rectal sizer so that it can be visualized within the pelvic cavity. The peritoneal lining overlying the rectovaginal and pubocervical fascia can be clearly seen. From Carter JE.[9]
B
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A
Figure 14.3.2.3. The left uterosacral ligament is shown here. The uterosacral ligaments are visualized as they enter the sacrum and are tagged by suture for later identification. From Carter JE.[9]
peritoneum and excess vagina are excised. Corner stitches are then placed on each side that approximate the edges of the pub­ocervical to the rectovaginal fascia overlying the vaginal mucosa. Permanent suture can be used for all aspects of the repair. The corner stitch is then incorporated into the ipsilateral uterosacral ligament, which had been previously tagged (Figure 14.3.2.5). The corner of the now reapproximated pubocervical and recto­vaginal fascia along the edges and corner of the vaginal apex is then incorporated into the ipsilateral uterosacral ligament as it courses to the sacrum. In this way, the rectovaginal–pubocervical complex is sutured to the unbroken portion of the uterosacral ligament, forming a very secure attachment of the vaginal apical corner (Figure 14.3.2.6). This procedure is performed on both sides of the apical vault, providing a very secure support for the lateral and upper corner of the vaginal vault.
The rectovaginal fascia is then approximated to the pubo­cervical fascia across the center of the vaginal vault with inter­rupted sutures (Figure 14.3.2.7). Reinforcing sutures from the uterosacral ligamentsto the posterior rectovaginal fascia are then placed bilaterally. These sutures do not cross the midline but rather reinforce the attachment of the corner of the vaginal
B
vault to the ipsilateral uterosacral complex. Thus, they provide an appropriate anatomic connection to the rectovaginal septum and maintainthe maximum possible transverse dimension of the upper portion of the vagina (Figure 14.3.2.8). Cystoscopy is per­formed to visualizethe ureteral orifice and assure the ureters were not kinked during suspension of the uterosacral ligaments to the vaginal vault.
Lin etal. [17] reviewed 133cases of laparoscopic vaginalvault suspension using uterosacral ligaments. Efficacy and anatomic outcome were assessed by the Baden–Walker halfway scoring system before and after the surgical procedure. Preoperatively, all patients showed evidence of grade 2 or greater prolapse (descenttothelevelofthehymen).Fifty-onepatients(38.4%)had uterovaginal prolapse, and 82 patients (61.6%) had vaginal vault prolapse. The patients were reevaluated at 1, 6, and 12 months postoperatively and yearly thereafter. In postoperative follow-up ranging from 2.0 to 7.3 years, 112 patients (87.2%) had no recur­rence of prolapse and 17 patients (12.8%) had recurrence of pro­lapse. The major complication rate was 2.25% and involved only three patients. One patient developed a deep vein thrombosis and pulmonary embolus on day 5. A second patient developed
A
Figure 14.3.2.4. The peritoneum has been divided, and with sharp dissection, the pubocervical and rectovaginal fascia has been identified. The break between them is clearly visible. From Carter JE.[9]
B
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A
Figure 14.3.2.5. The corner stitch is placed through the pubocervical and rectovaginal fascia. From Carter JE.[9]
A
Figure 14.3.2.6. The lateral edges and apical corner of the vaginal vault are secured to the unbroken portion of the uterosacral ligament as it courses to the sacrum. The left apical corner is shown here. From Carter JE.[9]
B
B
A
Figure 14.3.2.7. Interrupted sutures close the apex of the vaginal vault, restoring the integrity of the attachment of the pubocervical to the rectovaginal fascia. From Carter JE.[9]
B
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A
Figure 14.3.2.8. Completed vaginal vault apical support is visualized. From Carter JE.[9]
persistent pelvic pain, and a third patient developed an erosion of a suburethral sling graft through the vaginal mucosa; the graft had been placed as part of a concomitant procedure. There were no ureteral injuriesor blood transfusions.The authors concluded that laparoscopic vaginal vault suspension is a safe, efficacious, and durable alternative for the management of vaginal vault pro­lapse.
Margossian [20] described laparoscopic uterosacral ligament plication and shortening techniques for supporting both the uterus in place and the vaginal apex but did not report results. Seman [21] reported an objective success rate of 100% in 10 selected patients with defects in the apicalcompartment, with up to 12 months of follow-up The overall success rate in the series of 73 patients was 90% over a 2-year duration.
Another technique using the AVESTA kit(Inlet Medical,Eden Prairie, MN) involves the use of specialized instrumentation for the investment and placation of the uterosacral ligaments at the vaginal vaultafterclosure of theapex.It has beenreported to have satisfactory result in a series of 24 patients with a mean follow-up of 6 months.[1]
Wattiez et al. [22] commented that regardless of the recon­struction method used, all authors agree that theanatomic defect leading to vaginal vault prolapse is detachment of the pubocervi­cal and rectovaginal fasciae from each otherand from theirapical supports – the sacrouterine and cardinal ligaments. Hence, the principles of reconstruction should includeaglobal reattachment of all of the cervical ring fascial components.
Laparoscopic Sacrocolpopexy
Laparoscopic sacrocolpopexy represents the adaptation of abdominal sacrocolpopexy to different instrumentation. Nezhat et al. [18], Lyons and Winer [19], Wattiez et al. [22], and Ross [23,24] have all described laparoscopic techniques to perform sacrocolpopexy.
As described by Ross [23], the surgical repair was performed in the following order depending on the pelvic defects present: anal sphincteroplasty, posterior colporrhaphy, anterior colpor­rhaphy, laparoscopic sacrocolpopexy, laparoscopic paravaginal repair, and laparoscopic Burch colposuspension. This surgical order was used to ensure appropriate urethrovesical elevation
B
for the Burch colposuspension or other anterior compartment repairs. Anterior midline and posterior vaginal vault repairs were performed with site-specific vaginal repairs as described in detail by Ross.[24]
In Ross’s technique for laparoscopic sacrocolpopexy, the laparoscope is placed through an infraumbilical trocar site after establishing a pneumoperitoneum. One midline suprapubic and two lateral ports are placed for instrumentation under direct vision. A vaginal probe is placed at the apex of the vagina for dissection support. The peritoneum at the vaginal apex is mobi­lized until the pubocervical fascia and rectovaginal septum are found anteriorly and posteriorly. Thinned out vaginal wall, pri­marily mucosa, is treated as a hernia sac and amputated to the level of the ischial spine.A piece ofpolypropylene mesh (Ethicon, Inc., Somerville, NJ) is precut so that it extends posteriorly from the vaginal apex to the sacral promontory lengthwise, loosely fol­lowing the curve of the sacral hollow. A second piece of mesh is placed anteriorly and sutured with polypropylenesuture3to4cm from the distal end of the posterior piece of mesh, making a Y. In cases of descendingperineum, the posterior stripof mesh extends down to the perineal body. The added length necessary is mea­sured by approximation with a grasper. The posterior rim of the mesh is secured distally to the perineal body and the posterior vaginal wall with three to five polypropylene sutures (Ethicon, Inc., Somerville, NJ). The anterior rim of the mesh is fixed to the pubocervical fascia with two to three sutures per side. This tech­nique reestablishes the paracervical ring almost completely with sutures through mesh into the rectovaginal fascia posteriorly and pubocervical fascia anteriorly.
After vaginal attachment, the sacral promontory is identified and the loose peritoneum covering is elevated and incised. Using blunt dissection, the sacral anterolateral ligaments are exposed. The iliac vessels and ureter are visualized on the right. The left common iliac vein often crosses over the midline sacral promon­tory and must be identified. The peritoneal incision is continued down to the sacral hollow, just right of midline, to the apical vaginal vault. Laterally, the peritoneal dissection is opened to the edge of the colon on the left and to the uterosacral ligament on the right. The proximal end of the mesh is fixed to the ante­rior longitudinal sacral ligaments with three to four interrupted polypropylene sutures or hernia staples at the promontory. The
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mesh should create a tension-free suspension. The peritoneum is closed to completely cover the polypropylene mesh. Finally, the anterior pelvic compartment procedure and cystoscopy are performed.[23]
There were no intraoperative complications in Ross’ report.[23] Postoperatively, one patient developed a perineal hematoma after surgery, which was treated conservatively. Two patients (4%) experienced small bowel obstructions on days 10 and 14postoperativelyresulting in bowel resection. Four patients (8%) had mesh erosion into the vagina.
In long-term follow-up, there were only three patients with recurrent apical vault prolapse. The failures were at 6, 14, and 15 months, resulting in 98% (and 93%) 1- and 5-year objec­tive cure rates. Forty-one patients (80%) had reported impaired coitus before surgery. At 5-year followup, only 17 patients (43%) continued to report impaired coitus.
Wattiez et al. [22] described a technique for laparoscopic sacrocolpopexy using the following steps:
1. Dissection and identification of the pubocervical fascia
2. Dissection and identification of the cardinal–uterosacral complex (uterosacral ligamentsare dissected up to their ori­gin, the most solid part)
3. Dissection of the rectovaginal space down to the puborec­talis muscle, lateral to the anorectal junction
4. Subtotal hysterectomy (optional)
5. Dissection and identification of the prevertebral ligament and peritoneal incision laterally to the direction of the cul­de-sac of Douglas
6. Fixation of the posterior part of the synthetic mesh to the puborectal muscle, the cardinal–uterosacral complex
7. Fixation of the anterior part of the above-mentioned mesh to the pubocervical fascia
8. Attachment of both parts of the mesh together lateral to the cervix and reconstruction of the fascial pericervical ring
9. Fixation of the uterosacral ligaments to the mesh complex and re-creation of a double vaginal axis
10. Fixation of the mesh to the promontorium
11. Peritonization
12. Dissection of the space of Retzius and identification of the paravaginal defects
13. Paravaginal defect repair, as required
14. Burch colposuspension, if needed
In Wattiez et al.’s study[22], 125 patientsunderwentlaparoscopic sacrocolpopexyasdescribed with ameanfollow-upof32months. The objective overall success rate was 93.4%, and the subjective overall success rate was 100%.
It was concluded that the benefits of a global laparoscopic reconstructive repair using mesh include better assessment, a more precise and correct anatomic repair, the use of strong and acceptablematerials instead of the weak native tissue, faster recov­ery, and excellent anatomic and functional results. The authors’ later results improved onthe results originally obtained using the technique they described in 2001.[25]
Nezhat et al.[18] demonstrated earlythat laparoscopic sacro­colpopexy is an effective technique for treatment of vaginal vault prolapse. The authors reported 100% success for a series of 15 patients with apical vault prolapse, with a follow-up of 3 to 40
months. Lyons and Winer [19] reported a series of 20 patients with a cure rate of 80% in 1-year follow-up.
CONCLUSION
As pointed out by Nezhat [26], the introduction of vide­olaparoscopy and videolaseroscopy has revolutionized chest, abdominal, and pelvic surgery. Abdominal colpopexy performed by suspending a mesh hammock between the prolapsed vagi­nal vault and sacrum provides good results in carefully selected patients. By following the surgical principles in restoring correct anatomical position of the vault, the use of laparoscopic route is an alternative to abdominal sacrocolpopexy for patients who are not candidates for a vaginal approach.
REFERENCES
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