Laparoscopic Sacral Colpopexy: A - Hindawi Publishing...

Diagnostic and Therapeutic Endoscopy, 1995, Vol. 2, pp. 43-46Reprints available directly from the publisherPhotocopying permitted by license only

(C) 1995 Harwood Academic Publishers GmbHPrinted in Singapore

Laparoscopic Sacral Colpopexy: A Proposed Technique

CYNTHIA C. GOLDBERG, JOEL M. CHILDERS and EARL A. SURWlT

Department ofObstetrics and Gynecology, University ofArizona

(Received September 9, 1994; infinalform February 27, 1995)

This case report describes a laparoscopic sacral colpopexy using Mersilene mesh in a patient withcomplete vaginal vault prolapse. Mersilene mesh was placed as a hammock between the vaginal apexand the anterior surface of the sacrum, using intracorporeal needles and an extracorporeal knot tyingtechnique. Minor modifications are made from the traditional abdominal approach, because the pa-tient had previously undergone a pelvic lymphadenectomy and vaginal cuff radiation for a stage IBgrade adenocarcinoma of the endometrium.

KEY WORDS: laparoscopy, Mersilene mesh, sacral colpopexy, vaginal vault prolapse,

INTRODUCTION

Vaginal surgeons will be faced with an increasing num-berofpatients in which surgical correction ofvaginal vaultprolapse is necessary. This is largely due to the continu-ally enlarging geriatric population and compounded bythe large numbers of women who have had a hysterec-tomy. Both aging and inadequate support of the vaginalvault at the time of hysterectomy contribute to vaginalvault prolapse (1). There are a variety ofprocedures avail-able to correct this problem. In the patient who desirespreservation of a coitally functional vagina, an abdomi-nal sacral colpopexy with retroperitoneal interposition ofa synthetic suspensory hammock between the vaginalapex and the anterior surface of the sacrum can be used.Sacral colpopexy as first described in 1973, and subse-quent modifications, require a midline abdominal incisionand the accompanying hospitalization and recovery timeassociated with a laparotomy (2). We report the use ofop-erative laparoscopy for this procedure to circumvent thesedisadvantages of laparotomy.

Case Report

Our patient is a 69-year-old, gravida four, para three whitefemale, with a history of stage 1B grade endometrial can-cer. Her malignancy was managed with a laparoscopically

Address for correspondence: Joel Childers M.D., 2625 N. CraycroftRoad, Tucson, AZ 85724, 520-324-2469.

43

assisted vaginal hysterectomy and pelvic lymphadenec-tomy, and anterior and posterior colporrhaphy for pro-lapse. Thiswasfollowedbyhighdose vaginal cuffradiation,with 1500cGyadministered in 3 fractions. Approximatelytwo years post-operatively, the patient presented com-plaining ofprotrusion ofthe vaginal vault and pelvic pres-sure. An examination revealed complete vaginal vaultprolapse without an accompaning cystocele or rectocele.She was initially treated with a donut pessary which thepatient was not satisfied with so surgical correction wasundertaken.The procedure was performed with the patient in the

dorsal lithotomy position and the bladder drained. A 10mm umbilical port, two 5 mm lateral lower abdominalports, and one 12 mm suprapubic port were used. Thevagina was elevated by a sponge on a ring forceps in thevaginal vault. A Moschcowitz culdoplasty was performedto obliterate the deep cul-de-sac (Fig. 1). Three circum-ferential purse string sutures included the remnants ofuterosacral ligaments, the posterior vagina, and peri-toneum, and shallow bites of serosa over the sigmoid-colon laterally. This was performed using 000 coatednonabsorbable braided Ethibond sutures (Ethicon,Sommerville, MA) on a CT needle. Knots were tied ex-tracorporeally using the Clarke’s knot pusher.The Mersilene mesh (Ethicon, Sommerville, MA) was

then placed through the 12 mm port. With the index andmiddle fingers in the vagina, the vaginal apex was ele-vated. Three Ethibond sutures were placed in a single rowin the vaginal wall apex, and then through one end of the

44 C.C. GOLDBERG et al.

Figure I The first circumferential row of purse-string sutures has been placed and secured using an extra corporeal knot tying technique. The vaginais elevated to avoid being closed behind the Moschcowitz culdoplasty.

Mersilene mesh, and tied using an extracorporeal knottying technique. By palpating the needle with the fingersin the vagina, good linear bites of the vagina could be ob-tained without entering the vagina with the suture (Fig. 2).The parietal peritoneum overlying the promontory of

the sacrum was then sharply entered on the right side ofthe mesentery of the rectosigmoid. The right ureter wasidentified, and the sacral promontory was cleaned freeof its peritoneal and lymph vascular tissue. The perios-teum over the sacral promontory was used as an an-choring point. Three sutures were placed anchoring theMersilene gauze to the sacral promontory using OEthibond suture. The redundant Mersilene gauze was cutand extracted through the suprapubic port. The gauzebridge was then peritonealized by closing the peri-toneum of the sacral promontory, using the clip applierthrough the 12 mm port (Fig. 3). The vagina was thenpacked for 24 hours. The operative time was one hourand fifty-two minutes, with an estimated blood loss of50 ml.

On post-operative day number one, the foley catheterwas removed and the patient was discharged home withstool softeners to prevent constipation and associatedstraining. On examination six weeks postoperatively, thevaginal apex was well supported centrally. Twelve monthspostoperatively, the patient is asymptomatic and sexuallyactive without problems.

DISCUSSION

Abdominal colpopexy by suspending a mesh hammockbetween the prolapsed vaginal vault and sacrum is an ac-cepted surgical technique with good results in the repairof vaginal vault prolapse. This method has been chosenfor patients in whom a coitally functional vagina is para-mount. Addison described 54 of 56 patients, followed onaverage 3 years after abdominal sacral colpopexy, to haveexhibited good vault suspension and no difficulty withcoitus (3). Timmons described 163 patients, ofthose, 99%

LAPAROSCOPIC SACRAL COLPOPEXY 45

Figure 2 After placing the suture through the mesh, the surgeon secures an ample portion of vaginal tissue, by driving the needle with his/her fighthand and elevating the vagina, palpating the needle with his/her left fingers.

had good support at 9-18 months follow-up with only 2%complicated by recurrent enteroceles (4).

Variations in the surgical procedure have been reportedby numerous authors. The Halban technique to vertical-ly close the cul-de-sac has been used in place of theMoschcowitz culdoplasty (5). Different bridge materialsand techniques to attach the bridge to the vagina have beenreported (3,4). (Timmons et al, 1992). Whether the hol-low ofthe sacrum or the sacral promontory should be usedas the fixation point and whether simultaneous prophy-lactic urethropexy should be performed are debated is-sues.

In our patient, the bladder and rectum were not near thepreviously radiated vaginal apex, therefore dissection ofthe peritoneum off the vaginal mucosa was not necessary.We attached the graft to the anterior sacrum, not the hol-low of the sacrum because of its easier accessibility, min-imal venous plexous and better periosteum for anchoringsutures. Short-term follow up of this patient has demon-strated this angle to be without consequence. The lateral

angle created by the sacrospinal ligament fixation, whilenot entirely natural, is without problems as well (6).

There are multiple benefits of a minimally invasive la-paroscopic approach. The obvious benefits include asmaller incision, decreased blood loss and decreased hos-pitalization and recovery time. Theoretically, there shouldbe an overall decrease in the complications associatedwith a laparotomy, such as wound infection and dehis-cence, deep venous thrombophlebitis, adynamic ileus, andprolonged recovery.Wehave described a surgical technique forlaparoscopic

sacral colpopexy using Mersilene mesh and its relativeadvantages. However, a larger series ofpatients is requiredbefore conclusions can be reached concerning its feasi-bility, safety, limitations and success rate. Nezhat has re-ported 5 cases of laparoscopic sacral colpopexy, but hasalso been unable to present the long-term benefits (7).Initial experience by ourselves and others indicate that inproperly selected patients this technique is worthy of fur-ther investigation.

46 C.C. GOLDBERG et al.

Figure 3 The Mersilene mesh has been "reperitonealized" to avoid its exposure to intraperitoneal structures.

REFERENCES

1. Hendee AE. Sacral colpopexy for enterocele and vaginal vault pro-lapse. In: Thompson JD, Rock JA. (eds) Te Linde’s OperativeGynecology, Seventh Edition. J.P. Lippincott, Philadelphia, 1992.

2. Birnbaum SJ. Rational therapy for the prolapsed vagina. Am J ObstetGynecol, 1973;115:411.

3. Addison WA,LivengoodCH, et al. Abdominal sacral colpopexy withMersilene mesh in the retropedtoneal position in the management ofpost-hysterectomy vaginal vault prolapse and enterocele. ObstetGynecol, 1985; 153:140.

4. Timmons MC, Addison WA, et al. Abdominal sacral colpopexy in163 women with post-hysterectomy vaginal vault prolapse and en-terocele, evolution of operative techniques. J Reprod Med 1992;37:323.

5. Nichols DH, Randall CL. Vaginal Surgery. 3rd Edition. Baltimore,MD. Williams & Wilkins. 1989;322-323.

6. Nichols DH. Enterocele and Massive Eversion of the Vagina. In:Thompson JD, Rock JA. (eds) Te Linde’s Operative Gynecology,Seventh Edition. J.P. Lippincott, Philadelphia, 1992.

7. Nezhat C, Nezhat F, Nezhat C: Operative laparoscopy (Minimallyinvasive surgery): State of the Art. J Gyn Surg, 1992;8:111.

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